Surgical Case Reports最新文献

Introduction: Chylothorax is one of the complications in cardiovascular surgery. Although prolonged chylothorax leads to critical status and is associated with high mortality, its treatment has not been well established. We present a successful case of surgical treatment of chylothorax in a neonate using indocyanine green to identify the site of lymphatic leakage.

Case presentation: The patient with complete atrioventricular septal defect, patent ductus arteriosus, pulmonary hypertension, and chromosomal abnormality with trisomy 21 underwent pulmonary artery banding and patent ductus arteriosus ligation through median sternotomy. The postoperative course was complicated with chylothorax; conservative treatment was not effective, so surgical treatment was selected. Indocyanine green was injected subcutaneously between the first and second toes on the left side 30 min before surgery to identify the site of leakage. We could detect the lymphatic leakage from the para-aortic lymph node by indocyanine green camera in the left thoracic cavity, and the leakage sites could be closed with interrupted sutures.

Conclusion: Identification of lymphatic leakage sites using indocyanine green could be an effective technique in the surgical treatment of chylothorax in pediatric patients.

Introduction: Carcinoma of unknown primary (CUP) is rarely located in the mediastinum. Most cases are revealed to be metastatic lymph node carcinoma, which carries a poor prognosis. The optimal treatment for CUP confined to the mediastinum is yet to be established, and the long-term outcome of induction therapy in combination with surgery for mediastinal CUP is unclear.

Case presentation: A 46-year-old man with no history of malignancy was diagnosed with anterior mediastinal adenocarcinoma through biopsy. The patient underwent chemoradiation for the tumor, which was initially suspected as invasive T4 lung cancer. After a favorable response to presurgical therapy, the tumor was deemed more likely a mediastinal tumor, and it was completely resected simultaneously with the thymus, the partial left lung, and the partial left innominate vein. The tumor contained histologic features identifiable as a lymph node tissue and lacked any thymic tissue, which led to the final diagnosis as metastatic lymph node adenocarcinoma; however, its origin was unknown. No signs of recurrence were detected for 13 years after surgery.

Conclusions: Our case suggests that even patients with mediastinal CUP deemed an advanced disease can achieve long-term survival after undergoing induction therapy and definitive surgery.

Introduction: Localized cystic lymphangiomas (CL) are rare benign tumors deriving from the lymphatic system. CL is diagnosed more frequently in children than in the adult population and, although commonly affecting the cervical and axillary regions, can develop in various parts of the body. Abdominal cystic lymphangioma (ACL) comprises less than 5% of all CL cases.

Case presentation: A 35-year-old female patient with a history of benign appendectomy in childhood was transferred to our tertiary center for the operative management of a suspected extensive pseudomyxoma peritonei (PMP). In accordance with the multidisciplinary team discussion, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was planned. Intraoperatively, a typical "jelly belly" with high disease burden throughout the abdominal cavity and the small pelvis was found. A multi-visceral resection with complete cytoreduction (CCR 0) was performed. The postoperative histopathological findings revealed a diffuse, partially cystic lymphangiomatosis involving the peritoneum extensively without evidence of PMP or malignancy.

Conclusions: ACLs are uncommon in the adult population, and diffuse peritoneal involvement is even rarer. Surgical management with complete resection is the preferred treatment option. Other benign cysts, as well as infectious diseases and malignancy, should be considered during the preoperative workup.

Introduction: Recently, neoadjuvant immunotherapy plus chemotherapy has been provided for patients with stage II-III resectable lung cancer. We report a case in which a pneumonectomy was avoided by administrating neoadjuvant chemoimmunotherapy.

Case presentation: An 81-year-old man presented with a cough. Examination showed squamous cell lung cancer in the right lower lobe extending to the central side of the upper lobe, which would have required a pneumonectomy for complete resection. Neoadjuvant chemoimmunotherapy was administered to reduce the extent of pulmonary resection due to the patient's advanced age and impaired pulmonary function. Post-treatment examination showed tumor size reduction, and bronchoscopy showed disappearance of right upper bronchial erythema and persistent erythema of the bronchus intermedius. A sleeve right lower lobectomy was performed. Histopathological findings revealed complete resection of the cancerous lesion and a major pathological response.

Conclusions: Sleeve lobectomy after preoperative chemoimmunotherapy for an elder patient with low pulmonary function was safe and efficient.

