Incisura Angularis Research Articles

How-I-do-it: laparoscopic intragastric submucosal dissection (LISD) for gastric and gastro-oesophageal junction early lesions.

Laparoscopic intragastric submucosal dissection (LISD) is a novel approach to the resection of gastric lesion that are not amenable to conventional endoscopic approaches. The technique permits favourable access to lesions situated at the cardia and angular notch of the stomach, enables en-bloc resection of large areas of tissue, and can prevent the need of formal gastrectomy or oesophagectomy in selected patients. All cases were deemed suitable for LISD by a multidisciplinary team panel following endoscopic assessment (using white light enhancement, chromoendoscopy and magnification endoscopy) that was integrated when needed with EUS, CT scan or PET scan. The surgical technique consisted in a 3-port laparoscopic approach; after establishment of pneumoperitoneum, three gastrotomies were performed to enable port insertion into the stomach. Following establishment of stable pneumogastrium, the area of interest was identified, submucosal hyaluronic acid injection performed to provide a cushion in the plane of dissection, and the excision area was circumferentially marked with cautery. Resection was completed using cautery hook, along a plane parallel to the muscolaris propria. After the specimen was extracted in a retrieval bag, intracorporeal single layer running suture closure of gastrotomies was performed. The abdominal wall closed by layers and tap block performed along with local anaesthetic injection on skin incision. Measures were taken to ensure correct orientation of resected specimens prior to fixation. During the study period that spans from 2014 and 2022, a total of 11 patients underwent LISD for limited lesions of the stomach, 10 were located at gastro-oesophageal junction and one at the angular incisura. Four patients were female, seven males. The median age was 74 (46-79) years. R0 resection rate was 54.5%. Mean operative time was 109min with very low blood loss (10ml). Mortality rate was 0%, no immediate major complications (Grade II-V Clavien Dindo), including haemorrhage or perforation, occurred in these cases. Two patients developed dysphagia later that was successfully treated with endoscopic balloon dilatations. Median hospital stay was 3days and median oral intake was on day 1 post-procedural. Laparoscopic intragastric submucosal dissection is shown to be a safe and effective intervention for the treatment of early gastric cancers in selected patients having undergone deemed not amenable for endoscopic submucosal resection for their technically challenging location. Its application can serve as route to avoid formal surgery and the associated morbidity.

Carbon footprint and cost reduction by endoscopic grading of gastric intestinal metaplasia using narrow-band imaging.

Gastric intestinal metaplasia (GIM) is a high-risk factor for the development of gastric cancer. Narrow-band imaging (NBI) enables endoscopic grading of GIM (EGGIM). In the era of climate change, gastrointestinal endoscopists are expected to reduce greenhouse gas emissions and medical waste. Based on the diagnostic performance of NBI endoscopy, this study measured the environmental impact and reduced cost of implementing EGGIM during gastroscopy. Using NBI endoscopy in 242 patients, EGGIM classification and operative link on GIM (OLGIM) staging were prospectively performed in five different areas (lesser and greater curvatures of the corpus and antrum, and the incisura angularis). We estimated the environmental impact and cost reduction of the biopsy procedures and pathological processing if EGGIM were used instead of OLGIM. The diagnostic accuracy of NBI endoscopy for GIM was 93.0-97.1% depending on the gastric area. When a high EGGIM score ≥5 was the cut-off value for predicting OLGIM stages III-IV, the area under the curve was 0.862, sensitivity was 81.9%, and specificity was 90.4%. The reduction in the carbon footprint by EGGIM was -0.4059kg carbon dioxide equivalents per patient, equivalent to 1 mile driven by a gasoline-powered car. The cost savings were calculated to be $47.36 per patient. EGGIM is a reliable method for identifying high-risk gastric cancer patients, thereby reducing the carbon footprint and medical costs in endoscopy practice.

