Gastrointestinal bleeding due to small bowel metastasis from lung adenocarcinoma:A case report

BACKGROUND Lung cancer is the most prevalent malignant tumor in human body,and is characterized by a high level of malignancy.The most common metastatic sites include the liver,bone,brain,and adrenal gland,while lung cancer resulting in gastrointestinal tract metastasis is uncommon.CASE SUMMARY A 74-years-old man with lung cancer was hospitalized owing to blood in the stool,The cause was identified as metastasis to the small intestine,and the patient subsequently underwent radical resection of the small intestine tumor.Currently,the overall condition of the patient is good,and undergoing combined chemotherapy.CONCLUSION Early intervention in patients with metastatic tumors can significantly improve prognosis.

Proximal small intestinal bypass outperforms Roux-en-Y and jejunoileal bypass in glucose regulation in streptozotocin induced diabetic rats

BACKGROUND The efficacy of various bariatric surgeries varies in reducing blood glucose levels.Given the distinct mechanisms and anatomical alterations associated with each procedure,it is crucial to compare their glycemic control outcomes.We hypothesize that proximal small intestinal bypass(PSIB)is superior in blood glucose reduction over Roux-en-Y gastric bypass(RYGB)and jejunoileal bypass(JIB).AIM To compare the effectiveness of PSIB,RYGB,and JIB in lowering blood glucose.METHODS Rats with streptozotocin-induced diabetes were randomly divided into PSIB,RYGB,JIB,and sham-operated groups.Body weight,food intake,fasting blood glucose level,oral glucose tolerance test,insulin tolerance test,liver enzymes,and blood lipids were measured.RESULTS Postoperatively,only the JIB group had a lower body weight compared to the sham group.The food intake of the rats in all three surgical groups was significantly less than that in the sham group.Fasting blood glucose was reduced in all surgical groups and was lower in the PSIB group than in the RYGB and JIB groups.Glucose tolerance and insulin sensitivity improved in all three surgical groups compared to the sham group,but the improvement appeared earliest in the PSIB group.At six weeks postsurgery,the PSIB group showed a reduction in alanine transaminase levels and maintained a normal lipid profile.CONCLUSION PSIB demonstrated excellent hypoglycemic effects in the early postoperative period,and had better efficacy than RYGB and JIB.

Interlayer repair with porcine small intestinal submucosa versus internal repair with tragus cartilage in endoscopic tympanoplasty

Objective Endoscopic tympanoplasty includes various surgical methods,such as internal repair,interlayer repair,and external overlay.This technique requires autologous materials,allografts,and xenografts,which are used to repair tympanic membrane(TM)perforation.To obtain good results,appropriate surgical methods and repair materials should be selected.This study aims to assess the efficacy of repairing refractory TM perforations in the porcine small intestinal submucosa(SIS)during transcanal endoscopic type I tympanoplasty.Method A retrospective chart review was performed on patients who underwent TM perforation repair with porcine SIS and tragus cartilage between January 2022 and September 2022 at Sir Run Run Shaw Hospital,Zhejiang University School of Medicine.Perforation size,tympanic status,pre-and postoperative symptoms,follow-up data,wound healing rates,and hearing improvement were analysed.Results Of the 115 patients included in the study,56 underwent interlayer repair with porcine SIS of the TM,and 59 patients underwent internal repair with tragus cartilage.No significant difference was found between the two groups at baseline in terms of age,sex,disease course,perforation side,tympanic status,underlying disease,or preoperative infection.The total postoperative effective rate of interlayer implantation with porcine SIS was 91.07%(51 patients),and that of internal implantation with tragus cartilage was 88.14%(52 patients).No significant difference was found in terms of the graft success rate between the two surgical methods(p=0.887).Postoperative pure tone auditory(PTA)and air-bone gap(ABG)density significantly increased in both groups compared with before surgery(p<0.05).However,the postoperative PTA and ABG density were not significantly different 3 months post-surgery between the two groups(p>0.05).Compared to those in the internal implantation group,the patients in the interlayer group had a shorter operation duration(51.36±6.76 min vs.59.71±7.45 min,t=6.298,p<0.001)and less blood loss(11.91±2.61 mL vs.15.27±2.57 mL,t=7.019,p<0.001).Conclusions Our study suggests that the porcine SIS,as well as the tragus cartilage,has a high success rate in repairing irreversible TM perforation.Endoscopic tympanoplasty via interlayer implantation with porcine SIS offers distinct advantages,including the absence of donor-site incision and scar formation,and ease of graft modification and manipulation.

