Surgical Case Reports最新文献

Introduction: Thyroid angiosarcoma (TAS) is an extremely rare and highly aggressive cancer, representing less than 1% of all sarcomas. Typically diagnosed in individuals aged 50-80, with a higher incidence in women, TAS has a poor prognosis due to its tendency to metastasize, leading to a low 5-year survival rate. Due to its rarity, standardized treatment approaches are lacking, often involving a combination of surgery, chemotherapy, and radiation. This report presents TAS in a Japanese male.

Case presentation: A 78-year-old male with pre-existing conditions presented with a 30-year history of a slow-growing thyroid tumor that exhibited rapid enlargement 4 months prior to surgery. Initial fine-needle aspiration cytology was no malignancy. Examinations revealed a firm, poorly mobile 10 cm mass in the anterior neck, and left pleural effusion. Notably, papules developed at the aspiration site and progressively enlarged. Preoperative imaging indicated a malignant thyroid tumor, prompting a right thyroid lobectomy with resection of anterior neck muscles and overlying skin. Histological analysis confirmed a highly hemorrhagic angiosarcoma with infiltration into surrounding tissues. Immunohistochemical findings supported the diagnosis of TAS. A comprehensive genomic profiling testing yielded no specific therapeutic recommendations. Paclitaxel therapy was initiated 2 months after surgery, resulting in the shrinking of pulmonary nodules and the decreasing left pleural effusion. The patient subsequently died from septic shock due to a urinary tract infection 5 months after starting chemotherapy, without evidence of cervical recurrence or neutropenia during treatment.

Conclusions: This case highlights the perioperative management of a rare primary TAS. In the absence of established treatment guidelines, surgical resection followed by paclitaxel administration could be a potential therapeutic strategy to control disease progression. An accumulation of case reports is needed to better understand this aggressive malignancy and to facilitate the development of optimized therapeutic strategies.

Introduction: There are few reports of treatment strategies for ascending colon cancer after total gastrectomy. We report a case of intracorporeal anastomosis was performed for ascending colon cancer after total gastrectomy with Roux-en-Y reconstruction.

Case presentation: A 70-year-old man was referred to our institution due to a primary complaint of blood stool. A colonoscopy showed a Type 2 tumor near the hepatic fold of the ascending colon. The clinical diagnosis was ascending colon cancer. He had a history of open total gastrectomy (Roux-en-Y, retrocolic route) and cholecystectomy for gastric cancer in his 40s. Laparoscopic right hemicolectomy with intracorporeal anastomosis was performed. To perform an extracorporeal anastomosis, it was necessary to release adhesions between the reconstructed jejunum and the left-sided transverse colon and mobilize the splenic flexure. If the reconstructed jejunum was damaged, there will be a possibility of redoing the esophago-jejunostomy. By performing an intracorporeal anastomosis, surgery was accomplished with minimal mobilization and without requiring adhesion release between the reconstructed jejunum and the transverse colon. The patient's postoperative course was uneventful, and he was discharged at 8 days postoperatively.

Conclusions: Intracorporeal anastomosis may represent a useful and safe option when performing laparoscopic right colectomy in patients with a history of total gastrectomy.

Introduction: Thyroglossal duct cysts (TGDCs) are the most common congenital midline neck masses encountered in pediatric populations and are usually located anterior to the hyoid bone, making them readily identifiable by both superficial ultrasonography and skin palpation. However, intraoperative identification can be challenging in cases in which the cyst is located on the dorsal side of the hyoid bone or near the base of the tongue, which increases the risk of incomplete excision or rupture. This report describes the pediatric case of a TGDC located between the hyoid bone and the foramen cecum that was safely excised under intraoperative transoral ultrasonography (TOUS) guidance to facilitate identification of the entire cyst.

Case presentation: An 11-year-old boy was referred for evaluation of an incidentally detected midline neck mass. Neck ultrasonography and MRI revealed the presence of a 7-mm cyst located between the hyoid bone and the foramen cecum, consistent with the characteristics of a TGDC, and a Sistrunk procedure was scheduled. Intraoperatively, the cyst was successfully identified using TOUS with a small convex probe, which provided a stable and continuous view from the oral side throughout the dissection. A transverse cervical incision was made, the central hyoid bone was removed, and the cyst was visualized on its dorsal side under TOUS guidance. En bloc resection of the entire cyst and tract was completed without rupture, and histopathology confirmed the diagnosis of TGDC. The postoperative course was uneventful, and no recurrence was observed at the 4-month follow-up assessment.

