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A tight esophageal stricture secondary to a misplaced band and its management

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Here we report a case of a tight esophageal stricture and our subsequent management, in particular high - lighting the use of very flexible guidewires and biliary balloons. A 74 year old woman initially presented to a private hospital with hematemesis. Esophagogastro duo deno - scopy (EGD) revealed esophageal varices which were subsequently banded with a multiband shooter. Further investigations confirmed that she had chronic hepatitis B cirrhosis with portal hypertension. Hemostasis was achieved and she was discharged. Four months later she presented again with complaints of progressive dysphagia. A barium swallow revealed a tight stricture at the level of the aortic knuckle with eventual filling of the stomach. She was then referred to our hospital, which is a tertiary center, for further management. Subsequent EGD revealed a pinhole stricture at 20 cm (Fig. 1). A Savary-Gilliard metallic guidewire could not pass through the stricture but a 0.035 inch biliary guidewire (Jagwire) was successfully passed under fluoro scopic guidance. An attempt was made initially to pass a 5 mm Savary-Gilliard bougie dilator but we were unable to traverse the stricture. Finally, biliary balloon dilators over the wire were used. Max Force biliary balloons, a 4 mm/12F balloon (Fig. 2) followed by a 5 mm/12F balloon were both dilated to 12 Atm (atmosphere) and lastly the Quantum biliary dilation catheter 8 mm/24F was dilated to 120 Psi/8Atm. Distal to the stricture, columns of Grade 1 esophageal varices were noted but the mucosa was entirely normal. The stomach and duodenum were also normal. [Product Details...]

Advanced adenocarcinoma in a laterally spreading adenoma within a colonic diverticulum, followed-up for 4 years

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Colonic neoplasia can arise from normal mucosa near or within a diverticulum. However, an adenocarcinoma arising within a diverticulum is a very rare phenomenon and to date only sporadic cases have been reported (1-8). Due to the lack of muscular layers within the diverticulum, the use of endoscopic polypectomy of a tumour within the diverticulum carries a risk of colonic perforation. Additionally, it is usually difficult to determine whether the tumour component is benign or malignant ; hence, special precautions should be implemented in the diagnosis and treatment of such patients. A 71-year-old man was admitted to Nishijin Hospital because of melena on November 5, 2009. A laterally spreading tumour (LST) of adenoma developing in a right-sided colonic diverticulum was observed on colonoscopy, and pathological examination revealed moderate atypia from a biopsy obtained in April, 2005. There were no changes observed in the tumour four years later as determined by endoscopic examination on his latest admission. Surgical intervention was consequently recommended but refused by the patient. [Product Details...]

Ectopic pancreas mimicking submucosal gastric tumor

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A 35-year-old man presented with intermittent epigastric pain for about 3 months. On physical examination, the patient was in good health ; bowel sounds were normal and there was no tenderness in the epigastric region ; the liver and the spleen were not palpable. Laboratory findings were normal. An upper gastrointestinal endoscopy revealed a submucosal lesion over - lying the mucosa of the posterior wall of the fundus. The submucosal lesion measured about 2 cm in diameter. The histopathological examination of the biopsy sample revealed chronic gastritis and mucosal hyperplasia. Biopsies collected endoscopically do not often provide the representative histological sample needed for further therapeutic decisions. Abdominal CT scan showed a polycystic gastric mass of 20 mm in diameter, without any lymphadenopathies. Endoscopic ultrasonography (EUS) identified an heterogeneous lesion (i,e, iso- to hypoechoic) with well-defined margins, located in the stomach wall and originating from within the submucosa and the muscular propria layer (fourth layer). From this information, we postulated that the patient potentially had a gastrointestinal stromal tumour (GIST). Because a malignant etiology could not be ruled out, a laparotomy approach was considered to be appropriate for a curative and definitive diagnosis. A median laparotomy was performed and intra-operative exploration showed a localized gastric submucosal tumour of 2 cm in the posterior wall of the fundus. We performed a wedge resection of the fundus of the stomach. The resection margins were clear and the specimen was sent for pathological analysis. A nasogastric tube was inserted into the stomach and a drain tube was placed near the staple line. The final pathology report revealed that the resected specimen was an ectopic pancreas (Fig. 1). The patient was discharged on day 6 post-operation with no complications. He had an uneventful recovery. After a follow-up of 12 months, the patient has not reported any abdominal pain. [Product Details...]

