Surgical Case Reports最新文献

Introduction: Pulmonary artery intimal sarcoma (PAIS) is extremely rare and highly malignant. Although improved outcomes have been reported after complete surgical resection and chemotherapy, limited information is available regarding the indications, procedures, and prognosis of palliative surgery for PAIS. This report describes a successful salvage surgical case for rapid hemodynamic deterioration due to PAIS obstructing the pulmonary artery trunk.

Case presentation: A 64-year-old woman, complaining of dyspnea for a month, was referred for a pulmonary artery tumor. Imaging studies confirmed an intraluminal tumor that obstructs the pulmonary artery trunk and extends to the right ventricular wall and interventricular septum, suspecting a malignancy. During preoperative workups, she developed acute hemodynamic and respiratory deterioration due to pulmonary embolization, so emergency surgery was planned on a salvage basis. The tumor originated from the pulmonary artery intima just distal to the pulmonary valve, obstructed the pulmonary artery trunk, and extensively involved the left main coronary artery and the interventricular septum, where complete resection of the tumor was not achieved. Reconstruction of the pulmonary valve, the right ventricular outflow tract (RVOT), and bilateral pulmonary arteries were performed using a composite of a prosthetic valve and vascular grafts. The patient's postoperative course was uneventful, and she was discharged home asymptomatic. Pathological diagnosis of the operative specimen confirmed pulmonary intimal sarcoma. After 4 months of postoperative chemotherapy, tumor progression was confirmed. The patient passed away at home 8 months after surgery.

Conclusion: We reported a case of PAIS presenting with RVOT obstruction and rapid hemodynamic and respiratory deterioration, who underwent succeeding emergent surgery and was discharged home asymptomatic. Palliative RVOT reconstruction can be a useful surgical option for PAIS accompanying pulmonary embolization on a salvage basis.

Introduction: While simultaneous complex surgical procedures such as right hemicolectomies with pancreaticoduodenectomies (RHPD) may increase overall surgical complexity, complications, and risk of death, it is the only cure for advanced ascending colon cancer (AACC) that has directly invaded the duodenum/pancreas. There are a few reports, especially from Japan. Here, we report an extremely rare case of a patient who underwent RHPD for AACC with direct invasion to the duodenum and liver and describe the patient's long-term survival after en bloc resection.

Case presentation: The patient was a 76-year-old man who presented with a chief complaint of right abdominal pain and weight loss of 12 kg over the past month. Colonoscopy revealed the entire circumference of a type 2 tumor in the ascending colon. Preoperative computed tomography showed a 12 cm mass lesion with wall thickening in the ascending colon which was also invading the second portion of the duodenum. MSI-H/dMMR was negative. RHPD and partial hepatectomy were performed with open surgery because of a preoperative diagnosis of clinical T4b (duodenum and liver) N1bM0 stage IIIc cancer. Although grade 2 adverse effects, which delayed gastric emptying was observed during the patient's postoperative course, the patient's condition resolved through conservative therapy. Oral intake started on postoperative day 17, and the patient was discharged on postoperative day 25. Capecitabine plus oxaliplatin was administered as adjuvant chemotherapy for 6 months. Hematoxylin and eosin staining revealed moderately differentiated adenocarcinoma invading the duodenum and liver. The patient was diagnosed as pathological T4b (duodenum and liver) N1bM0 stage IIIc cancer. No recurrence was noted up to 40 months after the surgery.

Conclusions: The only curative therapy for AACC with involvement of the duodenum is en bloc RHPD. Here, we described a case in which long-term survival was achieved by ensuring R0 with en bloc resection.

Introduction: The incidence of spontaneous regression (SR) of malignancy is one in 60000-100000 cancer patients and spontaneous regression in colorectal cancer is quite rare, reported to account for less than 2% of spontaneous regression of malignancy. In recent years, some reports of spontaneous regression in colorectal cancer in patients with high-frequency microsatellite instability have suggested a deep association between high-frequency microsatellite instability and spontaneous regression. We report our experience of spontaneous regression of advanced colorectal cancer with high-frequency microsatellite instability and provide a review of spontaneous regression in colorectal cancer.

