Surgical Case Reports最新文献

Introduction: Pancreatic mucinous cystic neoplasm (MCN) is a cystic tumor of the pancreas typically located in the pancreatic body or tail in middle-aged women. However, MCN rupture is rare. This report describes a case of MCN with spontaneous rupture during follow-up.

Case presentation: The patient was a 34-year-old woman. Contrast-enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) revealed a 130 mm multifocal cyst in the pancreatic tail. The cyst, characterized by multiple septa and cyst-in-cyst structures, was diagnosed as an MCN. Initially, the patient opted for periodic follow-ups instead of surgical resection. After a gradual increase in cyst size, surgery was scheduled approximately 1 year later. Two days before the scheduled surgery, the patient experienced unexplained lower abdominal pain. Moreover, CECT revealed a shrinking cystic mass in the pancreatic tail along with the presence of ascites, leading to a diagnosis of spontaneous rupture of the pancreatic cyst. No peritonitis was detected, and a distal pancreatectomy was performed 2 days after admission. Pathological examination confirmed that the pancreatic cyst was a noninvasive mucinous cystadenocarcinoma. The abdominal cavity contained large amounts of turbid ascites with neutrophils but no bacterial growth. Strong inflammatory changes were noted at the cyst wall disruption site. Despite the development of a pancreatic fistula (ISGPF Grade BL, Clavien-Dindo Grade II), the patient was discharged from the hospital on postoperative day 16 and remained alive and recurrence-free for 18 months after surgery.

Conclusion: Spontaneous rupture of an MCN is rare. In this study, we report our case and review previously published cases of MCN rupture. We also discuss the potential causes of the spontaneous rupture in our case.

Introduction: Insufficient blood supply to free jejunal grafts after total pharyngo-laryngo-esophagectomy (TPLE) occurs primarily due to failure of the vascular anastomosis, often resulting in rapid graft necrosis. This report details a case of ischemic enteritis caused by an arteriovenous fistula (AVF) in the mesentery of the free jejunal graft, resulting in chronic stenosis and total removal of the jejunal graft.

Case presentation: A 61-year-old woman diagnosed with squamous cell carcinoma of the cervical and thoracic esophagus underwent TPLE with gastric conduit and free jejunal graft reconstruction. The third jejunal artery and vein were anastomosed to the left transverse cervical artery and the internal jugular vein, respectively. On postoperative day (POD) 9, leakage was observed at the free jejunal-gastric anastomosis. The fistula healed with conservative treatment but a stenosis at the pharyngeal-jejunal anastomosis developed. Endoscopic observation after balloon dilation of the stenosis showed mucosal hemorrhage and ulcer scarring in the jejunal graft. A 3D reconstructed contrast-enhanced CT revealed the presence of an AVF in the free jejunal mesentery despite well-preserved blood flow across the vascular anastomosis. As no local inflammation was observed in the neck, and oral intake was sufficient after balloon dilatation, she was discharged from hospital. Seven months after surgery, she was admitted to our hospital due to obstruction of the pharyngeal-jejunal anastomosis with cutaneous fistula. Based on the disease course and endoscopic findings of the free jejunal graft, she was diagnosed with cutaneous fistula with scarring obstruction following chronic ischemic enteritis, considered difficult to heal with conservative treatment. Total removal of the free jejunum and reconstruction with an antero-lateral femoral thigh (ALT) flap was performed at 8 months after initial surgery. Oral intake was allowed on POD13, and she was discharged in good condition on POD30.

Conclusions: We report here a rare case of late graft failure after TPLE due to chronic ischemia from an AVF in the mesentery of the free jejunal graft. Detailed assessment of mesenteric blood flow by 3D-constructed contrast-enhanced CT is useful and early removal of the ischemic jejunal graft is suggested.

Introduction: Pancreatic trauma is an uncommon, yet potentially lethal condition, with main pancreatic duct (MPD) disruption guiding surgical management. Middle pancreatectomy (MP) with Roux-en-Y pancreatojejunostomy (PJ) offers an organ-preserving alternative to distal pancreatectomy, particularly for young patients. However, the extent of its applicability and the specific surgical techniques-including key technical tips-remain unclear in the context of traumatic pancreatic injury. This is especially true in cases of delayed presentation, where severe intra-abdominal inflammation further complicates surgical intervention.