Introduction: Neoadjuvant, adjuvant, and perioperative immune checkpoint inhibitor (ICI) regimens for treating locally advanced lung cancer have dramatically evolved in recent years. Despite these immunotherapies being very promising, they can be associated with potential life-threatening immune-related adverse events (irAEs), and there is not much awareness regarding irAEs in surgical regimens.

Case presentation: A Japanese man in his 70s was diagnosed with right upper lobe lung adenocarcinoma (cT3N1[#12u]M0, parietal pleural invasion, cStage IIIA), with the programmed death-ligand 1 expression level of <1%. He underwent right upper lobectomy via open thoracotomy followed by 3 cycles of neoadjuvant cisplatin, pemetrexed, and nivolumab. The pathological response rate was 50% and the pathological stage was ypT2bN0M0, ypStage IIA. Seven months after the surgery, he experienced gradually worsening anorexia, fatigue, and hyponatremia. He was diagnosed with pituitary adrenal insufficiency induced by neoadjuvant immunotherapy by the 100 μg corticotropin-releasing hormone stress test. Cardiogenic shock caused by takotsubo cardiomyopathy occurred, and intensive treatment was performed. Steroid therapy was effective, but the physical dysfunction persisted, although no recurrence of lung cancer was observed.

Conclusions: Patients receiving neoadjuvant immunotherapies can develop life-threatening irAEs late in the postoperative period. Surgeons who follow up patients after neoadjuvant immunotherapies must be as vigilant regarding the development of irAEs in the postoperative phase as clinical oncologists.

Introduction: In laparoscopic gastrectomy, accurate marking of the lesion site is essential in determining the resection line of the stomach, owing to the lack of haptics and the direct link between negative pathological margins and prognosis. Intraoperative endoscopy may require personnel and prolong the operation time, whereas preoperative endoscopic tattooing using India ink faces problems related to the spread of ink and visibility. ZEOCLIP FS (Zeon Medical, Tokyo, Japan) is a clip made of fluorescent resin, covered by insurance since March 2019. It can be visualized from the serosal side using a near-infrared scope; however, its weak fluorescence intensity often poses viewing difficulties. Lumifinder (ADVANTEST, Tokyo, Japan) is a laparoscopic fluorescence spectrum system available for clinical use since February 2023. It can measure fluorescence intensity using a near-infrared laser and detect weak fluorescent signals. We report a case of gastric cancer in which the location of the lesion was confirmed intraoperatively using ZEOCLIP FS and Lumifinder.

Case presentation: A man in his 80s was diagnosed with gastric cancer following an examination for anemia. Two lesions were found: a 0-IIc type (cT1) at the lesser curvature of the gastric angle and a type 1 tumor (cT2) at the anterior wall of the upper gastric body. The preoperative assessment indicated no lymph node or distant metastasis. The tumor was diagnosed as cStage I and laparoscopic distal gastrectomy was planned. Two ZEOCLIP FS clips were placed on the oral side of the tumor on the anterior wall of the upper gastric body on the day before surgery. During surgery, fluorescent signals from the clips were detected using Lumifinder, enabling easy confirmation of the lesion location and determination of the gastric resection line.

Conclusions: The combined use of ZEOCLIP FS and Lumifinder was a useful new method for identifying the appropriate resection line of the stomach. We plan to evaluate this method further in additional cases to enhance the detection efficacy.

Introduction: A tracheal membranous injury is a known complication of tracheostomy. After esophageal resection, such injury may prove fatal. No natural buttressing of the lesion occurs, and severe sepsis and mediastinitis may occur. In these situations, a circumferential tracheal resection is the treatment of choice, sometimes on cardiopulmonary bypass. However, the outcome is not always favorable.

Case presentation: We report a case of a long tracheal membranous wall defect (> 7cm) after esophageal resection. We successfully performed a transtracheal direct repair of the defect through a partial sternotomy, and reconstructed the ventrolateral wall with a muscle flap using the right pectoralis major muscle.

Conclusion: Tracheal reconstruction through a T-shaped incision and anastomotic buttressing using a pectoralis major muscle flap could prove to be useful when reconstructing a posterior tracheal wall injury, especially after esophageal resection.

Introduction: The phosphatase and tensin homolog hamartoma tumor syndrome (PHTS) refers to a spectrum of disorders caused by variants of the phosphatase and tensin homolog (PTEN) gene, including Cowden syndrome (CS), Bannayan-Riley-Ruvalcaba syndrome, adult Lhermitte-Duclos disease, and autism spectrum disorders associated with macrocephaly. PHTS is characterized by hamartomas in multiple organs and is associated with an increased risk of developing malignant tumors including, breast, thyroid, endometrial, colorectal, and kidney tumors. Breast cancer is the most common malignancy associated with PHTS.

