Surgical Case Reports最新文献

Introduction: With advances in laparoscopic surgery, more sophisticated vessel-preserving techniques have become standardized. Laparoscopic partial colectomy aimed at maximizing colonic preservation is now widely performed. Along with this trend, cases of ischemic colitis developing after colorectal cancer surgery have occasionally been reported; however, cases requiring surgical resection remain exceedingly rare. Here, we report a case of ischemic colitis that developed 2 years and 2 months after partial laparoscopic resection of the descending colon, necessitating laparoscopic abdominoperineal resection.

Case presentation: A 65-year-old male underwent laparoscopic partial resection of the descending colon with preservation of the superior rectal artery to treat descending colon cancer at the age of 62 years. Two years and 2 months postoperatively, the patient developed left abdominal pain. Contrast-enhanced CT and colonoscopy revealed ischemic colitis. Because conservative management was ineffective, surgical resection was required, and laparoscopic abdominoperineal resection was performed. Histopathological examination confirmed a diagnosis of ischemic colitis. The patient was discharged 48 days after surgery.

Conclusions: Ischemic colitis occurring after colorectal cancer surgery is rare, and surgical intervention is extremely uncommon in such cases. Here, we present this case with a review of the relevant literature.

Introduction: Castleman disease is a lymphoproliferative disorder of unknown etiology, typically reported as a hypervascular tumor. Here, we report the first known case of unicentric Castleman disease in which a pseudoaneurysm developed within the tumor and ruptured spontaneously.

Case presentation: A 55-year-old male was hospitalized due to the sudden onset of epigastric pain. Contrast-enhanced CT revealed a 60-mm hypovascular mass located on the dorsal side of the pancreas, with evidence of extravasation within the tumor. Emergency angiography was performed; nonetheless, the pseudoaneurysm was not clearly identified. The patient was administered antihypertensive therapy and discharged. He was subsequently referred to our hospital for further examination and treatment. Upon reviewing the angiographic images obtained at the previous hospital, a pseudoaneurysm was retrospectively identified in a small branch of the splenic artery. Follow-up contrast-enhanced CT at our hospital showed slight tumor shrinkage and resolution of the extravasation. Although the ventral region of the tumor showed marked enhancement, no noticeable enhancement was observed in the dorsal region. Based on imaging findings, a pancreatic neuroendocrine tumor was suspected. While endoscopic ultrasonography fine-needle tissue acquisition was performed twice, a definitive diagnosis could not be made. Suspecting a pancreatic neuroendocrine tumor, we recommended surgery. The patient underwent anterior radical antegrade modular pancreatosplenectomy. Histopathological findings showed that the tumor had no continuity with the pancreatic tissue and was composed of 2 lesions. The ventral portion of the tumor showed lymphoid tissue proliferation with follicular hyperplasia. Blood vessels traversed the lymphoid follicles, and blood vessel walls showed hyalinization and thickening. No atypical lymphocytes were observed. The dorsal portion of the tumor was necrotic. Based on these findings, the patient was diagnosed with unicentric Castleman disease (hyaline vascular type). At the time of writing, there was no recurrence of the disease 24 months after surgery.

Conclusions: In Castleman disease, as demonstrated in this case, pseudoaneurysm formation may occur. In cases presenting with an intratumoral pseudoaneurysm, Castleman disease should be considered in the differential diagnosis, and angiography should be included for further evaluation and preoperative treatment.

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.

Introduction: Surgical resection of tumors compressing the suprahepatic inferior vena cava (IVC) is challenging, as such lesions may require vascular resection, reconstruction, or extracorporeal circulation. We present a case of a diaphragmatic phrenic neurilemmoma severely compressing the suprahepatic IVC and right hepatic vein, which was successfully resected laparoscopically with both thoracoscopic and laparoscopic assessment.

Case presentation: A 54-year-old woman was referred for evaluation of a thoracic mass detected during a health check-up. Enhanced CT revealed a 2.7-cm, well-circumscribed, heterogeneously enhancing round tumor compressing the suprahepatic IVC and right hepatic vein. Thoracoscopic exploration suggested that the tumor was not intrathoracic, and the right diaphragmatic nerve was identified near the lesion. Laparoscopic resection was then performed with preparation for possible open conversion. After establishing pneumoperitoneum, 4 additional ports were inserted. Dissection of the falciform and coronary ligaments exposed a well-encapsulated tumor originating from the diaphragm. The inferior diaphragmatic vein was transected using ultrasonic shears. The tumor was carefully dissected from the diaphragm without invasion into the IVC or hepatic vein. Complete resection was achieved without removal of adjacent organs, including the diaphragm. The specimen was retrieved via the umbilical incision. Operative time was 54 min, and blood loss was 2 mL. The postoperative course was uneventful. Histopathology revealed benign spindle cells arranged in a storiform pattern, confirming a benign neurilemmoma.

