Superior Mesenteric Arteriography Research Articles

A new imaging classification for safer radial access visceral intervention of the liver and optimal case selection: Apreliminary report.

The aim of this study was to evaluate the use of a new classification for safer transradial access hepatic interventional radiology, based on preoperative evaluation of the location of the left subclavian artery bifurcation in the aortic arch. A total of 38 consecutive patients with hepatocellular carcinoma and 74 sessions of radial access for visceral intervention (R.A.V.I.) were reviewed. We classified the location of the left subclavian artery bifurcation in the aortic arch in three areas using an oblique view computed tomography image matched with the curve of the aortic arches according to a new criteria Three Areas Criteria For R.A.V.I. (named "TAC-F-R"), and measured the required time from initial left radial artery arteriography to celiac artery or superior mesenteric artery arteriography. The median time required for left radial artery arteriography to the celiac artery or superior mesenteric artery arteriography in each of the three areas were: area A, 0:11:10 (h, min, s); area B, 0:14:44; and area C, 0:31:51. There were significant differences between each area after Bonferroni correction (p<0.01; A vs. B, p=0.086; A vs. C, p=0.001; and B vs. C, p=0.045), with areas A and B requiring a significantly shorter time. Finally, no patients showed neurogenic disfunction within 1week after the R.A.V.I. The new classification, "TAC-F-R," for safer transradial access hepatic interventional radiology is effective for avoiding difficult cases, and selects more suitable patients with hepatocellular carcinoma for the R.A.V.I.

Rapid identification of source of delayed hemobilia following endoscopic metallic stenting for malignant biliary obstruction.

Delayed hemobilia, a rare but potentially fatal complication of endoscopic metallic stenting for malignant biliary obstruction, requires prompt identification of the source of bleeding and subsequent embolization. However, hemobilia is characteristically intermittent, and computed tomography (CT) often fails to show pseudoaneurysms or extravasations. In particular, because the posterior superior pancreaticoduodenal artery (PSPDA) runs alongside the common bile duct for its whole length, it is readily obscured by metallic artifacts in that duct, such as stents, making identification of the source of bleeding by CT difficult. We have encountered three patients with delayed hemobilia from the PSPDA following endoscopic biliary stenting for malignant biliary obstruction in whom no extravasation or pseudoaneurysms were detected by contrast-enhanced CT during bleeding. However, when we identified that the PSPDA had a smaller diameter than in previous CTs in all three cases, we suspected that the PSPDA was the source of the bleeding. No extravasation or pseudoaneurysms were detected with celiac arteriography or superior mesenteric arteriography; however, extravasation and pseudoaneurysms were detected by direct PSPDA angiography. Hemostasis was achieved through embolization. Detecting a large decrease in the diameter of the PSPDA on contrast-enhanced CT during biliary bleeding may help to identify the source of that bleeding.

Recurrent acute portal vein thrombosis with severe abdominal infection after right hemihepatectomy in a patient with perihilar cholangiocarcinoma: A case report and literature review.

Introduction and importancePortal vein thrombosis (PVT) is a serious complication after hepatobiliary-pancreatic surgery. There have been few studies on recurrent PVT after hepatectomy for perihilar cholangiocarcinoma.Case presentationWe report the case of a 66-year-old woman who was diagnosed with perihilar cholangiocarcinoma and treated with right hemihepatectomy. On the sixth day, the patient developed acute portal vein thrombosis, and emergency portal vein incision and surgical thrombectomy were performed. On the seventh day after thrombectomy, the patient developed acute portal vein thrombosis again, and portal vein thrombectomy+portal vein bridging was performed again. There was still thrombosis after the operation. The patient was then treated with superior mesenteric arteriography + indirect portal vein catheterization thrombolysis and local thrombolysis + anticoagulation and systemic anticoagulation therapy. The patient had a complicated abdominal infection. The total hospital stay was 84 days. There was no thrombosis in the portal vein at discharge.Clinical discussionAlthough the procedure was carefully performed with a preoperative plan and fine intraoperative vascular anastomosis, postoperative PVT occurred. There are many factors of portal vein thrombosis, and there are many treatment methods.ConclusionPVT often develops in patients with liver cirrhosis postoperatively and after liver transplantation. Recurrent PVT after hepatectomy for perihilar cholangiocarcinoma is a rare complication.

