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Background Leiomyoma is a relatively common submucosal tumor in the upper-GI tract. The efficacy of a new method for resection of these tumors, endoscopic band ligation, was evaluated. Methods The study included 59 patients with 64 small upper-GI leiomyomas arising in the muscularis propria as determined by endoscopy, EUS, and EUS-guided FNA. The distribution of the 64 leiomyomas was the following: esophageal, 50; gastric, 12; duodenal, 2. A standard endoscope with a transparent cap attached to the tip was used. The cap was placed over the lesion, maximum sustained suction was applied, and an elastic band was released around the base. Beginning 2 weeks after banding, the lesions were observed endoscopically once per week until healing was complete. Results The 50 esophageal leiomyomas sloughed completely. The mean time required for complete healing after band ligation was 3.6 weeks. Nine of the 12 gastric leiomyomas sloughed completely; the resulting ulcer defect was healed at a mean of 4.5 weeks. The other 3 lesions did not slough because they were not completely ligated. The two duodenal lesions sloughed completely after banding, and the mean time until healing of the defect was 4.5 weeks. No perforation occurred. Follow-up ranged from 16 to 31 months, during which time no recurrence was observed. Conclusions Endoscopic band ligation is an effective and safe treatment for small upper-GI leiomyoma.

Gastric leiomyoma is a relatively rare gastric neoplasm. Before the routine use of laparoscopy, various methods of treatment for gastric leiomyoma included open celiotomy with gastric wedge resection, partial gastrectomy, enucleation, and extended gastrectomy with en bloc resection of adjacent organs. Below, we describe a case of laparoscopic wedge resection and review the various laparoscopic techniques for the treatment of gastric leiomyoma.

Obesity and bariatric surgery (BS) are increasing worldwide and can potentially lead to incidental diagnosis of benign gastric tumor including gastric leiomyoma (GL). When indicated, local tumor enucleation, completed through laparoscopic minimal-invasive approaches, has proven to be safe and effective especially when located near the esophagogastric junction (EGJ) with limited morbidity as compared to partial or total gastrectomies. Little is known regarding the most appropriate strategy concerning the management of GL regardless of the location in patients' candidate for BS.We present the case of a 67-year-old morbidly obese woman. She presented with an incidental 3-cm GL developed near the EGJ and antral histologic abnormalities mandating a gastric follow-up. Therefore, we performed both laparoscopic transgastric enucleation and sleeve gastrectomy simultaneously.After identification of the lesion, the gastrocolic ligament was divided and a gastrotomy was performed along the greater curvature to expose the tumor. Once the submucosal plan was identified, the lesion was enucleated from the submucosamuscle junction. After closure of the mucosal defect and ensuring the absence of gastric wall perforation, a conventional laparoscopic sleeve gastrectomy was performed. No adverse outcomes occurred during the post-operative period. The final pathologic diagnosis showed a completely resected and benign leiomyoma.Herein, we report the first laparoscopic transgastric enucleation of a GL localized close to the EGJ performed concomitant with a sleeve gastrectomy. This combined approach appeared feasible, safe, and do not compromise the access to the GI tract as well as potential future curative treatments on the gastric sleeve.

比較的稀な胃前庭部に発生した胃平滑筋腫に対して完全腹腔鏡下幽門側胃切除術を施行した1例を経験したので若干の文献的考察を加えて報告する.症例は26歳の女性.主訴は心窩部痛.上部消化管内視鏡検査にて胃前庭部後壁に径3.5cmのdelleを伴った粘膜下腫瘍を認めた.完全腹腔鏡下手術への希望が強いため,書面でのICをとった上で完全腹腔鏡下幽門側胃切除術を施行した.手術は気腹法で施行した.超音波凝固切開装置を用いて,胃大彎側および小彎側における胃壁周囲の血管処理と胃結腸間膜および小網の切離を行った.右胃大網動静脈の血管処理は,末梢にてクリップを使用した.十二指腸は,幽門輪から約2cm肛側,胃は胃角部にて切離した.再建はBillroth-I法とし,吻合は後壁の漿膜筋層を3針結紮縫合して胃と十二指腸を固定してから,後壁・前壁の順に全層連続縫合を施行した.腫瘍は3.5×3.5×1.8cmの大きさで,幽門輪までの距離が2cmであった.病理診断は平滑筋腫で術後経過は良好で術後17日目に退院した.幽門輪に近接した胃平滑筋に対し完全腹腔鏡下幽門側胃切除術は有効であると考えられた.

This case report describes the treatment of 67-year-old Jehovah's Witness with severe anemia and gastrointestinal haemorrhage from gastric leiomyoma and peptic ulcer. Minimal invasive surgery with meticulous hemostasis, controlled hypotension, hyperoxic normovolemia and normotermia were main principles. Minimal blood samples for necessary laboratory parametars and noninvasive monitoring were ways to decrease iatrogenic blood loss. The operative and postoperative period were uneventful and well tolerated. The patient was discharged home after eighteen days and well in follow up period.

