Tubulovillous adenoma (TVA) is a benign epithelial neoplasm typically found in the colon and rectum. While duodenal TVA is uncommon, it poses a significant risk of malignant transformation. When present, duodenal TVA is usually small and often associated with genetic syndromes. We report a rare case of a 58-year-old man with chronic hepatitis B infection who was incidentally found to have a giant TVA of the small bowel. The patient was admitted for healthcare-associated pneumonia and uncomplicated cystitis when he was incidentally found to have a small intestine mass on imaging. Further workup demonstrated a large, circumferential polypoid mass extending from the second and third portions of the duodenum into the proximal jejunum. Endoscopic biopsy confirmed a TVA without a report of malignant transformation. Given the size and location of the lesion, surgical resection was initially planned. This case represents the largest duodenal TVA reported in literature highlighting the importance of early detection.

The given paper describes a case of treating adenocarcinoma of the papilla of Vater diagnosed as the cause after an episode of acute pancreatitis. The etiology of aсute pancreatitis was considered idiopathic until the onset of complaints caused by tumor growth. The volume of radical surgery has changed intraoperatively due to the detection of infected limited necrotic clusters, didn't diagnosed both laboratory and instrumentally. Pathomorphological conclusion: considering clinical data, low-grade (G3) adenocarcinoma of the major duodenal papilla, which developed from pre-existing tubular villous adenoma of the duodenum or intraampullary papillary neoplasia (IAPN). Predicting the early detection of MNPs after AP episode requires further research by improving imaging techniques, introducing new non-invasive techniques and investigating circulating biomarkers. The scope of surgery for patients with clinically significant complications of tumor growth and identified competing diagnosis at the target site should be individually decided and weighed. Infected pancreatitis in the late stages requires careful diagnosis.

Sessile serrated adenomas/polyps (SSA/Ps), recently called sessile serrated lesions, have a neoplastic pathway in the large intestine and are treated as lesions with malignant potential. There are a few reports of traditional serrated adenomas in the duodenum but no reports of duodenal SSA/Ps. A 66-year-old man underwent screening upper gastrointestinal endoscopy and was found to have a white elevated lesion in the second portion of the duodenum. Magnifying blue laser imaging showed various sized villous-like structures with dilated crypt openings in the white surface mucosa, similar to a SSA/P. Based on these images, a duodenal adenoma was suspected at the time of endoscopic resection. Pathological findings of the resected specimen showed a saw-tooth structure corresponding to basal crypt dilatation and branching with mucus and positive immunostaining for MUC6 and MUC2, similar to a colonic SSA/P. MUC5AC did not stain the glandular crypt cells. KRAS mutation was detected. Immunohistochemical expression of Annexin A10 was clearly identified in the lesion. Although not all of molecular biological features were satisfied, these findings were similar to a colonic SSA/P which has malignant potential. This is the first report of a duodenal SSA/P which should be considered when evaluating elevated duodenal lesions.

A 68-year-old woman developed an asymptomatic left caruncular multilobular lesion over one year. Excision of the lesion displayed a benign sebaceous neoplasm taking origin from the surface squamous epithelium which invaginated into the stroma to create crypts resembling the conjunctival pseudoglands of Henle or the glands of Lieberkuhn of the small intestine. Scattered sebaceous cells were also discovered in the surface squamous epithelium. The cryptal walls spawned lateral sebaceous gland lobules that were adipophilin positive. p16 was positive in the surface epithelium, the cryptal walls, and in the basal cells of the sebaceous lobules. No defects in nuclear mismatch repair protein expression were identified, which together with the absence of a familial cancer history, rendered unlikely an association with the Muir-Torre syndrome.

Background: Duodenal polyposis (DP) is often associated in patients with in patients with familial adenomatous polyposis (FAP) and the risk of malignancy is endoscopically assessed using the Spigelman score. Endoscopic therapy is the first option for PD while surgery is indicated for the advanced stages of the disease (Spiegelman III-IV). Pancreas-sparing duodenectomy (PSD) was proposed as a less aggressive alternative to pancreatoduodenectomy (PD), leaving the entire pancreas in situ while the number of anastomoses is reduced. Open PSD with Billroth or pillorus preserving reconstruction is the general used. The use of a Roux limb is very limited in literature, as it increases the procedure complexity, the number of anastomosis and it may reduce the endoscopic access for the postoperative surveillance after total duodenectomy. We aim to describe the technique for Laparoscopic Pancreas Sparing Total Duodenectomy (LPSTD) with Roux-en-Y reconstruction and to present the procedure's outcomes in a patient presenting Spigelman IV duodenal polyposis associated with FAP after open total colectomy. Method: Laparoscopic Pancreas Sparing Total Duodenectomy (LPSTD) with antrectomy cholecystectomy and Roux en Y reconstruction was performed in a 39-year-old man with a history of FAP, open colectomy with ileorectal anastomosis and duodenal polyps. The preoperative investigations and the surgical steps of the laparoscopic approach are described in details. Results: The operative time was 280 minutes. Two postoperative complications were encountered, a self-limited pancreatico-jejunal anastomosis hemorrhage occurred in POD 1 and necrosis of the cystic duct stump with bile peritonitis (POD7). Both of them required laparoscopic exploration. Oral feeding was introduced in the POD 2. The patient has been discharged in the POD 14. No other complications like delayed gastric emptying, pancreatic or biliary fistula at the site of PJA or ulcer were encountered. The 6 months postoperative evaluation, including the CT scan and the endos-copic retrograde inspection of the neo-papilla revealed no recurrence on the jejunum. Conclusions: Although it is a complex technique, LPSTD represents a good alternative to PD for patients with FAP and large, periampullary villous adenoma especially those with high grade dysplasia. The use of laparoscopy and of Roux en Y reconstruction may reduce the postoperative morbidity rate in PSD.

