Clinical Journal of Gastroenterology最新文献

Background: Complex surgery during initial cancer treatment can limit surgical options when planning management of a secondary malignancy. Subtotal esophagectomy and pancreatoduodenectomy are the most invasive and difficult procedures in gastroenterological surgery. Surgical cases in which subtotal esophagectomy was performed after pancreatoduodenectomy with pancreaticogastrostomy are extremely rare and challenging procedures due to the resulting complicated anatomical changes.

Case presentation: A 60-year-old man with a history of conversion pancreatoduodenectomy with pancreaticogastrostomy for advanced pancreatic head cancer was diagnosed as having advanced thoracic esophageal squamous cell carcinoma. After neoadjuvant chemotherapy, we chose a two-staged surgery with thoracoscopic subtotal esophagectomy. Following percutaneous endoscopic gastrostomy, we performed subtotal esophagectomy, systematic lymph-node dissection, and esophagostomy as the first-stage operation. Fifty-six days later, we performed gastrointestinal reconstruction with pedicle jejunum and microvascular anastomosis by the percutaneous route as the second-stage operation. Postoperatively, the patient was relieved without major complications, and the tumors were amenable to curative pathologic resection.

Conclusions: The greatest advantages of staged surgery are to reduce surgical invasiveness and to circumvent the lower rate of curability. Our procedure reported here may be recommended as an option for staged resection and reconstruction in patients with advanced esophageal cancer after pancreatoduodenectomy with pancreaticogastrostomy.

The relationship between autoimmune gastritis (AIG) and Helicobacter pylori (H. pylori) gastritis remains unclear, particularly whether there is any interaction. Herein, we report a case of early-stage AIG diagnosed in an elderly patient with highly active H. pylori gastritis, who subsequently underwent eradication therapy. We were able to follow the changes in these two types of gastritis immediately before and after eradication therapy, through observation over a period of 5 years and 5 months. Despite the previous state of predominant H. pylori gastritis, eradication therapy led to rapid exacerbation of atrophic changes, which was especially evident in endoscopic findings. In addition, the anti-parietal cell antibody titer increased constantly from 1:320 to 1:1280. We concluded that AIG activity was enhanced compared to that before eradication therapy. This course suggests the following two possibilities: early-stage AIG may have progressed steadily regardless of H. pylori gastritis status, or its activity may have been suppressed until the time of eradication therapy.

Mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) of the colon is rare with a poor prognosis. Since the first description of a mixed neoplasm 100 years ago, the nomenclature has evolved, most recently with the 2022 World Health Organization (WHO) classification system. We describe our experience of a case of locoregionally advanced MiNEN of the descending colon treated with curative laparoscopic resection and adjuvant chemotherapy. The patient is a 72 year old woman who presented with haematochezia. Initial clinical diagnosis was poorly differentiated adenocarcinoma of the descending colon, cT2N0M0, cStage I. Laparoscopic partial colectomy of the descending colon with D3 lymph node dissection and intracorporeal overlap anastomosis was performed. The pathological diagnosis however, returned mixed adenocarcinoma-neuroendocrine carcinoma (MANEC) of the descending colon, pT4aN1bM0, pStage IIIB, a subgroup of MiNEN: 70% was neuroendocrine carcinoma (NEC), whilst poorly differentiated mucinous carcinoma constituted 30% of the tumour. She completed 4 courses of irinotecan plus cisplatin (IP) adjuvant chemotherapy and is currently recurrence-free at postoperative year 2. The clinical course of MiNEN depends on the biology of the two components, both of which must be pathologically characterised. Even quantitatively discrete components should be carefully subtyped as their prognostic relevance is undetermined.

Localized light chain amyloidosis is considered to be a plasmacytic B-cell lymphoproliferative disorder caused by antigenic induction. A hypothesis has been proposed that antigen-induced local plasmacytic B cells produce amyloidogenic proteins that are processed into amyloid fibrils in giant cells leading to amyloid fibril deposition. However, the inciting antigen exposure or immune response that signals plasmacytic B-cell infiltration, activation, and selection, is unknown. A case of localized light chain amyloidosis of the stomach that gradually regressed endoscopically after Helicobacter pylori eradication is presented. Histologically, plasmacytes decreased markedly and macrophages disappeared after eradication, and they are thought to play important roles in amyloid formation. There have been no reports of localized gastric amyloidosis in which the lesion regressed and few reports showing the relationship between localized gastric amyloidosis and Helicobacter pylori infection that evaluated the changes after eradication. Given the review of the latest findings about localized light chain amyloidosis, in addition to circumstantial evidence from the clinical course of this case, we would like to propose a bold new hypothesis that Helicobacter pylori could be one of the antigens inducing localized light chain amyloidosis of the stomach.

We describe a case of familial Mediterranean fever (FMF) with sigmoid colon stricture. The patient, a woman in her 30 s, had a 12-year history of ileocolitis-type Crohn's disease. The colonoscope could not pass because of the sigmoid colon stricture, and the patient was referred to our hospital with complaints of abdominal pain and fever. At 2-month postreferral, the patient presented with severe abdominal pain and fever. Computed tomography and intestinal ultrasonography revealed no bowel obstruction, whereas wall thickening was observed in the sigmoid colon and small bowel. Our medical interview revealed a cyclical nature to the symptoms. We diagnosed FMF and initiated colchicine. Subsequently, for more than 2 years, the patient remained asymptomatic, and the sigmoid colon stricture improved. FMF should be considered in patients with inflammatory bowel disease with periodic abdominal pain and fever.