Determining the coordinates of a ground target from aircraft board using the method of multiple corner notches

The calculating of the stationary ground target coordinates using multiple angular spatial notches obtained using sighting equipment installed on board of a moving aircraft is considered. As intermediate parameters, auxiliary variables were used — slant ranges, which made it possible to reduce the problem to solving a system of linear algebraic equations obtained using the weighted least squares method. A complete algorithm for determining the geodetic coordinates of the target is presented, taking into account the positional and angular position of the aircraft at the time of measurement. Keywords spatial corner notches, multiple notches method, method of the weighted least squares

Possible technical aspects involved in the development of GERD after sleeve gastrectomy: Surgical technique considerations

Sleeve gastrectomy (SG) is the most common bariatric surgery worldwide and has shown to cause de novo or worsen symptoms of gastroesophageal reflux disease (GERD). Esophageal motility and physiology studies are mandatory in bariatric and foregut centers. The predisposing factors in post-SG patients are disruption of His angle, resection of gastric fold and gastric fundus, increased gastric pressure, resection of the gastric antrum, cutting of the sling fibers and pyloric spasm. There are symptomatic complications due to sleeve morphology as torsion, incisura angularis stenosis, kinking and dilated fundus. In this article, we present recommendations, surgical technique and patient selection flow diagram for SG and avoid de novo or worsening GERD.

S1893 The Rarely Sampled Incisura Angularis Is Useful for the Detection of Gastric Preneoplastic Lesions

S1893 The Rarely Sampled Incisura Angularis Is Useful for the Detection of Gastric Preneoplastic Lesions

Posibles aspectos técnicos implicados en la aparición de RGE tras gastrectomía vertical. Consideraciones para la técnica quirúrgica

Sleeve gastrectomy (SG) is the most common bariatric surgery worldwide and has shown to cause de novo or worsen symptoms of gastroesophageal reflux disease (GERD). Esophageal motility and physiology studies are mandatory in bariatric and foregut centers. The predisposing factors in post-SG patients are disruption of His angle, resection of gastric fold and gastric fundus, increased gastric pressure, resection of the gastric antrum, cutting of the sling fibers and pyloric spasm. There are symptomatic complications due to sleeve morphology as torsion, incisura angularis stenosis, kinking and dilated fundus. In this article, we present recommendations, surgical technique and patient selection flow diagram for SG and avoid de novo or worsening GERD.

The Impact of the Angulus Biopsy on the Detection of Staging and the Grading of Chronic Gastritis.

A total of 718 patients (576 women and 142 men) aged 20 to 84 years were examined. Most of the patients were in the age group of 50 to 70 years (54.6%). Depending on the detection of H. pylori and autoimmune gastritis markers, all patients were divided into three groups. The first group included 380 patients with H. pylori gastritis without signs of autoimmune gastritis. The second group consisted of 209 patients with autoimmune gastritis, in whom no infection was detected during the examination, and there were no indications of H. pylori eradication. The third group consisted of 129 patients with chronic gastritis of combined etiology (autoimmune and H. pylori). Endoscopy biopsies were taken according to the updated Sydney System. Histological assessments of the grade and the stage of gastritis were carried out according to the standard OLGA-based protocol. Then, the same assessments were evaluated without taking into account histological changes in the incisura angularis. When assessing the severity of inflammatory changes in the gastric mucosa according to the OLGA system, grade II (72.3%) was most often detected in all groups of patients. A severe degree of activity of chronic gastritis was most often observed in the group of patients with H. pylori gastritis (6.1%). These indicators practically did not change if the assessment did not take the angulus biopsy into account. When assessing the severity of atrophy of the glands in the gastric mucosa in patients of the first group, mild stages of atrophy prevailed. Without taking into account the angulus biopsy, a decrease in the stage of atrophy was observed in 27 cases (7.11%), and in only 4 cases did stage IV change to stage III, while in 23 cases, discrepancies were noted only within groups with a mild stage of atrophy. There were no transitions from stage III to stage II. In the group of patients with autoimmune gastritis, pronounced stages of atrophy prevailed-in more than 77%. Without taking into account the angulus biopsy, a decrease in the stage of atrophy was observed in eight cases (3.83%), and in three (1.4%) patients, stage III was changed to stage II. In the group of patients with combined etiology (autoimmune + H. pylori), severe stages of atrophy also prevailed (70.5%). A decrease in the stage of atrophy without taking into account the angulus biopsy was only observed in three patients (2.32%), of which two cases concerned patients with mild stages of atrophy. Thus, in general, severe stages of atrophy of the gastric mucosa (stages III and IV according to the OLGA staging system) were detected in 313 patients (43.59%). If the assessment of the atrophy stage did not take into account changes in the angulus biopsy, then severe stages of atrophy (III and IV according to OLGA) were detected in 310 patients (43.17%). In total, changes in the assessment of the atrophy stage occurred in 38 patients (5.29%), and this was more often observed in patients with stages I and II of atrophy. Accounting for histological changes in the incisura angularis does not significantly affect the assessment of the grade and stage of chronic gastritis according to the OLGA system, regardless of the etiology of atrophic gastritis.