Conclusions: Laparoscopic resection of diaphragmatic phrenic neurilemmoma compressing the suprahepatic IVC can be safe and feasible when combined with careful intraoperative assessment. Thoracoscopic evaluation and preparation for potential vascular involvement are crucial to guide safe resection and manage possible adhesion or invasion.

Introduction: Patients with complications requiring prolonged mechanical ventilation after cardiac surgery may need a tracheostomy. However, a high rate of sternal wound infection (SWI) after tracheostomy is concerning. Cricotracheostomy is a novel method used to achieve a higher tracheal incision than that using conventional surgical tracheostomy and is often performed by otolaryngologists in patients with anatomical abnormalities. However, it may affect speech and is generally recommended only in cases where tracheal stoma closure is not considered. In addition, its usefulness after cardiac surgery has not been fully verified.

Case presentation: A female patient in her 60s was admitted for acute aortic dissection with cardiac tamponade and underwent ascending aortic replacement and pulmonary artery patch formation. On POD 7, the patient was extubated. Pericardial fenestration was performed because of pericardial effusion. On POD 14, the patient was re-intubated owing to inability to expel sputum. On POD 16, a tracheostomy was performed. A cricotracheostomy was performed to avoid SWI and because of her anatomical abnormality-a low-lying larynx. No major complications, including SWI, were observed after cricotracheostomy. On POD 41, the patient was completely weaned off the ventilator. Primary closure of the cricotracheostomy fistula was performed on POD 47, and the patient had no problems with speech or swallowing.

Conclusions: This case highlights the usefulness of cricotracheostomy after cardiac surgery. Cricotracheostomy may be an optimal method for preventing SWI and preserving vocal function after cardiac surgery.

Introduction: Axillary skip metastasis is a rare phenomenon in breast cancer and is defined as metastasis to level II or III lymph nodes without involvement of level I nodes. Interpectoral (Rotter's) nodes are situated between the pectoralis major and minor muscles and may occasionally be overlooked during sentinel node (SN) mapping. Reports of isolated interpectoral node metastases are rare. Here, we present a unique case of breast cancer with isolated interpectoral node involvement despite a negative sentinel lymph node, underscoring the clinical implications of preoperative imaging and surgical planning.

Case presentation: A 69-year-old woman was referred to our hospital after an abnormality was detected by mammography. MRI demonstrated a 20-mm enhancing breast mass located in the deep portion of the upper outer quadrant, along with a strongly enhancing 6-mm interpectoral lymph node; no suspicious axillary level I nodes were identified. The patient underwent a mastectomy with sentinel and interpectoral node biopsies. The SN was negative, whereas the interpectoral node was positive, prompting axillary dissection. Histology confirmed a 15-mm invasive ductal carcinoma, with only the interpectoral node being positive among the 12 dissected nodes. Immunohistochemistry showed an ER-positive, PgR-positive, and HER2-negative status. The patient was started on adjuvant endocrine therapy. Her postoperative course was uneventful and she remained disease-free at 54 months of follow-up.

Conclusions: This extraordinarily rare case of axillary skip metastasis limited to the interpectoral node emphasizes the potential for false-negative SN biopsies. Careful review of preoperative images, particularly MRI images, is crucial to avoid understaging. Awareness of interpectoral node involvement may help guide appropriate treatment strategies for selected patients.

Introduction: The Lichtenstein procedure is often selected for kidney transplantation (KT) recipients due to concerns about the risk of injury to the transplanted organ. However, there have been reports of complications such as ureteral obstruction in cases where the Lichtenstein procedure was performed; therefore, safer techniques and approaches must be selected. We herein report 2 cases of inguinal hernia on the transplant side after KT that were treated with laparoscopic hernia repair (transabdominal preperitoneal [TAPP]) following a careful preoperative assessment.

Case presentation: The first case was a 55-year-old man who had undergone KT 9 months earlier and developed a bulge in the right inguinal region 3 months prior to presentation. Contrast-enhanced CT was used to assess the ureteral course, and the extent of TAPP dissection was determined. Intraoperative findings revealed a direct hernia. Dissection was performed while confirming the ureteral course, and TAPP repair was completed. Postoperatively, the patient's condition progressed uneventfully without recurrence at 21 months. The second case was a 58-year-old woman who had undergone KT 1 year earlier and subsequently developed swelling in the right inguinal region. Due to deterioration of the kidney function, enhanced CT was to be avoided. Plain CT was thus performed, but the evaluation of the transplanted ureter course was difficult. Laparoscopic observation was performed to evaluate the location of the transplanted ureter and kidney. A direct hernia was recognized. After determining the dissection of exposure of the myopectineal orifice and mesh deployment, TAPP repair was performed completely. Postoperatively, the patient's condition progressed uneventfully without recurrence at 14 months.