A 38-year-old woman presented in early pregnancy with anemia due to an ulcerated gastric tumor which had the typical clinical presentation and endoscopic appearance of a gastric leiomyoma or gastrointestinal stromal tumor. At surgery this was subsequently found to be a mucinous cystic tumor of pancreas. Review of the literature shows that both gastrointestinal hemorrhage and infiltration of stomach are infrequent complications of this tumor.

Laparoscopic excision of gastric leiomyoma is technically feasible and safe, but it may fail to localize the exact placement of the lesion because of the lack of tactile sensitivity. The authors present two cases of small gastric leiomyomas that were resected by a totally laparoscopic approach, assisted with intraoperative laparoscopic ultrasonography because the lesions could not be palpated. A gastric wedge resection with tumor-free margins was performed with an endostapler device. Use of a harmonic scalpel to divide the gastroepiploic vessels facilitated the laparoscopic procedure.

Various techniques have been reported for the laparoscopic treatment of benign gastric lesions, depending on the site of the lesion. Recently, a new technique of endo-organ gastric surgery has been developed that is particular useful for the treatment of lesions on the posterior gastric wall. We report on two patients with submucosal gastric tumors. A 79-year-old man was found to have a submucosal tumor near the esophagogastric junction in the posterior wall of the stomach. Endosonography suggested that the tumor was a gastric leiomyoma. Under endoscopic guidance, three ports were inserted into the stomach and the tumor could be successfully enucleated. A 78-year-old woman was found to have a 2 x 1-cm submucosal tumor at the anterior wall of the antrum. The tumor was successfully removed by laparoscopic gastrotomy and resection. The various laparoscopic techniques for the treatment of gastric lesions are discussed.

We present a patient with extragastric pedunculated gastric leiomyoma together with some bibliographical discussion. A 74-year-old woman had jaundice, with a lesion in the duodenal papilla. A gastric tumor was detected on abdominal computed tomography, but there were no abnormal findings in other examinations. Gastric submucosal tumor was diagnosed, and surgery was performed to remove this tumor and the duodenal papillary lesion. A tumor growing extramurally in a pedunculated manner was observed in the greater curvature-side on the anterior wall of the gastric antrum. Since this tumor was within the range covered by pancreaticoduo-denectomy for a duodenal papillary lesion, it was also removed in lump. The tumor was 3.0×2.5×1.5cm in size, lobular and tuberous, grayish black, elastic and soft, and fragile. Histopathologically, it was a myoepithe-lial tumor without malignant findings, and leiomyoma was diagnosed. The proper muscular tunic occupied by the tumor was growing in a pedunculated manner, and extragastric pedunculated gastric leiomyoma was sus-pected. This leiomyoma is extremely rare, and so far only 23 cases have been reported in Japan.

Leiomyomas represent 2% of gastric tumors. Commonly, gastric leiomyomas are clinically silent. Most often they become clinically apparent due to bleeding from ulceration of the overlying gastric mucosa. Surgical extirpation of the tumor is the standard treatment. Gastric leiomyomectomy was done routinely through open laparotomy until availability of laparoscopic equipment and techniques. Recently, there have been a few published reports regarding laparoscopic or laparoscopic-assisted removal of smooth muscle gastric tumors. There is little data, however, describing or discussing a laparoscopic approach to gastric leiomyomas located on the posterior gastric wall. We describe two different laparoscopic approaches to posterior wall gastric leiomyomas that we used in two patients. The postoperative recovery of both patients was remarkably quick and uneventful.

症例は70歳の女性.胃噴門部に6×4cm大の粘膜下腫瘍を認め噴門側胃切除術を施行した.病理組織学的には胃平滑筋腫と診断され, 腫瘍内には石灰化とともに, 黄色の色素沈着を認めた.色素はSchrorl反応, Hall法が陽性であり, ビリルビンと考えられた.腫瘍組織内にはBerlin blue染色陽性のヘモジデリンと多数のマクロファージの浸潤を認めた.腫瘍は胆道系とは交通なく, 胃粘膜に潰瘍も認めなかったことより, 腫瘍内出血巣において, マクロファージにより貧食されたヘモグロビンがビリルビンへ変換された可能性が示唆された.

A 64-year-old woman was under observation for a submucosal tumor on the anterior wall of the stomach close to EC-junction which was detected 2 years before. The tumor rapidly enlarged in these several months. Upper gastrointestinal series and endoscopy revealed a submucosal tumor of Yamada's type II 2.5cm in longer diameter in the vicinity of the EC-junction with bridging fold. The tumor was shown as homogeneous mass connecting to the proper muscle layer in endoscopic ultrasonography. The patient underwent a laparoscopic wedge resection of the stomach after cutting of serosa surface on the tumor to prevent post-operative stenosis. The tumor was completely resected and histologically diagnosed as cellular leiomyoma. This procedure may be superior therapeutic method to the conventional laparotomy approach in the good curability, less post operative pain and excellent cosmetic benefit.