Case presentation: We report 2 cases of young patients with MPD injuries from blunt trauma, both presenting late with significant peripancreatic contamination. Case 1 included a 22-year-old male who sustained pancreatic and liver injuries while skiing. He was transferred 30 hours post-injury with stable hemodynamics. Endoscopic retrograde pancreatography (ERP) confirmed MPD disruption. Intraoperatively, saponification obscured the anatomical structures, but MP with PJ was successfully performed. The patient recovered without major complications. Case 2 involved a 17-year-old female who was initially observed at another hospital after a traffic accident. Three days later, she developed peritonitis, and a retrospective computed tomography review revealed a pancreatic body rupture. An ERP confirmed MPD disruption. During surgery, extensive inflammation and adhesions were noted, and the MPD was extremely small. Despite technical complexities, an MP with PJ was successfully completed. The pancreatic fistula from the pancreatic head stump required drainage treatment following spinal surgery for vertebral fractures, and the patient recovered without sequelae.

Conclusions: MP with Roux-en-Y PJ is a technically challenging but viable approach for MPD injuries in young patients, even with delayed presentation. It preserves the pancreatic and splenic functions, making it a valuable approach for young patients when performed by experienced surgeons. These cases demonstrate the clinical impact and potential implications of MP as a viable treatment approach for pancreatic trauma.

Introduction: Colorectal cancer (CRC) can metastasize to various sites, including the liver, lungs, ovaries, adrenal glands, and lymph nodes. Approximately 1%-2% of patients with CRC develop para-aortic lymph node metastases. Herein, we report a case of surgical resection of an isolated, metachronous, retrocaval lymph node recurrence of rectal cancer above the renal vein.

Case presentation: A 77-year-old woman was diagnosed with a solitary metachronous retrocaval lymph node metastasis from rectal cancer. The patient underwent robot-assisted laparoscopic abdominoperineal resection. The pathological status was T3, N0, M0, or Stage IIA. No recurrence was observed for 13 months after the initial surgery. CT revealed a 24-mm tumor on the dorsal side of the inferior vena cava (IVC). Tumor resection was performed, including right adrenalectomy, Spiegel lobectomy, and partial resection of the IVC. Pathological findings revealed adenocarcinoma metastasis to a solitary lymph node, which invaded the IVC and Spiegel lobe.

Conclusions: This is the first report of a surgical resection of a retrocaval lymph node metastasis from CRC that invaded both the IVC wall and the liver.

Introduction: Esophageal retention cysts are rare, benign lesions that can mimic submucosal tumors. Their clinical presentation and imaging characteristics may lead to diagnostic challenges, particularly when fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) shows increased uptake, raising suspicion of malignancy.

Case presentation: A 77-year-old man presented with epigastric pain. Upper gastrointestinal endoscopy revealed an esophageal mass, prompting referral to our hospital. Endoscopic ultrasonography (EUS) identified a hypoechoic submucosal tumor with multiple cystic components in the lower esophagus. However, EUS-guided fine-needle aspiration (EUS-FNA) did not yield a definitive diagnosis. CT scan demonstrated a 60-mm space-occupying lesion (SOL) in the lower thoracic esophagus with peripheral contrast enhancement and a central low-density area. MRI revealed a SOL in the lower esophagus with high signal intensity on T2-weighted images and moderate signal intensity on T1-weighted images. The lesion contained cystic components exhibiting high T2 and low T1 signal intensities. FDG-PET/CT revealed intense FDG uptake, increasing from maximum standardized uptake value (SUVmax) 11 to 18 over time. Given the large size of the tumor, symptomatology, and inability to exclude malignancy-particularly high-risk gastrointestinal stromal tumor-surgical resection was performed. Laparoscopic esophagectomy was conducted using intraoperative endoscopy for tumor identification. The esophagus was transected proximally using a linear stapler, followed by extracorporeal gastric conduit reconstruction and the overlap technique was used to perform an esophagogastric anastomosis. Postoperatively, anastomotic leakage was detected on day 3, requiring emergency reoperation. The leak had resolved by POD 26, and the patient was discharged on day 48 after the second surgery (day 51 after the initial surgery). Histopathological examination revealed multiple cysts of varying sizes within the lamina propria, lined by columnar epithelium, with no evidence of malignancy. The final diagnosis was esophageal retention cyst.

