Surgical Case Reports最新文献

Introduction: Achalasia is a primary esophageal motility disorder of unknown origin. The clinical manifestations are caused by the loss of peristalsis of the esophagus and functional obstruction at the esophagogastric junction. There are several treatment strategies for esophageal achalasia, such as medications, endoscopic treatment, and surgery. The successful treatment of a case of jejunal interposition surgery with overlap esophago-jejunal anastomosis for an esophageal stricture due to repeated endoscopic dilation for esophageal achalasia is reported.

Case presentation: The patient was a 67-year-old man who was diagnosed with esophageal achalasia 13 years earlier. Partial esophagectomy of the portion with the stricture and esophago-jejunal anastomosis using the overlap method were performed for the esophageal stricture due to rupture during endoscopic balloon dilatation. The patient's postoperative recovery was unremarkable, and the dysphagia due to esophageal stricture disappeared.

Conclusions: The overlap technique in esophago-jejunal anastomosis after partial esophagectomy was very effective for an esophageal stricture in a patient with achalasia because it made possible the additional resection of endoluminal muscle.

Introduction: Kommerell's diverticulum is often associated with a right-sided aortic arch. It presents as a saccular aneurysm. Although various surgical strategies have been reported, optimal treatment has not been established.

Case presentation: Four patients with right-sided aortic arch underwent different surgeries for Kommerell's diverticulum. The pattern of aortic arch was a mirror-image of the normal left aortic arch in Cases 1 and 2. In Cases 3 and 4, it was right-sided aortic arch with an aberrant left subclavian artery as its last branch. Cases 1 and 3 presented with compression symptoms caused by Kommerell's diverticulum. They underwent open surgery or thoracic endovascular aortic repair through the different approaches. Their postoperative courses were favorable.

Conclusions: The surgical strategy for Kommerell's diverticulum with a right-sided aortic arch should be selected based on the anatomical characteristics of the cervical vessels, compression symptoms, and surgical risks.

Introduction: Gastric adenocarcinoma with enteroblastic differentiation (GAED) is associated with a poor prognosis because of high rates of liver and lymph node metastases. While systemic chemotherapy is the standard treatment for gastric cancer (GC) with liver metastases, several studies suggest that hepatectomy, when combined with multimodal treatment, may provide a survival benefit. However, the role of surgical resection for GAED with liver metastases remains controversial.

Case presentation: A 71-year-old man presented with abdominal pain and nausea. Endoscopy revealed a type 2 tumor at the greater curvature of the gastric body. Contrast-enhanced computed tomography showed thickening and enhancement of the gastric wall, bulky lymph node metastases, and bilobar hepatic lesions, with the largest tumor measuring 60 mm in diameter. Histological examination of the stomach and liver tumors revealed adenocarcinoma composed of cuboidal or columnar cells resembling a primitive intestine-like structure with clear cells. Immunostaining showed heterogeneous cytoplasmic positivity for alpha-fetoprotein and spalt-like protein 4, leading to a diagnosis of GAED with liver metastases. Because the tumor was positive for human epidermal growth factor receptor 2 (HER2), chemotherapy with capecitabine, cisplatin, and trastuzumab was administered. After six cycles, the tumors had significantly decreased in size, and curative-intent surgery was performed, including distal gastrectomy, left lateral sectionectomy, and partial hepatectomy, successfully eradicating all five liver metastases. Histological examination of the liver metastases revealed extensive necrosis and fibrosis with no viable tumor cells. Adjuvant chemotherapy with the same regimen was continued for 1 year. At the time of this writing, the patient had remained recurrence-free for more than 2 years postoperatively.

Conclusions: We report a rare case of GAED with multiple liver metastases successfully treated with aggressive surgical resection following systemic chemotherapy. Trastuzumab-based chemotherapy may be a viable treatment option for HER2-overexpressing GAED. In addition, radical surgery for GAED with liver metastases might prolong the survival if the chemotherapeutic regimen was effective.

Introduction: Thromboangiitis obliterans (TAO) has become increasingly uncommon in Japan due to declining smoking prevalence. However, in advanced cases with severely compromised distal vasculature, achieving durable limb salvage remains a formidable surgical challenge.