Tumor-associated hypoglycemia has been reported in dogs with pancreatic beta-cell tumors, hepatic tumors, and, rarely, with other neoplasms. This article describes 4 dogs with marked hypoglycemia associated with smooth muscle tumors (jejunal leiomyoma, gastric leiomyoma and leiomyosarcoma, and splenic leiomyosarcoma). Presenting clinical signs included grand mal seizures, lethargy, weakness, ataxia, and, in 1 dog, polyuria/polydipsia. The serum insulin concentration was low in 1 dog and normal in the other dog evaluated. Immunohistochemical staining for insulin was negative in the 4 tumors; the 3 tumors arising from the stomach and jejunum stained diffusely positive for glucagon. Blood glucose concentrations rapidly returned to normal after complete surgical resection of the tumors, and clinical signs associated with hypoglycemia resolved. Long-term follow-up available in 3 of the 4 dogs found no recurrence of clinical signs related to hypoglycemia at 15, 31, and 38 months after surgery, respectively.

Gastric leiomyoma is an uncommonly found entity. Most leiomyomas are asymptomatic and are found at autopsy or on abdominal exploration for other reasons. Indications for resection include large size and symptoms of compression, obstruction, or hemorrhage. The traditional surgical approach consists of laparotomy and resection. This article describes a technique for minimally invasive resection using a combined laparoscopic and endoscopic approach.

This paper describes a case of pedunculated gastric smooth muscle tumor. An asymptomatic 46-year-old man was pointed out to have a huge abdominal tumor in the left upper quadrant of the abdomen at an annual medical examination. The patient was admitted to the hospital for examination. Abdominal CT scan and MRI visualized a solid tumor with scattered small portions internally which seemed like hemorrhagic foci. The solid tumor, which was not demarcated from the spleen, was located in the left upper abdominal cavity. Abdominal ultrasonography revealed strong internal dot echoes, but ultrasonographic Doppler examination did not indicate rich blood supply in the tumor. Celiac angiogram showed a hypervascular huge tumor which was mainly fed by dilated splenic artery. Laparotomy proved that the tumor was well circumscibed and located between the stomach and spleen. The tumor, which was extirpated with small area of adherent gastric wall, was 15cm in maximum diameter with homogeneous yellowish solid section. There was no metastatic lesion. Histological examination revealed the tumor consisted with smooth muscle of spindle shaped cells with few mitosis. The tumor was determined to be originated in the gastric wall, because the tumor was continuous with muscle layer of the stomach wall by thin stalk (0.3cm).

AIM: To explore endoscopic therapy methods for gastric stromal tumors originating from the muscularis propria. METHODS: For 69 cases diagnosed as gastric stromal tumors originating from the muscularis propria, three types of endoscopic therapy were selected, based on the size of the tumor. These methods included endoscopic ligation and resection (ELR), endoscopic submucosal excavation (ESE) and endoscopic full-thickness resection (EFR). The wound surface and the perforation of the gastric wall were closed with metal clips. Immunohistostaining for CD34, CD117, Dog-1, S-100 and smooth muscle actin (SMA) was performed on the resected tumors. RESULTS: A total of 38 cases in which the tumor size was less than 1.2 cm were treated with ELR; three cases were complicated by perforation, and the perforations were closed with metal clips. Additionally, 18 cases in which the tumor size was more than 1.5 cm were treated with ESE, and no perforation occurred. Finally, 13 cases in which the tumor size was more than 2.0 cm were treated with EFR; all of the cases were complicated by artificial perforation, and all of the perforations were closed with metal clips. All of the 69 cases recovered with medical treatment, and none required surgical operation. Immunohistostaining demonstrated that among all of the 69 gastric stromal tumors diagnosed by gastroscopy, 12 cases were gastric leiomyomas (SMA-positive), and the other 57 cases were gastric stromal tumors. CONCLUSION: Gastric stromal tumors originating from the muscularis propria can be treated successfully with endoscopic techniques, which could replace certain surgical operations and should be considered for further application.

Gastric leiomyoma is a rare gastric neoplasm that traditionally has been resected for negative margins using an open approach. The laparoscopic approach may also treat various gastric tumors without opening the gastric cavity. Robotic surgery was developed in response to the limitations and drawbacks of laparoscopic surgery. Herein, we describe a case of robotic-assisted laparoscopic wedge resection of a gastric leiomyoma. A 63-year-old male complaining of abdominal pain was found to have an incidental 3 cm antral mass on an abdominal CT. Endoscopy with endoscopic ultrasound (EUS) confirmed a submucosal mass. Biopsy of the lesion was consistent with a leiomyoma. The DaVinci robotic system was used for partial gastrectomy and reconstruction, with the addition of intraoperative ultrasound to localize the lesion intraoperatively. Pathological examination of the resected mass confirmed a diagnosis of leiomyoma with negative margins. There were no intraoperative or postoperative complications. The patient was discharged home on the second postoperative day. Intraoperative endoscopic ultrasound is a safe technique that may improve the success rate of surgery by confirming the location of the lesion. Robotic assistance in gastric resection offers an easy minimally invasive approach to such tumors. This approach can achieve adequate surgical margins and lead to short hospital stays.