Case presentation: An 83-year-old woman was diagnosed as having advanced colorectal cancer in the transverse colon by lower gastrointestinal endoscopy, and biopsy results revealed moderately differentiated adenocarcinoma. Contrast-enhanced computed tomography showed a tumor located near the hepatic flexure and an enlarged lymph node near the tumor. No distant metastasis was observed, and the preoperative diagnosis was cT3N1aM0 cStage IIIb cancer. Immunohistochemical analysis of the biopsy specimen suggested deficient mismatch repair. During the wait for surgery, the patient was urgently hospitalized due to severe dehydration. After her general condition improved, 38 days after the biopsy, we performed laparoscopic resection of the partial ascending and transverse colon with D3 lymph node dissection. The tumor noted preoperatively was not present in the specimen, and intraoperative endoscopy revealed no tumor on the anorectal side. Additional ileocecal resection was performed, but no tumor was found in the specimen, and another intraoperative endoscopy was performed, which revealed a discolored scar near the anal margin. We determined that tumor loss or morphological change had occurred, so after additional resection of the same area, ultimately, an extended right hemicolectomy was performed. Histopathological diagnosis was pT0N0M0 pStage0 cancer with no residual tumor. The patient has progressed without recurrence at 1 year after the operation.

Conclusions: The immunological response due to high-frequency microsatellite instability may be related to the mechanism of spontaneous regression in colorectal cancer. If high-frequency microsatellite instability is diagnosed preoperatively, we recommend that the tumor location should be confirmed preoperatively.

Introduction: Intrahepatic cholangiocarcinoma (ICC) is a highly malignant cancer for which surgery is the only curative treatment. The prognosis of ICC is extremely poor, especially in cases of lymph node metastasis (LNM), owing to the high postoperative recurrence rate. Herein, we present a case of advanced ICC with a breast cancer susceptibility gene-2 (BRCA2) mutation, treated with preoperative chemotherapy, including cisplatin, followed by surgery, in which we achieved a pathologic complete response.

Case presentation: A 52-year-old woman was referred to our hospital and was subsequently diagnosed with bilateral breast cancer. Computed tomography (CT) and magnetic resonance imaging incidentally detected a liver tumor in the hilar region and lymph node enlargement in the hepatoduodenal ligament. A 19 mm tumor was observed in the area surrounded by the right and left branches of the portal vein and an abnormal portal branch of segment 7. Positron emission tomography-CT showed fluorodeoxyglucose uptake in the liver tumor, hepatoduodenal ligament lymph nodes, and bilateral breasts. A tumor biopsy showed a papillary tumor, and ICC was suspected. As ICC with LNM has a poor prognosis, neoadjuvant chemotherapy was planned. Genetic testing using a blood sample revealed a BRCA2 mutation, indicating the patient would benefit from chemotherapy, particularly cisplatin. The patient received a chemotherapy regimen comprised of gemcitabine, cisplatin, and S-1 (GCS), and after 7 courses, her carbohydrate antigen 19-9 level decreased from 2433 to 15 U/mL. CT showed that the tumor had shrunk and the LNMs were indistinct. The patient was referred to our department for curative surgery, which included a left hepatectomy, caudate lobectomy, hepatoduodenal ligament lymph node dissection, bile duct resection, and choledocojejunostomy. The postoperative course was generally uneventful, and the patient was discharged on postoperative day 18. Pathological examination of the resected specimen revealed an absence of malignant cells. At 24 months postoperative, there was no evidence of recurrence.

Conclusions: We encountered a patient with advanced ICC with a BRCA2 mutation, which was successfully treated with preoperative GCS therapy followed by surgical resection, and a pathologic complete response was achieved. GCS therapy, therefore, appears promising as neoadjuvant chemotherapy for the treatment of ICC.

