Surgical Case Reports最新文献

Introduction: Partial anomalous pulmonary venous connection (PAPVC) is a potential cause of right-sided heart failure. Notably, a risk of sudden circulatory failure exists during lung surgery. Only a few reports of PAPVC complicated by lung cancer requiring lobectomy exist. Here, we report a case of left lower lung lobectomy complicated by an anomalous connection of the left upper pulmonary vein requiring revascularization.

Case presentation: A 66-year-old man was found with an abnormal mass shadow in the left lower lung field on chest radiography. Bronchoscopy revealed lung adenocarcinoma. Preoperative contrast-enhanced computed tomography showed that the left upper pulmonary vein did not perfuse the left atrium but was connected to the left brachiocephalic vein. Preoperative transthoracic echocardiography revealed right atrial and ventricular enlargement. The clinical diagnosis was stage IB (T2aN0M0). We decided to perform a left lower lobectomy and correct the PAPVC to maintain oxygenation after the lobectomy. The PAPVC was ligated, and the stump of the left upper pulmonary vein was anastomosed to the left atrial appendage without cardiopulmonary bypass. Postoperative contrast-enhanced computed tomography revealed intact reconstructed vessels. Postoperative transthoracic echocardiography showed no right ventricular overload. The patient's postoperative clinical course following the surgical procedure was uneventful. Furthermore, the patient was followed up without any complications.

Conclusions: This rare case of successful surgical correction can inform clinicians of similar cases.

Background: Blood supply to the remnant stomach should be preserved during pancreatectomy in patients with a history of gastrectomy. Moreover, ischemic complications should be considered when performing pancreatoduodenectomy in patients with celiac axis and superior mesenteric artery (SMA) stenosis. However, whether these surgical procedures can be safely performed remains unclear.

Case presentation: A 75-year-old man had a history of laparoscopic proximal gastrectomy (PG) with double-flap technique for gastric cancer and laparoscopic sigmoidectomy for sigmoid cancer treated 4 years ago. Follow-up computed tomography (CT) revealed an irregular nodular tumor measuring 13 mm in the pancreatic head. The patient was diagnosed with resectable pancreatic head cancer without lymph node metastasis (cT1cN0M0, cStageIA) according to the Union for International Cancer Control, 8th edition. As a standard pancreatic cancer treatment, two courses of preoperative chemotherapy with gemcitabine plus S-1 were administered. CT after preoperative chemotherapy identified no significant changes in tumor size but revealed SMA stenosis due to atherosclerosis. Blood flow to the left-sided colon was supplied from the middle colic artery via the SMA because of the past sigmoidectomy with inferior mesenteric artery detachment. Therefore, SMA stent placement was performed 1 day preoperatively. Subsequently, pylorus-preserving pancreatoduodenectomy (PPPD) was performed, preserving the remnant stomach with the right gastroepiploic (RGE) artery and vein. After resection, indocyanine green fluorescence imaging confirmed a good blood supply to the remnant stomach. The operation time was 467 min, and the blood lost was 442 mL. Histopathologically, the tumor was diagnosed as moderate adenocarcinoma and pT1cN0M0, Stage IA. The postoperative course was uneventful. The patient was discharged on postoperative day 23. S-1 as adjuvant chemotherapy was administered on postoperative day 63. The patient has been alive without recurrence for 7 months.

Conclusions: We performed PPPD preserving blood supply for pancreatic head cancer in a patient with benign SMA stenosis and a history of PG and sigmoidectomy. Blood supply was preserved through preoperative SMA stent placement and a surgical procedure preserving the RGE vessels. Furthermore, S-1 adjuvant chemotherapy was successfully initiated. These multimodal therapies contributed to a favorable clinical outcome.

Background: On-pump beating coronary artery bypass grafting (CABG) is a procedure that uses cardiopulmonary bypass to maintain circulation and it is a useful technique for CABG in patients with severely impaired cardiac function. Here, we report a case of left atrial rupture that occurred during CABG. Reports of left atrial injury are rare, and there have been no previous reports of such cases associated with on-pump beating CABG.