Leiomyomas are the most common benign mesenchymal tumours of the upper gastrointestinal tract. They rarely cause symptoms when they are smaller than 5 cm in diameter. Observation with repeated endoscopies is recommended in asymptomatic patients with small lesions. Surgical resection remains the main therapy option for symptomatic and complicated patients. The treatment of esophageal leiomyoma has been enhanced by improvements in diagnostic and therapeutic endoscopic techniques; however, the same cannot be said for gastric leiomyoma management. The present article describes the management of two cases involving giant gastric leiomyomas that were successfully treated using endoscopic injection of alcohol. To the authors' knowledge, the present study is the first report of the treatment of such hemorrhagic gastric tumours using this alternative and low-cost technique. Endoscopic local ethanol injection may be the treatment of choice in carefully selected patients with hemorrhagic leiomyomas of the upper gastrointestinal tract. ©2010 Pulsus Group Inc. All rights reserved.

Two rare cases of gastric leiomyoma with cyst formation are reported. Case 1: 74-year-old man visited the hospital because of an abdominal tumor. On admission an irregular surface mass (12×12 cm) was palpable at the epigastric region. Gastrofiberscopy and abdominal computed tomography revealed a submucosal tumor with multiple cyst formation. In May 1986, gastrectomy was performed and histological diagnosis was gastric leiomyoma. Case 2: A 60-year-old woman was hospitalized because of nausea and vomiting. Gastrofiberscopy, abdominal CT and ultrasonography revealed a submucosal tumor with cyst formation. In June 1990 partial gastrectomy including the tumor was performed. The histological diagnosis was gastric leiomyoma. Only one case of gastric leiomyoma with cyst formation has been in the Japanese literature. Because of a malignant potential, we should take surgical operation for the first choice.

In a 56-year-old man under the treatment of gastric ulcer with anemia, a submucosal tumor in the posterior wall of the middle portion of gastric corpus was accidentally found by upper gastrointestinal series and gastroendoscopy. Abdominal CT and unltrasonography revealed a solid mass about 7 cm in diameter, locating in front of the pancreas and presenting as extragastrical growth. An extragastrically growing leiomyosarcoma was strongly suspected preoperatively. On laparotomy, an egg-size tumor was found to be arising from the posterior wall of the corpus of the stomach. The mass was pedunculated and encapsulated with no evidence of invasion into the surrounding organs. No hepatic metastasis nor peritoneal dissemination was found. Subtotal gastrectomy with dissection of regional lymphnodes (R1) was performed. The resected mass measured 7.5×6.2×4.2 cm in size and lobulated with partial cystic degeneration.Pedunculated gastric leiomyomas growing extragastrically behave specifically and differently from those presenting as other growth patterns. Here we describe a case and discuss its clinicopathological features and some problems in the surgical treatment.

DNA ploidy was studied with flow cytometry in 20 cases of smooth-muscle tumor of gastroduodenal origin. There were 13 leiomyomas and 7 leiomyosarcomas. Clinico-pathological parameters, mitotic index, cellularity and histological grade clearly differed between leiomyoma and leiomyosarcoma. Only one of 13 cases of gastric leiomyoma revealed aneuploidy and the rest of 12 cases did diploidy. Conversely, 4 of 5 cases of gastric leiomyosarcoma showed aneuploidy. Two cases of duodenal leiomyosarcoma showed diploidy. Repeated measurements of DNA ploidy did not always yield the same ploidy as seen in the previous measurement, in that unhomogenous presence of DNA was inferred. Occurrence of aneuploidy was significantly higher in the leiomyosarcomas, but the prognostic value is still unlear, because postoperative late death occurred only in one case in which complete resection of widespread invasion was unsuccessful. Long-term follow-up is needed to evaluate the usefulness of DNA ploidy analysis as a prognostic factor of gastroduodenal smooth-muscle tumors.

We report herein the case of a 63-year-old male with hemoperitoneum secondary to exogastric leiomyoma. The patient had been receiving anticoagulation therapy for a cerebral embolism and complained of sudden, severe abdominal pain. A sonogram and computed tomography scan showed an exogastric mass and massive ascites. A peritoneal puncture proved the presence of an intraperitoneal hemorrhage. An emergency laparotomy revealed a pedunculated bleeding tumor, thus confirming the preoperative diagnosis of a ruptured exogastric tumor. A microscopic analysis of the excised tumor demonstrated gastric leiomyoma. Other authors have reported hemoperitoneum secondary to gastric myogenic tumors, but no cases of leiomyomas could be found in the literature.

To evaluate the ultrasonography (EUS) features of gastric gastrointestinal stromal tumors (GISTs) as compared with gastric leiomyomas and then to determine the EUS features that could predict malignant GISTs.We evaluated the endoscopic EUS features in 53 patients with gastric mesenchymal tumors confirmed by histopathologic diagnosis. The GISTs were classified into benign and malignant groups according to the histological risk classification.Immunohistochemical analyses demonstrated 7 leiomyomas and 46 GISTs. Inhomogenicity, hyperechogenic spots, a marginal halo and higher echogenicity as compared with the surrounding muscle layer appeared more frequently in the GISTs than in the leiomyomas (P0.05). The presence of at least two of these four features had a sensitivity of 89.1% and a specificity of 85.7% for predicting GISTs. Except for tumor size and irregularity of the border, most of the EUS features were not helpful for predicting the malignant potential of GISTs. On multivariate analysis, only the maximal diameter of the GISTs was an independent predictor. The optimal size for predicting malignant GISTs was 35 mm. The sensitivity and specificity using this value were 92.3% and 78.8%, respectively.EUS may help to differentiate gastric GISTs from gastric leiomyomas. Once GISTs are suspected, surgery should be considered if the size is greater than 3.5 cm.

