Surgical Case Reports最新文献

Introduction: Adult pancreatoblastoma (PB) is an extremely rare malignant pancreatic epithelial tumor. Although no standard treatment strategy has been established, complete resection is recommended for long-term survival. Here, we presented a case of an adult patient with PB who successfully underwent complete resection via robotic surgery. Furthermore, this is the first report of robotic surgery for PB, highlighting its novelty and potential clinical relevance.

Case presentation: A 40-year-old man presented with epigastric pain, and image examination revealed a well-defined tumor in the pancreatic tail extending into the main pancreatic duct (MPD) and reaching the pancreatic neck. With no evidence of distant metastases, surgery was planned following 2 courses of gemcitabine and S-1 chemotherapy for tumor shrinkage. There were no significant changes in the tumor's extension after chemotherapy, but no new lesions appeared, and robotic distal pancreatectomy was performed. Intraoperative findings confirmed the tumor extension into the MPD just above the superior mesenteric vein (SMV). The pancreas was sharply divided at the right edge of the SMV, and a negative transection margin was obtained. The pancreatic stump was closed by suture. The postoperative course was uneventful, and the pathological diagnosis confirmed PB with MPD and inferior mesenteric vein invasion.

Conclusions: We successfully resected an adult case of PB with tumor extension into the MPD via robotic surgery. Robotic surgery enabled precise pancreatic transection at the right edge of the SMV, ensuring a negative pancreatic transection margin in this case. In addition, robotic surgery contributed to the safe and secure suture closure of the pancreatic stump.

Introduction: Congenital esophageal stenosis (CES) is a rare clinical condition found in 1 in 25000-50000 live births. Surgical treatment is required when endoscopic balloon dilatation is ineffective. Laparoscopic and thoracoscopic approaches are selected based on lesion location. Gastroesophageal reflux (GER) is often observed as a postoperative complication that necessitates additional fundoplication. We report a case of CES in the lower third of the esophagus that was treated with simultaneous thoracoscopic resection and Thal fundoplication using the right thoracic approach.

Case presentation: The patient was a 6-month-old boy who presented with vomiting after consuming solid food. Although he had been previously treated by a physician, he was referred to our hospital for further examination because of persistent symptoms at 1 year and 7 months of age. As his oral intake was insufficient, he was thin compared with his twin brother. On esophagography, an abruptly narrowing lesion was found at the Th9-10 level, and congenital esophageal stenosis was diagnosed. Since balloon dilatation under upper gastrointestinal endoscopy was ineffective, the patient was treated surgically. Thoracoscopic esophagectomy (end-to-end anastomosis) and fundoplication (Thal procedure) were simultaneously performed via the right thoracic cavity. Although transient postoperative gastric paresis due to vagus nerve injury was observed, the patient improved with medical treatment and was discharged on postoperative day 14. He is currently able to ingest solid food orally, without GER.

Conclusions: CES can be a surgical indication for a thoracoscopic approach, depending on the site of the lesion. This is the first case in which anti-reflux surgery was performed simultaneously with thoracoscopic CES repair. We consider that this technique is useful for preventing not only GER, but also anastomotic leakage.

Introduction: Segmentectomy is being accepted as a valid operative procedure for small peripheral non-small cell lung cancer. Understanding pulmonary artery (PA) variations is essential to ensure safe and reliable surgeries. Herein, we report a case of left S3 and S8 segmentectomy involving a complete interlobar branch of the left A3, a relatively rare anomaly reported in less than 0.56% of cases in previous studies.

Case presentation: A woman in her sixties was referred to our hospital with two nodules in the left upper lobe anterior segment (S3, 1.1 × 0.8 cm) and the lower lobe anterior basal segment (S8, 1.8 × 1.7 cm), suggestive of double primary lung cancer. Preoperative thin-slice computed tomography (CT) and three-dimensional CT revealed a vascular anomaly in which the entire left A3 branched from the interlobar PA. Left S3 and S8 segmentectomies were performed via thoracotomy. The interlobar A3 branched at nearly the same level as the A6. After cutting the V3b and V3c veins, the intersegmental plane and the interlobar A3 were sequentially divided using staplers. To prevent torsion of the remaining lung, the edges of the apico-posterior segment (S1+2) and the lingular segment were loosely secured with silk sutures. The operative times were 4 h and 8 min with minimal blood loss. Pathological examination revealed that both nodules were squamous cell carcinomas of the lungs (pT1bN0M0, pStage IA2). The patient remained recurrence-free for over 1 year.

Conclusions: Complete interlobar branching of the left A3 is uncommon. During left S3 segmentectomy in cases involving an interlobar A3, the S1+2 and lingular segments may become solitary blocks, necessitating measures to prevent torsion.

Introduction: Primary cardiac tumors are rare, with malignant myxofibrosarcoma cases being particularly uncommon, while cardiac myxoma is a common diagnosis in clinical practice. We present a case of cardiac myxofibrosarcoma, whose clinical course was quite unusual.

Case presentation: A 67-year-old woman with no prior history of cardiac tumors was admitted for dyspnea and was found to have a 60 mm tumor in the left atrium. Despite initial resection, the tumor recurred twice, and a subsequent pleural mass biopsy revealed metastasis of myxofibrosarcoma. Retrospective analysis confirmed that the pathological findings of all the resected tumors were consistent with myxofibrosarcoma. Chemotherapy with doxorubicin was initiated, but severe side effects led to its discontinuation. The tumors continued to grow, causing significant pain, and she passed away a year later.