Combined treatment of an aortosplenic bypass followed by coil embolization in the treatment of pancreaticoduodenal artery aneurysms caused by median arcuate ligament compression: a report of two cases

BackgroundPancreaticoduodenal artery aneurysms (PDAAs) are rare visceral aneurysms, and prompt intervention/treatment of all PDAAs is recommended at the time of diagnosis to avoid rupture of aneurysms. Herein, we report two cases of PDAA caused by the median arcuate ligament syndrome, treated with surgical revascularization by aortosplenic bypass followed by coil embolization.Case presentationCase 1 A 54-year-old woman presented with a chief complaint of severe epigastralgia and was diagnosed with two large fusiform inferior PDAAs and celiac axis occlusion. To preserve the blood flow of the pancreatic head, duodenum, liver, and spleen, we performed elective surgery to release the MAL along with aortosplenic bypass. At 6 days postoperatively, transcatheter arterial embolization was performed. At the 8-year 6-month follow-up observation, no recurrent perfusion of the embolized PDAAs or rupture had occurred, including the non-embolized small PDAA, and the bypass graft had excellent patency.Case 2 A 39-year-old man who had been in good health was found to have a PDAA with celiac stenosis during a medical checkup. Computed tomography and superior mesenteric arteriography showed severe celiac axis stenosis and a markedly dilated pancreatic arcade with a large saccular PDAA. To preserve the blood flow of the pancreatic arcade, we performed elective surgery to release the MAL along with aortosplenic bypass. At 9 days postoperatively, transcatheter arterial embolization was performed. At the 6-year 7-month follow-up observation, no recurrent perfusion or rupture of the PDAA had occurred, and the bypass graft had excellent patency.ConclusionCombined treatment with bypass surgery and coil embolization can be an effective option for the treatment of PDAAs associated with celiac axis occlusion or severe stenosis.

S3453 Cavernous Hemangioma: A Rare Cause of Massive Lower Gastrointestinal Bleeding

INTRODUCTION: Hemangiomas are benign vascular tumors that rarely occur in the gastrointestinal tract. However, only 37 cases of small intestine hemangioma were reported from 2000 to 2018. Small bowel hemangiomas may cause massive lower gastrointestinal bleeding. In this report, we present a case of massive, and recurrent lower GI bleeding caused by a cavernous hemangioma of the small intestine. CASE DESCRIPTION/METHODS: A 32-year-old man came to the ER frequent episodes of large bloody bowel movements with a drop of Hb level, and he was transferred to MICU. The upper and lower endoscopy showed a large amount of blood with clots throughout the colon with no source of bleeding. A massive transfusion (of a total of 34 units) was given. Surgery and interventional radiology recommended Superior mesenteric artery arteriography, which demonstrated brisk bleeding from a jejunal branch overlying the left upper quadrant. Embolization of the bleeding jejunal branch was performed. A few days after, the patient developed other episodes of rectal bleeding. Capsule endoscopy revealed active small bowel bleeding, originating most likely from the proximal and mid-small intestine. Small intestine resection was performed, and the specimen analysis showed a cavernous hemangioma, measuring 1.2 × 1 × 0.8 cm. DISCUSSION: Hemangiomas are benign vascular neoplasms that can appear anywhere in the body, including the GIT, and it is considered as 0.05% of all gastrointestinal tumors. The jejunum is the most common site of occurrence. Hemangiomas may be solitary or multiple. Multiple hemangiomas are usually associated with the presence of similar lesions in other organs, such as liver and skin. Hemangiomas of GIT typically originate from the submucosal vascular plexus and extend from the submucosa to the muscular layer of the intestinal wall and they may extend beyond the serosa, involving the mesenteric, retroperitoneal, or pelvic fat. Histologically, hemangiomas classified into capillary, cavernous, and mixed. Initial investigations usually include upper and lower endoscopy. However, in most cases, these investigations are normal. CT angiography, MRI, radionuclide imaging, selective angiography, double-balloon enteroscopy, and capsule endoscopy could be used to identify the lesion. Surgical resection has conventionally been used for the treatment of intestinal hemangiomas. In recent years, less invasive therapeutic interventions, such as non-surgical endoscopic treatment and minimally invasive laparoscopic surgery, have become more common.