Introduction: Immune thrombocytopenic purpura (ITP) is one of the immune-related adverse events (irAEs) related to immune checkpoint inhibitors (ICIs). Here, we report a case of a 51-year-old woman with triple-negative breast cancer (TNBC) who experienced severe thrombocytopenic purpura during the neoadjuvant chemotherapy (NAC), including pembrolizumab.

Case presentation: A 51-year-old woman was diagnosed with Stage II B TNBC and underwent NAC using pembrolizumab + paclitaxel + carboplatin. Her blood test on cycle 4, day 15 (C4D15) showed a significant decrease in platelets to <2000/μL accompanied by overt bleeding tendency. She was hospitalized for further investigation and treatment. Her platelet count recovered after platelet concentrate transfusion and corticosteroid administration. Her bone marrow examination showed normal cellularity, and she was judged as ITP. Due to the event and good clinical response to NAC, she underwent a right partial mastectomy and axillary lymph node dissection without completion of the planned NAC. The surgical specimen showed a complete pathological response.

Conclusions: Thrombocytopenia is known as one of the hematologic irAEs; however, severe thrombocytopenia with a bleeding tendency is rarely reported. Sufficient explanations to patients and appropriate referral to other related departments are important for earlier detection and treatment of irAE.

Introduction: Lung resection after open esophagectomy poses significant technical challenges, particularly when the reconstructed gastrointestinal tract is on the same side as the lung lesion. The advent of 4K 3-dimensional (3D) endoscopic systems with near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) has improved the precision of thoracic surgeries. We present a case of successful right upper lung segmentectomy for primary lung cancer after open esophagectomy, utilizing a 4K 3D endoscopic system and NIR imaging.

Case presentation: An 85-year-old female with a history of open esophagectomy for esophageal cancer 19 years earlier and comorbidities, including aplastic anemia and diabetes mellitus, was referred for the evaluation of a growing lesion in the right upper lung. Computed tomography (CT) revealed a 43-mm tumor and the gastric tube, reconstructed during the prior esophagectomy, located in the right thoracic cavity. A CT-guided biopsy confirmed lung adenocarcinoma (cT2bN0M0, Stage IIA). Surgical challenges included severe adhesions from the previous thoracotomy and thrombocytopenia (platelet count: 20000) due to aplastic anemia. A thoracoscopic segmentectomy of the anterior segment of the right upper lobe was performed using a 4K 3D endoscopic system (TIPCAM1 Rubina; Karl Storz, Tuttlingen, Germany). Adhesions were meticulously dissected, and intraoperative platelet transfusions were administered. NIR imaging with ICG identified the intersegmental plane and confirmed blood flow to the gastric tube, preventing ischemic complications. The lung segmentectomy was completed using staplers, preserving the right gastroepiploic artery. Histopathology revealed acinar adenocarcinoma (pT3N0M0, Stage IIB). The patient resumed oral intake on postoperative Day 1 and was discharged on Day 13 without complications. No recurrence was noted during the follow-up.

Conclusions: This case demonstrates the effective use of 4K 3D endoscopic systems and NIR imaging with ICG in complex lung resections following open esophagectomy. These technologies facilitate precise dissection and blood flow assessment, which are crucial for preserving reconstructed structures and enhancing surgical safety.

Introduction: Corrosive esophagitis, often caused by the ingestion of alkalis, acids, or heavy metals, can result in severe esophageal damage and complications, such as stenosis or closure. Although initial treatment is conservative, surgical intervention is necessary when a chronic stricture occurs. A case of esophageal atresia persisting for 50 years due to corrosive esophagitis has not yet been reported. Here, we describe such a case.

