Surgical Case Reports最新文献

Introduction: Intrahepatic cholangiocarcinoma (ICC) is the second most common liver malignant tumor with a poor prognosis. Lymph node (LN) metastasis is found in 15% of ICC at the time of initial diagnosis. However, the LN metastasis to the anterior mediastinum is extremely rare. Herein, we report a case of anterior mediastinal LN metastasis of ICC.

Case presentation: The patient is a 74-year-old man who had surgery for cervical esophageal cancer. During follow-up, a low-density hepatic tumor and swollen LNs in the anterior mediastinum were detected. The tumor of the liver was diagnosed as ICC by needle biopsy. Excisional biopsy of the LN was performed and the diagnosis was metastasis of ICC. Because the prognosis of the patient with ICC Stage IVB is poor, the patient received 8 courses of chemotherapy. Although the new lesion appeared next to the main tumor, these tumors were located in the left liver. In addition, it was difficult for the patient to continue the chemotherapy due to the renal dysfunction. Hepatectomy with lymphadenectomy was performed. The patient survives without recurrence for 9 months after surgery. This is the first report of anterior mediastinal metastasis of ICC without any other organ involvement.

Conclusions: Metastasis to the anterior mediastinum of hepatic tumor can be explained by the system that lymphatic fluid running under the capsule of the liver drains to the anterior mediastinal LNs through the coronary ligament. Metastasis of ICC to mediastinal LNs can occur when the tumor is located at the surface of the liver. Excisional biopsy is effective in determining the accurate disease stage and the treatment strategy.

Introduction: Gastrointestinal duplication is a rare congenital anomaly, usually occurring in childhood and rarely in adults. It is most common in the ileum, but can occur anywhere in the gastrointestinal tract from the mouth to the anus. An adult case of intestinal duplication is accompanied by non-specific symptoms and, hence, it is often difficult to establish accurate diagnosis preoperatively in adults.

Case presentation: We experienced two cases of ileal duplication that was manifested as acute abdomen. In both cases, we performed emergency surgery with a tentative preoperative diagnosis of perforation peritonitis related to intestinal duplication. The first case was a 36-year-old male presenting with a cystic non-communicating intestinal duplication, which was perforated, causing abdominal pain. The second case was a 77-year-old male presenting with tubular communicating intestinal duplication, in which a fecal stone was fitted into the root of the duplicated intestine, and the duplicated intestine itself became abscessed, causing abdominal pain. Their postoperative courses were uneventful and the patients were discharged from hospital without any sequelae on the 5th and 10th postoperative day, respectively.

Conclusion: Although preoperative diagnosis is not easy, because the clinical presentation varies depending on the occurrence site, in-depth evaluation of preoperative CT images could lead to a precise diagnosis especially when considering intestinal duplication as one of the differential diagnoses of acute abdomen.

Introduction: Tracheal injuries due to blunt force trauma are rare yet life-threatening conditions, comprising only 4% of chest trauma cases. Diagnosis is often delayed, increasing the risk of severe complications. This report describes a unique case of tracheal obstruction caused by thyroid gland extension into the trachea following blunt trauma, which was managed successfully with venovenous extracorporeal membrane oxygenation (ECMO) and surgery.

Case presentation: A 50-year-old male presented with severe respiratory distress following a seizure-induced fall at his residence. On arrival at the hospital, the patient was in respiratory failure with an SpO₂ of 92% on a 10 L/min reservoir mask, had severe subcutaneous emphysema, and an upper airway stridor. Computed tomography revealed mediastinal emphysema and a 13-mm endotracheal mass obstructing the trachea. Flexible bronchoscopy indicated a suspected tracheal tumor, but intubation was unsuccessful due to bleeding and obstruction. Emergency tracheostomy was considered but deemed risky because imaging showed that the distal trachea was located near the sternum's suprasternal margin. The patient's respiratory distress worsened, and his SpO₂ dropped to 86%. Venovenous ECMO was then administered, stabilizing his condition. Surgical intervention was performed to address the endotracheal mass and tracheal injury. A transverse neck incision allowed dissection and identification of the tracheal injury, revealing the inferior thyroid gland which extended into the tracheal lumen. Pathological examination confirmed the endotracheal mass as normal thyroid tissue. Tracheal anastomosis was successfully completed, and the patient was discharged on postoperative day 10 without complications.

