Surgical Case Reports最新文献

Introduction: Ischemia in extra-lobar pulmonary sequestration is rare and mostly occurs in childhood; it is uncommon in adults but can be progressive, necessitating surgical removal.

Case presentation: A 37-year-old woman experienced sudden onset severe back pain and was initially diagnosed with pneumonia. Computed tomography revealed a 4.5 cm mass on the diaphragm and rapidly increasing pleural effusion. Emergency surgery confirmed a black mass that adhered to the diaphragm, which could be bluntly detached, but one was fixed in a cord shape that was detached by an energy device. Pathology showed significant hemorrhage and tissue destruction in extra-lobar pulmonary sequestration.

Conclusions: Extra-lobar pulmonary sequestration infarction, which develops suddenly with pain as the main complaint, is rare and mainly seen in early childhood but can also occur in adults.

Introduction: Mediastinal parathyroid cyst is a rare cystic disease that involves the parathyroid tissue within its walls. This case report is the first to document a mediastinal parathyroid cyst with recurrent laryngeal nerve paralysis and tracheal deviation that improved after surgical resection.

Case presentation: A 47-year-old man experienced hoarseness and dyspnea upon exertion for 1 month. Computed tomography revealed a mediastinal cystic lesion with a maximum diameter of 78 mm, compressing the trachea. Laryngofiberscopy suggested long-term left recurrent laryngeal nerve paralysis. Tumor resection was performed while preserving the left recurrent laryngeal nerve. The pathological examination led to the diagnosis of a mediastinal parathyroid cyst. Postoperatively, both tracheal deviation and recurrent laryngeal nerve paralysis improved.

Conclusions: Surgical resection improved the tracheal deviation and recurrent laryngeal nerve paralysis caused by a mediastinal parathyroid cyst. Long-standing recurrent laryngeal nerve paralysis can improve, emphasizing the need for proactive surgical intervention and the importance of careful preservation of the recurrent laryngeal nerve.

Introduction: A right-sided round ligament (RSRL) is a rare congenital anomaly characterized by the umbilical vein being connected to the right paramedian trunk. As it is associated with intrahepatic vascular anomalies, it poses special difficulties in hepatic resection, and an accurate understanding of those anomalies is indispensable.

Case presentation: An 80-year-old man visited a health clinic with the chief complaint of jaundice. Hyperbilirubinemia and impaired liver function were detected upon laboratory examination. Therefore, the patient was referred to our hospital for further examination and treatment. Contrast-enhanced computed tomography (CT) demonstrated dilatation of the intrahepatic bile ducts and the presence of a hypovascular tumor of 30 mm in size in the left lateral segment of the liver. The anterior branch of the portal vein (PV) formed a right-sided umbilical portion of the PV and was connected to the round ligament. This anomaly is known as an RSRL. The round ligament was located to the right of the gallbladder. Three-dimensional (3-D) CT of the PV clearly illustrated the independent ramification of the posterior branch and the subsequent bifurcation of the anterior branch and the left PV. Endoscopic, nasogastric biliary drainage was performed to treat the patient for obstructive jaundice, and endoscopic retrograde cholangiopancreatography demonstrated severe stenosis of the hilar bile duct. Biopsies of the stenotic bile ducts were suggestive of adenocarcinoma. The root of the posterior branch of the bile duct was intact from the cancer. The preoperative diagnosis was intrahepatic cholangiocarcinoma (T4N0M0, stage III B), according to the American Joint Committee on Cancer Staging System, 8th edition. Left trisectionectomy with extrahepatic bile-duct resection and hepaticojejunostomy was performed. The histological diagnosis of the tumor was intrahepatic cholangiocarcinoma (large duct type, 5.5 × 4.5 cm). The final pathological stage was T4N1M0, stage 3B. Three months after surgery, the patient was doing well without recurrence.