Case presentation: The patient was a 72-year-old woman. At 20 years of age, she ingested an alkali substance in a suicide attempt, leading to the development of corrosive esophagitis. Surgery was initially considered for esophageal atresia but was deemed unfeasible at the time; therefore, gastrostomy was performed instead. Subsequently, for over 50 years, she manually chewed food and inserted it into her gastric tube. She was urgently transported to a nearby hospital after her general condition deteriorated due to an influenza infection. During hospitalization, her nutritional intake was reassessed, and given her strong desire for oral intake, she was referred to our hospital for surgical treatment. Her gastric mucosa was intact, and imaging revealed mild mediastinal inflammation and fibrosis, rendering esophageal resection and reconstruction feasible. Considering surgical invasiveness, we opted for a mediastinoscopic esophagectomy and performed posterior mediastinal reconstruction using a gastric tube with a cervical hand-sewn anastomosis. The patient recovered without any complications and was discharged. Although postoperative aspiration and swallowing disorders were anticipated, the patient experienced none, likely because her unique self-feeding method preserved the functions of her masticatory and swallowing muscles.

Conclusions: We report an extremely rare case of a patient with a unique history of esophageal atresia following corrosive esophagitis for over 50 years who successfully underwent minimally invasive esophagectomy using mediastinoscopy and had a favorable outcome. Mediastinoscopic esophagectomy is a minimally invasive option for such patients.

Introduction: Horse kicks are a rare cause of injury and tend to cause severe complications such as visceral organ injury. Traumatic duodenal injuries are associated with high mortality rates. Furthermore, their reconstructive procedures vary widely and require appropriate on-the-spot judgment by the surgeon. We experienced a case of blunt abdominal trauma with a complete transection of the first portion of the duodenum caused by a horse kick without any associated lesions. A good postoperative course was achieved by trimming the pyloric part of the stomach and performing an end-to-end anastomosis between the gastric remnant and the duodenum, along with tube decompression and biliary drainage.

Case presentation: A woman in her 50s was kicked in the right upper quadrant of her abdomen by a horse and transported to a local hospital. Computed tomography revealed pneumoperitoneum and hematoma near the duodenum, discontinuity of the duodenal wall, and a poorly contrasted area in the pancreas head. The patient underwent emergent laparotomy 6h after the accident. The first portion of the duodenum was completely lacerated. No contamination around the pancreatic head or saponification of fat tissue was observed. Because the patient's vital signs were stable and the condition of the damaged tissue was favorable, the transection was repaired with trimming of the pyloric part of the stomach and end-to-end anastomosis between the gastric remnant and the duodenum. Decompression, feeding and biliary drainage tubes were placed. The patient's postoperative course was favorable and the patient was discharged on postoperative day 20 in a stable condition. At an outpatient visit 3 months postoperatively, the patient reported no abdominal pain or stenosis symptoms.

Conclusions: We experienced a rare case of a single complete duodenal transection due to a horse kick. End-to-end anastomosis with tube decompression and biliary drainage was performed because the patient's vital signs were stable, there was little contamination or contusion of the surrounding tissue, and it had not been >24h since the injury. The patient had a good course of treatment.

Introduction: Surgical repair of severe perineal tears is required immediately postpartum. Owing to their low prevalence, the post-treatment course of severe tears is not well known. Herein, we report a rare case of a young woman who underwent robot-assisted curative resection with anal preservation for a rectal neuroendocrine tumor (NET) incidentally discovered following a severe perineal tear.

Case presentation: A 29-year-old woman experienced a severe perineal tear during the first vaginal delivery, which led to the incidental discovery of a 20-mm rectal NET. Four months after the perineal tear, the gynecology and digestive surgery teams ensured that the tear wound had completely healed and anal function was preserved. The patient underwent robot-assisted ultra-low anterior resection with lymph node dissection. The procedure was successfully completed, preserving anal function, and histopathology confirmed an NET (G2, pT2N2aM0, pStage IIIB). The patient recovered smoothly and was discharged on the seventh postoperative day.

Conclusions: Rectal surgery after severe perineal tears may be associated with scarring and fibrosis around the rectum, and precautions should be taken at the time of rectal dissection. Depending on the tumor condition, it may be advisable to perform rectal surgery several months after the tear rather than immediately after treatment for the tear.