Conclusion: This case highlights an unusual presentation of tracheal obstruction caused by thyroid gland extension into the trachea following blunt trauma. Rapid initiation of ECMO enabled successful airway management and surgical repair. Recognizing atypical presentations of tracheal injuries is critical in trauma cases, as prompt intervention can prevent further complications and improve patient outcomes. This case underscores the importance of tailored airway management and the potential role of ECMO in cases of similar complex airway obstructions.

Introduction: Kartagener's syndrome (KS) is a rare disease characterized by a triad of situs inversus totalis, chronic sinusitis, and bronchiectasis. The disorder is caused by a hereditary genetic abnormality that impairs ciliary movement. Although aberrant pass course of the inferior laryngeal nerves due to visceral inversion should be considered during thyroid surgery in patients with KS, no report of surgical treatment for Graves' disease (GD) in patients with KS has been found to date.

Case presentation: A Japanese male in his 40s was referred to our hospital for surgical treatment for drug-refractory GD. He was diagnosed to have KS by genetic alteration of the DNAH5 gene as well as clinical triad. No abnormal branching in the mediastinal great vessels was identified in the present case, and left-sided non-recurrent inferior laryngeal nerve (NRLN) was not observed during surgery. Previous literature has demonstrated that the presence of a right-sided aortic arch and an anomalous branch of the left subclavian artery, as well as the absence of a left ductus arteriosus demonstrable on preoperative imaging studies, are prerequisites for the development of the extremely rare left-sided NRLN.

Conclusion: We reported the first case of surgical treatment for GD in a patient with KS and discussed the preoperative diagnosis of NRLN.

Introduction: Pulmonary vein stenosis (PVS) is known as one of the chronic complications after catheter ablation for atrial fibrillation (AF). The endovascular approach is a less invasive treatment option for PVS, while pulmonary lobectomy is also chosen, especially for patients with pulmonary vein occlusion. Here, we present a case of pulmonary vein occlusion accompanied by pulmonary necrosis that was successfully treated by pulmonary lobectomy.

Case presentation: A 65-year-old man underwent catheter ablation for AF along with administration of anticoagulants at his previous hospital. After treatment for 6 months, hemoptysis appeared, and chest computed tomography (CT) showed an infiltration shadow in the lower lobe of the left lung. The patient was admitted to the hospital, and antibiotic therapy was initiated. Despite 10 days of antibiotic therapy, there was no improvement, and the lung infiltration worsened. Therefore, on the 10th day of hospitalization, the patient was transferred to our institute. A bloody lavage fluid was obtained under a bronchoalveolar lavage, suggesting alveolar hemorrhage. Then, a contrast-enhanced chest CT scan confirmed a complete occlusion of the left inferior pulmonary vein with suspicion of pulmonary necrosis. We performed a left lower lobectomy under a video-assisted thoracic approach. The lower lobe of the left lung was dark red with a bad smell, and there was 500-ml bloody pleural fluid. Intraoperative transesophageal echocardiography showed no thrombus in the inferior pulmonary vein. The surrounding tissue of the occlusion area of pulmonary vein was sclerotic and inflammatory with firm adhesions to the vagus nerve. The inferior pulmonary vein was separated on the non-hardening peripheral side of the occlusion point using a stapler. Pathological examination confirmed multiple hemorrhagic infarctions in the parenchyma. The patient was discharged on the 8th postoperative day, and there was no recurrence of hemoptysis at 6 months postoperatively.

