Shinshu Med J, 60⑴ :21〜25, 2012

Emergency Operation for Non‑Hodgkin Lymphoma of the Small Intestine
Naohiko KOIDE ＊, Yasushi SEKINO , Akira SUZUKI
Taiji AKAMATSU and Shinichi MIYAGAWA
1） Department of Surgery, Shinshu University School of Medicine
2） Department of Gastroenterology, Shinshu University School of Medicine

We report 5 cases of non‑Hodgkin lymphoma of the small intestine (S‑NHL) treated with emergency
operation. These cases showed three reasons for emergency operation :［1］massive hemorrhage with shock
before diagnosis of S‑NHL (Case 1),［2］obstruction of the small intestine before and during chemotherapeutic
treatment for S‑NHL (Cases 2 and 3),and［3］spontaneous perforation with peritonitis before diagnosis of S‑
NHL or iatrogenic perforation following chemotherapy (Cases 4 and 5).For tumor discovery,double‑balloon
endoscopy of the small intestine was employed in 3 cases.Three tumors were histologically diagnosed before
treatment,while 2 were histopathologicallydiagnosed using the resected specimens after emergencyoperation.
An advanced stage of NHL was frequently observed.No surgical mortality accurred.We always consider the
possibility of emergency operation before, during, and after the diagnosis and treatment of patients with S‑
NHL. Shinshu Med J 60 : 21―25, 2012
(Received for publication August 10, 2011;accepted in revised form October 7, 2011)
Key words:lymphoma, small intestine, emergency, surgery

Introduction

mens . The role of surgery in S‑NHL couldchange after the development of these endoscopic

Non‑Hodgkin lymphoma (NHL)is the third mosttechniques and devices. However, surgery, espe-

common malignant neoplasm of the small intes-

cially emergency operations due to acute abdominaltine . The small intestine is the second most com-conditions, should still be considered for S‑NHL

mon site for NHL of the gastrointestinal(GI)tract ,patients as perforation or obstruction of the smalland NHL of the small intestine (S‑NHL) is obser-

intestine has been reported in S‑NHL patients with

ved in approximately 20% of GI‑NHL in Japan .

or without chemotherapy .We report 5 cases of S‑

Previously,surgery was frequently adopted for GI‑

NHL that required emergency operation.

NHL patients for both the treatment and histologic
diagnosis . However, initial chemotherapy has

Case Reports

recently been performed in GI‑NHL patients .

Case 1, a 75‑year‑old woman, was operated on

Recently,new endoscopic techniques,including cap-

for massive hemorrhage of the GI tract, clinicallysule‑endoscopy and DBE,have been made available

showing dynamic shock.Before surgery,no cause offor several tumors and disorders of the small intes-

massive intestinal hemorrhage had been identiﬁed.

tine . These devices have contributed to the diag-

At laparotomy, a jejunal tumor was detected andnosis of S‑NHL,including not only the detection ofremoved. The resected tumor was histopath-

S‑NHL but also the sampling of biopsy speci-

ologically diagnosed as diﬀuse large B ‑cell
lymphoma (DLBCL) of the jejunum after surgery.

Corresponding author:Naohiko Koide
Department of Surgery, Shinshu University School of

Three months after the operation, the patient died

Medicine, 3‑1‑1 Asahi, M atsumoto, Nagano 390‑8621

of the systemic involvement of NHL, although theJapanpostoperative course was uneventful.

No. 1, 201221

Koide.Sekino.Suzuki et al.

Fig.1 Operative ﬁndings
Ａ Case 3:Intestinal obstruction caused by repeated chemotherapy.The arrow shows that the obstruction originated from the intestinal lymphoma with degenerative and ﬁbrous changes.
Ｂ Case 4:Spontaneous perforation of the intestinal lymphoma. The arrow shows the perforation.

