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: 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: 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: 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: Segmentectomy in cases with fused fissures poses technical challenges due to increased risks of air leakage, as reported in lobectomy. The single-direction approach avoids fissure manipulation through hilar-first dissection but has been rarely reported for posterior segments. We report the first case of a posterior single-direction approach for combined S2+S6 segmentectomy in a patient with a tumor located in an incomplete right interlobar fissure.

Case presentation: A 52-year-old woman with bilateral multiple ground-glass nodules presented with a 22-mm heterogeneous ground-glass nodule located in an incomplete fissure between the right upper and lower lobes. Preoperative CT revealed a fused fissure and concomitant S2 lesions, including a 15-mm subpleural nodule and a 7-mm deeper parenchymal nodule, as well as a 7-mm S6 lesion. Three-port thoracoscopic S2+S6 segmentectomy was performed with the surgeon positioned dorsally and ports placed posteriorly. Selective segmental inflation was performed prior to hilar dissection to mark intersegmental planes. Sequential division of V6 and the common trunk of ascending A2 and A6 was performed from the posterior hilar approach, followed by B6 division using a suction-device trick. After intersegmental division of S6 to improve hilar exposure, B2 was divided using the same approach, followed by V2 division and completion of S2+S6 segmentectomy. The postoperative course was uneventful.

Conclusions: The posterior single-direction approach successfully achieved complete oncologic resection without fissure manipulation, providing a safe alternative for posterior segmentectomy in patients with fused fissures.

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.

Introduction: Pelvic squamous cell carcinoma (SCC) originating from a dermoid cyst (DC) is extremely rare. Here, we report the first case of SCC that developed in the anterior rectal area.

Case presentation: A 46-year-old man was initially diagnosed with rectal SCC by endoscopic biopsy, and multimodal image findings demonstrated direct invasion of the urinary system. Accordingly, total pelvic exenteration with bilateral lymph node dissection was performed with robotic assistance, and the patient was discharged without severe postoperative complications. Histological assessment revealed that the cancer originated in a DC with direct invasion of the seminal vesicle.

Conclusions: Pelvic DC-derived SCC is rare but possesses high malignant potential. Because of the difficulty in preoperative diagnosis, diagnostic excision may be selected if complete resection is possible. Importantly, robot-assisted surgery enables precise management and might be an optimal strategy for preventing cancer dissemination by rupture during surgery.

Introduction: Zolbetuximab, a monoclonal antibody targeting claudin (CLDN) 18.2, has been approved as a first-line treatment for patients with human epidermal growth factor receptor 2 (HER2)-negative and CLDN-positive advanced gastric cancer. Conversion surgery following chemotherapy has emerged as a promising strategy for improving outcomes in patients with stage IV gastric cancer. Herein, we report a case of CLDN-positive gastric cancer with peritoneal dissemination and cervical lymph node metastasis that was successfully treated with subtotal gastrectomy (sTG) following zolbetuximab-based chemotherapy.

Case presentation: A 73-year-old male was diagnosed with HER2-negative, CLDN-positive gastric cancer, accompanied by peritoneal dissemination and cervical lymph node metastasis. He received 6 cycles of zolbetuximab in combination with capecitabine and oxaliplatin as first-line chemotherapy. Primary tumor, peritoneal lesions, and lymph node metastases exhibited marked regression, including complete resolution of the metastatic cervical lymph nodes. Complete response was achieved according to the Response Evaluation Criteria for Solid Tumors. After confirming the disappearance of the peritoneal dissemination, the patient underwent sTG with D2 lymphadenectomy. Histopathological examination revealed a grade 2 therapeutic response and no residual lymph node metastasis. The postoperative course was uneventful, and the patient remained recurrence-free for 5 months after the conversion surgery.

Conclusions: Zolbetuximab-based chemotherapy followed by conversion surgery is a promising therapeutic strategy for patients with CLDN-positive advanced gastric cancer.