Case presentation: A 51-year-old man with a 12-year history of TAO presented with rest pain and a necrotic ulcer on the 2nd toe. He had recently ceased smoking after a 31-year history. Imaging demonstrated complete occlusion of the popliteal and tibial arteries, with foot perfusion reliant on corkscrew collaterals. The ankle-brachial index was 0.43, and skin perfusion pressure (SPP) was critically low. A severely diseased plantar artery was identified as a potential distal target. Given the high risk of graft failure, a hybrid strategy combining in situ bypass and surgical distal venous arterialization (DVA) was preoperatively planned. To mitigate perioperative vasospasm, a lumbar sympathetic block was administered 1 week prior to surgery. An in situ bypass using the ipsilateral great saphenous vein was constructed from the superficial femoral artery to the plantar artery. DVA was established via retrograde puncture of the plantar vein, balloon angioplasty for valve sites, and end-to-side anastomosis to the bypass graft. Early duplex ultrasonography revealed anastomotic stenosis at the DVA site as well as stenosis at valve sites, both of which were successfully managed with a single endovascular procedure. The toe stump healed completely within 3 months. The graft remained patent for 2 years, and SPP was preserved even after graft occlusion. Notably, graft failure coincided with DVA occlusion, suggesting its critical role in maintaining flow. At 42 months postoperatively, the patient remained ulcer-free with favorable perfusion, pain-free ambulation, and full return to work.

Conclusions: Preoperatively planned surgical DVA, in conjunction with sympathetic modulation and timely postoperative intervention, may offer a durable limb salvage strategy in advanced TAO with limited distal targets.

Introduction: Congenital anomalies of the umbilicus, including remnants of the omphalomesenteric duct and urachus, result from the incomplete regression of fetal structures around the 10th week of gestation. The coexistence of these anomalies in a single patient is exceptionally uncommon. This report presents the case of a neonate with an umbilical nodule and periumbilical cyst, subsequently identified as coexisting remnants of the omphalomesenteric duct and urachus.

Case presentation: This study reports the case of a 17-day-old female infant who presented with a small moist umbilical nodule and a persistent yellowish mucinous discharge. Initial treatment for umbilical granuloma failed to resolve the lesion. Imaging revealed a 2-cm cyst beneath the umbilicus and a cord-like structure connecting it to the bladder. Surgical exploration identified a 6-cm fibrous band extending from the cyst to the ileal wall, consistent with an omphalomesenteric duct remnant, and a 5-mm diameter urachal remnant connecting the cyst to the bladder. Histological analysis confirmed the presence of intestinal mucosa and transitional epithelium. The postoperative recovery of the patient was without complications.

Conclusions: This case elucidates the diagnostic challenges posed by persistent umbilical lesions and highlights the importance of detailed imaging and surgical exploration for identifying rare congenital anomalies. Histopathological confirmation is essential for an accurate diagnosis. Further research is required to clarify the embryological basis and clinical implications of these anomalies.

Introduction: Stanford Type A acute aortic dissection (AAD) complicated by mesenteric malperfusion has a mortality rate exceeding 60%. Conventional immediate central aortic repair may be inadequate in such complex cases. Emerging evidence suggests that a staged approach may improve outcomes.

Case presentation: A 71-year-old male presented with acute chest pain and was diagnosed with Stanford Type A AAD extending to the abdominal aorta, with superior mesenteric artery (SMA) dissection leading to intestinal ischemia. To restore intestinal perfusion, emergency endovascular SMA stenting was performed as the initial intervention, followed by ascending aorta and total arch replacement using the frozen elephant trunk technique 12 hours later. The patient recovered without complications and was discharged ambulatory on postoperative day 20.

Conclusions: This case highlights the efficacy of a staged approach prioritizing mesenteric revascularization before central aortic repair in AAD complicated by visceral malperfusion. By first addressing end-organ ischemia, we potentially mitigated the risk of irreversible bowel necrosis while enabling subsequent central aortic repair. Our experience adds to the growing body of evidence supporting individualized, pathophysiology-guided treatment strategies for this challenging clinical scenario.

Introduction: Left trisectionectomy with bile duct resection is a high-risk procedure that requires thorough preoperative evaluation to prevent postoperative liver failure. In addition, there are a few reports of highly invasive hepatectomy in cases where hepatic vein thrombosis is present preoperatively.

Case presentation: In a 58-year-old man, papillary epithelium was detected in the left hepatic duct during a bile duct biopsy, and the anterior segment of Glisson's capsule was compressed by the cystic components. Left trisectionectomy with bile duct resection was planned, based on a diagnosis of intraductal papillary neoplasm of the bile duct (IPNB). In our department, portal vein embolization (PVE) is essential when considering left trisectionectomy with bile duct resection, so surgery was scheduled after PVE. However, CT after PVE showed thrombus formation in the right hepatic vein (RHV), which persisted despite the initiation of anticoagulant therapy. Owing to the absence of a major drainage vein and the risk of postoperative liver failure, the patient was treated with gemcitabine + cisplatin + S-1 therapy. CT after chemotherapy still showed RHV thrombosis, along with newly developed peripheral venous shunt formation between the obliterated RHV branches. After 6 months, the same findings were observed, and as the tumor had shrunk, the case was deemed resectable. Left trisectionectomy with bile duct resection was performed. Pathological diagnosis confirmed IPNB (pTisN0M0, pStage 0 according to the Union for International Cancer Control, 8th edition). Following adjuvant chemotherapy, the patient developed pulmonary metastases, which were surgically resected. As of 38 months post-hepatectomy, the patient remains cancer-free.

