José Barbosa

Primary gastric adenosquamous carcinoma in a Caucasian woman: a case report

IntroductionMost gastric tumors are adenocarcinomas. Primary gastric adenosquamous carcinoma is a rare malignancy, mostly associated with Asian populations. It constitutes less than one percent of all gastric carcinomas and its clinical presentation is the same as adenocarcinoma. It occurs more frequently in the proximal stomach, usually presents with muscular layer invasion and tends to be found in advanced stages at diagnosis, with a worse prognosis than adenocarcinoma.Case presentationWe report the case of an 84-year-old Caucasian woman with an adenosquamous carcinoma extending to her serosa with lymphatic and venous invasion (T3N1M1). Nodal and hepatic metastasis presented with both cellular types, with dominance of the squamous component.ConclusionsAdenosquamous gastric cancer is a rare diagnosis in western populations. We present the case of a woman with a very aggressive adenosquamous carcinoma with a preponderance of squamous cell component in the metastasis. Several origins have been proposed for this kind of carcinoma; either evolution from adenocarcinoma de-differentiation or stem cell origin might be possible. The hypothesis that a particular histological type of gastric cancer may arise from stem cells might be a field of research in oncological disease of the stomach.

Endoscopic Pyloromyotomy for the Treatment of Severe Refractory Diabetic Gastroparesis.

A 34 year-old-woman was admitted for food intolerance, vomiting, and electrolytic disturbances. She had type 1 diabetes mellitus, severe gastroparesis, and a recent miscarriage due to hyperemesis gravidarum. Gastric scintigraphy in 2014 showed the presence of 100% of gastric content after 3 hours. She exhibited no clinical improvement in the first 30 days after admission, even with administration of ondansetrom, domperidone, droperidol, and erythromycin, and required total parenteral nutrition. Discussion by a multidisciplinary team and with the patient led to the decision to perform a peroral endoscopic pyloromyotomy. In the upper endoscopy, an incision was performed in the proximal antrum, using a dual knife. A submucosal tunnel was created with a triangletip knife until the pyloric ring was identified (Figure 1a). Pyloromyotomy was performed (1b and 1c), with a 2-cm proximal extension of the myotomy in the superficial muscle layers of the antrum (1d). The mucosal defect was closed with 10 clips (Figure 2: a, fixed open pylorus after myotomy; b, mucosal defect; c, after clipping). After 48 hours, gastroduodenal transit showed no contrast extravasation, with normal progression of the barium contrast. The patient had a dramatic response to the procedure. She progressively stopped all the prokinetic drugs and started oral feeding. Gastric scintigraphy after two weeks showed normalization of gastric emptying times in the first two hours, with a slight delay between 120 and 160 minutes of examination, and she was discharged on a soft diet. Therapeutic options for gastroparesis refractory to pharmacological treatment have disappointing results overall. Endoscopic pyloromyotomy without submucosal tunneling was initially developed for patients with congenital pyloric stenosis. The technique was refined and was recently described for the treatment of gastroparesis due to various etiologies. It has shown promising short-term results and can be a valuable alternative to more invasive techniques. (Informed consent was obtained from the patient to publish these images.)

Effect of different bariatric surgery type on the leukocyte formula

BACKGROUND Obesity is associated with higher leukocyte counts, whereas weight loss decreases these counts. It is unknown if different bariatric surgery (BS) types have different effects on leukocytes. OBJECTIVES The aim of the study was to determine predictors of leukocyte and their subset count variation in patients submitted to BS. SETTING Tertiary care university hospital, Porto, Portugal. METHODS This was a retrospective analysis of patients submitted to Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), or sleeve gastrectomy (SG). Leukocyte and subset counts were compared between baseline and 1-year postsurgery and between BS types. A multivariate linear regression model was built to study determinants of leukocyte and subset variation. RESULTS We analyzed 764 patients: 238 submitted to LAGB; 452 to RYGB, and 74 to SG. Mean age was 42 years and 86.6% were women. All BS types were associated with a decrease in leukocyte and neutrophil counts but the variation in body mass index and homeostatic model assessment (HOMA-IR) were the only variables independently associated with a decrease 1-year postsurgery. Monocytes increased in patients submitted to LAGB and decreased in those who underwent RYGB and SG. The BS type was independently associated with monocyte variation. Patients who underwent RYGB and SG had a decrease in monocyte counts of 77/µL and 62/µL, respectively, compared with LAGB. CONCLUSION Weight and insulin resistance are the main predictors of leukocyte and neutrophil variation after BS. The specific type of BS is a determinant of monocyte count variation independent of the amount of weight loss or the degree of insulin resistance improvement.