Surgical Case Reports最新文献

Introduction: Intrahepatic cholangiocarcinoma (iCCA) is the second most common liver cancer and has a poor prognosis. Given the recent advancements in drug therapy, the topic of so-called "conversion surgery" in biliary tract cancer, including iCCA, is evolving; however, only a few cases have been reported.

Case presentation: A 50-year-old female was referred to our hospital for a liver tumor identified on abdominal ultrasonography. She was diagnosed with iCCA based on tumor biopsy. Due to extensive vascular and bile duct invasion, iCCA was initially considered unresectable. After 8 cycles of gemcitabine, cisplatin plus S-1 (GCS) therapy, CT revealed a partial response. Considering that microsatellite instability-high (MSI-H) was detected, we switched the regimen from GCS to pembrolizumab. However, after 1 cycle of pembrolizumab therapy, immune checkpoint inhibitor (ICI)-induced hepatitis was suspected; therefore, pembrolizumab therapy was suspended. GCS therapy was restarted, and after another 3 cycles, the iCCA was deemed resectable; therefore, conversion surgery was performed. Postoperative histopathological examination revealed a pathological complete response (pCR), and the patient remained alive more than 5 years postoperatively without recurrence or metastasis.

Conclusions: We experienced a case of pCR induced by GCS chemotherapy and pembrolizumab monotherapy. Although the direct contribution of pembrolizumab remains unclear, a possible synergistic effect with GCS chemotherapy was suggested, particularly in MSI-H tumors.

Introduction: A bladder hernia associated with bladder calculi is an extremely rare condition, with no consensus established regarding its management. Herein, we report a case in which 1-stage surgical treatment was performed for a bladder hernia complicated by bladder calculi.

Case presentation: The patient presented with a swelling in the right inguinal region. CT revealed a bladder hernia accompanied by multiple bladder calculi. An inguinal incision was made, the bladder stones were removed, and hernia repair was performed using the Lichtenstein method. At 3 years postoperatively, there was no recurrence of either bladder calculi or hernia.

Conclusions: For inguinal hernias accompanied by bladder calculi in which transurethral lithotripsy is challenging, open surgical fragmentation of bladder calculi and inguinal hernia repair by using the Lichtenstein method through the same surgical field may be useful approaches.

Introduction: Although breast cancer occurring within a phyllodes tumor (PT) has been reported, it is extremely rare in young patients. Herein, we describe a case of breast cancer complicated by a PT in a 21-year-old female.

Case presentation: A 21-year-old female was referred to our hospital with a rapidly growing breast mass and suspected PT. Mammography revealed a well-defined, high-density mass. Ultrasonography revealed a blood-flow-rich hypoechoic mass with multiple slit structures, and MRI revealed a heterogeneous high signal on T2 weighted image with some diffusion restriction. A core needle biopsy revealed fibroepithelial lesions, and the lack of stromal changes suggested a high possibility of fibroadenoma. Based on the clinical and imaging findings, we considered the possibility of the PT being more than borderline malignant and planned tumor resection with a safety margin. The postoperative pathology revealed a benign PT complicated by invasive ductal carcinoma, with a predominance of intraductal carcinoma.

Conclusions: We report the case of a 21-year-old female with breast cancer occurring within a PT. The presence of cancer was difficult to predict preoperatively based on the patient's young age and imaging findings.

Introduction: Parastomal hernia is a common complication of stoma creation; however, gastric involvement is extremely rare, with only approximately 2 dozen cases reported. Gastric incarceration in a parastomal hernia can cause severe complications, including gastric outlet obstruction and ischemia, and requires timely surgical management.

Case presentation: We describe the case of a 57-year-old obese female who underwent transverse colostomy for ischemic colitis and presented with upper abdominal pain and vomiting. She had a history of Buerger's disease, bilateral lower limb amputation, central adrenal insufficiency, and recurrent colonic stoma prolapse requiring colonic resections. CT revealed gastric outlet obstruction due to stomach incarceration within the parastomal hernia sac. After stabilization of her general condition and nasogastric decompression, she underwent laparoscopic repair 18 days after admission. Intraoperatively, the stomach was incarcerated by traction on the gastrocolic ligament. The gastrocolic ligament was divided, and the stomach was dissected from the mesocolon to maintain a safe distance from the stoma and prevent further traction by the colon. The hernia defect was closed using barbed sutures, followed by laparoscopic Sugarbaker repair with mesh placement. Her postoperative course was uneventful, and no recurrence was observed at 10 months of follow-up.

Conclusions: We present a rare case of parastomal hernia with gastric incarceration that was successfully managed using laparoscopic Sugarbaker repair. Sufficient gastric mobilization, including division of the gastrocolic ligament and dissection from the mesocolon, is essential to ensure mesh coverage of the hernia defect and minimize recurrence risk.

Introduction: Thyroid transcription factor-1 (TTF-1) is a well-established immunohistochemical marker for tumors of lung and thyroid origin. Metastatic adenocarcinomas are often tested for TTF-1 expression to identify their primary site. Herein, we report a rare case of TTF-1-positive primary gastric adenocarcinoma that was initially misdiagnosed and treated as postoperative gastric metastasis from primary lung cancer.