Conclusions: The anatomy of patients with an RSRL should be evaluated in detail before surgery, especially when curative hepatic resection is performed for intrahepatic or perihilar cholangiocarcinoma.

Introduction: Postpancreatectomy hemorrhage (PPH) is a life-threatening complication following pancreaticoduodenectomy, requiring prompt and accurate diagnostic and therapeutic measures to ensure patient survival.

Case presentation: A 79-year-old man underwent robot-assisted pancreaticoduodenectomy for suspected intraductal papillary mucinous carcinoma. Postoperatively, he developed a pancreatic fistula and major bile leak, leading to a hemorrhagic event on postoperative day 6. Initial stabilization was achieved with intravenous fluids and blood transfusions, followed by emergent angiography, which identified bleeding from the gastroduodenal artery (GDA) stump. Due to the short length of the remaining GDA, simple embolization of the GDA stump was considered inadequate. Given the anatomy of the short proper hepatic artery (PHA) and its immediate bifurcation into the left and right hepatic arteries, coil embolization was feared to cause infarction of the entire liver, and even with stenting, the left hepatic artery (LHA) would have to be sacrificed. Temporary balloon occlusion of the common hepatic artery (CHA) was used to stabilize the hemodynamics, serving as a bridge to surgical intervention to maintain hepatic blood flow. Although it was an emergency laparotomy, intraoperative CHA balloon occlusion created a controlled environment, allowing for precise localization and effective management of the hemorrhage. The root of the GDA was ligated, and hepatic blood flow was preserved. The choledochojejunostomy leak was repaired by re-anastomosis. The patient was discharged following successful conservative management of the pancreatic fistula. Eight months post-intervention, follow-up imaging confirmed preserved hepatic arterial flow.

Conclusion: This case underscores the efficacy of a multidisciplinary approach in managing delayed PPH in hemodynamically stable patients. Comprehensive angiographic assessment, combined with temporary CHA balloon occlusion for bleeding control and meticulous surgical hemostasis, offers a viable strategy ensuring immediate and mid-term patient well-being.

Introduction: An ilio-iliac arteriovenous fistula (IIAVF) secondary to the rupture of a common iliac artery aneurysm (CIAA) is rare. Sudden arteriovenous shunting and subsequent fistula enlargement can result in acute cardiac failure. Immediate diagnosis and treatment are required; however, the clinical symptoms differ from those of a free wall rupture of an aortic aneurysm, making a quick diagnosis difficult. Thus, we reported the case of a patient with severe right-sided cardiac failure, due to an arteriovenous shunt formation secondary to an IIAVF who underwent an artificial blood vessel replacement with favorable results.

Case presentation: A 71-year-old male patient presented to our hospital with polypnea and palpitations. Initial early-phase computed tomography (CT) revealed a 60-mm-in-diameter right CIAA and an inferior vena cava (IVC) dilatation. Severe congestive heart failure, due to an arteriovenous shunt formation secondary to an IIAVF was diagnosed. The massive shunt of blood flowed from the right common iliac artery (CIA) to the right common iliac vein (CIV). He underwent an emergency open abdominal aortic replacement. The IVC ran anomalously anterior to the giant right CIAA and strongly adhered to the IVC and right CIV. Two guidewires were inserted from the bilateral femoral veins into the IVC intraoperatively. Moreover, an occlusion balloon was inserted into the right CIV. Thus, bleeding from the fistula was well-controlled by the time of aneurysm opening. The proximal side of the artificial graft was anastomosed to the abdominal aorta, while the right and left peripheral branches of the prosthesis were anastomosed to the right external iliac artery and left CIA, respectively.

Conclusions: We reported the case of a giant right CIAA that directly created a shunt into the right CIV. Contrast-enhanced CT is a useful method for confirming the working diagnosis of an IIAVF. In particular, in cases of IVC anomalies or strong perivenous tissue adhesions, bleeding can be controlled using devices, such as occlusion balloons and a meticulous surgical plan.