Recurrent small intestinal perforation from gastric mucosal heterotopia:A case report

BACKGROUND Gastric mucosal heterotopia(GMH)is a rare,typically asymptomatic condition characterized by ectopic gastric mucosa in tissues outside the stomach.However,it can lead to severe complications,including small intestinal perforation.This case report highlights the unique clinical presentation of GMH-induced recurrent small intestinal perforations,which has been rarely documented.These findings emphasize the importance of considering GMH in patients with unexplained recurrent gastrointestinal perforations.CASE SUMMARY A 13-year-old female presented with acute abdominal pain.Her medical history included four prior surgeries for small intestinal perforations.Enhanced compu-ted tomography revealed localized bowel thickening and perforation,prompting emergency surgery.A 20 cm segment of the ileum was resected and anastomosed.Pathological analysis confirmed extensive GMH with ulceration and perforation,identifying GMH as the cause of the recurrent perforations.Postoperatively,the patient recovered well with no recurrence by the 10-month follow-up.CONCLUSION GMH should be considered in cases of recurrent unexplained intestinal perfor-ations.©The Author(s)2024.Published by Baishideng Publishing Group Inc.All rights reserved.

Intestinal tuberculosis with small bowel stricture and hemorrhage as the predominant manifestation: Three case reports

BACKGROUND Intestinal tuberculosis is a chronic disease caused by Mycobacterium tuberculosis that mainly affects the ileum and cecum.Small bowel tuberculosis,characterized by predominant involvement of the small intestine,is an extremely rare condition with highly atypical clinical presentations,making diagnosis even more challenging.CASE SUMMARY We report three cases of small intestinal tuberculosis,two of the patients pre-sented primarily with abdominal pain,and one presented with gastrointestinal bleeding.All patients underwent blood tests and imaging examinations.Small bowel endoscopy(SBE)revealed that the main lesions in these patients were in-testinal stenosis or gastrointestinal bleeding caused by small intestinal ulcers.One patient ultimately underwent surgical treatment.Following a complex diagnostic process and comprehensive analysis,all patients were confirmed to have small intestinal tuberculosis and received standard antituberculosis treatment,leading to an improvement in their condition.CONCLUSION Patients with SBTs present with nonspecific symptoms such as abdominal pain,weight loss,and occasional gastrointestinal bleeding.Accurate diagnosis requires a thorough evaluation of clinical symptoms and various tests to avoid misdiagno-sis and complications.

Clinicopathological analysis of small intestinal metastasis from extra-abdominal/extra-pelvic malignancy

BACKGROUND The metastatic tumors in the small intestine secondary to extra-abdominal/extrapelvic malignancy are extremely rare.However,the small intestine metastases are extremely prone to misdiagnosis and missed diagnosis due to the lack of specific clinical manifestations and examination methods,thus delaying its treatment.Therefore,in order to improve clinical diagnosis and treatment capabilities,it is necessary to summarize its clinical pathological characteristics and prognosis.AIM To summarize the clinicopathological characteristics of patients with small intestinal metastases from extra-abdominal/extra-pelvic malignancy,and to improve the clinical capability of diagnosis and treatment for rare metastatic tumors in the small intestine.METHODS The clinical data of patients with small intestinal metastases from extra-abdominal/extra-pelvic malignancy were retrieved and summarized,who admitted to and treated in the Air Force Medical Center,Chinese People’s Liberation Army.Then descriptive statistics were performed on the general conditions,primary tumors,secondary tumors in the small intestine,diagnosis and treatment processes,and prognosis.RESULTS Totally 11 patients(9 males and 2 females)were enrolled in this study,including 8 cases(72.3%)of primary lung cancer,1 case(9.1%)of malignant lymphoma of the thyroid,1 case(9.1%)of cutaneous malignant melanoma,and 1 case(9.1%)of testicular cancer.The median age at the diagnosis of primary tumors was 57.9 years old,the median age at the diagnosis of metastatic tumors in the small intestine was 58.81 years old,and the average duration from initial diagnosis of primary tumors to definite diagnosis of small intestinal metastases was 9 months(0-36 months).Moreover,small intestinal metastases was identified at the diagnosis of primary tumors in 4 cases.The small intestinal metastases were distributed in the jejunum and ileum,with such clinical manifestations as hematochezia(5,45.4%)and abdominal pain,vomiting and other obstruction(4,36.4%).In addition,2 patients had no obvious symptoms at the diagnosis of small intestinal metastases,and 5 patients underwent radical resection of small intestinal malignancies and recovered well after surgery.A total of 3 patients did not receive subsequent treatment due to advanced conditions.CONCLUSION Small intestinal metastases of extra-abdominal/extra-pelvic malignancy is rare with high malignancy and great difficulty in diagnosis and treatment.Clinically,patients with extra-abdominal/extra-pelvic malignancy should be alert to the occurrence of this disease,and their prognosis may be improved through active surgery combined with standard targeted therapy.