Case presentation: An 80-year-old man with a history of myocardial infarction was admitted to another hospital for acute heart failure. Coronary angiography revealed triple-vessel disease, and echocardiography showed reduced left ventricular function and moderate mitral regurgitation. He was transferred to our hospital for coronary artery bypass grafting and the operation was scheduled. Surgery was started with the intention of off-pump CABG, but due to circulatory instability, the patient was converted to on-pump beating CABG. While the heart was being dislocated and anastomosis was being performed, sudden bleeding from the left atrium occurred. To achieve hemostasis, we needed to arrest the patient's heart. A 5-cm laceration along the posterior mitral annulus was found in the left atrium and repaired with a bovine pericardial patch. Mitral annuloplasty with a flexible ring was performed simultaneously. He recovered uneventfully.

Conclusions: The left atrial rupture during on-pump beating coronary artery bypass grafting is extremely rare. The wall of the atrium is thought to have been damaged by the stress applied during the displacement of the heart and the impact of the enlarged mitral regurgitant jet. Repair under cardiac arrest is necessary, and in some cases, mitral annuloplasty may be additionally required.

Background: We report the exceedingly rare case of diaphragmatic hernia after esophageal surgery resulting in obstructive shock and cardiac arrest.

Case presentation: An 82-year-old man, who had undergone a robotic-assisted thoracoscopic esophagectomy and gastric tube reconstruction via a subcutaneously route with three-field lymphadenectomy for esophagogastric junction cancer at another hospital 3 months prior, complaining of persistent epigastric pain and nausea. Computed tomography revealed that the proximal jejunum had herniated through the esophageal hiatus into the left thoracic cavity, with dilation of the subcutaneous gastric tube and duodenum. He was urgently admitted, and a nasogastric tube was inserted. His respiratory and circulatory parameters were normal upon admission, however, nine hours after admission, there was a rapid increase in oxygen demand, and he subsequently developed shock. His blood pressure was 106/65 mmHg, pulse rate of 150bpm, respiratory rate of 30/min with an O2 saturation of 97% on High-flow nasal cannula FiO2:0.4, cyanosis and peripheral coldness appeared. Chest X-ray showed a severe mediastinal shift to the right, suggesting obstructive shock due to intestinal hernia into the thoracic cavity. Emergency surgery was planned, but shortly after endotracheal intubation, the patient experienced cardiac arrest. It was found that approximately 220 cm of small intestine had herniated into the thoracic cavity through the esophageal hiatus, and it was being strangulated by the diaphragmatic crura. A portion of the diaphragmatic crura was incised to manually reduce the herniated small intestine back into the abdominal cavity. The strangulated intestine was congested, but improvement in coloration was observed and it had not become necrotic. The procedure finished with closure of the esophageal hiatus. Intensive care was continued, but he died on postoperative day 29 because of complications including perforation of the descending colon and aspiration pneumonia.

Conclusion: Rapid progression of small intestine hernia into the thoracic cavity, leading to obstructive shock, was suspected. While this case was rare, early recognition of the condition and prompt reduction could have potentially led to life-saving outcomes.

Introduction: We encountered a case of adenocarcinoma of the ectopic pancreas, causing intussusception.

Case presentation: A 76-year-old man presented with complaints of abdominal distention and vomiting to the emergency department in March 2022. Computed tomography showed that the small bowel piled up approximately 20 cm from the ligament of the traits. Endoscopic repair was challenging; therefore, laparoscopic repair and partial resection of the small bowel were performed. The specimen showed a mass in the small bowel arising from an ectopic pancreas that had caused accumulation. Pathological examination revealed ectopic pancreatic cancer. Two years postoperatively, no apparent recurrence has been observed. We report a relatively rare case of a cancerous ectopic jejunal pancreas causing a mass, with a discussion in the literature.