Conclusions: We encountered a case in which left trisectionectomy with bile duct resection was possible owing to the formation of an RHV shunt, enabling resection of both the primary and recurrent lesions. Continuous imaging is essential for the dynamic assessment of resectability.

Introduction: Immaturity of ganglia (IG) is a rare disease and is classified as a type of allied disorders of Hirschsprung's disease (HSCR). Recently, familial occurrence of HSCR has often been reported. However, there have been very few reports of familial occurrence of IG. We report 3 cases of intrafamilial occurrence of IG.

Case presentation: Case 1 was an older brother. He was born vaginally at 40 weeks and 6 days of gestation, weighing 3658 g. No prenatal diagnosis was made. On the day of birth, abdominal distention appeared, and a gastric tube was inserted. On the 1st day of life, colonography showed microcolons throughout the colon. We diagnosed gastrointestinal obstruction or Hirschsprung's disease and performed surgery on the same day. Cases 2 and 3 were monozygotic twins. They were born vaginally at 37 weeks and 0 days, weighing 2778 and 2810 g, respectively. Neither of them had a prenatal diagnosis. On the 1st day of life, abdominal distention, malfeeding, and delayed evacuation of feces were observed, and colonography was performed. Due to the presence of microcolons throughout the colon, we decided to operate on them. In all 3 cases, ileostomies were created, and the stomas were closed after 6 months. They began oral intake and infusion early on, and anal defecation was established. Also, immature ganglion cells were confirmed by HuC/D staining during the 1st operation. At the time of stoma closure, we confirmed that ganglion cells had matured.

Conclusions: IG, like HSCR, may have intrafamilial onset. Therefore, early diagnosis and treatment planning are important. Also, a careful explanation to the family is essential.

Introduction: Internal hernias are rare causes of small bowel obstruction and are often difficult to diagnose preoperatively. Retro-appendicular internal hernias are exceedingly rare, with very few reports in the literature. This case is noteworthy for involving a patient with no prior history of abdominal surgery, highlighting an unusual presentation of a retro-appendicular internal hernia.

Case presentation: A man in his mid-60s, with no history of abdominal surgery, presented to the emergency department with acute right lower quadrant abdominal pain. Physical examination revealed localized peritonism, and laboratory results were unremarkable. CT showed signs of small bowel distension with segmental hypoperfusion of the bowel loop in the right lower quadrant. Given the clinical presentation of an acute abdomen, the patient underwent exploratory laparoscopy, which revealed a herniation of the small intestine into the retro-appendicular space. The herniated bowel appeared ischemic but was successfully reduced without further need for resection. The patient had an uneventful postoperative recovery.

Conclusions: This case underscores the importance of considering internal hernias in the differential diagnosis of acute abdomen, even in patients without prior abdominal surgery. Awareness of rare anatomical variants such as retro-appendicular hernias is critical, as early surgical exploration can prevent bowel necrosis and reduce morbidity. This report contributes to the limited research literature on retro-appendicular internal hernias and emphasizes the value of maintaining a high index of suspicion in atypical presentations.

Introduction: Gastric neuroendocrine carcinoma (NEC) is a rare disease among gastric cancers, accounting for only 0.1%-0.6% of all cases. This disease is known to have a poor prognosis and a higher risk of recurrence compared to conventional gastric adenocarcinoma.

Case presentation: At the age of 44, a 60-year-old female underwent a laparoscopic-assisted proximal gastrectomy for gastric cancer at a previous hospital. Neuroendocrine carcinoma was diagnosed following a postoperative pathological examination based on histological findings and immunostaining results. The patient was followed up without any recurrences. After 14 years, a follow-up contrast-enhanced CT revealed a 9-mm mass on the greater curvature side of the gastric antrum, which was suspected to be lymph node swelling at the previous hospital. After 8 months, she came to our hospital with abdominal discomfort and distention. The CT scan revealed a 55-mm mass, indicating an increase in the previously mentioned mass. At our hospital, the patient underwent open tumor resection. The pathological findings revealed a recurrence of gastric NEC. The patient has been recurrence-free for 6 months following surgery.

Conclusions: We present a case of gastric NEC with disseminated recurrence. To our knowledge, this is the first report of a disseminated case in which a recurrent lesion caused by omental dissemination grew in size and infiltrated a portion of the gastric serosa approximately 14 years after the initial surgery.