Massive bleeding in small intestinal mucosa-associated lymphoid tissue lymphoma associated with COVID-19 infection:a case report

The increased risk of mucosa-associated lymphoid tissue(MALT)lymphoma is closely associated with chronic antigenic stimulation,with infection being the most common cause of recurrence.Lesions are usually associated with the gastrointestinal tract,and the involvement of small intestinal is rare.Recent studies have established a close relationship between novel coronavirus 2019(COVID-19)and the occurrence and progression of various diseases.This article presents a rare case of a small intestinal MALT lymphoma.The patient was initially admitted with COVID-19 pneumonia and subsequently developed gastrointestinal bleeding during hospitalization.Medical and endoscopic treatments were ineffective,and an emergency exploratory laparotomy was performed.The affected segment of the small intestine was excised,and a pathological biopsy confirmed the diagnosis of MALT lymphoma.This case underscores the significance of raising clinical awareness of this condition among health care professionals.

Evaluating the accuracy and reproducibility of ChatGPT-4 in answering patient questions related to small intestinal bacterial overgrowth

BACKGROUND Small intestinal bacterial overgrowth(SIBO)poses diagnostic and treatment challenges due to its complex management and evolving guidelines.Patients often seek online information related to their health,prompting interest in large language models,like GPT-4,as potential sources of patient education.AIM To investigate ChatGPT-4's accuracy and reproducibility in responding to patient questions related to SIBO.METHODS A total of 27 patient questions related to SIBO were curated from professional societies,Facebook groups,and Reddit threads.Each question was entered into GPT-4 twice on separate days to examine reproducibility of accuracy on separate occasions.GPT-4 generated responses were independently evaluated for accuracy and reproducibility by two motility fellowship-trained gastroenterologists.A third senior fellowship-trained gastroenterologist resolved disagreements.Accuracy of responses were graded using the scale:(1)Comprehensive;(2)Correct but inadequate;(3)Some correct and some incorrect;or(4)Completely incorrect.Two responses were generated for every question to evaluate reproducibility in accuracy.RESULTS In evaluating GPT-4's effectiveness at answering SIBO-related questions,it provided responses with correct information to 18/27(66.7%)of questions,with 16/27(59.3%)of responses graded as comprehensive and 2/27(7.4%)responses graded as correct but inadequate.The model provided responses with incorrect information to 9/27(33.3%)of questions,with 4/27(14.8%)of responses graded as completely incorrect and 5/27(18.5%)of responses graded as mixed correct and incorrect data.Accuracy varied by question category,with questions related to“basic knowledge”achieving the highest proportion of comprehensive responses(90%)and no incorrect responses.On the other hand,the“treatment”related questions yielded the lowest proportion of comprehensive responses(33.3%)and highest percent of completely incorrect responses(33.3%).A total of 77.8%of questions yielded reproducible responses.CONCLUSION Though GPT-4 shows promise as a supplementary tool for SIBO-related patient education,the model requires further refinement and validation in subsequent iterations prior to its integration into patient care.

Comparative study of intestinal tuberculosis and primary small intestinal lymphoma

AIM: To characterize the clinical, radiological, endoscopic and pathological features of intestinal tuberculosis (ITB) and primary small intestinal lymphoma (PSIL).