A case of calcified gastric leiomyoma is reported. A 76-year-old female complaining of upper abdominal pain was pointed out calcifications on an abdominal plain X-ray film, and an abdominal tumor touching to tail of the pancreas on CT. On laparotomy performed under a diagnosis of pseudo-pancreatic cyst, the tumor was found to be a gastric leiomyoma growing as extrastomach.To our knowledge, in Japan, 12 cases of calcified leiomyoma of the stomach have been reported. From a review of these literature, calcified leiomyomas, when compared to noncalcified leiomyoma, are characterized by 1) to be predominant in aged women; 2) to be frequently in the middle of the stomach, where the leiomyomas attend to show no manifestations; and grow extrastomachically. These characteristics and pathologic findings suggest that a possible inclusion of dystrophic calcification might contribute to the mechanism of the calcification. In addition it was extremely remarkable that all calcifications were massive type.

胃の平滑筋腫は胃の粘膜下腫瘍中ではもっとも頻度の高い疾患であり, 最近の診断技術の向上により, 診断は比較的容易になってきた. しかしそれが十二指腸内に脱出するとなると診断は非常に困難となる. われわれは胃体上部に発生した石灰化を伴う胃平滑筋腫が十二指腸球部に脱出したきわめてまれな症例を経験したので報告する.症例は46歳, 女性で, 突然心窩部の激痛, 嘔吐といういわゆるball valve syndromeがあり, 胃X線検査, 胃内視鏡検査にて十二指腸球部に脱出した胃体上部の胃粘膜下腫瘍と診断した. 超音波検査, computed tomography検査でこの腫瘍には石灰化が認められた. 手術は胃切除術を行い, 病理検査にて胃平滑筋腫と診断された.

A 12-year-old entire male Maltese terrier was presented with a 1 month history of vomiting and haematemesis. Microcytic hypochromic anaemia was detected. Abdominal radiography, ultrasonography and gastric endoscopy identified a discrete intramural mass in the pyloric antrum. An ulcerated leiomyoma was removed by a partial-thickness intraluminal resection of the gastric wall. The dog recovered well and is free from clinical signs 20 months after surgery.

Bizarre leiomyoma is a rare form of leiomyoma with benign behavior, despite microscopic features of malignancy. We report a case of a 33-year-old woman with a bizarre leiomyoma originating in the posterior vaginal fornix. The woman's only reported symptom was dysmenorrhea and her past medical and surgical histories were unremarkable. Physical examination was also unremarkable, except for a sense of fullness in the posterior vaginal fornix. Magnetic resonance imaging of the pelvis confirmed the presence of a soft tissue mass (7.5×6.5×3 cm) filling the posterior cul-de-sac (Fig. 1). The mass was completely resected by an exploratory laparotomy under general anesthesia without entering the vagina and without compromising any of the adjacent organs. Evaluation of the abdominal cavity did not reveal any other pathology. The tumor had a solid, soft, multinodular, yellow-tan, semitranslucent cut surface giving the impression of a lipomatous neoplasm. Histologic evaluation of the mass revealed a well circumscribed neoplasm with a multinodular growth pattern composed of epithelioid cells. Most of the cells showed prominent pleomorphism with large, hyperchromatic, irregular, often multiple nuclei and eosinophilic intranuclear cytoplasmic inclusions. There was no mitotic activity or necrosis. Immunohistochemical stains revealed the neoplastic cells to be variably positive for desmin, smooth muscle actin, and muscle-specific actin (HHF-35) expression. These stains also highlighted smooth muscle bundles at the periphery of the lesion. The neoplastic cells were negative for CD34, pan-keratin, cytokeratin Cam5.2, epithelial membrane antigen (EMA), S-100 protein, HMB-45, Melan A, and CD117. Less than 2% of the neoplastic cells were positive for Ki-67 expression. The tumor was diagnosed as an epithelioid neoplasm with features consistent with bizarre leiomyoma. One year after the operation a transvaginal ultrasound revealed no evidence of recurrence. The term “bizarre” was originally used by Martin et al. [1] in 1960 to describe gastric leiomyomas. Subsequently, the term “bizarre leiomyoma” was adopted by the World Health Organization [2] to describe “a leiomyoma containing giant cells with pleomorphic nuclei and little or no mitotic activity.” The terms “atypical,” “pleomorphic,” and “symplastic” were acknowledged as synonymous designations. According to the largest series published by Downes et al. [3], these tumors generally resemble ordinary leiomyomas. In these series, mitoses ranged from 0 to 2.8 mitotic figures

Our resource-limited environment notwithstanding, extensive scientific work has been published about the causes of upper gastrointestinal bleeding in our locality. Interestingly however, gastric leiomyoma is most uncommonly mentioned as one of the findings in these publications. This paper, therefore, seeks to document gastric leiomyoma as a rare cause of bleeding in our environment and highlight the need for deployment of appropriate radiology and endoscopy techniques in diagnosing upper gastrointestinal bleeds.

