Surgical Case Reports最新文献

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: 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: Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete mirror-image transposition of thoracic and abdominal organs. Although laparoscopic colectomy in SIT has been increasingly reported, the reversed anatomy and inherent limitations of laparoscopy make such procedures technically demanding. Robotic-assisted surgery may overcome these issues by providing enhanced ergonomics and intuitive instrument control, yet reports in SIT remain scarce.

Case presentation: A 51-year-old man with SIT presented with anal bleeding and was diagnosed with sigmoid colon cancer. Preoperative CT confirmed complete visceral inversion without distant metastasis. Robotic-assisted sigmoidectomy with D3 lymphadenectomy was performed using the da Vinci Xi surgical system. A patient-specific port configuration was designed based on preoperative imaging, minimized arm collisions, and optimized instrument mobility. The procedure was uneventful, with an operative time of 232 minutes and minimal blood loss. The patient was discharged on POD 7 without complications. Histopathological examination revealed pT3, pN1a, cM0, Stage IIIB adenocarcinoma.

Conclusions: This case demonstrates that robotic-assisted colectomy can effectively overcome the ergonomic and technical challenges posed by SIT. Patient-specific port mapping, guided by preoperative imaging, is essential to maximize the benefits of robotic technology. Furthermore, this report contributes to the limited evidence supporting robotic colectomy as a feasible and advantageous approach for patients with SIT.

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.

Introduction: Cardiac metastasis from pancreatic ductal adenocarcinoma (PDAC) is extremely rare. Pleomorphic-type anaplastic carcinoma of the pancreas (PACP) is an uncommon, highly aggressive PDAC variant with lymphatic and hematogenous spread and poor prognosis. We report, to our knowledge, the first PACP case with antemortem diagnosis of cardiac metastasis and a rapidly fatal course.

Case presentation: A 75-year-old man presented with left hypochondrial pain. CT showed a 4-cm, gradually and heterogeneously enhancing pancreatic tail mass without distant metastasis. Gadolinium-enhanced MRI demonstrated peripheral progressive enhancement with internal non-enhancing areas, suggesting a non-conventional PDAC. Ultrasound-guided fine needle aspiration (EUS-FNA), nevertheless, yielded mainly scattered atypical epithelial cells with a small cohesive columnar component, and adenocarcinoma was diagnosed; further subclassification was not feasible on the limited cytologic material. Because the tumor was radiologically resectable, neoadjuvant gemcitabine plus S-1 was administered. Follow-up CT showed enlargement to 5.5 cm, new invasion of the spleen and gastric wall, and peripheral progressive enhancement-previously demonstrated on MRI-now appreciable on CT, while distant disease remained absent. Distal pancreatectomy with splenectomy, regional lymphadenectomy, and partial gastrectomy was performed. The resected specimen revealed a whitish solid tail tumor with focal hemorrhage/necrosis; histology confirmed PACP. Adjuvant S-1 was initiated 1 month postoperatively. Three months after surgery, CA19-9 increased despite no recurrence on CT. One month later he presented with exertional dyspnea and complete atrioventricular block. Echocardiography and CT showed an approximately 8-cm interatrial mass and a left-ventricular wall lesion. Retrospective review of CT performed 1 month earlier identified a 2-cm atrial nodule at the same site, indicating very rapid intracardiac growth. He was transferred to a cardiovascular center for planned pacemaker implantation, and heart-failure therapy was initiated first. During preparation he developed sudden cardiac arrest and died. Postmortem myocardial biopsy confirmed PACP metastasis.

Conclusions: Clinicians need to recognize that PACP can metastasize to the heart and incorporate this risk into routine follow-up, maintaining vigilance for imaging features suggestive of cardiac involvement and for new-onset cardiac symptoms or conduction disturbances; when cardiac metastasis is suspected, prompt evaluation and intervention are warranted.

Introduction: Recurrence of pancreatic ductal adenocarcinoma (PDAC) after primary resection remains a challenging condition, and operative indications for metachronous liver metastases are limited.

Case presentation: A 60-year-old woman with no elevation of carcinoembryonic antigen, carbohydrate antigen 19-9, and Duke pancreatic monoclonal antigen type 2 underwent a distal pancreatectomy for PDAC. Two years and 4 months after the primary surgery, metachronous liver metastases in liver segments 4 and 5 were diagnosed. After receiving 8 courses of bi-weekly gemcitabine plus nab-paclitaxel, a partial liver resection of segment 5 with radiofrequency ablation (RFA) of segment 4 was performed. A laparoscopic partial liver resection of segment 8 was performed for another liver metastasis 5 years and 2 months after the primary resection. An open partial liver resection of segment 8 was performed for the liver recurrence adjacent to the previous resection area 7 years and 2 months after the initial pancreatectomy. More than 8 years have passed since the initial pancreatic surgery, and she is currently alive without disease.

Conclusion: Multidisciplinary treatment, including chemotherapy, resection, and RFA, may increase survival time in selected PDAC patients.

Introduction: Absence of portal vein bifurcation (APB) is a rare congenital anomaly in which the main portal vein does not bifurcate at the hepatic hilum. After giving off posterior and anterior sectoral branches, the trunk curves ventrally around the middle hepatic vein-forming a so-called "portal ring"-and finally enters the umbilical portion of the left portal vein. Hepatectomy performed inside this ring risks compromising perfusion if the portal trunk is injured. We report a case in which anatomical segmentectomy (S4a+S5) was performed for the gallbladder carcinoma with this portal vein anomaly.

