Surgical Case Reports最新文献

Introduction: Immune thrombocytopenia (ITP) is an autoimmune hematologic disorder characterized by a reduced platelet count resulting from immune-mediated platelet destruction and/or impaired thrombopoiesis. This condition is often associated with malignant tumors, making perioperative management crucial to maintain hemostasis during and after surgery. Herein, we report a case of ITP successfully controlled following surgical dissection of a large mediastinal lymph node metastasis originating from squamous cell carcinoma of unknown primary.

Case presentation: A 57-year-old man with poorly controlled ITP was found to have progressively enlarging mediastinal lymph nodes on chest CT over 4 months. The largest lymph node measured 72× 37× 31 mm. The patient received preoperative intravenous immunoglobulin therapy (0.4 g/kg/day) for 4 days, after which mediastinal lymph node dissection was safely performed without hemorrhagic complications. The platelet count improved transiently after surgery. Histopathology revealed metastatic poorly differentiated squamous cell carcinoma, but imaging failed to identify a primary lesion, leading to a diagnosis of squamous cell carcinoma of unknown primary.

Conclusions: With appropriate preoperative management, the platelet count was effectively controlled, allowing safe removal of the large mediastinal lymph node. As the platelet level improved postoperatively, prednisolone tapering was initiated. Given that recurrent malignancy may precipitate a decline in platelet count, close follow-up is warranted.

Introduction: Chronic mesenteric ischemia (CMI) is usually caused by atherosclerotic stenosis of multiple mesenteric arteries. However, aortic stenosis secondary to Takayasu arteritis can rarely cause intestinal ischemia through hemodynamic steal from the mesenteric to lower limb circulation.

Case presentation: A 67-year-old woman with a history of Takayasu arteritis presented with postprandial and exertional abdominal pain and a 3-kg weight loss over 2 weeks. CTA revealed isolated severe stenosis of the infrarenal aorta with development of the arc of Riolan, and Doppler ultrasonography demonstrated retrograde flow in the inferior mesenteric artery. Based on these findings, a diagnosis of mesenteric steal syndrome secondary to Takayasu arteritis was made. Endovascular stenting of the infrarenal aorta was performed, resulting in improved antegrade aortic flow and reduced collateral circulation. After treatment, the patient's abdominal pain resolved and her weight recovered.

Conclusions: This rare case demonstrates that Takayasu arteritis can cause mesenteric steal syndrome without mesenteric arterial lesions and highlights that endovascular stenting can effectively restore physiological blood flow and relieve ischemic symptoms.

Introduction: Spontaneous tumor regression (STR) is a rare phenomenon in which cancer cells partially or completely disappear without treatment. We report a case of intrahepatic cholangiocarcinoma demonstrating STR following endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA).

Case presentation: A 77-year-old male presented with acute cholecystitis 1 day after percutaneous coronary intervention for acute myocardial infarction. Conservative treatment and endoscopic retrograde gallbladder drainage were performed due to antiplatelet therapy. Cytology of bile juice unexpectedly revealed adenocarcinoma. Further imaging, including CT and mapping biopsy, failed to detect a tumor. Laparoscopic cholecystectomy with gallbladder bed resection showed no histological evidence of malignancy. Four months later, surveillance CT revealed a 15 × 15 mm lesion in segment 3 of the liver. EUS-FNA confirmed adenocarcinoma. Laparoscopic left lateral resection was performed; however, no viable cancer cells were identified, and the lesion was replaced by epithelioid granulomas. Immunohistochemistry demonstrated dense infiltration of CD8-positive cytotoxic T cells, suggesting an immune-mediated regression of the tumor.

Conclusions: This case highlights the possibility of tumor regression in intrahepatic adenocarcinoma following EUS-FNA, potentially triggered by an immune response.

Introduction: Primary neuroendocrine carcinoma (NEC) of the colon is extremely rare, accounting for only 0.2% of all colorectal malignancies, and is associated with a poor prognosis. Early diagnosis is often challenging, as endoscopic biopsies are frequently misinterpreted as adenocarcinoma. Although platinum-based regimens such as etoposide plus cisplatin or irinotecan are commonly used, no standard chemotherapy protocol has been established. We report a case of locally recurrent cecal NEC that responded remarkably to a colorectal cancer-based chemotherapy regimen, achieving a pathological complete response.

Case presentation: A 52-year-old man presented with severe anemia. Imaging and colonoscopy revealed a cecal tumor initially diagnosed as adenocarcinoma. He underwent laparoscopic right hemicolectomy with lymph node dissection. Final pathology revealed NEC, staged as pT3N2aM0, Stage IIIB. Adjuvant etoposide-cisplatin chemotherapy was initiated. Three months postoperatively, carcinoembryonic antigen (CEA) rose to 44.4 ng/mL, and CT demonstrated a perianastomotic peritoneal nodule and lymphadenopathy, consistent with recurrence. Considering the adenocarcinoma component in the primary tumor and elevated CEA, chemotherapy was switched to a colorectal cancer-based regimen: FOLFOXIRI plus bevacizumab. After 7 cycles, both radiologic regression and normalization of CEA levels were achieved. Resection of the recurrent lesions confirmed a pathological complete response with no residual tumor cells.