Effects of psychological stress on small intestinal motility and bacteria and mucosa in mice

AIM: To investigate the effects of psychological stress on small intestinal motility and bacteria and mucosa in mice, and to explore the relationship between small intestinal dysfunction and small intestinal motility and bacteria and mucosa under psychological stress. METHODS: Sixty mice were randomly divided into psychological stress group and control group. Each group were subdivided into small intestinal motility group (n= 10), bacteria group (n = 10), and D-xylose administered to stomach group (n= 10). An animal model with psychological stress was established housing the mice with a hungry cat in separate layers of a two-layer cage. A semi-solid colored marker (carbon-ink) was used for monitoring small intestinal transit. The proximal small intestine was harvested under sterile condition and processed for quantitation for aerobes (Escherichia coli) and anaerobes (Lactobacilli). The quantitation of bacteria was expressed as Iog10(colony forming units/g). D-xylose levels in plasma were measured for estimating trie damage of small intestinal mucosa. RESULTS: Small intestinal transit was inhibited (39.80±9.50% vs 58.79±11.47%,P<0.01) in mice after psychological stress, compared with the controls. Psychological stress resulted in quantitative alterations in the aerobes (E.coli). There was an increase in the number of E coli in the proximal small intestinal flora (1.78±0.30 log10(CFU/g) vs 1.37±0.21 log10(CFU/g), P<0.01), and there was decrease in relative proportion of Lactobacilli and E.coli of stressed mice (0.53±0.63 vs 1.14±1.07,P<0.05), while there was no significant difference in the anaerobes (Lactobacilli) between the two groups (2.31±0.70 log10 (CFU/g) vs 2.44±0.37 log10(CFU/g), P>0.05). D-xylose concentrations in plasma in psychological stress mice were significantly higher than those in the control group (2.90±0.89 mmol/L vs 0.97±0.33 mmol/L, P<0.01). CONCLUSION: Small intestinal dysfunction under psychological stress may be related to the small intestinal motility disorder and dysbacteriosis and the damage of mucosa probably caused by psychological stress.

Nursing Care of a Patient with Active Crohn’s Disease Complicated with Small Intestinal Obstruction

This study summarizes the nursing experience of a patient with active Crohn’s disease in the acute stage,complicated by small bowel obstruction.Key aspects of nursing include psychological response guidance during the active phase of Crohn’s disease,support before and after various gastroenteroscopy procedures and related reports,and self-monitoring guidance for symptoms such as intestinal obstruction combined with endoscopic mucosal ulcers.Using the 5A nursing model,nursing staff assessed the patient’s needs,provided targeted nursing recommendations in stages,implemented health behavior strategies,and offered continuous nursing care,including positive support for sexual health beliefs.These interventions helped the patient overcome psychological challenges,such as resistance to indwelling gastric tubes,and adopt healthy behaviors.After six weeks of follow-up through phone and WeChat consultations,the patient demonstrated significant improvement,including a weight gain of 15 kg.Various test results indicated normalized nutritional and inflammatory indexes,and the Crohn’s Disease Activity Index decreased by≥70 points.In conclusion,establishing a nursing team and applying the 5A nursing model to formulate detailed nursing diagnoses and interventions can significantly improve outcomes for patients with active Crohn’s disease complicated by small intestinal obstruction.

Small intestinal bacteria overgrowth decreases small intestinalmotility in the NASH rats

AIM: To explore the relationship between small intestinalmotility and small intestinal bacteria overgrowth(SIBO) in Nonalcoholic steatohepatitis (NASH), andto investigate the effect of SIBO on the pathogenesisof NASH in rats. The effect of cidomycin in alleviatingseverity of NASH is also studied. METHODS: Forty eight rats were randomly dividedinto NASH group (n = 16), cidomycin group (n = 16)and control group (n = 16). Then each group weresubdivided into small intestinal motility group (n = 8),bacteria group (n = 8) respectively. A semi-solid coloredmarker was used for monitoring small intestinal transit.The proximal small intestine was harvested under sterilecondition and processed for quantitation for aerobes(E. coli) and anaerobes (Lactobacilli). Liver pathologicscore was calculated to qualify the severity of hepatitis.Serum ALT, AST levels were detected to evaluate theseverity of hepatitis. RESULTS: Small intestinal transit was inhibited inNASH group (P < 0.01). Rats treated with cidomycinhad higher small intestine transit rate than rats in NASHgroup (P < 0.01). High fat diet resulted in quantitativealterations in the aerobes (E. coli ) but not in theanoerobics (Lactobacill). There was an increase in thenumber of E. coli in the proximal small intestinal florain NASH group than in control group (1.70 ± 0.12 log10(CFU/g) vs 1.28 ± 0.07 log10 (CFU/g), P < 0.01). TNF-αconcentration was significantly higher in NASH groupthan in control group (1.13 ± 0.15 mmol/L vs 0.57 ±0.09 mmol/L, P < 0.01). TNF-α concentration was lowerin cidomycin group than in NASH group (0.63 ± 0.09mmol/L vs 1.13 ± 0.15 mmol/L, P < 0.01). Treatmentwith cidomycin showed its effect by significantly loweringserum ALT, AST and TNF-α levels of NASH rats. CONCLUSION: SIBO may decrease small intestinalmovement in NASH rats. SIBO may be an importantpathogenesis of Nash. And treatment with cidomycin by mouth can alleviate the severity of NASH.