Case presentation: A 58-year-old man underwent thoracoscopic right upper lobectomy with systemic lymph node dissection for lung cancer of the right upper lobe. The pathological diagnosis was invasive adenocarcinoma (pT2bN0M0, Stage IIA). He received 3 courses of postoperative adjuvant platinum doublet chemotherapy. One year and 2 months after surgery, he was diagnosed with gastric and adrenal tumors. Immunohistochemical analysis of the gastric lesion demonstrated TTF-1 positivity, leading to the diagnosis of gastric and adrenal metastatic recurrence of lung cancer. The patient received triple therapy with carboplatin, pemetrexed, and pembrolizumab, followed by maintenance therapy with pemetrexed and pembrolizumab. During treatment, the adrenal metastasis achieved a complete response; however, the gastric lesion showed gradual progression on endoscopic follow-up. As primary gastric cancer could not be ruled out, the patient underwent robot-assisted distal gastrectomy with D2 lymph node dissection and Billroth I reconstruction, 3 years and 4 months following lung resection. Immunohistochemical staining of the gastric tumor revealed adenocarcinoma that was positive for TTF-1 and caudal-related homeodomain protein 2 (CDX2) and negative for napsin A. In contrast, lung cancer tissue was weakly positive for TTF-1 and negative for napsin A and CDX2. Based on the immunohistochemical staining and histological findings, the final diagnosis was primary gastric adenocarcinoma. The postoperative course was uneventful, and maintenance chemotherapy with pemetrexed and pembrolizumab was resumed. Four years and 10 months after cancer surgery, the patient remains in complete response.

Conclusions: This case highlights the diagnostic challenge posed by TTF-1-positive gastric tumors, which may be mistaken for metastatic lesions from lung cancer. As TTF-1 expression is not entirely specific to tissues of lung or thyroid origin, diagnosis should be based on a comprehensive evaluation of morphological and immunohistochemical findings, together with clinical information, including treatment response and disease course.

Introduction: Recurrence of colon cancer after 5 years or longer from primary surgery is relatively rare and furthermore, isolated metastasis to the duodenum is extremely rare.

Case presentation: The patient was a 79-year-old male. He underwent laparoscopic partial colectomy with radical lymphadenectomy for transverse colon cancer. Pathohistological examination revealed that the tumor stage was T4aN0M0, resulting in R0 resection. An oral adjuvant chemotherapy was administered only one course due to side effects. The serum carcinoembryonic antigen level began to increase after 5 years and 1 month postoperatively. An upper gastrointestinal endoscopy at 6 years postoperatively revealed a submucosal tumor at the inferior duodenal angle, and subsequent endoscopic ultrasound-fine needle aspiration confirmed the diagnosis of duodenal metastasis from transverse colon cancer. As no other metastatic lesion was detected, open partial duodenectomy was undergone and R0 resection was achieved. The patient has been under regular follow-up without adjuvant chemotherapy and has survived without recurrence for 2 years since the second surgery.

Conclusions: Although extremely rare, the possibility of isolated duodenal recurrence after surgery for colon cancer exists. With a brief review of the literature, we report here a rare recurrence case of transverse colon cancer which was discovered at 6 years postoperatively and resulted in curative resection.

Introduction: Radiotherapy for pelvic malignancies contributes to improved patient survival. However, early and late radiation-induced complications are increasing and cause significant impairment of quality of life. We reported a case of late radiation-induced enteritis associated with an enterocutaneous fistula suggestive of enterolith, which required 2 times of surgical treatments.

Case presentation: A 70-year-old female in a postoperative state of bladder cancer was treated with neoadjuvant chemotherapy followed by surgery. Total radiotherapy at 61.2 Gy was performed 1 month after surgery. The patient had intestinal obstruction 6 months after completing irradiation. As the intestinal obstruction was refractory to conservative treatment, she underwent surgical treatment. Because of the difficulty of adhesiolysis, bypass surgery between the jejunum at 150 cm from the Treitz ligament and the ascending colon was performed. The postoperative course was good. However, an enterocutaneous fistula, likely associated with an enterolith, occurred 45 months after surgery. The development of enterolith was considered to be due to intestinal stenosis associated with late-induced radiation injury. Because the conservative treatment did not improve, she had to undergo surgical treatment. The surgical findings showed that most of the small intestine was adhered and immobilized. An enterocutaneous fistula was formed through the abscess with an enterolith. A massive intestinal resection was performed, resulting in a short bowel syndrome. Macroscopically, edematous changes in the submucosal layer of the wall and thickening of the ileum were observed. Histopathological examination revealed fibrosis and vascular obstruction in the mesentery. Atrophy and reduced crypts of the villi, as well as eosinophil infiltration, were observed, indicating the occurrence of late radiation injury. Therefore, we diagnosed that enterolith due to radiation-induced late enteritis caused intestinal obstruction and enterocutaneous fistula. Three years after intestinal resection, there was no recurrence of bowel obstruction and no evidence of severe malnutritional status.

