Synchronous occurrence of gastrointestinal stromal tumors and other primary gastrointestinal neoplasms

AIM: To review clinical and pathologic features of Gas-trointestinal stromal tumors (GISTs) occurring synchro-nously with other primary gastrointestinal neoplasms.METHODS: Twenty-eight patients with primary GIST were treated at our institution between 1989 and 2005. Clinical and pathologic records were reviewed. RESULTS: The gastrointestinal stromal tumor occurred simultaneously with other primary GI malignancies in 14% of all patients with GIST. The synchronous stromal tumors were located in the stomach and were incidentally found during the operation. The coexistent neoplasms were colon adenocarcinoma, gastric cancer (2 cases) and gastric lymphoma.CONCLUSION: The synchronous occurrence of GISTs and other gastrointestinal malignancies is more common than it has been considered. The development of gastrointestinal stromal tumors and other neoplasms may involve the same carcinogenic agents.

Optimizing management of pancreaticopleural fistulas

AIM:To evaluate the management of pancreaticopleural fistulas involving early endoscopic instrumentation of the pancreatic duct.METHODS:Eight patients with a spontaneous pancre-aticopleural fistula underwent endoscopic retrograde cholang iopancreatography(ERCP) with an intentionto stent the site of a ductal disruption as the primarytreatment. Imaging features and management were evaluated retrospectively and compared with outcome.RESULTS:In one case,the stent bridged the site of aductal disruption. The fistula in this patient closed with in3 wk. The main pancreatic duct in this case appearednormal,except for a leak located in the body of the pancreas. In another patient,the papilla of Vater couldnot be found and cannulation of the pancreatic ductfailed. This patient underwent surgical treatment. In the remaining 6 cases,it was impossible to insert a stentinto the main pancreatic duct properly so as to coverthe site of leakage or traverse a stenosis situated down-stream to the fistula. The placement of the stent failed because intraductal stones(n = 2) and ductal strictures(n = 2) precluded its passage or the stent was too short to reach the fistula located in the distal part of the pancreas(n = 2) . In 3 out of these 6 patients,the pancre-aticopleural fistula closed on further medical treatment.In these cases,the main pancreatic duct was normalor only mildly dilated,and there was a leakage at the body/tail of the pancreas. In one of these 3 patients,additional percutaneous drainage of the peripancre atic fluid collections allowed better control of the leakageand facilitated resolution of the fistula. The remaining3 patients had a tight stenosis of the main pancreatic duct resistible to dilatation and the stent could not beinserted across the stenosis. Subsequent conservative treatment proved unsuccessful in these patients. Aftera failed the rapeutic ERCP,3 patients in our series developed superinfection of the pleural or peripancreatic fluid collections. Four out of 8 patients in our series required subsequent surgery due to a failed non-operative treat-ment. Distal pancreatectomy with splenectomy was performed in 3 cases. In one case,only external drainage of the pancreatic pseudocyst was done because of diffuse peripancreatic inflammatory infiltration precluding safe dissection. There were no perioperative mortalities.There was no recurrence of a pancreati copleural fistulain any of the patients.CONCLUSION:Optimal management of pancreaticopleural fistulas requires appropriate patient selection that should be based on the underlying pancreatic ductab normalities.