Conclusions: A preoperative evaluation of the transplanted kidney and ureter using CT is an important surgical strategy for KT patients with groin hernias. The TAPP procedure is appropriate because it allows safe visualization of the hernia type and the transplanted ureter from the abdominal cavity and enables dissection. TAPP was considered the most appropriate surgical procedure when an adequate distance between the hernial orifice and transplanted ureter could be confirmed.

Introduction: A cancer of unknown primary site is a malignant tumor for which the primary site is unknown despite a thorough examination, and which has been histologically proven to be a metastatic lesion. Metastases to intraperitoneal and to gastric regional lymph nodes are rare.

Case presentation: A 75-year-old woman was diagnosed with a gastric submucosal tumor with infiltration to other organs. Endoscopic ultrasound-guided fine needle aspiration revealed cells that appeared to be derived from epithelial tissue, but a definitive diagnosis could not be obtained. Because the possibility of gastric cancer could not be ruled out, an open proximal gastrectomy with systematic lymph node dissection and combined resection of other organs were performed. A grade II pancreatic fistula developed, but resolved with conservative treatment, and the patient was discharged 15 days after surgery. Histopathologically, the tumor was a lymph node metastasis consisting of squamous cell carcinoma cells that had grown primarily outside the gastric wall, but involved the gastric wall and pancreas and protruded into the gastric mucosa. Thirty-five gastric lymph nodes were dissected, and metastases were found in five of them. Primary squamous cell carcinoma of the stomach and pancreas was ruled out. Because no head and neck, esophageal, or pulmonary lesions that could be squamous cell carcinoma were identified, the primary tumor could not be identified. The diagnosis was a gastric regional lymph node metastasis of a cancer of unknown primary site protruding into the gastric wall. Nivolumab was initiated after surgery, and the patient has remained alive and free of recurrence 7 months after surgery.

Conclusions: In cases of metastases originating from a cancer of unknown primary site to lymph nodes in the gastric region, the removal of the affected lymph nodes followed by inability to detect the primary lesion might be considered to be equivalent to an R0 resection.

Introduction: Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular tumor. Treatment strategy remains controversial because of its rarity. Liver resection is considered as the optimal treatment for solitary HEHE, while a small subset of patients have a solitary tumor. We present the rare case of a patient with solitary primary HEHE who experienced solitary recurrence following liver resection and underwent subsequent liver resection.

Case presentation: A 55-year-old man was referred to our department with a suspected intrahepatic cholangiocarcinoma, based on imaging findings. Anatomic liver resection of segment 8 was performed, and the tumor was confirmed to be HEHE from the pathological findings. Fifteen months later, a solitary recurrence developed in segment 7. After a 5-month observation period, partial liver resection was performed, and the tumor was consistent with recurrent HEHE. The postoperative course was uneventful, and the patient remained recurrence-free for 9 months following the procedure.

Conclusions: Repeat liver resection may be a feasible treatment option for patients with solitary recurrent HEHE.

Introduction: Splenic abscess is a rare but potentially life-threatening condition that can rupture, leading to pneumoperitoneum and symptoms that mimic gastrointestinal perforation in rare cases. This can significantly complicate accurate diagnosis and prompt treatment. A splenic abscess can become life-threatening by rupturing, which may cause diffuse peritonitis or sepsis.

Case presentation: A 68-year-old man with uncontrolled diabetes presented with fever, chills, and abdominal pain. Initial evaluation at a previous hospital, including computed tomography (CT), suggested a lower gastrointestinal perforation, leading to his transfer to our facility. CT revealed a non-enhancing lesion with gas in the spleen and free intraperitoneal air; however, there was no clear evidence of gastrointestinal perforation. An emergency exploratory laparotomy was performed, which revealed purulent ascites and a ruptured splenic abscess without any gastrointestinal perforation. After thorough lavage to eliminate contamination, open abdominal management was initiated owing to a need for catecholamine support and an inability to completely rule out the possibility of gastrointestinal perforation. A second-look laparotomy confirmed that there was no further contamination or gastrointestinal tract perforation. Blood and abscess cultures revealed Escherichia coli, leading us to initiate targeted antibiotic therapy. The patient recovered successfully and was discharged on postoperative day 40 without any recurrence. Ruptured splenic abscess with pneumoperitoneum is rare and poses significant diagnostic challenges, particularly in patients with diabetes, owing to its clinical similarity to gastrointestinal perforation. This study highlights the utility of exploratory laparotomy and staged open abdominal management when gastrointestinal perforation cannot be ruled out.

Conclusions: Physicians should consider ruptured splenic abscesses in patients with pneumoperitoneum, particularly those with diabetes. Exploratory laparotomy with staged open abdominal management may represent an effective approach that facilitates safe monitoring and targeted treatment, thereby reducing the risk of fatal complications.