Introduction: Cardiac surgery for cardiovascular-associated mesothelioma has a poor prognosis. However, life-saving surgery is unavoidable to maintain circulation. This report describes a case in which metastatic intracardiac mesothelioma triggered sudden respiratory failure, which was reduced by surgical resection.

Case presentation: An 81-year-old man with a history of asbestos exposure presented to our hospital with sudden onset of dyspnea. Prior to this event, the pleura was involved in an epithelial malignancy, which was immunohistochemically negatively stained with anti-D2-40, WT-1, or anti-calretinin antibodies, which are positive markers of mesothelioma. Transthoracic echocardiography revealed a fragile and mobile tumor occupying the right atrium, and the patient was admitted for surgical tumorectomy. The operation was performed urgently using a cardiopulmonary bypass via a full sternotomy. The pericardium is grossly intact and does not adhere to the heart. A 3 × 5 cm tumor was tightly attached to the right atrium and was large enough to fit into the tricuspid valve. Therefore, the entire margin of the tumor stem attachment was resected from the lateral wall of the right atrium. Although the resected tumor was not positive for any of the three histopathological markers of mesothelioma, CDKN2A co-deletion revealed by fluorescence in situ hybridization led to a diagnosis of malignant mesothelioma.

Conclusions: Surgical removal of intracardiac tumors that cause circulatory and respiratory instability is essential for the prevention of sudden death, regardless of prognostic determinants. This case demonstrates that mesotheliomas can metastasize to the endocardium. Even when nuclear atypia and negative results for immunohistochemical tests for the three mesothelioma markers suggest carcinoma, mesothelioma should still be considered and p16/CDKN2A co-deletion should be evaluated.

Background: In patients with pancreaticobiliary maljunction complicated by congenital biliary dilatation, the pancreatic enzyme flows back into the bile, leading to bile duct carcinogenesis. Although the biliary tract resection and reconstruction is well documented to decrease the rate of malignancy, cancer occurrence has been reported in the residual intrahepatic or intrapancreatic bile duct, even after resection. We report a case of multiple biliary tract cancers in the liver complicated by congenital biliary dilatation, whose tumor lesions were resected en bloc without disconnecting the biliary tract by simultaneous pancreatoduodenectomy and living donor liver transplantation.

Case presentation: A 27-year-old woman presented with epigastric discomfort. Examination indicated multiple biliary tract cancers complicated by congenital biliary dilatation. Computed tomography scan revealed three papillary tumors in the right hepatic duct with increased ¹⁸F-FDG accumulation on positron emission tomography. Contrast-enhanced ultrasound revealed another lesion in the left hepatic duct. Adenocarcinoma cells were detected using bile and choledochal brush cytology. Tumors resection by right lobectomy or trisegmentectomy of the liver and extrahepatic bile duct resection indicated a high risk of postoperative liver failure; the residual liver volumes were calculated only 277 ml or 176 ml, respectively. In addition, tumor recurrence owing to bile leakage during the surgery and carcinogenesis from the remaining bile duct were concerned. Pancreatoduodenectomy was performed without disconnecting the biliary tract, and the tumors were resected en bloc with the whole liver. The left lobe liver graft from the husband was then transplanted. After 5 years of adjuvant treatment with tegafur/gimeracil/oteracil potassium, she remained in remission eight and half years after the surgery.

Conclusions: Given the mechanism and development of cancer in the congenital biliary dilatation, simultaneous pancreatoduodenectomy and liver transplantation may be considered, especially in the case of young patients.

Background: The majority of colorectal malignancies are primary tumors. Secondary tumors are rare, and colorectal metastasis from endometrial carcinoma is exceptionally uncommon. We report a case of serous endometrial carcinoma that metastasized to the sigmoid colon, initially presenting as a primary colon carcinoma due to bowel obstruction.