Delayed bowel stricture complicating superior mesenteric vein thrombosis

Superior mesenteric thrombosis is a rare disease of acute abdomen; many risk factors have been identified including arrhythmia, deep vein thrombosis, and hematologic or rheumatologic causes. Image study is more helpful than laboratory test. The standard therapy is anticoagulant (unfractionated heparin or low-molecular-weight heparins) administration, but there is still low possibility to need surgery for the complications such as bowel stricture or ischemic bowel disease. We describe the case of acute abdominal pain, the computed tomography showed superior mesenteric thrombosis, and the patient received the therapy with unfractionated heparin and the procedure of superior mesenteric arteriography with intravascular thrombolytic therapy. However, the complication of delayed bowel stricture occurred, which was proved by upper gastrointestinal series. Then, he was cured by surgical intervention with segmental resection of small bowel.

Arteriography after embolization before distal pancreatectomy with en bloc celiac axis resection

Objective: To evaluate hemodynamics by arteriographic examinations with and without CT in the stomach wall and liver after preoperative embolization to redistribute blood flow to the stomach and liver, which is unified to be supplied from the superior mesenteric artery, before distal pancreatectomy with en bloc celiac axis resection (DP-CAR). Material and methods: In six patients with locally advanced cancer of the pancreatic body in whom DP-CAR was planned, the left gastric artery and common hepatic artery were embolized with coils. Celiac arteriography and superior mesenteric arteriography with and without CT were performed after embolization. Results: In all six patients, intrahepatic arteries and the left gastric artery were not visualized on celiac arteriography. On both superior mesenteric arteriography and CT obtained while contrast medium was infused via the superior mesenteric artery and which was performed immediately after embolization procedures, the right gastric artery, gastroepiploic artery, gastroduodenal artery, and all hepatic arterial branches were clearly detected. Also the distal part of the left gastric artery close to the embolized point was detected with at least one of the imaging modalities. Conclusion: It was clarified radiologically that preoperative embolization results in increased blood supply to the stomach wall and liver through the pancreatic arcade.

Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft

We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI) hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD) and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC) imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population.

Symptomatic Meckelʼs Diverticulum in a Geriatric Patient Evaluated for Ongoing Gastrointestinal Bleeding and Hemodynamic Instability

Background: Meckel's diverticulum is the most common congenital anomaly of the small intestine, presenting in 1-3% of the general population. When symptomatic, common complications include painless bleeding, intestinal obstruction, umbilical discharge, perforation, and peritonitis. It is classically a pediatric disorder, and 30-40% of cases are asymptomatic. Meckel's diverticulum is infrequently considered in the differential diagnosis for geriatric patients presenting with common gastrointestinal symptoms. We report a rare case in which ongoing gastrointestinal bleeding and hemodynamic instability were signs of symptomatic Meckel's diverticulum in a geriatric patient. Case Presentation: A 90-year-old male presented for evaluation of a painful, localized swelling on the right upper thigh. Hemoglobin was 115 g/L. He was found to have a ruptured right femoral artery aneurysm, requiring urgent surgical repair. Twelve days post-operatively, the patient had ongoing melena suggestive of upper GI bleeding and became hemodynamically unstable. Hemoglobin dropped as low as 67 g/L, and rose only to 70 g/L following transfusion. The patient underwent urgent upper endoscopy, revealing an oozing duodenal ulcer, which was hemoclipped. However, the bleeding and hemodynamic instability continued. Repeat endoscopy revealed ongoing bleeding in the duodenum; however, an actively bleeding vessel was not found by superior mesenteric arteriography. The gastroduodenal artery was empirically embolized. Bleeding continued despite embolization. The patient underwent an exploratory laparotomy. This revealed a Meckel's diverticulum in the small intestine, filled with blood and with distended vascular malformations at the apex. A wedge resection of the diverticulum was performed and hemoglobin stabilized at 81 g/L post-operatively. Discussion: Symptomatic Meckel's diverticulum has been reported as an uncommon complication in the elderly. In patients older than 65 years, it has masqueraded as more common gastrointestinal disorders such as small bowel obstruction, ischemic colitis, diverticulitis, and appendicitis. Presenting complaints reported in geriatric patients include nausea, vomiting, diffuse, severe abdominal pain with intestinal obstruction, periumbilical pain, constipation and rectal bleeding. Similar to our case, hematochezia was reported in an elderly patient with a bleeding Meckel's diverticulum. Rare complications in the elderly include gastrointestinal stromal tumor, and Littre hernia as a cause of unexpected death. Although rare in the geriatric population, the potential for complications should alert clinicians to the possibility of a Meckel's diverticulum in older adults with obscure GI bleeding.