Conclusions: Detection typically requires surgery due to advanced-stage intestinal obstruction or accumulation, as observed in the present case. However, preoperative diagnosis and early detection of ectopic pancreatic cancer are challenging. The disease progresses similarly to pancreatic cancer, highlighting the need for early detection methods. Additionally, accumulating more case reports is essential for establishing an effective treatment strategy.

Background: Primary solitary fibrous tumors (SFTs) of the gallbladder are rare. Here, we report the case of a patient who underwent surgical treatment for a primary SFT originating in the gallbladder.

Case presentation: A 48-mm gallbladder tumor was detected in a 70-year-old man using abdominal ultrasonography at a primary hospital, and he was subsequently referred to our department. A 50-mm enhanced tumor in the gallbladder was identified using computed tomography. Magnetic resonance imaging revealed a smooth-marginated tumor with hyperintensity on T2-weighted imaging. 18F-Fluorodeoxyglucose positron emission tomography confirmed high-level fluorodeoxyglucose uptake in the gallbladder tumor in the early phase without increasing uptake in the later phase. Surgical resection was planned to evaluate the tumor diagnosis. Initially, we performed open cholecystectomy with wedge resection of the gallbladder bed. Intraoperative pathological examination suggested gallbladder cancer; therefore, we performed radical surgery, including resection of the common bile duct, extended radical lymphadenectomy, and choledochojejunostomy. Ultimately, the final pathological examination revealed an SFT originating from the gallbladder with a negative surgical margin. Postoperatively, the patient developed bile leakage that was treated with tube drainage. The patient recovered satisfactorily and was discharged on postoperative day 20. At 24 months postoperatively, the patient was in good general condition without recurrence.

Conclusions: We report a rare case of a primary SFT originating in the gallbladder. Clinicians should be aware that SFT can be found in the gallbladder, and when it is difficult to make a preoperative diagnosis, surgical treatment should be considered.

Background: Neurofibromatosis type 1 (NF1), also known as von Recklinghausen disease, is an autosomal dominant disorder that can affect multiple organs. Although gastrointestinal manifestations, such as neurofibromas and gastrointestinal stromal tumors (GISTs), can occur, appendiceal neurofibromas are extremely rare, with no documented cases of their occurrence following other gastrointestinal lesions. Herein, we report a case of an appendiceal neurofibroma following the resection of multiple small intestinal GISTs.

Case presentation: A 68-year-old man with NF1 presented with melena and was diagnosed with anemia due to bleeding from multiple small intestinal GISTs. Laparoscopic three partial resection of the small intestine was performed to control the bleeding. Histopathologic examination revealed the proliferation of spindle cells that are positive for c-kit and Discovered on GIST-1, confirming the diagnosis of GIST. Two years later, a follow-up computed tomography (CT) scan revealed a progressively enlarging mass in the appendix with suspected invasion into the small intestine. Positron emission tomography/CT showed fludeoxyglucose accumulation in the tumor. Therefore, considering the possibility of malignancy, laparoscopic ileocecal resection with lymph node dissection was performed. Postoperatively, melena was observed, but the anemia did not progress and improved with fasting and hemostatic therapy. The patient was eventually discharged on postoperative day 8. Histopathologic examination revealed spindle cell proliferation with positivity for S-100, confirming the diagnosis of neurofibroma.

Conclusions: Patients with NF1 can develop a variety of gastrointestinal lesions. Appendiceal neurofibroma can be difficult to diagnose preoperatively and differentiate from malignancy. Hence, surgical resection should be considered.

Background: Intussusception of the appendiceal endometriosis is rare. Although approximately 200 cases of appendiceal intussusception have been reported in the literature, very few have ever been diagnosed preoperatively. Here, we report the case of intussusception of the appendiceal endometriosis with laparoscopic ileocecal resection.