Conclusions: Radiotherapy improves the survival of cancer patients. Nevertheless, irreversible and progressive late radiation-induced enteritis needs to be considered. Intensive follow-up is required to avoid severe complications or provide early treatment.

Introduction: Postoperative aspiration pneumonia is an uncommon but severe pulmonary complication, particularly in older adults with cognitive impairment. We report an autopsy case of fulminant aspiration pneumonia, caused by food aspiration following colorectal cancer surgery, that progressed to tension pyopneumothorax.

Case presentation: A male aged ≥75 years with dementia underwent laparoscopic high anterior resection for rectal cancer and resumed oral intake after passing a water-swallowing test. Shortly thereafter, he developed rapidly progressive pneumonia, hypoxemia, and septic shock, ultimately progressing to bilateral tension pneumothorax and death. Autopsy revealed multiple pulmonary abscesses, extensive lobular pneumonia, and subpleural fistulae in all lobes of both lungs. Grocott staining identified vegetable matter consistent with aspirated food, and colonies of Actinomyces species were also present, confirming aspiration pneumonia complicated by lung abscesses. Multiple pleural surface perforations from these abscesses likely caused substantial air leakage into the pleural space, culminating in uncontrolled tension pyopneumothorax. No histological signs of chronic aspiration were found.

Conclusions: In older adults with dementia, massive food aspiration can lead to fatal pneumonia with progression to pyopneumothorax, even in the absence of prior aspiration history. Vigilance is essential when resuming oral intake in such patients after surgery.

Introduction: Esophageal cancer is often diagnosed at an advanced stage and with distant metastases. While cardiac metastases from solid tumors have been reported in 0.2%-6.5% of postmortem cases, solitary cardiac metastases remain exceedingly rare. Infective endocarditis, a life-threatening condition typically associated with valvular involvement and bacteremia, has not been widely associated with cardiac metastases. Here, we present an extremely rare case of esophageal squamous cell carcinoma directly invading the left atrium during chemotherapy, which was further complicated by infective endocarditis.

Case presentation: A 52-year-old female who presented with chest and back pain and progressive dysphagia was diagnosed with esophageal squamous cell carcinoma following an endoscopic biopsy. Chemotherapy and chemoradiotherapy resulted in inadequate tumor control. During the second course of second-line chemoimmunotherapy, the patient developed a high fever, followed by seizures and loss of consciousness, and required emergency intubation. Echocardiography revealed a mobile mass 5 × 30 mm in size attached to the posterior wall of the left atrium. To prevent further embolic complications, emergency surgery was performed, which revealed a tumor invading the left atrial wall. Histopathological findings revealed a necrotic mass containing keratinizing squamous cell carcinoma fragments and a septic thrombus, consistent with infective endocarditis originating from the tumor surface. The patient did not regain consciousness following surgery, possibly because of hypoxic-ischemic brain injury following seizure-induced hypoxemia. Infection control remained poor, and the patient died of sepsis on POD 56.

Conclusions: Direct invasion of the left atrium by esophageal squamous cell carcinoma is rare, and infective endocarditis arising from tumor surfaces within the cardiac chamber is exceptionally uncommon, particularly in immunosuppressed patients. In this case, surgery was performed to prevent further embolic events and remove the infected tumor mass. Although the direct source of the infection was surgically removed, infection control remained difficult, likely due to persistent infection under immunosuppressive conditions and the use of cardiopulmonary bypass. This case highlights the challenges of managing infective endocarditis in patients with cancer and suggests that early surgical intervention may help reduce embolic risk, even when complete infection control cannot be achieved.

Introduction: A pancreatic pseudoaneurysm is a rare but potentially life-threatening complication of pancreatitis. Although pseudoaneurysms typically arise from the splenic, gastroduodenal, or pancreaticoduodenal arteries, transverse pancreatic artery involvement is uncommon. Here, we report the case of a pseudoaneurysm in the transverse pancreatic artery that presented with repeated episodes of obscure gastrointestinal bleeding over an extended period, with a clinical course suggestive of pancreatic duct rupture.

Case presentation: A 49-year-old male with chronic alcohol-related pancreatitis was brought to our hospital via ambulance because of abdominal pain and lower gastrointestinal bleeding. He had a history of recurrent obscure gastrointestinal bleeding for >11 years, with no source identified despite repeated upper and lower endoscopies, capsule endoscopy, and double-balloon enteroscopy. On admission, the patient was hemodynamically stable and had mild anemia. Contrast-enhanced CT revealed pancreatic calcifications, and upper endoscopy revealed bleeding from the major duodenal papilla. Angiography revealed a pseudoaneurysm in a tortuous branch of the transverse pancreatic artery. Coil embolization was attempted but could not be completed due to anatomical complexity. Rebleeding occurred during the procedure, prompting an emergency distal pancreatectomy and splenectomy. Surgical resection was achieved, and the patient recovered uneventfully with no recurrent bleeding at 6 months of follow-up.

Conclusions: Although rare, pseudoaneurysms arising from the transverse pancreatic artery can cause life-threatening hemorrhages in the pancreatic duct. In such cases, early recognition, prompt angiographic investigation, and appropriate surgical intervention are critical for successful management.