Case 2, a 68‑year‑old man, underwent an emer-

and the patient received systemic chemotherapy

gency operation involving partial resection of theusing R‑CHOP. The patient is well without any

ileum. Intestinal obstruction due to rapid enlarge-

recurrence 36 months after surgery.

ment of the ileal tumor was observed when theCase 5,a 78‑year‑old woman,had diﬀuse peritoni-patient was admitted for chemotherapy for DLBCL

tis due to a perforation of the duodenum, whenof the ileum detected by double balloon endoscopy

balloon dilation was endoscopically performed for(DBE). The postoperative course was uneventful.

stenosis caused by repeated chemotherapy using

After surgery, chemotherapy using cyclophos-

CHOP for duodenal DLBCL.The patient surgicallyphamide, doxorubicin hydrochloride, vincristine,

underwent wide drainage of the abdominal cavity.

and methylpredonisolone with rituximab (R‑CHOP)

Although infection of the postoperative surgical site

was performed. The patient is well without any

was observed, the patient survived for 61 months

recurrence 42 months after surgery.

after surgery without recurrence. The clinicopath-

Case 3, a 52‑year‑old man, showed intestinal

ologic features of the 5 S‑NHL cases treated by

obstruction after 4 cycles of CHOP chemotherapy

emergency operation are summarized in Table 1.

for T‑cell lymphoma of the jejunum diagnosed by

All patients satisﬁed the diagnostic criteria for

DBE.Although conservative treatment for the intes-

primary lymphoma of the gastrointestinal tract

tinal obstruction using a long intestinal tube wasdescribed by Lewin et al . The histologic

performed, it did not improve. The patient under-classiﬁcation of NHL was carried out according towent an emergency operation (Fig.1A). The pos-

WHO criteria . The NHL stage was determined

toperative course was uneventful.Although further

according to the Lugano International Conference

chemotherapy was performed, the patient died ofClassiﬁcation .

central nervous system involvement of S‑NHL 18
months after surgery.

Discussion

Case 4, a 78‑year‑old man, was operated on due

Emergency surgery has occasionally been neces-to diﬀuse peritonitis with sudden onset. At lapar-sary for S‑NHL patients. There are a few recent

otomy, a perforated tumor was detected in thereports concerning limited investigation of thisjejunum and removed (Fig.1B).The resected tumor

speciﬁc situation regarding S‑NHL

was histopathologically diagnosed as DLBCL after

several reports concerning emergency surgery forsurgery. The postoperative course was uneventful,small intestinal tumors, including gastrointestinal

22, although

Shinshu Med J Vol.60

alive (61)died (18)

alive (36)died (3)alive (42)reasons such as massive bleeding and dynamic
shock (Case 1), obstruction of the small intestine
without and with chemotherapy(Cases 2 and 3),and−−

intestine (Cases 4 and 5). These emergency situa−

SSI−

spontaneous or iatrogenic perforation of the small
tions were encountered in every period around thethe possibility of emergency surgery before,during,

−

−

＋

−

−

treatment of S‑NHL. We should always consider

Intestinal hemorrhage has been clinically obser-

＋

＋

＋

＋

and after treatment in patients with S‑NHL.
−surgery (months)
morbidity
Rx
Cx

The patients were urgently operated on for various

ved in approximately 10% of S‑NHL :6.3% repor-

−

−

−

−

−

Rx

M assive hemorrhage caused by S‑NHL has rarely＋, Lugano staging classiﬁcation ;Cx, chemotherapy;Rx, radiotherapy.

DBE, double balloon endoscopy;DLBCL, diﬀuse large B‑cell lymphoma ;SSI, surgical site infection.