Case presentation: A woman in her 50s presented to the out-patients clinic with epigastric pain lasting for a several month. Contrast-enhanced computed tomography (CT) scanning revealed ileocolic intussusception in which a cecum polypoid mass lesion extended to the hepatic flexure of the ascending colon. A colonoscopy showed a large pedunculated polyp in the cecum. Laparoscopic ileocecal resection was performed. Pathology confirmed an invaginated appendix demonstrating endometriosis implants.

Conclusions: Possible intrinsic causes of intussusception are varied, appendiceal intussusception secondary to endometriosis is extremely rare. Intussusception of the appendix is a rare finding, often mistaken for a polyp. We suggest considering inverted appendix as a differential diagnosis when investigating cecal lesions.

Background: Methotrexate-associated lymphoproliferative disease (MTX-LPD) is a rare and life-threatening complication of MTX administration. MTX-LPD features more extranodal lesions than malignant lymphoma; however, the liver is an extremely rare organ that develops LPD. Herein, we present a case of hepatic MTX-LPD treated with surgical resection. We also reviewed the literature on hepatic MTX-LPD.

Case presentation: A 66-year-old man with a history of rheumatoid arthritis (RA) was admitted to our department for the treatment of hepatic solitary liver tumor. The patient had been receiving MTX (14 mg/week) for RA for 6 years. MTX was withdrawn and salazosulfapyridine was prescribed 3 weeks prior to admission because of mediastinal MTX-LPD. Abdominal contrast-enhanced computed tomography showed a slightly ring-like enhanced hypovascularized mass (80 mm) in the lateral section of the liver. Carbohydrate antigen 19-9 (78.1 U/mL) level was elevated. No evidence was observed on esophagogastroduodenoscopy or colonoscopy. The tumor was suspected to be an intrahepatic cholangiocarcinoma. The patient underwent hepatic lateral sectionectomy and lymphadenectomy. Pathological examination revealed that the hepatic mass was coagulative necrosis of the CD20-positive B-cell lymphocytes. These histological findings were similar to those of rapid necrotic lymphoma. MTX-LPD is known to spontaneously regress after withdrawing MTX, and the patient was diagnosed with hepatic MTX-LPD.

Conclusions: MTX-LPD can occur in the liver. Clinician should suspect hepatic MTX-LPD when a liver mass is detected in patient who had been treating with MTX for RA.

Background: Solid pseudopapillary neoplasm (SPN) is a low-grade malignant tumor that occurs in 60% of all pediatric pancreas tumors. Radical tumor resection is essential; however, spleen preservation is also crucial to prevent overwhelming post-splenectomy infection. In contrast, spleen preservation is not always possible, because left-sided portal hypertension (LSPH) can cause splenic vein stenosis or occlusion induced by pancreatic tumor. We herein report on a pediatric patient of LSPH due to SPN in the pancreatic tail.

Case presentation: A 12-year-old girl was admitted to our hospital with left upper quadrant abdominal pain. A solid mass was palpated in the left costal region. The patient showed slight anemia (Hb: 11.8 g/dL) and elevation of inflammatory reaction (CRP: 5.98 mg/dL) without positive tumor markers. A radiological examination revealed that a 9 cm-sized mass with hemorrhagic necrosis in the pancreatic tail. Splenic venous flow was not detected and collateral draining into the left gastric vein and left renal veins were developed with splenomegaly. LSPH was involved at the time of diagnosis. The tumor was diagnosed with SPN, hence tumor resection with spleen preservation was performed. Six months after surgery, the patient developed a left quadrant abdominal pain that worsened during exercise. There was no improvement of splenic venous flow and splenomegaly. LSPH remained with splenomegaly, which possibly triggered the patient's abdominal pain. The patient underwent splenectomy 9 months after the tumor resection. After the splenectomy, the patient's abdominal pain disappeared without any recurrence 8-year post-surgery.

Conclusions: LSPH has not been a major focus in previous SPN pediatric patients, although most symptomatic LSPH patients required splenectomy. Careful post-operative observation for LSPH is important for pediatric SPN patients.