Between 1963 and 1987, 131 patients with benign gastrointestinal stromal tumors, primarily leiomyomas, were treated at the Massachusetts General Hospital. Eighty per cent of tumors were located in stomach or small intestine. Two thirds of the tumors were discovered in symptomatic patients before operation by a variety of diagnostic studies. A mitotic index (MI) was determined for each tumor, defined as the number of mitoses per 50 high-power microscopic fields. Only gastric and small intestine tumors had MIs more than 2. Tumors were treated by conservative excision in 67% and radical excision in 33%. At a median follow-up of 6 years there were no local recurrences. No patient with a tumor discovered incidentally has recurred. Three symptomatic patients have died of metastatic liver disease. Each patient with recurrence had a tumor with MI of 2 or more, which represents a recurrence rate of 16% in this group. We conclude that symptomatic gastric and small intestine tumors having two or more mitoses per 50 high-power fields carry a significant risk for recurrence, and that routine pathologic assessment of MI may identify a subset of patients who would potentially benefit from close follow-up and consideration for further therapy.

NEOPLASMS in free-living cetaceans are not commonly found, which may reflect the difficulty of assessing animals that usually die in the aquatic environment, negating any postmortem examination or resulting in an advanced state of autolysis. Individual or, occasionally, clusters of neoplasms such as fibroleiomyomas in Beluga whales (Mikaelian and others 2000) have been reported. Tumour types include epithelial, mesenchymal and, less commonly, neuroendocrine tumours (Gulland and others 2001). Renal adenoma, reticuloendotheliosis, lymphosarcoma, squamous cell carcinoma and pancreatic adenoma have been reported in Atlantic bottlenosed dolphins (Tursiops truncatus) (Gulland and others 2001). Mesenchymal tumours are less common in the species; leiomyomas of the digestive tract have been recorded only in single individuals, including in the intestine of an Atlantic white-sided dolphin (Lagenorhynchus acutus) (Geraci and others 1987) and in the stomach of a common dolphin (Delphinus delphis) (Cowan and others 1986). This short communication details the gross, histological and immunohistochemical findings of a gastric leiomyoma in an Atlantic bottlenosed dolphin. An emaciated, adult, male Atlantic bottlenosed dolphin, 268 cm in length and weighing 262·2 kg, was stranded dead off the coast of North Carolina, USA. Postmortem examination revealed lesions in the digestive, musculoskeletal, urogenital and endocrine systems. Specific gross findings were left mandibular swelling, urinary calculi in the penile urethra, focal proliferations on the penis, adrenocortical cysts, serous atrophy, a healed costal fracture and gastric trematodiasis. In the pylorus, there was a focal intramural mass measuring 3·0 cm x 2·0 cm x 2·0 cm, which was ulcerated on the mucosal surface, although luminal circumference was not reduced (Fig 1). On the cut surface, the mass was firm and white. Gastric contents were absent save for a bilious fluid. Representative sections were collected in 10 per cent formalin and processed routinely. Histologically, lesions were found in the cardiovascular, respiratory, digestive, endocrine, musculoskeletal and urogenital tracts. Specific microscopic findings unrelated to the pyloric mass included myocarditis, aortitis, pulmonary oedema, gastric trematodiasis (Braunina cordiformis), colitis, hepatic haemosiderosis, proliferative balanitis, urethritis, focal mandibular callus (present before fracture) and adrenocortical cysts. The pyloric mass was composed of plump spindyloid cells forming interlacing bundles (Fig 2a). Cells had abundant eosinophilic cytoplasm and small, elongated nuclei, with minimal anisocytosis and anisokaryosis. Mitoses were not observed. Moderate inflammation was evident, associated with plasma cells and macrophages. Based upon the histological findings, two differential diagnoses for the neoplasm were proposed: leiomyoma and gastrointestinal stromal tumour. Immunohistochemical stains were applied to identify the tumours, including the myogenic markers smooth muscle actin (SMA), muscle-specific actin (MSA) and desmin (Des), as well as cytokine markers (c-kit) and neurogenic markers (S-100). Results of staining indicated positive intracytoplasmic staining for SMA (Fig 2b) and MSA (Fig 2c), rare positive intracytoplasmic staining for c-kit and S-100, and negative staining for desmin. A leiomyoma was therefore diagnosed. Leiomyomas, which are of smooth muscle origin, exhibit positive immunohistochemical staining for SMA, MSA and desmin; however, in one study of dogs, only 62 per cent of the tumours were positive for desmin and 97 per cent were positive for SMA (Frost and others 2003). Gastrointestinal stromal tumours are proposed to arise from the interstitial cells of Cajal and exhibit positive staining for c-kit, a protooncogene that encodes for a transmembrane tyrosine kinase. Infrequent staining is observed with SMA, MSA and S-100 (Frost and others 2003). Gastrointestinal stromal tumours have been reported in human beings, dogs and horses. The gastric leiomyoma in this case was an incidental finding; the animal is likely to have died from the combination FIG 1: Tumour found in the pylorus of an Atlantic bottlenosed dolphin (Tursiops truncatus) in which the tunica media is expanded by a well-demarcated nodule (white line); the arrow indicates the gastric mucosa