Case presentation: A 79-year-old woman presented with abdominal distention and constipation. Five years earlier, she had undergone an open total hysterectomy with bilateral salpingo-oophorectomy for endometrial serous carcinoma. A colonoscopy revealed stenosis encircling the entire sigmoid colon. Abdominal computed tomography demonstrated irregular wall thickening in the sigmoid colon with enhanced regional lymph node enlargement and upstream bowel dilatation. Peritoneal dissemination in the pelvis was also noted. To relieve the obstruction, two self-expanding metal stents were inserted. Subsequently, due to the presumed diagnosis of sigmoid colon carcinoma with peritoneal dissemination, an open left hemicolectomy with resection of the peritoneal dissemination was performed. Histopathological examination identified the colon tumor and peritoneal dissemination as metastatic serous endometrial carcinoma. Immunohistochemical studies showed the tumor cells were negative for CK7, CK20, and CDX2. No chemotherapy was administered, and 6 months post-operation, no recurrence was observed.

Conclusions: Metastasis of endometrial carcinoma to the colon is extremely rare. Diagnosing a colon tumor as a metastasis from endometrial carcinoma is challenging during preoperative examinations. Therefore, in patients with a history of endometrial carcinoma, the possibility that the primary site might be the uterus should be considered.

Background: The selection of the surgical approach for chronic pancreatitis (CP) is determined by various factors including inflammatory location, presence of pancreatic duct dilatation, or possibility of cancer. Total pancreatectomy (TP), with or without islet cell autotransplantation, is considered for patients with refractory CP after the failure of other surgical treatments. Considering the increasing incidence of CP requiring surgical treatment, the number of cases in which TP is performed after previous surgical treatment is expected to increase.

Case presentation: We reported a case of TPIAT in a patient with alcoholic CP who had previously undergone Frey's procedure. During the operation, the sufficient length of the elevated jejunal loop for pancreaticojejunostomy in Frey's procedure allowed it to be used directly for biliary jejunostomy during TP. In addition, jejunojejunostomy from the previous operation could be used, and these methods contributed to simplifying the operative procedure. We need open hemostasis on post-operative day (POD) 1and a percutaneous drainage tube replacement for an intraperitoneal abscess on POD 24. The patient was discharged from the hospital on POD 37 with normal serum C-peptide level, which suggests favorable insulin secretion from transplanted islets, and the epigastric pain that suffered her preoperatively resulted in a dramatic improvement.

Conclusions: When performing the Frey's procedure, the elevated jejunal loop and Y-anastomosis jejunal loop with sufficient length allow them to be used directly for the reconstructions in the possible subsequent TP.

Background: Colonoscopy is widely performed. However, reports of colonoscopic incarceration within inguinal hernias are rare. Incarceration during colonoscopy is a critical condition, and attempting forced reduction may exacerbate complications; therefore, a careful approach is required. Here, we present a case of colonoscopic incarceration of a left inguinal hernia that was successfully reduced under fluoroscopic guidance, followed by elective endoscopic surgery.

Case presentation: A 74-year-old man presented for colonoscopy at a primary care clinic and was referred to our hospital for the incarceration of the colonoscope within the inguinal hernia. On arrival, the colonoscope remained in situ through the anus. Laboratory tests and imaging studies confirmed the absence of perforation. Manual pressure was applied under fluoroscopic guidance to successfully reduce the hernia and allow for scope extraction. No evidence of perforation was revealed in the follow-up fluoroscopic examination using a gastrografin enema. Six weeks later, the patient underwent definitive surgery for total extraperitoneal hernia repair.

Conclusions: A complication of colonoscopy is the incarceration of the colonoscope within the inguinal hernia, particularly in older men. Therefore, inquiring about the patient's history of inguinal hernia, particularly those accompanied by scrotal swelling, besides assessing the surgical history before performing a colonoscopy, is critical. Furthermore, recent trends include attempts at incarceration reduction under fluoroscopic guidance, with emergency surgery reserved for irreducible cases.