Effects of psychological stress on small intestinal motility and expression of cholecystokinin and vasoactive intestinal polypeptide in plasma and small intestine in mice

AIM: To investigate the effects of psychological stress on small intestinal motility and expression of cholecystokinin (CCK) and vasoactive intestinal polypeptide (VIP) in plasma and small intestine, and to explore the relationship between small intestinal motor disorders and gastrointestinal hormones under psychological stress. METHODS: Thirty-six mice were randomly divided into psychological stress group and control group. A mouse model with psychological stress was established by housing the mice with a hungry cat in separate layers of a two-layer cage. A semi-solid colored marker (carbon-ink) was used for monitoring small intestinal transit. CCK and VIP levels in plasma and small intestine in mice were measured by radioimmunoassay (RIA). RESULTS: Small intestinal transit was inhibited (52.18±19.15% vs70.19±17.79%, P<0.01) in mice after psychological stress, compared to the controls. Small intestinal CCK levels in psychological stress mice were significantly lower than those in the control group (0.75±0.53 μg/g vs1.98±1.17 μg/g, P<0.01), whereas plasma CCK concentrations were not different between the groups. VIP levels in small intestine were significantly higher in psychological stress mice than those in the control group (8.45±1.09 μg/g vs7.03±2.36 μg/g, P<0.01), while there was no significant difference in plasma VIP levels between the two groups. CONCLUSION: Psychological stress inhibits the small intestinal transit, probably by down-regulating CCK and up-regulating VIP expression in small intestine.

Influencing factors of rat small intestinal epithelial cell cultivation and effects of radiation on cell proliferation

INTRODUCTIONCrypt epithelial cells in normal small intestineproliferate at a high speed. But they are verydifficult to culture in vitro and passage stably. A lotof studies have been done[1-16]. Some domestic labsisolated and cultured crypt cells from embryonalintestines and aseptic animal intestine, but failed.We introduced normal rat epithelial cell line-IEC-6from the USA and its living condition for stablepassage was successfully established after trials. Thecell line was testified to be the small intestinalepithelial cell by electron microscopy,immunihistochemistry and enzymatic histoch-emistry. It has been applied to some relatedresearch work[17-21]. It was found that manyfactors were involved in the culture system. Ourpresent study focuses on the culture method and theinfluencing factors on IEC-6.

Clinical presentations of gastric small gastrointestinal stromal tumors mimics functional dyspepsia symptoms

AIM: To explore whether clinical presentations of gastric small gastrointestinal tumors (GISTs) mimics gastrointestinal dyspepsia symptoms.

Balloon-assisted endoscopic submucosal dissection for treating small intestinal lipomas:Report of two cases

BACKGROUND Most small intestinal lipomas are treated surgically,and some require repeated surgeries for multiple lipomas.However,application of endoscopic submucosal dissection(ESD)technology in the deep small intestine is rarely reported owing to the special anatomical structure of the small intestine,medical equipment limitations,and the lack of relevant experience among endoscopists.CASE SUMMARY Two patients with small intestinal lipomas treated at the Air Force Medical Center from November 2015 to September 2019 were selected to undergo balloonassisted ESD to treat the lipomas and explore the technical feasibility and safety of ESD for treating small intestinal lipomas.The two patients successfully underwent balloon-assisted ESD to treat four small intestinal lipomas,with a complete resection rate of 100%(4/4),without intraoperative or postoperative bleeding,perforation,or other complications.After 3-6 mo of postoperative follow-up,the clinical symptoms caused by the lipomas were significantly relieved or disappeared after treatment.CONCLUSION Balloon-assisted ESD is a safe and reliable new method for treating deep intestinal lipomas and shows good clinical feasibility.