A 67-year-old man with a history of myocardial infarction, who had been suffering intermittent epigastric pain and tarry stool for nine months, was referred to our hospital with a suspected gastric tumor. The panendoscopy showed a round, hard submucosal tumor at the greater curvature of the upper gastric body, near the fundus. An ulcer scar was observed on the surface of the tumor. Polypectomy using snare cauterization was carried out. However, severe abdominal pain and abdominal distension developed. A chest radiograph revealed bilateral subphrenic free air. Due to the high risk in this patient, laparoscopic repair of the gastric perforation was carried out using an Endo-GIA instrument. The postoperative course was uneventful. Feeding started on the third postoperative day, and the patient was discharged on the eighth day. A follow-up panendoscopy two months later showed a well-healed scar.

A 45-year-old Japanese man was admitted for polypectomy (gastric leiomyoma). After the polypectomy, a 1-cm perforation was noted in his gastric fundus. We used five metallic clips to close the perfora

A 99-year-old woman was admitted to Shizuoka Shimizu Municipal Hospital because of fever and anasarca. Imaging and laboratory tests showed pneumonia, urinary tract infection, and cardiac failure. The patient died 20 days after admission. An autopsy revealed marked diffuse dilations of the biliary tree ranging from the lower common bile duct to intrahepatic bile ducts. Intrahepatic calcium bilirubinate stones and biliary sludges were recognized within the dilated bile ducts. A unilocular cyst (2 cm in diameter) was present in the pancreatic head adjacent to the lower common bile duct, and it appeared to compress the common bile duct. Histologically, the walls of the dilated biliary tree showed proliferation of peribiliary glands, fibrosis, and infiltration of lymphocytes and neutrophils (cholangitis). The lumens of the dilated biliary ducts contained neutral and acidic mucins, fibrinous materials, bacteria, neutrophils, and Aspergillus fungi, in addition to the calculi and sludges. The background liver showed atrophy (400 g). The pancreatic unilocular cyst was composed of mucous columnar cells with a few infoldings, and the pancreas also showed foci of mucinous duct hyperplasia and ectasia; the pathological diagnosis of the cyst was cystic dilations of a pancreatic duct branch (mucinous ductal ectasia or mucinous cyst). Other lesions included aspiration pneumonia, emaciation, atrophy of systemic organs, gastric leiomyoma, serous cystadenoma of the right ovary, and arteriosclerotic nephrosclerosis. The present case suggests that a mucinous cyst of the pancreas may compress the biliary tree and lead to marked diffuse dilations of the biliary tree. Alternatively, the dilations of the bile ducts may be associated with aging or may be of congenital origin. The dilated bile ducts may, in turn, give rise to bacterial and fungal cholangitis and formation of biliary sludges and intrahepatic calcium bilirubinate stones.

Less than 2% of gastric neoplasms that are resected surgically are of smooth-muscle origin. Gastric leiomyomas are not encapsulated, and the distinction of benign from malignant leiomyoma may be difficult. Some of these tumors manifest malignant behavior. The histological basis for the diagnosis of benign or malignant smooth-muscle tumor is not entirely satisfactory, and misclassification occurs in some cases. The aggressiveness of those tumors reported as malignant is usually low, and the term "malignant leiomyoma" is usually used rather than the more ominous "leiomyosarcoma." A case is presented of a patient with a 4.5-cm leiomyoma of the gastric antrum resected by the laparoscopic approach. Four laparoscopy trocars were used and multiple applications of the Endo-GIA were needed. Satisfactory margins of resection were obtained. The patient made an excellent recovery with minimal pain. She promptly returned to work and full physical activity.

A 63-year-old man presented with melena and iron-deficiency anemia. He had a 3-year history of ulcerative colitis involving the rectum and sigmoid colon, for which he was on maintenance Azulfidine therapy. Rectosigmoidoscopy was performed and revealed inactive inflammatory bowel disease. On UGI endoscopy he was found to have a firm, rounded, protruding submucosal tumor, measuring 4 cm, in the fundus (Fig. lA). The tumor had a thick, short stalk and was mobile. No evidence for active gastrointestinal bleeding was observed. Endosonography was performed and revealed a well-circumscribed 3.7 X 3.4 cm submucosal tumor originating from the muscle layer compatible with leiomyoma (Fig. 2). No vascular structures were seen within or in the vicinity of the tumor. No enlarged or pathologic lymph nodes were noted. The tumor was diagnosed as a leiomyoma. Informed consent was obtained for endoscopic removal of the submucosal tumor. Epinephrine (1:20,000, approximately 2 cc) was injected at the base area of attachment as a prophylactic measure to reduce the risk of bleeding. A standard polypectomy snare was used to excise the tumor. After the snare was applied to the base of the tumor, the tumor was transected by applying several seconds of blended current while gradually tightening the snare. The stalk was kept under constant tension by lifting the tumor away from

Gastric stromal tumors represent a small percentage of gastric neoplasms. Establishing a diagnosis when these lesions are encountered usually is not possible with limited biopsies. Benign and malignant gastric stromal tumors require only local excision for definitive treatment. However, most lesions are not amenable to endoscopic excision. As a result, laparoscopic local excision offers the ideal method to establish a diagnosis and to treat patients with gastric smooth muscle tumors. We present a minimally invasive local excision of a gastric stromal tumor. We also review the previously published management of gastric stromal tumors and show how it is being influenced by laparoscopy.