Villous morphology in urinary bladder biopsy is a relatively uncommon finding. Villi are slender, finger-like structures that are commonly seen in the small intestine or in neoplastic lesions of gastrointestinal lineage/differentiation. Importantly, placenta also exhibits villi that are morphologically and functionally different from the intestinal one. Majority of the neoplastic lesions of urinary bladder are urothelial in origin with a minor subset showing glandular differentiation. While the presence of benign villi in urinary bladder biopsy necessitates a search for an occult perforation, provided a sample mismatch is ruled out, cytoarchitecturally abnormal/dysplastic villi indicate a neoplastic lesion of the urinary bladder encompassing villous adenoma and adenocarcinoma and urothelial carcinoma with villoglandular differentiation. The dysplastic villi in urinary bladder also imply a lower gastrointestinal endoscopy to rule out a colorectal primary. The development of the villous lesions in the urinary bladder and the colorectum are embryologically related and pose a major diagnostic challenge to the clinicians and surgical pathologists due to identical histomorphology and immunohistochemistry. We tend to discuss the morphological differentials and diagnostic approach to the villous lesions in the urinary bladder biopsy.

The tumorigenesis of non-ampullary duodenal epithelial tumors (NADETs) might be different between the oral and anal sides of Vater's papilla. We conducted an immunohistological review to elucidate the clinicopathological features according to the tumor location and phenotypic classification. A review of an institutional database identified 121 patients with 125 superficial NADETs. NADETs were histologically evaluated and classified into the intestinal or gastric type based on immunohistochemical analysis. Clinicopathological factors were compared based on the tumor location and phenotype. Logistic regression analysis was performed to identify independent predictors for gastric-type NADETs. According to location analysis, the mucin phenotype was significantly different (oral side, intestinal-type 64.8%, gastric-type 35.3%; anal side, intestinal-type 87.3%, gastric-type 12.7%; P < 0.01). Although the incidence of adenoma was significantly predominant in the intestinal type (75.3%), most gastric-type NADETs were cancerous (64.3%). Notably, most gastric-type NADETs were adenocarcinomas even when the tumor size was ≤0 mm. In multivariate analysis, tumor location on the oral side (odds ratio [OR], 4.42), villous structure (OR, 6.44), and low tumor gland density (OR, 9.49) were independent predictors of gastric-type tumors. Gastric-type NADETs significantly differ from intestinal-type NADETs in terms of tumor location, morphology, and biology.

The small intestine is a relatively privileged organ; primary tumors are uncommon among malignancies of the gastrointestinal tract, with an average annual incidence rate of 9.9 per million people. Among these uncommon tumors, duodenal tumors are even rarer with an average incidence rate of 0.4% only. Histopathological examination mostly shows villous type. Tubulovillous histology is extremely rare with an incidence of less than 1% of all duodenal tumors. These tumors are either found incidentally or during screening for familial disorders such as familial adenomatous polyposis or Gardner's syndrome. Patients usually have symptoms such as diarrhea and abdominal pain along with weight loss over a period of months. Itching over the whole body and progressive yellow discoloration of sclera and skin (jaundice) can also be present when tumor compresses the common bile duct (CBD) and causes obstruction, especially in the region of ampulla of Vater. Examination of the abdomen may or may not reveal a mass lesion. Abdominal radiography and ultrasound show intra- and extra-hepatic biliary dilatation along with distention of CBD and growth at the lower end of CBD. Endoscopic retrograde cholangiopancreatography (ERCP) is, however, the investigation of choice as it not only allows direct visualization of a biliary tree but biopsy specimens can also be taken. Palliative procedures like placing a stent in the common bile duct to relieve obstruction can be done or a drain can be placed to drain bile. The definitive treatment is the Whipple procedure involving gastrojejunostomy, choledochojejunostomy, and cholecystectomy. Our case is unique as the patient had duodenal tubulovillous adenoma, a very rare tumor among the already uncommon duodenal tumors. The patient underwent Whipple procedure, T tube was placed, and feeding jejunostomy was done. An uneventful recovery occurred.