Conclusions: We successfully treated patients with pulmonary vein occlusion following catheter ablation through pulmonary lobectomy. While endovascular treatment is less invasive and remains the first choice for PVS, lobectomy should be considered in patients with complete occlusion, especially when accompanied by pulmonary necrosis, or in recurrent patients after endovascular treatment.

Introduction: This case report presents the world's first transanal total mesorectal excision (taTME) using the Senhance Digital Laparoscopy System for rectal cancer. Senhance has been gaining attention as an advanced surgical robot, providing better visualization, stable dissection, and reduced surgeon fatigue compared to conventional methods.

Case presentation: A 68-year-old woman underwent Senhance-assisted taTME for a rectal tumor located 4 cm from the anal verge. The procedure was completed safely with a total operation time of 209 minutes, a cockpit time of 85 minutes, and a blood loss of 40 mL. Pathological evaluation confirmed complete resection (R0) with no residual cancer or lymph node metastases. The patient was discharged on postoperative day 7 without complications.

Conclusions: This case demonstrates the potential advantages of Senhance-assisted taTME, including improved visualization, stable dissection, and reduced surgeon fatigue. Further studies are needed to evaluate long-term outcomes and establish the role of this technique in rectal cancer surgery.

Introduction: Undifferentiated sarcomas of the gastrointestinal tract are rare and have poor prognoses, especially those with lymph node metastases. There is no consensus on the treatment plan. While there are reports on undifferentiated pleomorphic sarcomas of the rectum, no reports on undifferentiated rectal spindle sarcomas with lymph node metastases have been presented previously.

Case presentation: We report a case of a 97-year-old woman referred to our hospital with anal pain. Imaging findings indicated multiple tumors in the rectum below the peritoneal reflection protruding from the anus and two enlarged pararectal lymph nodes. Laparoscopic abdominoperineal resection of the rectal sarcomas with lymph node metastasis was performed to alleviate the pain with uneventful postoperative courses. The immunostaining did not reveal a trend of tumor cell differentiation. The tumor was diagnosed as undifferentiated spindle cell sarcoma based on histopathological findings. Because of advanced age, the patient is followed up on an outpatient basis without additional postoperative treatment.

Conclusion: The prognosis of undifferentiated sarcomas is poor. While radical resection is the primary treatment, the efficacy of preoperative radiation therapy, cytotoxic chemotherapy, and immune checkpoint inhibitors has been investigated recently. Accumulating cases of this disease is important to determine treatment plans, and this report is valuable in this regard.

Introduction: Pulmonary vein stump thrombosis can sometimes occur at the pulmonary vein stump after lung surgery, possibly causing systemic infarction. Here, we report a rare case of acute myocardial infarction (AMI) caused by pulmonary vein stump thrombosis after the left upper lobectomy.

Case presentation: A 43-year-old male patient with a nodule in the left lingular segment was referred to our hospital. A bronchoscopic biopsy performed at the previous hospital was negative for malignancy; however, the nodule was highly suspicious of primary lung cancer. Therefore, we decided to perform a thoracoscopic lung resection for a definite diagnosis and treatment. Lingular segmentectomy was performed to diagnose the nodule, and a rapid pathological diagnosis confirmed that the nodule was an adenocarcinoma. Subsequently, a left upper lobectomy and systemic lymph node dissection were performed. The left lingular and superior segmental veins were separately dissected using a stapler. The day after the operation, the patient suddenly developed cardiac arrest. Cardiopulmonary resuscitation and venoarterial extracorporeal membrane oxygenation were immediately initiated. After the return of spontaneous circulation was obtained, contrast computed tomography was performed, which suggested thrombosis of the pulmonary vein stump without any signs of brain hemorrhage or infarction. As intermittent ventricular fibrillation persisted, the patient underwent coronary angiography and was diagnosed with AMI due to pulmonary vein stump thrombosis. The thrombosis of the coronary artery was removed using percutaneous coronary intervention. The patient recovered gradually after the intervention and was discharged 2 weeks later from the intensive care unit. One month after rehabilitation for higher brain dysfunction, the patient was discharged from our hospital without any sequelae and received adjuvant chemotherapy for lung cancer.