Endoscopic resection of gastrointestinal tumors is being performed with increased frequency. Submucosal mass lesions pose a particular problem, because of the risk of malignancy and the risk of complications associated with endoscopic removal. Increased incidences of both perforation and bleeding have been reported. We report here on a case in which we used a combined approach that included gastrointestinal endoscopy, laparoscopy, and laparoscopic ultrasound to resect a gastric leiomyoma. We consider that this approach enhanced our diagnostic capabilities, provided intraoperative options for resection, and enhanced the safety of the procedure.

Laparoscopic gastric surgery is gaining momentum, especially in the treatment of benign disease. Simultaneous endoscopy and laparoscopy allow precise localization of lesions. Because of the stomach's size, mobility, and distensibility, relatively large lesions can be safely excised. Wedge resection for anterior lesions and a transgastric or intragastric approach for posterior lesions are feasible laparoscopically. Two cases of posterior gastric leiomyomas successfully resected laparoscopically are presented. The use of stapling devices greatly facilitates this procedure.

The development of laparoscopic surgery has suggested new technical procedures for the treatment of several pathologies. Herein we report a case of laparoscopic excision of a posterior gastric wall leiomyoma. The technique reproduces that used in conventional surgery but with a transgastric approach, and the advantages of minimally invasive surgery are maintained. This laparoscopic approach may be considered an alternative strategy for surgical treatment of benign tumors of the stomach.

A 62 years old male patient presented by an acute attack of upper gastrointestinal bleeding. The patient gave no history of any chronic medical disease. He then was admitted to the emergency unit of Al-Reyah Hospital (a charity hospital, Biala, Kafr El-Sheikh, Egypt) and after resuscitation measures an emergency upper GIT endoscopy was done, the source of bleeding was identified as a lower esophageal linear crack while a large gastric smooth mass not yielding on pressure was seen and it seems to be most probably a gastric leiomyoma.

A 47-year-old woman presented with abdominal pain. A barium meal and CT scan suggested a gastric leiomyoma. Follow-up CT showed that a cyst of the left lobe of the liver was responsible for the appearances. The differential diagnosis is discussed.

Our two-step technique for endoscopic treatment of gastric leiomyomas is illustrated. From January 1979 to June 1991, nine symptomatic patients with sessile leiomyomas of the stomach were treated at the Endoscopy Division of Istituto Nazionale Tumori, Milan. The diagnosis was achieved by means of endoscopic observation of the lesion and, when possible, by ultrasound endoscopy. This new technique consists of first removing superficial portion of the tumor by electrosurgical snare. Second, a cleavage plane is found within the proper muscle layer; the tumor is enucleated as much as possible by tightening the snare around it and creating a pseudo-stalk. No major complication occurred nor were any recurrences observed at 21.8 months in the 7/9 patients treated by endoscopy alone. Endoscopic therapy was performed on an outpatient basis and only large lesions required short hospitalization.

Gastroduodenal intussusception is a rare complication of polypoidal gastric tumours, and it has not previously been described as a cause of acute pancreatitis. We report a case of an endoscopically, radiologically and histologically proven intussuscepting gastric leiomyoma presenting with biochemical evidence of acute pancreatitis. The radiological appearance is illustrated and possible mechanisms for the pancreatitis are discussed.

Summary Nineteen of 700 outwardly healthy captive adult Japanese newts, Cynops pyrrhogaster , had nodular neoplasms protruding on the gastric serosal surface. These tumours were characterized as sharply circumscribed leiomyomas of the muscularis externa with occasional submucosal involvement. Ultrastructural analysis of tumour myocytes revealed irregular-shaped, well-differentiated cells with cytoplasmic processes, and reduced quantities of intracellular myofibrils. They were surrounded by enlarged intercellular spaces filled with disorganized and increased amounts of collagen. Vacuolation was seen both in tumour myocytes and in mucous epithelial cells. Virus-like particles were observed in nuclei of some tumour myocytes. Interstitial cells with laminated-type granules were seen amongst tumour cells. These relatively benign leiomyomas shared some morphologic features with human gastric leiomyomas. Their cause and prognosis remain unknown.

Laparoscopic treatment of benign gastric disease is rapidly expanding. Gastric leiomyoma, a benign gastric neoplasm, can now be resected laparoscopically. A wide variety of laparoscopic procedures is presented in case reports during the last few years. The authors report a successful laparoscopic enucleation of a gastric leiomyoma combined with laparoscopic cholecystectomy for cholelithiasis.