Ichiro Yoshinaka

Primary hypertrophic pyloric stenosis in the adult

A case is reported of a 55 year old male patient with primary hypertrophic pyloric stenosis who was subjected to distal gastrectomy. Adult hypertrophic pyloric stenosis is an uncommon condition which is usually misdiagnosed as carcinoma of the antrum. It is a benign disease resulting from hypertrophy of the circular fibres of the pyloric canal and is recognizable radiologically by narrowing and elongation of the pyloric canal and endoscopically by appearances resembling those of the cervix. This condition is probably congenital although aetiology has not been established. In the absence of symptoms, no clinical treatment is required. However, surgical intervention is advocated, when stenosis gives rise to symptoms, there is a suspicion of malignancy, or the ulceration due to the disease. Distal gastrectomy with gastroduodenostomy is the treatment of choice.

Endoscopic Diagnosis of Early Malignant Lymphoma of the Stomach

Abstract: The findings and results obtained by endoscopies and direct vision biopsies carried out in 13 patients with early primary gastric lymphoma, were compared with those of 8 patients with RLH, 28 with depressed type of early gastric carcinoma, and 10 patients with benign gastric ulcers, to deal with problems inherent to endoscopic diagnosis of early primary gastric lymphoma

Reversible protruded lesion regarded as idiopathic appendiceal intussusception

A patient with a reversible protruded lesion regarded as idiopathic appendiceal intussusception was investigated in this study. The patient was a 78‐year‐old male, who consulted our department as a result of positive occult blood in his stool sample. There was no associated pain, nausea, vomiting, fever, chill or anorexia. He had no prior surgical history. Total colonoscopy detected a sigmoidal polyp and a protruded lesion in the caecum. The protruded lesion (about 12 mm in diameter) covered with normal mucosa was diagnosed as a benign submucosal tumor at that time. The periodic follow‐up colonoscopy showed an orifice on top of the protuberance. Further detailed observation revealed that the lesion reduced by itself, and resulted in showing a normal orifice of the appendix; however, afterwards it protruded again. These observations led to the diagnosis of the lesion as type B of Atkinsons classification in appendiceal intussusception. To our knowledge, approximately 200 cases of appendiceal intussusception have been documented in scientific reports worldwide. In Japan, only 10 cases of idiopathic appendiceal intussusception have been described. This case is considered to be important for presenting the initial stage of the complete intussusception of the appendix.

A case of local recurrence of periductal stromal sarcoma of the breast

The case involved a 63-year-old female who had complained of a hard reddish lump in the right breast. Although the lump initially appeared to be a phyllodes tumor, histopathology after initial surgery indicated mastopathy as a likely diagnosis. Two years later, regrowth of the lump at the same location prompted revaluation. Ultrasound scan (US) revealed the following features : a) an irregular low-signal lesion with a diameter of 5 cm in the right A region extending toward the hypertrophic epidermis, b) marked increase in blood flow on power Doppler, c) increased thickness between the skin and underlying pectoralis major, and d) irregular and unclear margin of low-echoic lesion. Based on those findings along with clinical symptoms, advanced stage of inflammatory breast cancer was suspected, and a second surgery was performed. Histopathology revealed infiltration of atypical spindle cells around normal mammary ducts, but it did not show the architecture of a phyllodes tumor. The atypical spindle cells were positive for vimentin and CD34 and negative for hormone receptors according to immunohistochemistry. These were consistent with the characteristics of periductal stromal sarcoma. The section diagnosed as mastopathy 2 years previously was re-evaluated by pathologists, and components of stromal sarcoma were found in the section. Stromal sarcoma is rare for the breast region and usually lacks specific features, which may make the precise diagnosis quite difficult. In our case, the following factors contributed to the misleading diagnosis : invasive growth without forming a firm mass, less prominent nuclear pleomorphism and low proliferation index, and inconsistent US features compared to the previous report, etc. The generally poor prognosis of this tumor should demand long-term observation even though no recurrence has been found after the second surgery.

Case of cecal volvulus successfully treated with endoscopic colopexy: Cecal volvulus treated endoscopically

We herein report a case of cecal volvulus successfully treated with endoscopic colopexy. A 73‐year‐old man with a high fever and abdominal fullness was diagnosed with ileus caused by cecal volvulus. CT showed a dilated cecum and small intestine without bowel strangulation as well as acute pneumonia. Because the pneumonia increased the risk associated with general anesthesia, we attempted decompression of the bowel using endoscopy to avoid surgery. On day 1, a transanal ileus tube was inserted to the terminal ileum through the dilated cecum. On day 7, the bowel torsion spontaneously released. On day 8, we performed percutaneous endoscopic colopexy to fix the cecum on the abdominal wall and prevent re‐twisting. The patient was discharged on day 15 without postoperative complications. Percutaneous endoscopic colopexy for cecal volvulus may be a treatment option when the risk associated with general anesthesia or surgery is high because of a comorbidity.

A Case of Kissing Esophageal Ulcers of Unknown Etiology

Abstract: A 41‐year‐old man with esophageal ulcers of unknown etiology is reported. Endoscopic examination was performed for evaluation of swallowing difficulty. The lesions were located in the middle portion of the esophagus. There were no findings correlating with either peptic ulcer or reflux esophagitis. In addition, he had no history of provoking factors, such as bacterial, chemical, traumatic or physical agents. Although the cause of these lesions was not clarified, we diagnosed acute benign ulcers following histological examination of the biopsy specimens. The patient was treated with a proton pump inhibitor and sodium alginate. The dysphagia and other symptoms subsided promptly, and the lesions healed completely within three weeks. We discuss herein the relationship between endoscopic findings and the etiology of kissing ulcer.

Indication for Curative Endoscopic Mucosal Resection for Early Gastric Cancer: Analysis of 290 Surgical Cases

In the present study, lymph node metastasis and incontinuous invasion were evaluated in 290 gastrectomy cases of early gastric cancer. All mucosal cancers (m-cancers) were free of lymph node metastasis whereas 24.4% of submucosal cancers (sm-cancers) showed the metastasis. Grossly, lymph node metastasis was absent in elevated lesions of 20 mm or less in size, depressed lesions of 10 mm or less, and all flat lesions; histologically, well differentiated lesions of 20 mm or less and moderately or poorly differentiated lesions of 10 mm or less. Among 34 cases with the main lesion of 20 mm or less, regardless of the gross and histologic types, incontinuous invasion was located within 2 mm from the main lesion in 97.1%.