Conclusions: We encountered a case of AMI caused by pulmonary vein stump infarction after the left upper lobectomy. Given that this complication is rare but lethal, clinicians should consider it and take great care of the residual length of the pulmonary vein stump to prevent thrombosis.

Introduction: Signet ring cell carcinoma (SRC) of the gallbladder is a rare type of gallbladder cancer. We report a case of SRC of the gallbladder that was characterized by the diffuse presence of SRC on the gallbladder mucosa and diagnosed after cholecystectomy.

Case presentation: A 40-year-old man was referred to our department with upper abdominal pain and vomiting. Based on the findings of blood tests, computed tomography, and magnetic resonance imaging, acute cholecystitis was suspected, and emergency laparoscopic cholecystectomy was performed. Intraoperative findings showed mild inflammation. Although the tumor remained within the mucosa, tumor cell infiltration was suspected at the edge of cystic duct pathologically. Although additional endoscopic ultrasound and endoscopic retrograde cholangiography showed that horizontal extension into the residual cholecystic duct was suspected, there was no evidence of invasion into the common bile duct, lymph node metastasis, or distant metastasis. One and a half months after cholecystectomy, the patient underwent extrahepatic bile duct resection, lymph node dissection, and bile duct jejunal anastomosis. The postoperative course was uneventful, and the patient was discharged on the 10th postoperative day. Postoperative pathological analysis showed no obvious residual tumor tissue in the common bile duct or choledochal duct margins, and no metastasis in the submitted lymph nodes. Based on the above, a diagnosis of pT1aN0M0, pStage IA SRC was made. As no lymph node metastasis was observed, it was decided to follow up the patient without initiating postoperative chemotherapy, and the patient has been recurrence-free for 12 months after surgery.

Conclusions: We describe an incidentally discovered case of intramucosal SRC diffusely spreading throughout the gallbladder after cholecystectomy for acute cholecystitis.

Introduction: Biliary intraepithelial neoplasia (BilIN) is defined as a bile duct epithelial tumor with intraductal papillary neoplasia of the bile duct. BiIlN is a precancerous lesion of intrabiliary neoplasia. We performed laparoscopic hepatic resection for recurrent cholangitis due to intrahepatic lithiasis and diagnosed BilIN. This case suggests that it is necessary to consider the possibility of malignancy in cases of repeat cholangitis due to intrahepatic lithiasis.

Case presentation: A 34-year-old man developed cholecystitis due to gallstones at the age of 25 years and underwent laparoscopic cholecystectomy at the age of 26 years. One year later, cholangitis developed, and 2 years later, acute pancreatitis developed due to bile duct stones. Three years later, at the age of 31 years, he underwent endoscopic lithotripsy for bile duct stones and cholangitis. At that time, intrahepatic lithiasis was also detected in segment 6, but there was no stricture in the bile duct, and he was kept under observation. Three years later, at the age of 34 years, cholangitis in the bile duct of segment 6 was observed, and endoscopic nasobiliary drainage was performed. At that time, no strictures or common bile duct stones were found in bile duct of segment 6; however, we decided to perform laparoscopic hepatic resection of the ventral region of segment 6 because of the recurrent cholangitis. Pathological examination revealed bile duct inflammation and BilIN-1 in the bile duct epithelium; the bile duct stump was negative.

Conclusions: We experienced a case of a young patient with recurrent cholangitis due to intrahepatic lithiasis and diagnosed BilIN after laparoscopic hepatectomy. In such a case, it is also necessary to select a strategy that considers the coexistence of precancerous lesions, such as BilIN.