Extensive heterotopic pancreas in a rare site: A case report and a review of literature.

Heterotopic pancreas is a pancreatic tissue that occurs outside the normal anatomical site, the most common site is antrum. Due to the lack of specific imaging and endoscopic signs, heterotopic pancreas especially those occurring in the rare site, are often misdiagnosed, and leading to unnecessary surgical treatment. Endoscopic incisional biopsy and endoscopic ultrasound-guided fine-needle aspiration are effective means for diagnosing heterotopic pancreas. We reports a case of extensive heterotopic pancreas in a rare site, which was finally diagnosed by this way. A 62-year-old man was admitted due to the presence of an angular notch lesion, which was suspected as gastric cancer before. He denied any history of tumor or gastric disease. No abnormality was found in the physical examination and laboratory testing after admission. Computed tomography showed localized thickening of the gastric wall measuring 30 mm in the long diameter. Gastroscope revealed a nodular-like submucosal protuberance at the angular notch with size of about 3*4 cm. Ultrasonic gastroscope showed that the lesion was located in the submucosa. The lesion exhibited mixed echogenicity. The diagnosis can not be identified. 2 times of incision biopsy were performed to make a clear diagnosis. Finally, appropriate tissue specimens were obtained for pathology testing. The patient was diagnosed as heterotopic pancreas according to pathology. He was recommended to undergo observation and regular follow-ups rather than surgery. Then he was discharged home with no discomfort. Heterotopic pancreas occurring in the angular notch is extremely rare, the site is scarcely reported in the relevant literature. Therefore, it is easy to be misdiagnosed. In the cases of an vague diagnosis, endoscopic incisional biopsy or endoscopic ultrasound-guided fine-needle aspiration may be a good choice.

Endoscopic causes and characteristics of missed gastric cancers after endoscopic submucosal dissection

Because endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) preserves the entire stomach, missed gastric cancers (MGCs) are often found in the remaining gastric mucosa. However, the endoscopic causes of MGCs remain unclear. Therefore, we aimed to elucidate the endoscopic causes and characteristics of MGCs after ESD. From January 2009 to December 2018, all patients undergoing ESD for initially detected EGC were enrolled. According to a review of EGD images before ESD, we identified the endoscopic causes (perceptual, exposure, sampling errors, and inadequate preparation) and characteristics of MGC in each endoscopic cause. Of 2208 patients who underwent ESD for initial EGC, 82 patients (3.7%) had 100 MGCs. The breakdown of endoscopic causes of MGCs was as follows: 69 (69%) perceptual errors, 23 (23%) exposure errors, 7 (7%) sampling errors, and 1 (1%) inadequate preparation. Logistic regression analysis showed that the risk factors for perceptual error were male sex (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.16-5.18), isochromatic coloration (OR, 3.17; 95% CI, 1.47-6.84), greater curvature (OR, 2.31; 95% CI, 1.121-4.40), and lesion size≤12mm (OR, 1.74; 95% CI, 1.07-2.84). The sites of exposure errors were around the incisura angularis (11 [48%]), posterior wall of the gastric body (6 [26%]), and antrum (5 [21%]). We identified MGCs in 4 categories and clarified their characteristics. Quality improvements in EGD observation, with attention to the risks of perceptual and site of exposure errors, can potentially prevent missing EGCs.

Our approach to early and late complıcatıons of laparoscopıc sleeve gastrectomy patients