Pancreatic cancer (PC) manifests as a highly aggressive neoplastic growth, ranking as the fourth major contributor to cancer-related mortality in the United States. Despite sustained efforts, the incidence of PC is projected to rise, and the mortality rate has seen only a marginal reduction over time. A mere 15% of pancreatic cancer cases are deemed resectable upon presentation, explaining the notably low 5-year survival rate associated with this malignancy. Acute pancreatitis (AP) encompasses various degrees of inflammation in the pancreas, leading to diverse outcomes. While commonly associated with gallstone and alcohol use, it can serve as the initial presentation of PC in approximately 1% of cases. Our case series highlights two patients diagnosed with pancreatic cancer (PC) following an episode of acute pancreatitis (AP). It is not uncommon for PC to be preceded by AP, with up to 5.9% of PC cases in the United States presenting similarly.

Although steatotic liver onset after natural menopause has been reported, evidence on the clinical course and treatment options for steatotic liver after surgical menopause is scarce. A 34-year-old woman with a history of severe obesity presented to our department with liver dysfunction following total hysterectomy and bilateral oophorectomy. Her serum estradiol level was notably low at 22 pg/mL, and a liver biopsy revealed significant fatty degeneration, lobular inflammation, hepatocyte ballooning, and stage F1 fibrosis. These findings supported a diagnosis of steatotic liver disease following surgical menopause. Subsequent initiation of hormone replacement therapy (HRT) with estrogen led to rapid improvements in liver function and steatotic liver symptoms. Steatotic liver disease should be considered in cases of liver impairment in postoperative menopausal patients, for which HRT represents a promising treatment option.

Marginal ulcers are a common complication following Roux-en-Y bypass surgeries with an approximate incidence of 4.6%. The pathophysiology is complex and risk factors include smoking, nonsteroidal anti-inflammatory drugs (NSAIDs) use, Helicobacter pylori infection, and a larger pouch size. The management is usually medical encompassing control of modifiable risk factors and the administration of acid-reducing medications with data pointing towards faster healing time by using open capsule proton pump inhibitors (PPIs). Emergent surgical management is indicated for complication such as fistula formation, perforation, stricture, or intractable bleeding. Multiple surgical approaches have been proposed in the past, including: resection of the gastrojejunal (GJ) junction, revision of the bypass and total gastrectomy for recurrent ulcers. We present a unique case of a complicated recurrent marginal ulcer after Roux-en-Y surgery in a patient with multiple surgical revisions that healed completely after placing a celiac artery stent for severe celiac artery stenosis. Our case highlights an association between ischemia and marginal ulcers. This association has been previously theorized, however, there is scarce evidence to support this theory. Our case not only supports this belief but also introduces a novel and potential alternative treatment for resistant marginal ulcers that have failed medical therapy. Our approach hypothesizes that addressing ischemia as the culprit for recurrent marginal ulcers in high-risk populations, might be a minimally invasive, yet successful method for treatment.

Surgical resection is the only curative treatment for cholangiocarcinoma, but it is often diagnosed at advanced stages, making surgical resection infeasible. Recently, the concept of conversion surgery has expanded the indications for surgical treatment, thanks to advancements in both perioperative management and chemotherapy. However, it remains unclear which patients benefit most from this treatment strategy. We present a case of initially unresectable cholangiocarcinoma in which a pathologic complete response was achieved following chemotherapy. A man in his seventies presented with jaundice and was referred to our hospital. Abdominal computed tomography revealed dilation of the intrahepatic bile ducts and thickening of the common bile duct, suggestive of distal cholangiocarcinoma. The tumor was initially unresectable due to metastatic para-aortic lymph nodes, and chemotherapy with gemcitabine and cisplatin was initiated. After six courses of chemotherapy, the lymph nodes showed a partial response, and tumor markers returned to normal levels. However, further chemotherapy was intolerable due to thrombocytopenia. Our cancer board then decided to perform a pancreaticoduodenectomy. Pathologic examination of the resected specimen showed complete disappearance of the primary tumor, but viable cancer cells were found in the resected lymph nodes. Seven months post-surgery, recurrence in the para-aortic nodes was detected through imaging and elevated tumor markers. Despite this, the patient remains alive 16 months post-surgery with normal tumor marker levels, following additional chemotherapy. Pathologic complete response of the primary tumor is rarely observed in patients with initially unresectable distal cholangiocarcinoma, and a multidisciplinary approach, including conversion surgery, may be effective in such cases.

Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy for bladder cancer rarely leads to disseminated BCG infections, most of which occur early after BCG instillations or in immunocompromised patients. We report late-onset disseminated BCG infection after intravesical BCG immunotherapy in a non-immunocompromised patient. A 78-year-old non-immunocompromised man was admitted with fever and hepatosplenomegaly. He had received intravesical BCG immunotherapy four years earlier. Granulomas were detected in multiple organs and BCG was identified in urine and bone marrow fluid, leading to a diagnosis of disseminated BCG infection. Longitudinal measurements of liver and spleen volumes by computed tomography were useful in determining treatment efficacy.