Emergency transcatheter arterial embolization for patients with acute massive duodenal ulcer hemorrhage

To evaluate the efficacy and safety of emergency transcatheter arterial embolization (ETAE) for patients with acute massive duodenal ulcer hemorrhage. Twenty-nine consecutive patients with acute massive bleeding of duodenal ulcer were admitted to our hospital from 2006 to 2011. Superselective angiography of the celiac and gastroduodenal arteries was performed to find out the bleeding sites before ETAE, then, embolotherapy was done with gelatin sponge particles or microstrips via a 5 French angiographic catheter or 3 French microcatheter. After ETAE, further superior mesenteric arteriography was undertaken in case collateral circulation supplied areas of the duodenal ulcer. Technical and clinical success rates were analyzed. Changes in the mucous membrane were observed using endoscopy following ETAE. Angiography showed active bleeding with extravasation of contrast medium in seven cases with a 24% positive rate of celiac artery bleeding, and in 19 cases with a 65.5% rate of gastroduodenal artery bleeding. There were no angiographic signs of bleeding in three patients who underwent endoscopy prior to ETAE. Twenty-six patients achieved immediate hemostasis and technical success rate reached 90%. No hemostasis was observed in 27 patients within 30 d after ETAE and clinical success rate was 93%. Recurrent hemorrhage occurred in two patients who drank a lot of wine who were treated by a second embolotherapy in the same way. Five patients underwent transient ischem with light abdominal pain under xiphoid, spontaneous restoration without special treatment. No mucous necrosis happened to 29 cases for ischem of gastroduodenal arteries embolized. ETAE is an effective and safe measure to control acute massive bleeding of duodenal ulcer.

Postembolization small bowel ischaemia

A 28-year-old man presented with massive gastrointestinal aemorrhage and hypovolemic shock. His haemoglobin level ropped to 5 g/dl over a six-hour period. Emergency upper ndoscopy to the second part of the duodenum showed no bnormalities. Digital subtraction visceral angiography was perormed. Superior mesenteric arteriography revealed bleeding from marginal branch of the ileocolic artery (Fig. 1A, arrow) that suplied the distal ileum, consistent with small bowel angiodysplasia. uperselective mesenteric embolization with gelatin sponges was erformed (Fig. 1B, arrow). Twelve hours after this procedure, the patient complained f crampy abdominal pain in the lower quadrants. On physial examination, the abdomen was tender and diffusely tense. aboratory findings revealed increased levels of lactate dehydroenase (1065 IU/L), hematocrit (75%) and neutrophil granulocytes 17.220 mm−3). Under the suspicion of intestinal ischaemia, an exploratory aparotomy was performed, and a 5 cm ischaemic ileal loop was ound and resected (Fig. 2). The patient recovered uneventfully and was discharged on postperative day 4. Small bowel ischaemia represents a rare side effect after uperselective mesenteric embolization in patients with acute gasrointestinal bleeding, 3% according to the most recent series [1].

Ruptured left colic arterial aneurysm treated by transcatheter arterial embolization alone and without a subsequent laparotomy: Report of a case

We herein report the case of a 49-year-old male patient with a ruptured aneurysm originating in the left colic artery, which was successfully treated by transcatheter arterial embolization (TAE) Abdominal computed tomography revealed a large hematoma with a central small aneurysm in the left upper abdomen. Celiac and superior mesenteric arteriography showed no dye extravasation. Subsequent aortography showed an aneurysm arising from the branch of the left colic artery that was successfully treated by selective TAE. Further surgery for subsequent ischemia was not performed. In cases presenting with an unclear source of intraabdominal bleeding, an aneurysm of the inferior mesenteric arterial branch should be considered. Transcatheter arterial embolization is a plausible initial treatment option as an effective therapeutic approach because it provides a curative and less invasive alternative to other therapies. Based on our experience and a review of the literature, surgery may not necessarily be imperative, even in cases of a ruptured aneurysm of a colic arterial branch after TAE.