Aim: Laparoscopic Sleeve Gastrectomy (LSG) is used as an effective surgical method in the treatment of morbid obesity. In our study, we investigated the early and late complications and treatment methods of our patients who underwent LSG.Material and method: 390 patients between the ages of 18-70 who were operated between January 2016 and December 2020 were included in the study. Patient records were retrospectively scanned electronically and the results were recorded.Results: Laparoscopic sleeve gastrectomy surgery was performed on 390 morbidly obese patients. Of the patients, 310 (78.1%) were female, 80 (21.9%) were male, with a mean age of 42.1 years (22-65) and 42.9 years (24-70) patients. Complications were observed in 22 (5.64%) patients with LSG. Ten (2.56%) of the patients developed complications in the early period, 9 (2.33%) developed complications in the late period, and 3 (0.75%) of them developed both early and late complications.Early complications; Postoperative early anastomosis leakage in 4 (1%) patients, atelectasis in 2 (0.5%) patients, bleeding in 1 (0.25%) patient, dehydration in 1 (0.25%) patient, intra-abdominal collection in 1 (0.25%) patient, pleurosis in 1 (0.25%) patient was detected. Stent was applied to the patients with leakage, and the patient with bleeding was operated. Other patients received medical treatment.Late complications; Minimal stenosis causing reflux in the incisura angularis was found in 5 (1.25%) patients, and trocar port hernia was found in 4 (1%) patients.Early and late complication; Late complications were also observed in 3 (0.75%) patients who underwent stenting due to early leakage. Late pyloric stenosis was detected in 1 (0.25%) of these patients, gastric ulcers in 1 (0.25%) and esophagocardial stenosis in 1 (0.25%) patient. Patients with trocar port hernia and patients with severe symptomatic incisura angularis stenosis were treated surgically, while other patients were treated medically. No mortality was observed.Conclusion: Laparoscopic sleeve gastrectomy, which is an effective method in the treatment of morbid obesity, can have serious early and late complications. For this reason, we believe that it will be safer to operate them in centers where necessary intensive care conditions and endoscopic interventions such as stenting can be performed quickly and reliably.

Upper Gastrointestinal Tract Video Capsule as an Alternative to Oesophago-Gastro-Duodenoscopy in Clinical Practice

Introduction. Upper gastrointestinal (UGI) video capsule endoscopy (VCE) provides a possible alternative to conventional oesophago-gastro-duodenoscopy (OGD). In Ireland, the COVID-19 pandemic led to unprecedented change in endoscopy services, accelerating the need for UGI VCE to help reduce patient exposure but allow the continuation of endoscopy services. We report on using UGI VCE as an alternative to OGD throughout all phases of COVID-related endoscopy adjustments. Aims/Background. Prospective observational study to assess identification of relevant UGI anatomical landmarks on UGI VCE as defined in the British Society of Gastroenterology. Method. Inclusion criteria were: patients with dyspepsia under 40 years of age with no alarm symptoms; known cirrhosis for variceal screening; UGI bleeds with the Blatchford score ≤ 2 . A protocol for preparation and a series of positional movements were adapted for the procedure. Landmarks and pathology detection were evaluated by two independent endoscopists. Results. 127 UGI VCE was performed from June 2020 to December 2021, of which 22 required further evaluation with OGD. The most common indications were dyspepsia and abdominal pain, 71% and 19%, respectively. With the use of the dual-facing camera, clear views of the OGJ in 100% of cases, cardia 100%, fundus 97%, greater curve 99%, lesser curve 98%, incisura angularis 95%, antrum 95%, pylorus 94%, D1/bulb 83%, and D2 82% were obtained. The main findings at UGI VCE were reflux oesophagitis and gastritis, with normal mucosa observed in 48% of cases. Findings suggesting a neoplastic lesion at the OG junction were detected in 1 case. Conclusion. Since June 2020, 81% ( N = 103 ) of a selected cohort of patients referred for UGI endoscopy avoided invasive traditional endoscopy and were successfully managed by VCE, thus reducing endoscopy waiting lists. UGI VCE may serve as a clinical diagnostic tool, used alongside OGD in appropriate cases, to help improve patient services and care delivery.

S1783 Noncirrhotic Portal Hypertension and Pancreaticogastric Fistula Complicating Acute Pancreatitis With Fluid Collections