Gallbladder involvement of diffuse large B-cell lymphoma mimicking gall bladder carcinoma

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We report a case of diffuse large B-cell lymphoma of the gallbladder mimicking gallbladder carcinoma. In this case, ERCP-guided brush cytology was useful for the differential diagnosis. A 54-year-old male was admitted to the hospital due to abdominal pain in September 2009. A physical examination revealed cervical lymphadenopathy. The laboratory data revealed increased serum levels of LDH (539 IU/l) and soluble interleukin-2 receptor (1230 U/ml). Abdominal ultrasonography (US) showed gallbladder wall thickening. Contrast computed tomography (CT) revealed irregular thickening of the gallbladder wall. The gallbladder lesion showed low-intensity on T1-weighted magnetic resonance (MR) images and high intensity on diffusion-weighted (DW) images (Fig. 1). A cervical lymph node biopsy was performed and the pathological examination revealed a diffuse large B-cell lymphoma (DLBCL). His serum CA19-9 level was also elevated (49.6 U/ml). Unfortunately, it was very difficult to distinguish gallbladder involvement of DLBCL from primary gallbladder carcinoma. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and the bile duct cytology showed a non-specific findings. However, ERCP-guided brush cytology demonstrated large abnormal lymphoid cells (Fig. 2). Flow cytometric analysis revealed that these abnormal lymphoid cells were positive for CD19 and CD20. A chromosome analysis revealed a normal karyotype. These results led us to the diagnosis of gallbladder involvement of DLBCL. He was treated with R-CHOP therapy and complete remission was achieved. CT and US showed that the GB wall thickening had disappeared. [Product Details...]

Immediate post-operative hypersensitivity reaction to Cetuximab in patients prepreoperatively treated by the monoclonal antibody : what’s wrong ?

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Cetuximab, an anti-Epidermal Growth Factor Receptor (EGFR) monoclonal antibody, has been considered for years as an effective drug in metastatic colorectal cancer (mCRC). Three patients, median age 65, were treated in our institution for rectal well-differentiated adenocarcinoma associated with synchronous liver-only metastatic disease. Pre-operative treatment consisted in 6 cycles of FOLFOX (Oxaliplatin 85 mg/m2 day 1, Elvorine 200 mg/m2 day 1, bolus 5-Fluorouracil 400 mg/m2 day 1 and continuous infusion 5-fluorouracil 2.4 g/m2 for 46 hours, administered every 2 weeks), combined with Cetuximab given weekly (first dose 400 mg/m2 in a 2-hours infusion, next doses 250 mg/m2 in 1-hour infusion, with Dexamethasone and anti-histamine drugs given as pre-medication). Chemotherapy was followed by short course radiation therapy (25 Gy in 5 fractions). Primary tumour and liver metastases were then completely removed and followed by 6 other cycles of FOLFOX-Cetuximab. Whereas no reaction to Cetuximab were observed during the first 12 administrations, the 3 patients developed a very acute allergic reaction combining generalized pruritus, skin and palmoplantar rash (Fig. 1) as well as dyspnea during first postoperative cetuximab administration, despite adapted therapy with corticosteroids and anti-histamine drugs. Cetuximab was immediately stopped leading recovery from the side effects. Skin reactions recurred during the next 2 administrations, leading to definitely suspend Cetuximab infusion in one patient. The 2 other patients completed their scheduled post-operative treatment. When reviewing patients’ files, no history of allergy was found. On the other hand, all patients had positive Gram negative bacterial infection during the immediate postoperative time, efficiently treated with antibiotics. [Product Details...]

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