Conclusions: The use of TOUS enabled real-time visualization of a deep TGDC structure that was difficult to identify via superficial ultrasonography after neck incision. Thus, TOUS can serve as a reliable guide during the Sistrunk procedure, reducing the risk of cyst rupture and incomplete resection, thereby enabling safe and complete excision. The experience of this case highlights the potential benefit of using TOUS in managing deep TGDCs located on the dorsal side of the hyoid bone, especially in pediatric patients.

Introduction: Solid-basaloid adenoid cystic carcinoma (SB-AdCC) is a rare and aggressive variant of AdCC of the breast. Moreover, it is an extremely rare subtype of triple-negative breast cancer, accounting for <1% of all breast cancers. We report a case of SB-AdCC.

Case presentation: Ten years ago, an 82-year-old woman underwent a partial mastectomy for the luminal HER2 (human epidermal growth factor receptor type 2)-type invasive ductal carcinoma of the left breast cancer. Ten years later, she noticed another lump in her left breast. A needle biopsy was performed, and an unclassified carcinoma was detected. Histological examination revealed that the carcinoma was of the triple-negative type. A mastectomy of the left breast and sentinel lymph node biopsy were performed. The postoperative pathological diagnosis was an SB-AdCC of the breast. The Ki-67 index was 80%, corresponding to a high-grade malignancy. She received postoperative chemotherapy with tegafur-gimeracil-oteracil potassium. At 1 year postoperatively, she is recovering well without signs of metastasis.

Conclusions: We reported a case of SB-AdCC.

Introduction: Extracorporeal membrane oxygenation (ECMO) is a type of extracorporeal circulation used to divert blood from and deliver blood to peripheral blood vessels. Recently, the use of ECMO has been reported in various non-transplant surgeries. Particularly in tracheal surgeries, ECMO provides an unobstructed surgical field and enables safe induction of general anesthesia in difficult intubation cases. Here, we report on 10 cases of thoracic surgery in which ECMO was employed at our institution.

Case presentation: These 10 cases comprise 4 tracheal cancer surgeries, 2 lung cancer surgeries, and 1 case each of surgery for thyroid cancer, mediastinal cancer, tracheomalacia, and tracheobronchial injury. Veno-venous (VV)-ECMO is most often selected, but veno-arterial (VA)-ECMO is chosen when recirculation with VV-ECMO is unacceptable, when pulmonary artery bleeding needs to be controlled, or when cardiac support is necessary. Among the 10 presented cases, VV-ECMO was used in 8, while VA-ECMO was employed in 2. Three of these cases involved ECMO bailout due to dyspnea caused by airway stenosis. Six of the patients did not receive heparin maintenance. Of those, 1 was maintained on nafamostat mesilate, 2 were maintained on nafamostat mesilate after receiving a single dose of heparin, and 3 received only a single dose of heparin. In none of those cases did ECMO fail to maintain flow due to thrombus formation. A postoperative hemothorax occurred as one of the ECMO-related complications in Case 4. There were no perioperative cardiopulmonary complications, in-hospital deaths, or deaths within 30 days after surgery. One patient died from metastatic recurrence of non-small cell lung cancer 5 months after surgery, another from progression of disease in mediastinal anaplastic cancer 4 months after surgery, and the 3rd from upper gastrointestinal bleeding 2 years after surgery. The other 7 patients remain alive.

Conclusions: ECMO is useful in tracheal surgery and in cases where intubation is difficult or dangerous, because it facilitates safe and accurate surgery. We also believe that individualized anticoagulant strategies can be safely implemented.