Introduction: Noncirrhotic portal hypertension constitutes an increase in pressure of the portal venous system in the absence of cirrhosis. This is a rare condition; however, it is insufficiently acknowledged given its decreased prevalence in North America and Europe compared to other nations. We present a rare case of noncirrhotic portal hypertension and pancreatico-gastric fistula complicating acute pancreatitis with an acute fluid collection and resultant portal vein narrowing. Case Description/Methods: A 55-year-old man with history of alcohol use disorder presented to the emergency department with worsening abdominal pain 2 weeks after discharge for uncomplicated acute pancreatitis. Lipase was 48 IU/L (normal 11-82 IU/L). CT abdomen showed increasing peripancreatic fluid collection with marked narrowing of the main portal vein, which appeared near threadlike, and narrowing of the bifurcation of the portal vein extending into the left portal vein. The splenic vein was also severely narrowed (Figure A). He was discharged home with outpatient follow-up, however, returned to the ED for intractable pain one month later. A CT abdomen showed florid changes of pancreatitis with pseudocyst formation with new foci of air within the collection concerning for fistulous tract formation with the gastric lumen (Figure B). The portal vein and splenic vein narrowing improved, but the narrowing of the right and left portal veins worsened. He underwent upper endoscopy which showed a small area of White "milky" base in the posterior wall of the incisura angularis which was suggestive of fistulous opening in the area (Figure C). Four columns of small distal esophageal varices were also noted. During admission, paracentesis was performed for ascites. Serum ascites albumin gradient was over 1.1 consistent with ascites due to portal hypertension – likely due to the portal vein narrowing. Patient was discharged in stable, improved condition. Discussion: Although portal hypertension normally presents in cirrhotic patients, it may rarely present in the absence of cirrhosis by conditions such as portal vein thrombosis or portosinusoidal vascular disease. Compression of the portal vein from an acute pancreatic fluid collection is an extremely rare cause of noncirrhotic portal hypertension. Clinicians should have a high index of suspicion for complications related to portal hypertension such as ascites or varices in patients with a prolonged course of acute pancreatitis without cirrhosis.Figure 1.: (A) Contrast CT abdomen showing marked narrowing of the main portal vein, which appears near threadlike. (B) One of 2 foci of air in the collection at the anterior superior aspect of the pancreatic body. Appears inseparable from the posterior wall of the gastric body, concerning for fistulous involvement. (C) Area of White “milky” base in the posterior wall of the incisura angularis. This area was rinsed, however re-accumulated despite no obvious opening seen.

Effect of endoscopic resection of gastrointestinal stromal tumors in the stomach under double-channel gastroscopy: A retrospective observational study.

We aimed to investigate the safety and efficacy of endoscopic resection for the treatment of gastric gastrointestinal stromal tumors (GISTs) under single-channel gastroscopy and double-channel gastroscopy.We identified 154 patients with GISTs of the stomach who underwent endoscopic resection and were retrospectively analyzed at our hospital between May 2016 and March 2020, including 49 patients by single-channel gastroscopy and 105 patients by double-channel gastroscopy. We observed the clinical efficacy, complications, and safety of endoscopic resection of gastric GISTs, and the data were evaluated retrospectively.All patients underwent endoscopic resection successfully, without conversion to open surgery. In the single-channel gastroscopy group, 7 patients had lesions in the gastric cardia, 17 in the gastric fundus, 20 in the gastric corpus, and 5 in the gastric antrum. In the double-channel gastroscopy group, 13 patients had lesions in the gastric cardia, 34 in the gastric fundus, 46 in the gastric body, 10 in the gastric antrum, 1 in the pylorus, and 1 in the gastric angular incisure. The double-channel gastroscopy group had a shorter operation time than the single-channel gastroscopy group (59.9 ± 34.9 minutes vs 74.8 ± 26.7 minutes; P = .009 and P < .01, respectively), while they also had a lower perforation rate than the single-channel gastroscopy group (34.3% vs 51.0%; P = .048 and P < .05, respectively). No residual or recurrent lesions were discovered in any patients by gastroscopy reexamination.Both single-channel gastroscopy and double-channel gastroscopy can provide safe, effective, feasible endoscopic resection. However, double-channel gastroscopy has some distinct advantages in endoscopic resection.

Improving the Endoscopic Detection and Management of Gastric Intestinal Metaplasia Through Training: A Practical Guide

Improving the Endoscopic Detection and Management of Gastric Intestinal Metaplasia Through Training: A Practical Guide

A108 Increasing the angle at the incisura angularis using omentopexy reduces/prevents GERD symptoms five years after laparoscopic sleeve gastrectomy?

A108 Increasing the angle at the incisura angularis using omentopexy reduces/prevents GERD symptoms five years after laparoscopic sleeve gastrectomy?

Macroscopic, morphometric, and tomographic features of the mandible of the collared peccary (Pecari tajacu) applied to clinical morpho-physiology and imaging.