A dialysis patient with hyperammonaemia: inferior mesenteric-caval shunt as a cause of portal-systemic encephalopathy.

Sir, We report here a rare case of portal-systemic encephalopathy with occasional loss of consciousness caused by an inferior mesenteric-caval shunt via the internal iliac vein in a peritoneal dialysis (PD) patient who was switched to haemodialysis (HD). A 71-year-old man with end-stage renal disease, who had undergone PD and was shifted to HD, was admitted to our hospital for occasional loss of consciousness. Physical examination showed dysarthria, asterixis and ataxic gait without clinical signs of portal hypertension and liver cirrhosis. Laboratory studies revealed normal liver function (albumin 2.3 g/dL, total bilirubin 0.62 mg/dL, lactate dehydrogenase 174 IU/L, aspartate aminotransferase 12 IU/L, alanine transferase 8 IU/L, and gamma-glutamyl transpeptidase 8 IU/L) and increased ammonia concentration in peripheral blood (151.5 μmol/L, normal range: 17.7–47.0). Neither hepatitis B surface antigen nor antibodies to hepatitis C were detected. Results from the brain computed tomography (CT) scan and magnetic resonance imaging were normal. An electroencephalogram showed an increase in delta waves. An endoscopy did not find esophageal varices or haemorrhoids. An enhanced abdominal pelvic cavity CT scan detected the presence of the inferior mesenteric vein (IMV)–internal iliac vein shunt. The inferior vena cava (IVC) was enhanced through the shunt in an early phase of enhanced CT. The venous phase of both the superior and inferior mesenteric arteriogram revealed a large shunt between the IMV and left internal iliac vein, with blood flowing from the portal vein to the IVC (Figure 1). Selective venous sampling for blood ammonia levels showed a higher value of 180.3 μmol/L in the shunt vessel in contrast with 132.1 μmol/L in the IVC and 94.5 μmol/L in the left external iliac vein. Portal vein pressure was normal, 10–16 mmHg. A transcatheter coil embolization of the shunt vessel was performed. The high preoperative serum ammonia concentration decreased to the normal range postoperatively. Two years after the embolization, a follow-up enhanced CT scan showed a narrowing of the shunt. The patient has suffered no further episodes (such as occasional loss of consciousness or an increase in blood ammonia levels) after the embolization. Fig. 1. The venous phase of superior mesenteric arteriography shows a large shunt between the inferior mesenteric vein and left internal iliac vein. Portal-systemic encephalopathy without portal hypertension by an IMV–internal iliac vein shunt in a patient undergoing HD following unsuccessful PD is a very rare [1–3]. Our case may have a congenital portal-systemic venous shunt, since the shunt vessel was single and he did not have liver dysfunction and/or portal hypertension [4]. The placement of peritoneal catheter for a long period also might cause peritoneal fibrosis and sclerosis although this patient did not have any findings of peritoneal damages during surgery for catheter extraction. Haemodynamic changes during both HD and PD may also increase the flow of ammonia-rich portal venous blood into the systemic circulation through the shunt vessel [1]. Portal-systemic encephalopathy should be recognized as one of the neuropsychiatric disorders and be considered in the diagnosis of a hyperammonaemia-induced conscious disturbance in the dialysis population without liver dysfunction.

Diagnostic and Therapeutic Tricks in a Rare Case of Pediatric Ileal Congenital Arteriovenous Malformation

Diagnostic and Therapeutic Tricks in a Rare Case of Pediatric Ileal Congenital Arteriovenous Malformation

Successful Treatment of Mesenteric Varices After Living Donor Liver Transplantation with Retrograde Transvenous Obliteration Via an Abdominal Wall Vein

Balloon-occluded retrograde transvenous obliteration is an established treatment for gastric varices; it has been used more rarely to treat mesenteric varices. We report a 12-year-old girl who had received a living donor liver transplant and suffered melena due to ruptured mesenteric varices. We addressed treatment of the mesenteric varices by retrograde transvenous obliteration of an abdominal wall collateral vein detected by superior mesenteric arteriography.