Villous adenomas arising in the bladder following augmentation cystoplasty procedures are exceedingly rare. Even rarer is their occurrence in the native bladder mucosa and the upper urinary tract. In this article, we present a unique case of multifocal recurrent villous adenoma involving native bladder mucosa of an augmented bladder, bilateral ureters, and renal pelvis, with coexistent foci of adenocarcinoma and neuroendocrine carcinoma, in a patient with history of augmentation colocystoplasty. We additionally discuss the pathogenesis of development of carcinoma in the setting of augmentation cystoplasty.

Frequency indices of tubulovillous adenoma are higher than the ones of colorectal cancer, and probably, the majority of adenomas are prone to malignancy. It is often impossible to determine which adenoma tends to tumorous neoplasia. However, increase in the adenomas and expressed dysplasia contribute to adenomas malignant transformation. In this regard, the purpose of the study is to evaluate cellular proliferation, apoptosis, beta-catenin in tubulovillous intestinal adenomas with varying degrees of dysplasia. The study used biopsy materials of tubulovillous adenomas obtained from 50 patients who underwent ectomy. After resection the adenomas were cut by the maximum size for the full thickness of tunicae mucosae, muscularis be included into the section. Immunohistochemical reactions used a cellular proliferation marker (Ki-67), that of apoptosis (P-53), of a transcription factor (β-catenin). In tubulovillous adenomas with the low grade dysplasia degree there are low indicators of cellular proliferation and apoptosis, located primarily in basal glandular segments. As dysplasia degree increases, cellular division in the glandular epithelium intensifies and nuclear expression of beta-catenin appears as well. Against the background of a meaningful increase in cellular proliferation, a small number of cells in apoptotic condition are revealed. Thus, increased indicators of Ki-67 and β-catenin in a tubulovillous adenomas in high grade dysplasia contributes to limiting cellular differentiation, violates intercellular contacts.

We present here a case of transduodenal ampullectomy for an ampullary neoplasm coexisting with gastric and colon cancer. The patient was a 72-year-old man who was referred to our hospital with a positive fecal blood test. Colonoscopy revealed advanced cancer in the descending colon. As part of the preoperative examination, for the colonic cancer, upper gastrointestinal endoscopy was performed. Endoscopy showed a 2 cm elevated lesion(0'-II a type)with subserosalinfil tration on the small curvature side of the upper part of the stomach, and a 2 cm elevated lesion on the papilla of Vater. Histopathological examination showed that the former was a well differentiated tubular adenocarcinoma and the latter was a villous tubular adenoma with severe atypia. First, laparoscopic colectomy for advanced descending colon cancer was performed. Totalgastrectomy with Roux-en-Y reconstruction, cholecystectomy, and transduodenal ampullectomy for the ampullary neoplasm 21 days after the first surgery. The patient was discharged without any complications, such as postoperative suture failure. According to pathological tissue diagnosis, the degrees of progress of the colorectal cancer and the gastric cancer were pT2(MP)and pT1b(SM2), respectively, and there was no lymph node metastasis. The duodenal papillary tumor was a tubular villous adenoma(high grade). Local excision of the papilla is minimally invasive, leaves easy-to-secure stumps, and has less risk of complications such as bleeding and pancreatitis. Taking into account the balance with coexisting gastrointestinal cancer treatment, local excision of the papilla in this case was considered to be an appropriate treatment.

This study describes the case of the youngest patient ever reported with ampullary adenoma. The incidence of ampullary adenomas in childhood is unknown. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound are used in adults to assess and treat these lesions, although there are no instruments designed specifically for use in young children. A six-year-old girl was admitted for abdominal pain, vomiting, pruritus and weight loss. Abdominal ultrasound showed biliary tree (8mm) and pancreatic duct dilatation (4mm). Magnetic resonance cholangiopancreatography and computed tomography confirmed these findings, and also showed displacement of the ampulla to the left upper quadrant. An upper endoscopy confirmed a large ampullary adenoma. A laparotomy was performed and a 5cm villous tumour arising from the ampulla was excised. The postoperative course was uneventful. The histology demonstrated adenoma of the ampulla (intestinal type) without low-grade dysplasia. all clinical and radiological parameters are normal at 20 months follow-up. We describe the case of the youngest patient ever reported with ampullary adenoma. Pancreaticoduodenectomy carries high morbidity and mortality rates, and therefore it should be avoided in absence of histologically proven malignancy. We believe that surgical ampullectomy is a safe and oncologically correct procedure until better endoscopic instruments for peadiatric use will be designed.