Veterinary dentistry is one of the specialties with the greatest potential to contribute to animal welfare; however, it requires a deep anatomical knowledge of the region to be treated. Therefore, the aim was to describe the macroscopic, morphometric, and tomographic anatomy of the mandible of the collared peccary in order to provide support for a better understanding of local morpho-physiology and to improve clinical procedures and interpretation of imaging exams in live adult specimens. Four mandibles from wild adult Pecari tajacu were used. The mandibles were submitted to CT scanning, and comparative analyses were performed using multiplanar views. Afterward, mandibular morphometry was conducted following the literature. Each hemimandible is composed of body, angle, and ramus. The main bony landmarks are the mandibular foramen, three main lateral mental foramina, two medial mental foramina, condylar and coronoid processes, and mandibular and angular notches. The teeth are bunodont, and the dental formula is I3/C1/PM3/M3. All bony structures were observed both in the prepared mandible and in the tomographic images and their 3D reconstruction. No obvious differences were observed in the morphometric data between males and females, or between right and left hemimandibles. It can be concluded that the mandible of the collared peccary may be anatomically structured to favor its omnivorous feeding habit. CT scan proved to be an excellent tool for evaluating the teeth and mandible, and it also provides reliable 3D bone reconstructions that can be helpful in the structural identification and the planning of oral care in live adult animals.

Comparison of the diagnostic accuracy of the updated Sydney system and single biopsy.

Updated Sydney system (USS) recommends taking biopsies from certain areas of the stomach for the diagnosis of precancerous lesions associated with Helicobacter pylori. Our aim was to evaluate the contribution of each of the biopsy sites to the diagnosis. This prospective study included 97 patients aged 40 and over with dyspeptic complaints. Biopsies were taken from five regions: the lesser curvature of the antrum (LCA), the lesser curvature of the corpus (LCC), incisura angularis (IA), the greater curvature of the antrum (GCA), and the greater curvature of the corpus (GCC). Biopsy specimens were stained with hematoxylin-eosin stain, periodic acid Schiff-alcian blue, and Giemsa histochemical stain and evaluated according to the Sydney classification. Thirty-seven (38%) patients were positive for H. pylori in at least one biopsy site. Atrophic gastritis without intestinal metaplasia (IM) was found in 17 (17.5%) of the patients (6.2% in IA, 5.2% in each of LCA, GCA, and LCC, and 2% in GCC). The prevalence of atrophic gastritis with IM was 42.3% (21.6% in LCA, 20.6% in GCA, 20.6% in IA, 14.4% in LCC, and 5.2% in GCC). Endoscopic follow-up was planned in 21 (22%) patients due to the presence of extensive atrophy or incomplete IM. If a single biopsy of the LCA or a biopsy of both LCA and GCA was taken, endoscopic follow-up would have been missed in 12 (57%) or 6 (29%) patients, respectively. Taking biopsies in accordance with the USS had higher sensitivity in detecting atrophic gastritis with or without IM compared to single biopsy. One or two biopsies is not sufficient to identify patients for whom endoscopic follow-up is recommended.

A case of early gastric cancer with a single giant lymph node metastasis

BackgroundEarly gastric cancer (EGC) is often associated with lymphatic metastasis, but it is extremely rare to be found as a single giant lymph node. Cancer often becomes more malignant in metastatic lesions than in primary lesions, and retrodifferentiation to the fetal gastrointestinal tract during the metastatic process has been reported in gastric cancer. We report an extremely rare case of EGC with a 13-cm giant lymph node metastasis in which an adenocarcinoma with enteroblastic differentiation and yolk sac tumor-like components was observed.Case presentationThe case was a 70-year-old man who visited his local doctor with right hypochondrial pain, which was identified by computed tomography (CT) as a giant mass. Upper endoscopy revealed a 30-mm-sized 0-IIc lesion in the greater curvature of the angular incisure and a 15-mm-sized 0-IIa lesion in the anterior wall of the lower body of the gastric body. Endoscopic biopsy revealed tubular adenocarcinoma in both lesions. The gastric lesion and the giant tumor were clinically regarded as independent lesions (gastrointestinal stromal tumor, [GIST], and EGCs), and distal gastrectomy and D1 + dissection were performed to comprehensively treat all lesions. Pathological examination revealed that the giant tumor was tubular adenocarcinoma with an intestinal phenotype and was considered a lymph node metastasis of EGCs. To exclude the possibility of metastasis of adenocarcinoma other than EGCs, postoperative positron emission tomography-computed tomography (PET-CT) and colonoscopy were performed; however, no primary site other than the stomach was found. Metastatic lymph nodes have an increased degree of atypia compared with the primary tumor, and yolk sac tumor-like carcinoma morphology was observed along with α-fetoprotein (AFP) and Spalt-like 4 (SALL4) expression in this case. It was considered that retrodifferentiation to a fetal phenotype occurred during the metastatic process. Liver metastasis occurred 6 months after surgery, and chemotherapy is currently being introduced.ConclusionsWe experienced a case of EGC with a single giant lymph node metastasis. Retrodifferentiation to the fetal gastrointestinal tract during metastasis was speculated to be involved in the formation of giant lymph node metastasis and liver metastasis in this case.