Introduction: The right top pulmonary vein (RTPV) is a rare anatomical variant that arises independently of the right superior lobe. It drains behind the right main bronchus or bronchus intermedius and into the left atrium or another pulmonary vein. This anomaly poses challenges during subcarinal lymph node dissection in thoracic surgery, such as esophagectomy, owing to the risk of vascular injury. The RTPV is mainly located behind the right main bronchus and right intermediate bronchus; however, reports of subcarinal dissection focusing on these sites are lacking. Herein, we present a case of esophageal cancer with an RTPV that was treated with thoracoscopic esophagectomy and propose a convenient classification for the anatomical findings and RTPV site.

Case presentation: A 71-year-old man underwent a thoracoscopic esophagectomy for esophageal cancer (T1bN0M0) during a routine medical checkup. A preoperative computed tomography scan revealed an anomaly in which the RTPV drained into the left atrium behind the right main bronchus. Radical subcarinal lymphadenectomy was performed while preserving the RTPV, using 3 dimensions for preoperative simulation and intraoperative navigation. The operation lasted 6 h and 42 min, and the blood loss volume was 30 mL. The patient's postoperative course was uneventful, and he was discharged on postoperative day 21.

Conclusions: In a retrospective review of esophageal cancer surgery cases at our hospital, RTPV was observed in 17/314 cases (5.4%). The most common inflow site was the inferior pulmonary vein (IPV) (9 cases), followed by the left atrium (5 cases), superior pulmonary vein (2 cases), and superior branch of the IPV (1 case). The inflow site was behind the right main bronchus and the right intermediate bronchus in 4 and 13 cases, respectively. Compared to past reviews, the inflow site varied somewhat; however, the vascular location remained the same. By classifying the areas behind the right main and right intermediate bronchi as Zones 1 and 2, respectively, cases in which the RTPV runs through Zone 1, as identified on preoperative computed tomography, should be manipulated with caution due to the risk of injury during lymph node dissection beneath the tracheal bifurcation.

Introduction: Primary malignant lymphoma of the appendix is a rare disease, and primary Burkitt lymphoma of the appendix has been reported very rarely in Japan. Burkitt lymphoma is an aggressive lymphoma that progresses more rapidly than other malignant lymphomas, making it sometimes difficult to distinguish between systemic symptoms, such as fever associated with lymphoma progression and fever caused by appendicitis.

Case presentation: A 21-year-old man underwent open appendectomy after antibiotic treatment for acute appendicitis proved ineffective. Postoperative pathological findings confirmed acute appendicitis. Antibiotics were continued after surgery, and the patient's fever and abdominal symptoms gradually improved. However, abdominal distension recurred on the 18th day of hospitalization. Blood tests showed a re-elevation of the white blood cell count, suggesting a postoperative intraperitoneal abscess. Despite further antibiotic treatment, fever and leukocytosis persisted. On the 28th day of hospitalization, abnormal lymphocytes were detected in the peripheral blood, and we realized that the persistent fever was due to systemic symptoms of malignant lymphoma rather than a complication of appendicitis. On the 30th day, the patient was referred to the hematology department and subsequently diagnosed with Burkitt lymphoma. Chemotherapy was initiated on the 40th day of hospitalization. At the time of this writing, the patient had remained alive without recurrence for 4 years 3 months postoperatively.

Conclusion: In this case, symptoms of acute appendicitis and systemic symptoms of malignant lymphoma appeared simultaneously. As a result, the systemic symptoms of malignant lymphoma were misdiagnosed as postoperative complications, leading to a delay in diagnosis. Primary appendiceal Burkitt lymphoma is extremely rare, and its clinical features remain unknown. It is important to recognize that primary appendiceal Burkitt lymphoma can present with systemic symptoms concurrently with appendicitis. Surgeons should be aware of the clinical features of appendicitis caused by Burkitt lymphoma, which differ from those caused by other appendiceal tumors or malignant lymphoma.

Introduction: The interest of this case lies in the exceptional and rare character of the observed association.: Meckel's diverticulum (MD) mimicking a postoperative flange complicated by acute intestinal obstruction and malrotation by midgut volvulus.