Portal-systemic encephalopathy after Fontan-type operation in patient with polysplenia syndrome

An 18-year-old patient, who had polysplenia and single ventricle, presented with altered mental status 9 years after a Fontan-type operation and pacemaker implantation. He underwent replacement of common atrioventricular valve and aortic valve plasty 1 year previously and has been placed on multiple medications including beta-blocker for his poor ventricular function. Blood chemistry revealed hyperammonemia of 2420 microg/l as a cause of this altered mental status disturbance. Superior mesenteric arteriography revealed large portal-systemic shunts in venous phase as a cause of hyperammonemia. To control blood ammonia level, we placed him on low protein diet, oral polymixin B, and lactulose instead of closing shunt with device. This case illustrates that portal-systemic shunt may result in hyperammonemia leading to altered mental status long after a Fontan-type operation.

Congenital Portal Systemic Encephalopathy Misdiagnosed as Senile Dementia

Congenital portal systemic encephalopathy without liver cirrhosis and/or portal hypertension is rare. An 86-year-old man with senile dementia was admitted due to disturbance of consciousness. His serum ammonia level was high, but there was no evidence of liver cirrhosis or portal hypertension on laboratory tests and upper abdominal enhanced computed tomography (CT). However, on lower abdominal enhanced CT, a meso-caval shunt was found in the right lower abdomen. Superior mesenteric arteriography revealed a shunt flowing into the inferior vena cava via the right gonadal vein. The shunt was closed by balloon occluded retrograde transvenous obliteration, and dementia-like symptoms improved.

Colonic diverticular bleeding: precise localization and successful management by a combination of CT angiography and interventional radiology

We report a case of 50-year-old man with relapsing severe colonic diverticular bleeding. The patient required total blood transfusion of 14 units, despite fasting for bowel rest. Repeated CT, colonoscopy, and angiography could not determine the accurate bleeding site. Superselective arterial embolization could be finally achieved by precise localization on CT immediately after superior mesenteric arteriography.

Microballoon Occlusion Test to Predict Colonic Ischemia After Transcatheter Embolization of a Ruptured Aneurysm of the Middle Colic Artery

A 76-year-old woman presented with sudden massive melena, and superior mesenteric arteriography showed an aneurysm in the middle colic artery (MCA). Because she had a history of right hemicolectomy and ligation of the inferior mesenteric artery (IMA) during open abdominal aortic aneurysm repair, embolization of the MCA aneurysm was considered to pose a risk comparable to that of colonic ischemia. A microballoon occlusion test during occlusion of the MCA confirmed retrograde visualization of the IMA branches through the collateral arteries by way of the left internal iliac artery, and embolization was successfully performed using microcoils. No colonic ischemia or aneurysm rupture occurred after embolization.

Male Choriocarcinoma with Metastasis to the Jejunum: A Case Report and Review of the Literature

We report on a patient with male choriocarcinoma. The patient was a 31-year-old male patient with jejunal choriocarcinoma that metastasized from the mediastinum. He was admitted complaining of melena and severe anemia. Upper and lower gastrointestinal endosocopy was performed, but no source of bleeding was seen. Chest X-ray and CT revealed a mediastinal tumor 7 cm in size anterior to the arotic arch. Superior mesenteric arteriography showed irregularities and macular opacity in the jejunal artery. An emergency laparatomy was performed because of massive gastrointestinal bleeding. A jejunal tumor approximately 4 cm in size was resected and numerous metastases were observed in the liver and mesentery. Histopathological examination showed metastatic jejunal choriocarcinoma. Gynecomastia was not present and the testes were normal. Serum beta-human chorionic gonadotropin (HCG) was at an abnormally high level of 4,396 ng/mL. Because of metastases to the brain and invasion to the trachea, he died on postoperative day 20. We report this rare case of a male patient with metastases of choriocarcinoma to the gastrointestinal tract from the mediastinum, together with a review of the literature.