Histologic features in an autoimmune gastritis patient with hypergastrinemia: Call for a grading system for G cell hyperplasia

Abstract Introduction/Objective Autoimmune gastritis (AG) is characterized by oxyntic glands destruction, metaplasia, enterochromaffin-like endocrine cell abnormality and G-cell hyperplasia with hypergastrinemia. The gastrin level can be extraordinarily high in certain cases to justify suspicion of Zollinger-Ellison syndrome. We herein report one such case and discuss clinical implication of a grading system for G-cell hyperplasia to correlate histology with gastrin levels. Methods/Case Report The patient was a symptomatic 65 year-old female with hypergastrinemia (2,068 pg/mL), negative abdomen/pelvis CT scan, positive anti-intrinsic factor and anti-parietal cell antibodies. Under esophagogastroduodenoscopy, biopsies were obtained from gastric cardia, fundus, corpus, incisura angularis, and antrum. Morphology and immunostains confirmed autoimmune gastritis. Diffuse linear pattern G-cell hyperplasia was evident in antrum and incisura angularis, counting up to 200 G-cells per linear millimeter. One study defined G-cell hyperplasia as &amp;gt;140 gastrin-positive cells per linear millimeter while another proposed a 2-tier stratification, i.e., simple hyperplasia (4-5 cells for each gland) and linear hyperplasia (continuous chain-like distribution of G-cells). Such scoring, however, was largely qualitative and fell short in delineating the extent of G-cell hyperplasia and correlation with gastrinemia. Results (if a Case Study enter NA) NA Conclusion Lack of G-cell grading system hindered our unequivocal determination of the G-cell hyperplasia as underlying or contributing cause of hypergastrenemia. The unique features of our case highlighted the necessity for installing a practical grading system that incorporates G-cell density, pattern (linear vs. nodular), extent of involved areas, other features of AG to correspond to gastrin level. With accumulation of clinical information, one such grading system is feasible and will improve our knowledge and patient care.

A preliminary review of Nephelomys albigularis (Tomes, 1860) (Rodentia: Cricetidae), with the description of a new species from the Peruvian montane forests.

Nephelomys albigularis is a sigmodontine rodent of the tribe Oryzomyini distributed in the Andean forests from central Ecuador to central Peru. Although several studies recognize this species as monotypic, significant morphological variation has been reported in Peruvian populations that were not properly assessed by direct comparisons with the type series from central Ecuador. We present a preliminary review of N. albigularis with an integrative approach and emphasis on Peruvian populations. We analyzed specimens using morphological and morphometric methods, complemented with phylogenetic analyses and species delimitation using sequence data from the cytochrome-b gene. Our results reveal that N. albigularis (sensu lato) comprises two taxa: N. albigularis s.s., from the montane forests in central and southern Ecuador and northwestern Peru, and Nephelomys sp. nov. from montane forest east of the Maran River. These taxa are morphologically distinct and are separated by a genetic distance of 5.90 1.01%. Nephelomys sp. nov. differs from N. albigularis s.s. by longer rump hairs, narrow hypothenar pads, faintly bicolor tail; absent interorbital ridges, low zygomatic plates, smoothly squared posterior margin of the hard palate or with a small median postpalatal process, smoothly edged ventral margin of the external auditory meatus, and slightly angular mandibular sigmoid notches. In this work, we present a diagnosis and description of the new species of Nephelomys and discuss the role of the Maran River as a potential driver for speciation in the genus Nephelomys.