Case presentation: We describe the case of a 44-year-old female patient with invasive ductal carcinoma of the right breast. Cobblestone papillomatosis was present in the gingiva. She had a medical history of bilateral adenomatous goiters for 10 years. Her mother had been diagnosed with breast cancer, thyroid and tongue tumors, gastric polyps, hepatic hemangioma, and collagen disease. Additionally, the patient's maternal grandmother had a history of colon cancer. Based on the patient's family history and physical findings, CS was suspected, and direct DNA sequencing analysis revealed a haplotype c.634del mutation in exon 7 of the PTEN gene. Although there is no clear evidence supporting risk-reducing surgery for PHTS, a right nipple-sparing mastectomy, sentinel lymph node biopsy, and tissue expander reconstruction were performed.

Conclusions: We report a case of breast cancer with a newly diagnosed c.634del mutation in the PTEN gene. We also reviewed the current literature on PTEN genetic variants and breast cancer subtypes.

Introduction: Metastasis to the hilar and mediastinal lymph nodes in gynecological cancer is rare, and isolated hilar or mediastinal lymph node metastases are even rarer. In this report, we describe the results of lymph node dissection performed on 3 patients with hilar mediastinal lymph node metastasis but no lung metastasis from uterine or ovarian cancer.

Case presentation: Case 1 was a 50-year-old woman diagnosed with ovarian cancer with mediastinal lymph node metastasis. After 4 courses of chemotherapy, a total hysterectomy, omentectomy, and mediastinal lymph node dissection were performed simultaneously. The patient is still alive 58 months after surgery. Case 2 was a 68-year-old woman who underwent a total hysterectomy after chemotherapy for endometrial cancer with multiple lymph node metastases. Forty-two months after surgery, mediastinal lymph node dissection was performed for metastasis of uterine cancer. She is still alive 75 months after surgery. Case 3 was a 69-year-old woman who underwent a hysterectomy for endometrial cancer. One year after surgery, she underwent thoracoscopic hilar and mediastinal lymph node dissection due to metastasis. Thirty-nine months have passed with no recurrence. Aggressive local control, particularly surgical resection of isolated hilar mediastinal lymph nodes in gynecological cancer, may contribute to prolonging patient survival.

Conclusions: Aggressive local control, especially surgical resection, for isolated hilar mediastinal lymph nodes due to gynecological cancer is safe and may contribute to prolonging survival.

Introduction: Cystic neutrophilic granulomatous mastitis (CNGM) is characterized by granulomas with cysts that sometimes contain bacteria in the lumen, a surrounding neutrophilic infiltrate, and Langhans giant cells. There are no universally accepted diagnostic criteria for CNGM. Corynebacterium kroppenstedtii, a Gram-positive bacillus, has been reported to cause several infections, but the exact cause remains unclear. We report our experience with a case of CNGM, thought to be due to a rare Mycobacteroides abscessus infection.

Case presentation: We report the case of a 36-year-old Japanese woman with granulomatous mastitis due to Mycobacteroides abscessus who had not undergone surgery and was not immunosuppressed. She presented with a chief complaint of pain and swelling in her left breast for 1 month. Mammography showed asymmetrical focal increased density, and ultrasonography showed an irregular hypoechoic area in the left 3 o'clock position. Contrast-enhanced magnetic resonance imaging showed segmental non-mass-enhancement. Ultrasound-guided vacuum-assisted biopsy with pathology revealed granulomatous mastitis. Ziehl-Neelsen staining revealed red-staining bacilli. The patient was followed up for observation because her breast pain had decreased after the examination, and there was no redness or fever. However, the breast pain has not completely disappeared, and intermittent purulent discharge from the biopsy site persisted for 5 months. Hence, two 12-Fr drains were inserted along the ductal dilatation-like hypoechoic area. Imipenem, amikacin, and clarithromycin were administered for 8 days. After 8 days of this therapy, the patient developed a drug-associated rash; therefore, antimicrobial therapy was discontinued, and the drains were removed. Her symptoms improved, and magnetic resonance imaging after 1 month showed that the previous imaging findings in her left breast had disappeared. At the time of writing, 18 months have passed since treatment, and no recurrence has been observed.

Conclusions: We experienced a rare case of CNGM associated with Mycobacteroides abscessus. This case suggests that a combination of drainage and antimicrobial therapy may shorten the duration of antimicrobial therapy in CNGM.