The Influence of Chinese Medicinal Herb on Chicken Immune Organs and Small Intestinal Mucosa Immune Organization

[Objective] The aim was to explore the mechanism of Chinese medicinal herb to enhance the body＇s immune. [Method] The quantitative distribution of immunocytes in chicken small intestinal mucosa lymphoid tissue-secretory type immune globulin cell A were dynamic observed to research chicken immune organ growth with histology conventional slice technology and immunohistochemistry dye. 1 day age healthy roosters were divided into 3 groups： the group 3 was control group. 1% and 0.5% concentration of Chinese herbal medicine immunopotentiator drinking water were added in the group 1 and 2 in continuous 60 d. The immune organ index was determined every 12 d and the histotomy of chicken small intes- tine in group control and 1% were taken for histological observation on day 24, 36 and 48. [ Result] Treatment group immune organ index was significantly higher than that of the control group and 1% group of small intestinal villus inherent intraformational immune cells number significantly increased （P〈0.01） compared with controls. Day 36 age group and day 48 group immune cells were higher than day 24 group of cell number （P〈 0.01 ）. [ Conclusionl Chinese medicinal herb had obvious role in promoting chicken immune organ growth and obvious influence on the quantity change of the intestinal mucosal immune cells.

Perforation of metastatic melanoma to the small bowel with simultaneous gastrointestinal stromal tumor

The gastrointestinal tract (GIT) is a common site of metastases for malignant melanoma. These metastatic tumors are often asymptomatic. We describe a case of a 58-year-old male who presented with a sudden onset of generalized abdominal pain. The patient's past medical history was significant for lentigo melanoma of the right cheek. Laparotomy was performed and two segments ofsmall bowel, one with a perforated tumor, the other with a non-perforated tumor, were removed. Histology and immunohistochemical staining revealed the perforated tumor to be a metastatic malignant melanoma and the non-perforated tumor was found to be a gastrointestinal stromal tumor (GIST). The patient was discharged 7 d postoperatively. To the best of our knowledge, this is the first reported case in the literature of a simultaneous metastatic malignant melanoma and a GIST. Surgical intervention is warranted in patients with symptomatic GIT metastases to improve the quality of life or in those patients with surgical emergencies.

Inhibition of Porcine Small Intestinal Sucrase by Validamine

As an important medicinal intermediate with broad uses, validamine, an aminocyclitol, isolated from the enzymolysis broth of validamycins, has gained more and more attention. The absolute configuration of validamine is similar to that of a-D-glucose, and it demonstrates powerful inhibition activity on glycosidase. In this paper, the inhibitory effect of validamine on porcine small intestinal sucrase was investigated. Validamine was found to be a potent, competitive inhibitor to porcine small intestinal sucrase in vitro with an IC50 value of 6.85 X 10(-4) mol center dot L-1. Validamine exhibited a dose-dependent inhibition effect on porcine small intestinal sucrase, whereby the inhibition interaction of validamine and porcine small intestinal sucrase was a fast binding process. The inhibition of validamine on porcine small intestinal sucrase was pH-dependent.

Laparoscopic resection of synchronous gastric cancer and primary small intestinal lymphoma: A case report

Synchronous gastric cancer and primary small intestinal lymphoma are extremely rare. A 49-year-old woman was referred to our hospital with a history of upper abdominal pain for two weeks and was diagnosed with synchronous cancer. During hospitalization, the patient underwent laparoscopic distal gastrectomy + resection of bilateral ovaries + partial resection of both small intestine and descending colon. Pathological examination revealed a synchronous cancer consisting of early gastric cancer with poorly differentiated adenocarcinoma located in mucosa, with lymph node metastasis (3+/29) (T1N1M0, stage IB); and diffuse large B cell lymphoma of small intestine involving descending colon and bilateral ovaries, with lymph node metastasis (2+/5) (Ann Arbor IIE). The patient recovered well, without any obvious complications and was discharged on post-operative day 7. The patient received six cycles of chemotherapy after operation. She has been doing well with no evidence of recurrence for 13 mo.