Conclusions: This case highlights the diagnostic challenge of esophageal retention cysts with high FDG uptake. While PET/CT is essential in oncologic imaging, FDG accumulation does not always indicate malignancy.

Introduction: Bronchopleural fistulae (BPFs) following pulmonary resection are potentially fatal complications, with right lower lobectomy being the most susceptible among lobectomies. As esophagectomy also increases the risk of tracheobronchial ischemia and postoperative malnutrition, performing a single-stage esophagectomy combined with right lower lobectomy may further elevate the risk of BPFs, underscoring the need for meticulous preoperative planning.

Case presentation: A 64-year-old male with a history of heavy smoking was referred to our hospital after an abnormal mass was detected on a chest radiograph during an annual health check. Chest CT revealed a 3.7 cm consolidative mass in the right lower lobe, resulting in a diagnosis of primary lung cancer, classified as T2aN0M0, stage IB. Additionally, abnormal fluorodeoxyglucose (FDG) uptake was observed in the lower thoracic esophagus, leading to a diagnosis of synchronous esophageal cancer, classified as T1bN0M0, stage I. As both lesions required upfront surgical resection via the right thoracic cavity, a single-stage esophagectomy and right lower lobectomy were planned. Initially, esophagectomy was performed using a five-port video-assisted thoracic surgery (VATS) approach in the prone position from the right side. To preserve the blood supply to the fifth intercostal muscle for subsequent harvesting as a muscle flap, the utility port in the corresponding intercostal space was placed as ventrally as possible. The esophagectomy was performed while preserving the right main bronchial artery. The patient was then repositioned to the left lateral decubitus position, and the preserved fifth intercostal muscle flap was harvested. A right lower lobectomy was completed, preserving the bronchial artery, and the bronchial stump was reinforced using the harvested muscle flap. Despite postoperative development of esophagogastric anastomotic leakage, the patient did not develop a BPF, and no signs of BPF have been observed during 12 months of follow-up.

Conclusions: Preservation of the right main bronchial artery and reinforcement of the bronchial stump with an intercostal muscle flap facilitated prevention of BPF following single-stage esophagectomy and right lower lobectomy, despite the patient's history of heavy smoking and transient postoperative malnutrition.

Introduction: Gastric diverticulum is a rare condition, often asymptomatic and incidentally detected. Laparoscopic sleeve gastrectomy (LSG) is a widely performed bariatric procedure, but a gastric diverticulum complicates surgical planning. In this case, careful preoperative assessment allowed safe execution of LSG despite the diverticulum's proximity to the esophagogastric junction.

Case presentation: A 45-year-old woman (BMI: 46.8 kg/m²) with hypertension, dyslipidemia, and glucose intolerance was referred for bariatric surgery after unsuccessful weight loss with conservative management. Preoperative endoscopy revealed an 18 × 14 mm gastric diverticulum on the posterior wall of the gastric fundus, 40 mm from the esophagogastric junction. LSG was performed using a surgical stapler, ensuring complete diverticulum resection while preserving gastric tube integrity. The surgery was uneventful, with minimal blood loss and a duration of 2 hours and 52 minutes. The patient had an uneventful postoperative course and was discharged on day 9. Her BMI decreased to 39.3 kg/m² at the 1-year follow-up, with improved metabolic parameters.

Conclusions: This case highlights the importance of thorough preoperative evaluation when performing LSG in patients with gastric diverticulum. Accurate endoscopic measurement of the diverticulum's location aids in determining the optimal resection line, ensuring surgical safety and efficacy. Surgeons should remain vigilant when encountering such anatomical variations to optimize outcomes in bariatric surgery.

Introduction: Although seminomas typically arise in the testes, primary mediastinal seminomas are classified as extragonadal germ cell tumors. Diagnosis is often challenging and requires not only blood tests and imaging but also a tumor biopsy. However, diagnosis may be particularly difficult when the tumor shows nonspecific pathological features or is accompanied by granulomatous changes.

