Japanese Journal of Gastroenterology最新文献

A 79-year-old female presented to the emergency department with complaints of abdominal pain and hematemesis/melena. Blood tests revealed anemia (hemoglobin:10.0g/dl). Abdominal plain computed tomography demonstrated situs inversus totalis and a cystic structure with high attenuation extending from the descending to the horizontal portion of the duodenum, suggesting duodenal diverticular bleeding. An emergency upper gastrointestinal endoscopy was performed, which revealed an exposed vessel in the descending part of the duodenum after the removal of blood clots. Hemostasis was successfully achieved using the endoscopic clipping method. This case highlights that even in patients with situs inversus totalis, where endoscopic manipulation can be difficult, careful technique modifications and procedural planning can facilitate successful endoscopic hemostasis.

An 88-year-old female was admitted with a complaint of melena. Abdominal computed tomography revealed a dense mass and a target sign in the distal ileum, suggesting an intestinal mass and associated intussusception. However, there were no signs of intestinal obstruction or ischemic change. Retrograde single-balloon enteroscopy revealed a lesion in the distal ileum that appeared as a spherical mass in the frontal view, with a long stalk visible posteriorly. Detailed observation was challenging. At that time, intussusception was not observed. Contrast examination revealed a long and slender mass with a hemispherical, dome-shaped head. As the source of bleeding remained unidentified, enteroscopic clipping and tattooing were performed for preoperative marking. Given the patient's stable hemodynamic and respiratory status, single-incision laparoscopic surgery was performed one week later. Intraoperatively, the tattooed section of the ileum, demonstrating evidence of intussusception, was easily identified. The affected segment was exteriorized through the single-incision port, and the intussusception was relieved using the Hutchinson maneuver. Approximately 20cm of the ileum, including the tattooed segment, was resected, followed by reconstruction using a functional end-to-end anastomosis. Gross examination of the resected specimen revealed a 20×90mm polyp with a slender, "worm-like" appearance-typical of an enteric muco-submucosal elongated polyp (EMSEP). Histopathological analysis confirmed the presence of normal mucosa and submucosa with a variably prominent mixture of blood and lymphatic vessels. Although EMSEPs are frequently observed in the colon, they are exceedingly rare in the small intestine. Their detection during routine health screenings is challenging due to their location, and they often manifest as intussusception. Because endoscopic management of small EMSEPs can be challenging, lesion tattooing followed by laparoscopic surgery is a good treatment choice.

The patient was a 63-year-old man at initial consultation. After pre-operative chemotherapy for advanced gastric cancer, he underwent distal gastrectomy. Eight months later, liver metastases appeared in segments 6 and 7. First-line chemotherapy with capecitabine plus cisplatin was administered, but the liver lesions worsened, and a para-aortic lymph node metastasis was observed. Second-line ramucirumab plus paclitaxel shrank the metastatic lesions without new lesions. Because he could not tolerate further combined chemotherapy, third-line nivolumab monotherapy was started 12 months after chemotherapy initiation. After 6 courses, grade 4 adrenal insufficiency developed, and nivolumab was discontinued. Nevertheless, all metastatic lesions had shrunk and showed peripheral calcification. Ramucirumab monotherapy was resumed (43 courses) based on the patient's clinical status. During this period, the liver metastases continued to decrease and became completely calcified;the para-aortic lymph node resolved. PET-CT showed no FDG accumulation in the liver, consistent with organized, tumor-free lesions. The recurrent disease was judged equivalent to a complete response (CR), and no further treatment was given. Subsequent CT scans showed ongoing shrinkage and gradual decalcification of the organized liver lesions. Thirty-five months after discontinuing ramucirumab, the lesions are cystic and the CR persists. Given the high microsatellite instability status and the timing of lesion shrinkage and calcification, nivolumab likely played the dominant role in achieving CR. Our review of the limited number of reported cases suggests that discontinuing nivolumab after CR in gastric cancer can be a valid option.