Case presentation: A 17-year-old black male student, with a body mass index of 28 kg/m² was admitted to the emergency department of a 4th category rural hospital, with paroxystic abdominal pain and vomiting. Medical history revealed an abdominal surgery for an umbilical hernia 3 years earlier. There was no malformation such as imperforate anus, Hirschsprung's disease, esophageal tracheal fistula, or cardiac anomaly in the medical history. An abdominal X-ray confirmed an acute intestinal obstruction showing hydroaeric levels. The diagnosis of acute intestinal obstruction on a flange was retained. A median laparotomy was performed; a solid mass-like lengthy structure mimicking postoperative flange was seen associated with midgut volvulus, while a malposition of the intestine was observed with a mesenteric band, as well as a hyperemic appendix. A 90° rotation stop of the midgut also called a complete common mesentery was in place; we then carried out a Ladd procedure. Morpho-pathological examination of the surgical specimens revealed the following: richly vascularized fibro-adipose tissues with no evidence of malignancy in the diverticular specimen, and acute pan-appendicitis with no evidence of malignancy in the appendicular specimen. The patient started to ingest food orally on the third postoperative day, and he was discharged uneventfully on the fifth day.

Conclusion: MD, although generally a tubular structure, may sometimes appear as a non-tubular mass during clinical examination. Intestinal obstruction due to MD associated with midgut volvulus is exceptional. Management of this association should be based on accurate knowledge of the morpho-embryological specificities during gut development.

Introduction: Experience with the Hugo RAS system in robot-assisted colorectal surgery is limited. This is particularly noticeable when focusing on complex procedures, such as total proctocolectomy (TPC). This study aimed to demonstrate the feasibility and safety of using the Hugo RAS system for TPC.

Case presentation: A 27-year-old woman with multiple colorectal cancers with a background of familial adenomatous polyposis underwent robot-assisted TPC, including lymph node dissection of the entire colorectal region using the Hugo RAS system. The robotic procedure was divided into 3 steps: 1) Trendelenburg position to perform ascending colon complete mesocolic excision (CME) to the hepatic flexure, 2) descending colon CME and total mesorectal excision with D3 lymph node dissection, and 3) flat position to perform central vessel ligation along the superior mesenteric artery. After undocking, the specimen was extracted transanally, and an ileal pouch was constructed from a small laparotomy at the umbilical incision, followed by ileal pouch-anal anastomosis. The operative time was 632 min, and the estimated blood loss was minimal. The postoperative period was uneventful.

Conclusions: Robot-assisted TPC using the Hugo RAS system is safe and feasible. The flexibility of Hugo, which is carried by a modular-type surgical robot with multiple independent arms, enables safe and effective advanced procedures.

Introduction: Aneurysms of peripheral foot arteries are extremely rare. Dorsalis pedis artery aneurysms account for 0.5% of peripheral artery aneurysms of the lower limbs. Here, we present a case of pseudoaneurysm of the first dorsal metatarsal artery of the foot and discuss the therapeutic strategy based on a literature review.

Case presentation: A 76-year-old man with no history of foot trauma presented with pain and a pounding mass in the dorsum of the left foot. Echography revealed a 29 × 18 × 20 mm saccular aneurysm with to-and-fro blood flow. Contrast-enhanced computed tomography revealed an aneurysm in the first dorsal metatarsal artery. Angiography of the aneurysm revealed no arterial drainage. Embolization was subsequently performed only for the feeding artery, which was the proximal first dorsal metatarsal artery, using the 2 Target nanocoils (Stryker; Boston, MA, USA), resulting in successful occlusion. However, echography performed a few months after embolization revealed a recurrence of blood flow and enlargement of the coiled aneurysm. Nine months after embolization, the pain in the dorsum of the foot recurred. Therefore, we performed a surgical resection of the dorsal metatarsal artery aneurysm (38 × 26 × 26 mm) under general anesthesia. The first distal dorsal metatarsal artery exhibited pulsatile bleeding, and angiography of the distal dorsal metatarsal artery revealed a patent pedal arch and posterior tibial artery. Therefore, revascularization was not performed. The postoperative course was uneventful. The pathological examination indicated that the mass was a pseudoaneurysm.

Conclusions: The treatments for peripheral foot artery aneurysms include observation, thrombin injection, ultrasound compression, embolization, surgical excision, and ligation. As the long-term outcomes of embolization for such aneurysms are unknown and cases are limited, surgical excision that is safe and definitive is recommended as the first-line treatment.