Graft Duodenal Perforation due to Internal Hernia after Simultaneous Pancreas-Kidney Transplantation: Report of a Case

Although complications including graft thrombosis, graft pancreatitis, and rejection have been well documented after pancreas transplantation, the occurrence of graft duodenal perforation is uncommon. In this article, we report a case of graft duodenal perforation due to internal hernia after simultaneous pancreas-kidney transplantation (SPK). A patient with type I diabetes mellitus and diabetic nephropathy had undergone SPK from a cadaveric donor. One year later, she was admitted to our hospital for severe lower abdominal pain with preshock status. She was immediately examined by abdominal computed tomography and both peripancreas graft fluid accumulation and severe dilatation of the ileum were detected. On emergency operation, two punched holes located at the graft duodenal side near the suture line and an obstruction of herniated bowel behind the graft pancreas were detected. These holes were repaired and the internal hernia was reduced. However, a control of the intraabdominal infection was very difficult despite intensive treatment with antibiotics and additional abdominal drainage. Finally, a graft pancreatectomy was unavoidably required. When complications, including symptomatic intraabdominal infection, require re-laparotomy after pancreas transplantation, the therapeutic focus should be switched from salvaging the graft to the preservation of life

Local Resection by Combined Laparoendoscopic Surgery for Duodenal Gastrointestinal Stromal Tumor

Combined laparoendoscopic surgery is a novel surgical method which consists of both endoscopic surgery from inside the gastrointestinal tract and laparoscopic surgery from the outside. We report a case of duodenal GIST, in which combined laparoendoscopic local resection was attempted. The lesion was resected endoscopically using endoscopic submucosal dissection technique under laparoscopic assistance. Laparoscope was used for originating the orientation of the tumor, intra-operative EUS, and monitoring serosal injury from the peritoneal cavity. Postoperative hemorrhage occurred; however, precise orientation of the lesion helped us to manage the patient with minimal invasive reoperation. And thus, the bowel integrity was completely preserved, by avoiding segmental duodenal resection and pancreaticoduodenectomy. This novel, less invasive surgical procedure may become an attractive option for the lesions originating in the anatomically challenging portion of the GI tract for endoscopic or laparoscopic surgery alone

Localized Giant Inflammatory Polyposis of the Ileocecum Associated with Crohn's Disease: Report of a Case

Although inflammatory polyposis is one of the common complications in patients with inflammatory bowel disease, it is rare that each poly grows up to more than 1.5 cm. We describe a case of localized giant inflammatory polyposis of the ileocecum associated with Crohn's disease. A 40-year-old man who had been followed for 28 years because of Crohn's disease was hospitalized for right lower abdominal pain after meals. Barium enema and colonoscopy showed numerous worm-like polyps in the ascending colon which grew up to the hepatic flexure of the colon from the ileocecum, causing an obstruction of the ileocecal orifice. Since histology of a biopsy specimen taken from the giant polyps showed no dysplasia, he was diagnosed with ileus due to the localized giant inflammatory polyposis. A laparoscopically assisted ileocecal resection was performed. The resected specimen showed that the giant polyps grew up into the ileocecum. Histological examination revealed inflammatory polyposis without neoplasm. Generally, conservative treatment is indicated for localized giant inflammatory polyposis because this lesion is regarded as benign. However, occasionally serious complications arise, requiring surgical treatment

Biological and clinical review of stromal tumors in the gastrointestinal tract

Submucosal tumors of the gastrointestinal tract (G1 tract) mainly consist of gastrointestinal mesenchymal tumors (GIMTs) that are distributed in the G1 tract from the esophagus through the rectum. GIMTs include myogenic tumors, neurogenic tumors and gastrointestinal stromal tumors (GISTs). The term "GIST" is now preferentially used for the tumors that express CD34 and KIT. GIMTs are composed of spindle or epithelioid cells, and 20% to 30% show malignant behavior, including peritonea1 dissemination and hematogenous metastasis. KIT expression and mutations in the c-kit gene are found only in GISTs, but not in myogenic or neurogenic tumors. Mutation in the c-kit gene is associated with aggressive features and poor prognosis, and malignant GISTs frequently have mutations in the c-kit gene. The clinicopathological features of GISTs with or without c-kit mutations are markedly different. Therefore, GIMTs may be divided into four major categories based on histochemical and genetic data: myogenic tumors; neurogenic tumors; GISTs with c-kit mutation; and GISTs without c-kit mutation. The origin of GISTs is not fully understood. However, phenotypical resemblance to the interstitial cells of Cajal (ICCs) and gain-of-function mutations in the c-kit gene may suggest origin from ICCs andlor multipotential mesenchymal cells that differentiate into ICCs