Conclusions: To the best of our knowledge, this is the first reported case of cecal NEC achieving pathological complete regression with a colorectal cancer-based chemotherapy regimen. Our findings indicate that colorectal NEC may respond not only to platinum-based regimens but also to colorectal cancer-based regimens. Furthermore, CEA levels may serve as a clinically relevant biomarker to guide chemotherapy selection in this setting.

Introduction: There is no consensus regarding surgery and endotracheal treatment for bronchial stenosis. We report a case of right main bronchus stenosis treated using a novel approach of mediastinal mobilization with pericardial suspension.

Case presentation: A 57-year-old woman who developed radiation pneumonitis after postoperative radiation therapy for left breast cancer was admitted to our hospital due to worsening respiratory distress over 2 years. Chest CT revealed severe stenosis of the right main bronchus owing to lung destruction and scoliosis. Although isolated lung ventilation using a double-lumen tube was initiated, the ventilation was unstable. The patient underwent surgery, including sternal elevation using the Nuss technique, mediastinal mobilization using pericardial suspension, and tracheobronchial stenting to ameliorate bronchial stenosis.

Conclusions: After surgery, oxygenation was no longer required. This novel pericardial suspension technique fundamentally corrects the extrinsic mediastinal shift, serving as an essential prerequisite for safe stenting against secondary tracheobronchomalacia in adult cases.

Introduction: An aberrant pancreas is pancreatic tissue lacking anatomical and vascular continuity with the normal pancreas. It typically occurs in the gastrointestinal tract, especially in the stomach, duodenum, and small intestine. Most cases are asymptomatic and discovered incidentally during imaging or surgery. Gastric aberrant pancreas rarely presents with bleeding, making diagnosis and treatment decisions challenging.

Case presentation: A 34-year-old man presented with epigastric pain and melena. Endoscopy at a local hospital revealed a submucosal tumor (SMT) with active bleeding at the greater curvature of the stomach. After admission, further imaging and endoscopic ultrasonography showed a 20-mm low-echo mass in the submucosa and muscularis propria with ulceration. Histopathology of a biopsy confirmed aberrant pancreatic tissue. Due to progressive anemia from ulcer bleeding, laparoscopic partial gastrectomy was performed. The SMT was completely resected, and the postoperative course was uneventful. Pathological examination confirmed a Heinrich type I aberrant pancreas.

Conclusions: Most cases of aberrant pancreas are asymptomatic; however, in this case, a preoperative diagnosis of gastric submucosal aberrant pancreas was made by endoscopic examination and puncture aspiration cytology because of the relatively rare bleeding symptoms. In this case, laparoscopic partial gastrectomy was performed to control bleeding.

Introduction: Jejunogastric intussusception is a rare complication that can occur following gastrectomy or gastric bypass surgery. The occurrence of intestinal intussusception after pancreaticoduodenectomy (Child reconstruction) has been reported in very few cases in the literature.

Case presentation: Here, we present the case of a 75-year-old patient who developed jejunogastric intussusception following pancreaticoduodenectomy performed for intraductal papillary mucinous neoplasm of the pancreatic head. The diagnosis was confirmed by contrast-enhanced abdominal CT and upper gastrointestinal endoscopy. During the operation, the efferent limb was intussuscepted into the gastric lumen. Manual Hutchinson's maneuver of the intussusception was successfully performed without incision of the stomach or jejunum. Intestinal blood flow was assessed during surgery using indocyanine green fluorescence imaging and adequate blood flow was confirmed. The surgery was completed without intestinal resection or incision of the stomach or jejunum. The patient's postoperative course was uneventful, and he was discharged in stable condition on POD 11. He showed no recurrence at follow-up 1 year after the surgery.

Conclusions: Although jejunogastric intussusception is an uncommon complication following pancreaticoduodenectomy, it can lead to life-threatening outcomes. Delayed diagnosis can necessitate bowel resection. Prompt diagnosis and emergent surgical intervention are essential for effective treatment, highlighting the importance of a rapid clinical response from diagnosis to treatment regarding jejunogastric intussusception.

Introduction: Immune checkpoint inhibitors (ICIs) have recently emerged as an important treatment option for various cancers. In 2024, pembrolizumab was approved as a first-line treatment for unresectable or recurrent gastric cancer. Conversion surgery following ICI-based chemotherapy has been reported; however, cases involving pembrolizumab-based first-line therapy remain rare. Here, we report a case of conversion surgery after treatment with capecitabine plus oxaliplatin (CAPOX), combined with pembrolizumab for unresectable advanced gastric cancer.