Case presentation: The patient was a 25-year-old man who had been experiencing labored breathing when leaning forward for the past month. Physical examination revealed distended jugular veins and neck edema. Chest computed tomography revealed an irregular mass measuring 80 mm in the anterior mediastinum, suggesting invasion of the superior vena cava. Additionally, fluorodeoxyglucose-positron emission tomography showed high accumulation in the same area, with a maximum standardized uptake value of 11.3. A tumor biopsy was performed under thoracoscopic guidance for definitive diagnosis. Histopathological examination of the resected specimen revealed a seminoma with granulomatous changes. Based on these findings, a diagnosis of anterior mediastinal seminoma with superior vena cava syndrome was made. It was classified as having a good prognosis, and the patient received three courses of induction chemotherapy with etoposide, cisplatin, and ifosfamide. Complete remission was achieved. Since then, the patient has been monitored every 3 months, with no recurrence or metastasis observed for approximately 2 years.

Conclusions: Immunohistochemical analysis plays a crucial role in the accurate diagnosis of mediastinal seminomas, especially in cases with unusual histological features such as granulomatous changes. Recognizing the immunoprofile of seminomas and differentiating them from thymomas and lymphomas is essential for avoiding diagnostic pitfalls.

Introduction: Gallbladder metastases from malignancies, including gastric cancer, are extremely rare. Diagnosis is challenging due to the lack of specific symptoms and the absence of distinctive radiological features that can differentiate metastatic lesions from primary gallbladder tumors.

Case presentation: An 81-year-old male was diagnosed as early gastric cancer and underwent endoscopic submucosal dissection and additional laparoscopic proximal gastrectomy for residual tumor and lymph node metastasis 5 years prior. Following adjuvant chemotherapy, the patient underwent multiple interventions for metastatic disease, including liver resection for liver metastasis of segment 2/3, radiofrequency ablation for liver metastasis of segment 5/6, and lobectomy of the right middle lobe for lung metastasis. During follow-up, a nodular lesion was newly detected at the gallbladder fundus through computed tomography. Diagnostic imaging, including endoscopic ultrasonography and Gd-EOB-DTPA, suggested a potential gallbladder cancer with sub-serosal lesion. We performed an extended cholecystectomy lymph node dissection, and pathological examination revealed the tumor to be a gallbladder metastasis from the original gastric cancer, confirmed through immunohistochemical staining.

Conclusions: We herein report a rare case of metachronous gallbladder metastasis from gastric cancer. Preoperative diagnosis of gallbladder metastasis is challenging due to its radiological similarity to primary gallbladder cancer.

Introduction: Intracholecystic papillary neoplasm (ICPN) is a recently identified disease characterized by papillary pre-invasive neoplasm of the gallbladder. Despite its characterization, the natural history of ICPN remains elusive. Furthermore, a few cases of metachronous ICPN in the remnant biliary system have been documented. Here, we report a surgical case involving metachronous ICPN in the remnant cystic duct 19 years post-cholecystectomy for primary ICPN.

Case presentation: A 77-year-old man presented to our hospital with general fatigue and jaundice. He had previously undergone an open cholecystectomy and lithotomy for gallbladder cancer and common bile duct stones 19 years earlier. Blood tests revealed elevated levels of hepatobiliary enzymes and tumor markers. Both computed tomography and magnetic resonance imaging indicated dilatation of the intrahepatic and common bile ducts, and an enhanced nodule was observed in the common hepatic duct. Intraductal ultrasonography identified a papillary tumor infiltrating the distal bile duct from the common hepatic duct. Brush cytology subsequently helped confirm adenocarcinoma. Consequently, the patient was diagnosed with Bismuth type 1 perihilar cholangiocarcinoma and underwent subtotal stomach-preserving pancreaticoduodenectomy. Histological examination revealed the tumor as pancreatobiliary-type ICPN associated with invasive carcinoma, which had originated in the remnant cystic duct and invaded the common hepatic duct. A retrospective review of the resected gallbladder specimens from 19 years earlier confirmed ICPN according to the current classification, establishing this as a metachronous occurrence of ICPN.

Conclusions: These findings suggest that ICPN can recur as metachronous lesions in the remnant biliary system after resection of primary lesion, highlighting the necessity of sustained, long-term biliary surveillance following primary lesion resection.