Case presentation: A 69-year-old man presented with 1 month of epigastric pain. Imaging revealed gallbladder carcinoma invading the gallbladder bed and liver parenchyma, together with APB confirmed by 3D reconstruction. Based on preoperative simulation, we performed anatomical resection of segments 4a and 5 with lymphadenectomy. Intraoperative ultrasonography verified the portal ring anatomy; the anterior Glissonean pedicle (G5) was ligated and the demarcation line was followed for parenchymal transection under intermittent Pringle maneuver (total ischemic time 70 minutes). Operative time was 6 hours 3 minutes, and blood loss 170 mL. Pathology showed nodular gallbladder carcinoma (UICC 8th: pT3a, pN1 [#8p, #12a], cM0; Stage IIIB) with negative margins. The postoperative course was uneventful and the patient was discharged on day 12.

Conclusions: Preoperative 3D simulation and meticulous intraoperative ultrasonography enabled safe hepatectomy inside the portal ring without compromising portal perfusion. In APB, right-sided major hepatectomy may jeopardize global portal inflow; tailored anatomical resection (S4a+S5) achieved an R0 resection while preserving perfusion.

Introduction: Takotsubo syndrome (TTS), once considered a benign self-limiting disease, is now recognized to have substantial short-term morbidity and mortality. During the acute phase, it can result in severe heart failure, cardiogenic shock, arrhythmias, cardiac rupture, ventricular septal perforation (VSP), and thromboembolic events, with in-hospital mortality rates comparable to those observed in acute coronary syndrome. Although VSP is rare, it represents a potentially lethal complication of TTS. Herein, we present a case of VSP associated with TTS and discuss a mechanism for the development of VSP in TTS.

Case presentation: A 69-year-old female presented with dyspnea. The diagnosis of TTS was established based on the presence of apical ballooning of the left ventricle (LV), hyperkinesis of the LV basal walls, normal coronary arteries, and apical defect in myocardial scintigraphy. Additionally, a VSP was identified, and given the stabilization of hemodynamics with an intra-aortic balloon pump and medical treatment, it was deemed preferable to delay surgical treatment. Approximately 1 month later, after the LV wall motion abnormality had been normalized, the VSP was successfully closed. Histopathological examination of the ventricular septum revealed contraction band necrosis along with fibrosis and focal cardiomyocyte necrosis.

Conclusions: While VSP is a potentially lethal complication of TTS, recovery of LV function can be anticipated, suggesting that surgical treatment could be deferred, provided that hemodynamic stability is maintained. This case demonstrates that focal myocardial necrosis can occur in TTS. Furthermore, increased wall tension occurs in the ballooning segments during systole, as the LV radius increases and the ventricular wall fails to thicken, in accordance with Laplace's law. Both myocardial fragility resulting from focal myocardial necrosis and increased LV wall tension due to systolic ballooning are considered to be key mechanisms underlying the development of VSP in TTS.

Introduction: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is widely used for the diagnosis of pancreatic cancer, other pancreatic tumors, and autoimmune pancreatitis. Among the adverse events, needle tract seeding (NTS) is the most concerning. NTS is a phenomenon in which tumor cells are observed at the site of biopsy needle passage. We herein report a case of multiple gastric wall recurrences resulting from NTS after laparoscopic distal pancreatectomy for pancreatic tail cancer.

Case presentation: A 71-year-old woman was diagnosed with pancreatic tail adenocarcinoma using EUS-TA and underwent laparoscopic distal pancreatectomy following neoadjuvant chemotherapy. Three and a half years postoperatively, two submucosal gastric lesions were identified and histologically confirmed as NTS. Since there was no recurrence at any site other than the site of NTS on close examination, a total gastrectomy was performed with postoperative adjuvant chemotherapy, and the patient remained recurrence-free.

Conclusions: We report a case of multiple synchronous NTS after EUS-TA. EUS-TA is a very useful examination method for pancreatic tumors; however, it should be performed with particular care in cases of invasive pancreatic ductal carcinoma after distal pancreatectomy. If NTS in the gastric wall is detected at an early stage, surgical resection is possible and the patient prognosis can be improved.

Introduction: Brain metastasis from intrahepatic cholangiocarcinoma (ICC) is a rare condition with a poor prognosis, and no standard treatment has been established. This report aims to present a case of solitary ICC brain metastasis successfully treated with a multimodal approach guided by comprehensive genomic profiling (CGP).

Case presentation: A 64-year-old man, who had undergone a left hepatectomy for ICC 15 months prior, presented with recent memory difficulties. A brain MRI revealed a solitary 39-mm ring-enhancing mass in the left temporal lobe. The patient underwent surgical resection of the brain tumor, and histological examination confirmed the lesion was a metastasis from the primary ICC. Postoperatively, he received systemic therapy consisting of gemcitabine, cisplatin, and durvalumab. CGP on the resected brain specimen revealed a high tumor mutational burden status (23 mutations/Mb) and microsatellite stability. At the 8-month follow-up after the craniotomy, the patient remains disease-free with no signs of recurrence.

Conclusions: This case suggests that an integrated approach, combining aggressive local therapy with systemic immunotherapy informed by biomarkers, can achieve a favorable outcome in selected patients with ICC. The identification of a high tumor mutational burden was crucial in guiding treatment and supports its potential as a predictive biomarker. This precision oncology strategy may improve the poor prognosis associated with this condition.