Case presentation: An 82-year-old man presented with anorexia and was referred to our department for surgical evaluation. Upper gastrointestinal endoscopy revealed circumferential type 3 gastric cancer extending from the lower gastric body to the antrum with pyloric stenosis. Contrast-enhanced CT showed para-aortic lymph node metastases, resulting in a diagnosis of stage IVB gastric cancer (cT4aN2M1, 15th edition of the Japanese Classification of Gastric Carcinoma [JGCA]). First, we performed a laparoscopic gastrojejunal bypass to treat anorexia and oral intake difficulties due to pyloric stenosis. The patient then received 5 cycles of CAPOX plus pembrolizumab. Subsequent upper gastrointestinal endoscopy revealed significant scarring with residual cancer cells, and contrast-enhanced CT showed significant shrinkage of the primary tumor lesion and para-aortic lymph nodes. Because R0 resection was achievable, we performed conversion surgery involving open distal gastrectomy with D2 and para-aortic lymphadenectomy. Postoperative pathological findings revealed a small number of residual cancer cells in the submucosa, with no viable cancer cells detected in the para-aortic lymph nodes (ypT1bN0M0, ypStage IA). The pathological response grade was 2b according to the 15th edition of the JGCA. At 6 months postoperatively, the patient remains alive and recurrence-free.

Conclusions: Conversion surgery after CAPOX plus pembrolizumab chemotherapy is a potential therapeutic strategy for unresectable advanced gastric cancer.

Introduction: Sigmoid volvulus is a clinically significant cause of large bowel obstruction that occurs particularly in older patients with a reduced physical function. Although endoscopic detorsion is the first-line treatment, volvulus recurrence is common and often requires elective surgery. Despite various reports on the surgical procedures, the optimal approach remains controversial. The Sharon operation, first introduced in 1985, is a minimally invasive technique that avoids mobilization of the sigmoid colon via a small incision in the left lower quadrant. Although it offers several advantages, such as shorter operative time, minimal invasiveness, and favorable clinical outcomes, it remains underutilized, especially in Japan. We evaluated the clinical utility and indications of the Sharon operation in high-risk patients with recurrent sigmoid volvulus.

Case presentation: This retrospective study analyzed 6 patients who underwent surgery for sigmoid volvulus at our institution between 2015 and 2023. The median age was 82.5 years, and all patients had a prior history of volvulus. Four patients underwent elective surgery following successful endoscopic detorsion, and 2 underwent emergency surgery due to suspected bowel necrosis. Among the elective cases, 2 received laparoscopic sigmoidectomy and 2 underwent the Sharon operation. The Sharon operation group had a shorter operative time (mean 74 min) than the laparoscopic surgery group (mean 225.5 min), with minimal blood loss in both groups. The only postoperative complication was superficial surgical site infection (SSI) in 1 laparoscopic case. During a median follow-up period of 61 months, no recurrence was observed. We chose the Sharon operation preferentially for patients with advanced age, poor nutritional status, or severe comorbidities including cardiac dysfunction.

Conclusions: The Sharon operation is a safe and effective option for recurrent sigmoid volvulus, particularly in older patients or those with significant comorbidities. Considering its shorter operative time and minimal incision, it may be helpful in patients who are unsuitable for standard laparoscopic or open procedures. No recurrence was observed during long-term follow-up, suggesting a potentially curative outcome of the Sharon operation.

Introduction: Gastrointestinal stromal tumors (GISTs) that present as large jejunal diverticulum-like lesions are exceedingly rare, with only 8 cases reported in the English literature to date. Notably, all previously documented cases were treated via open surgery. To our knowledge, this is the first report of successful laparoscopic resection of such a lesion. This case contributes novel insight into the management of rare GIST presentations and demonstrates the potential applicability of minimally invasive surgery.

Case presentation: A man in his 70s was incidentally diagnosed with a large jejunal diverticulum-like structure on abdominal CT. The lesion eventually perforated during follow-up, requiring emergency laparoscopic partial jejunal resection. Due to severe inflammation and infiltration around the lesion, partial colectomy was also required. Intracorporeal anastomoses were performed for both the jejuno-jejunal and colo-colic reconstructions. Histopathological analysis confirmed the diagnosis of GIST, revealing a 10.2-cm mass that had completely replaced the original jejunal wall structure. The tumor was thought to have arisen from the jejunal muscularis propria and expanded outward, creating a pseudo-diverticular appearance. Postoperative recovery was uneventful; however, multiple liver metastases developed shortly thereafter. The patient was started on imatinib therapy, resulting in a sustained reduction in tumor size.

Conclusions: This case demonstrates that laparoscopic resection is feasible even for rare and complicated presentations of jejunal GISTs, such as those mimicking large jejunal diverticula. It provides new evidence supporting the safety and effectiveness of minimally invasive surgery in emergency settings involving tumor perforation.