II
DLBCL
48
perforation duodenum
DBE
pain
78/F
5

＋

−
II
DLBCL

II
150

40
jejunum

jejunumileus
DBE

surgery perforation
pain

pain
52/M

78/M
4

3

−

−
IV

IV
DLBCL

DLBCL
T‑cell60

54
jejunum

ileum
ileus

shock
surgeryDBE
pain

bleeding

75/F
68/M
2

1

Cx
Histology
Size (mm)Site
for surgery

distal to the ligament of Treitz, and its frequency
was approximately 1‑2% of patients with small
intestinal bleeding. Massive hemorrhage of S‑

NHL is a fatal complication, although Case 1 withdynamic shock was cured by emergency surgery
and intensive care. The patient did not receive
chemotherapy after surgery, because the generalcondition worsened. It was expected that the clinical outcome would be poor. The emergent state of
S‑NHL patients is an issue concerning the clinicaloutcome after surgery.
Regarding intestinal obstruction, NHL was thesecond‑most common tumor of the small intestine , and it was frequently observed in S‑NHL
patients. This complication can aﬀect the diag-nosis and treatment of S‑NHL. Usually, elective
surgery was performed for intestinal stenosis
caused by S‑NHL before chemotherapy, andchemotherapy was subsequently performed. Emergency surgery would be required for S‑NHL
patients with intestinal obstruction,and two modesof obstruction should be considered for S‑NHL
patients: chemotherapeutic complications of S‑
NHL, such as Case 3;and optimal surgery for an
unknown tumor with obstruction of the small intestine.
Perforation of the small intestine has sometimes
been observed in patients with S‑NHL.Koch et al

No. 1, 2012.

been observed in patients involving the lower GI

Stage

Before surgery After Surgery
Clinicopathologic features
Reasonstromal tumor and other tumors, are available

ted by Koch et al and 14.3% by Daum et al .

Cases Age/Sex Symptom Detection

Table 1 Cases of small intestinal non‑Hodgkin lymphoma treated by emergency operation

SurgicalOutcome after

Lymphoma of the small intestine

23

Koide.Sekino.Suzuki et al.

reported that it was observed in 9.4% of S‑NHL

operation.As a reason for this,emergent situations

patients.Daum et al reported that it was observed

such as perforation and obstruction of the small

in 25% of S‑NHL patients, and there was a highintestine are often characterized by systemicrate(37%)in T‑cell lymphoma.Free perforation of

inﬂammatory response syndrome, and an im-

the small intestine or tumors occurs spontaneously

munosuppressed state may be observed. However,or after chemotherapy in patients with S‑NHL.

in S‑NHL patients, no information has been madeWhen NHL is treated by eﬀective chemotherapy,

available regarding these emergent situations, andperforation of the GI tract may be a potential

further studies may be needed.Careful management

complication caused by tumor degeneration. How-of S‑NHL patients undergoing emergency surgery

ever, as in Case 5, iatrogenic perforation due tois required for a safe postoperative course, andballoon dilation for stenosis after chemotherapy forpromoting eﬀective postoperative treatment and

S‑NHL has been rarely reported. New technicalprolonged survival.

devices for endoscopy have been developed andIn conclusion, the recent role of surgery for S‑

archived for small intestinal disorders including S‑

NHL patients has changed after the clinical presen-NHL. We considered these complicated perfora-

tation of new endoscopic techniques and devices,

tions even though they are unlikely in S‑NHLsuch as DBE and capsule‑endoscopy, for the small

patients, involving not only chemotherapeutic

intestine. We should consider the possibility ofeﬀects but also iatrogenic complications.

emergency surgery before, during, and after man-

Surgery for malignant tumors of the small intes-

agement and treatment in patients with S‑NHL.

tine, including S‑NHL, has often been associatedAcknowledgementwith a high mortality rate;previous reports demonstrated a rate of 5% or more

.In our series,noWe gratefully acknowledge Dr. Kumiko Shiro-

surgical mortality was observed. Furthermore,hata (Department of Internal M edicine,Iida M unici-

intestinal perforation has been associated with apal Hospital),and Dr.Masato Kitazawa,Dr.Risako

poor prognosis in patients with S‑NHL.Two ofHiraga and Dr. Satoshi Ishizone (Department of

the 5 patients showed a poor outcome, with lower‑

Surgery,Shinshu UniversitySchool of Medicine)forlevel morbidity and morbidity after emergency

their considerable contributions to this paper.

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（2011. 8.10 received ; 2011.10. 7 accepted）

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