Conclusions: The differential diagnosis of cardiac myxofibrosarcoma is challenging due to its similarity to benign myxomas. Accurate diagnosis requires thorough histological and immunohistochemical evaluation is essential.

Introduction: Endoscopic submucosal dissection (ESD) is an effective procedure for resecting noninvasive colorectal neoplasms. However, submucosal fibrosis affects the technical difficulty of ESD. We experienced a combined ESD and transanal minimally invasive surgery (TAMIS) for a rectal neoplasm with submucosal fibrosis.

Case presentation: We report our experience with a 75-year-old woman who had a rectal laterally spreading tumor with scarring from a prior transanal resection. She underwent combined ESD and TAMIS to overcome the procedural difficulty of ESD for submucosal fibrosis. The portion of the bowel without scarring was dissected using ESD, while the portion with scarring was dissected using TAMIS. A successful en bloc resection of the tumor was achieved, and there was no recurrence.

Conclusions: Based on the findings from this case, the combination of ESD and TAMIS may be particularly effective under conditions such as rectal neoplasms with submucosal fibrosis.

Introduction: Colon leiomyosarcoma (CLMS) is an extremely rare neoplasm and the information regarding its clinical characteristics and specific treatment was still unclear.

Case presentation: A 73-year-old female who had been diagnosed with transverse CLMS underwent laparoscopic surgery. The resected specimen showed that the tumor contained proliferation of spindle-shaped cells and arranged in fascicular pattern, which was immunohistochemically positive for smooth muscle actin and desmin. Moreover, the tumor bottom was not continuous with the muscularis propria and had a clear border in the submucosa layer. According to these findings, we finally diagnosed it as primary CLMS arising from the muscularis mucosa (MM). No recurrence was noted 24 months after surgery.

Conclusions: This literature demonstrates CLMS arising from MM and suggests that its pathological diagnosis is associated with disease prognosis.

Introduction: Achalasia is a primary esophageal motility disorder of unknown origin. The clinical manifestations are caused by the loss of peristalsis of the esophagus and functional obstruction at the esophagogastric junction. There are several treatment strategies for esophageal achalasia, such as medications, endoscopic treatment, and surgery. The successful treatment of a case of jejunal interposition surgery with overlap esophago-jejunal anastomosis for an esophageal stricture due to repeated endoscopic dilation for esophageal achalasia is reported.

Case presentation: The patient was a 67-year-old man who was diagnosed with esophageal achalasia 13 years earlier. Partial esophagectomy of the portion with the stricture and esophago-jejunal anastomosis using the overlap method were performed for the esophageal stricture due to rupture during endoscopic balloon dilatation. The patient's postoperative recovery was unremarkable, and the dysphagia due to esophageal stricture disappeared.

Conclusions: The overlap technique in esophago-jejunal anastomosis after partial esophagectomy was very effective for an esophageal stricture in a patient with achalasia because it made possible the additional resection of endoluminal muscle.

Introduction: Kommerell's diverticulum is often associated with a right-sided aortic arch. It presents as a saccular aneurysm. Although various surgical strategies have been reported, optimal treatment has not been established.

Case presentation: Four patients with right-sided aortic arch underwent different surgeries for Kommerell's diverticulum. The pattern of aortic arch was a mirror-image of the normal left aortic arch in Cases 1 and 2. In Cases 3 and 4, it was right-sided aortic arch with an aberrant left subclavian artery as its last branch. Cases 1 and 3 presented with compression symptoms caused by Kommerell's diverticulum. They underwent open surgery or thoracic endovascular aortic repair through the different approaches. Their postoperative courses were favorable.

Conclusions: The surgical strategy for Kommerell's diverticulum with a right-sided aortic arch should be selected based on the anatomical characteristics of the cervical vessels, compression symptoms, and surgical risks.

Introduction: Gastric adenocarcinoma with enteroblastic differentiation (GAED) is associated with a poor prognosis because of high rates of liver and lymph node metastases. While systemic chemotherapy is the standard treatment for gastric cancer (GC) with liver metastases, several studies suggest that hepatectomy, when combined with multimodal treatment, may provide a survival benefit. However, the role of surgical resection for GAED with liver metastases remains controversial.

Case presentation: A 71-year-old man presented with abdominal pain and nausea. Endoscopy revealed a type 2 tumor at the greater curvature of the gastric body. Contrast-enhanced computed tomography showed thickening and enhancement of the gastric wall, bulky lymph node metastases, and bilobar hepatic lesions, with the largest tumor measuring 60 mm in diameter. Histological examination of the stomach and liver tumors revealed adenocarcinoma composed of cuboidal or columnar cells resembling a primitive intestine-like structure with clear cells. Immunostaining showed heterogeneous cytoplasmic positivity for alpha-fetoprotein and spalt-like protein 4, leading to a diagnosis of GAED with liver metastases. Because the tumor was positive for human epidermal growth factor receptor 2 (HER2), chemotherapy with capecitabine, cisplatin, and trastuzumab was administered. After six cycles, the tumors had significantly decreased in size, and curative-intent surgery was performed, including distal gastrectomy, left lateral sectionectomy, and partial hepatectomy, successfully eradicating all five liver metastases. Histological examination of the liver metastases revealed extensive necrosis and fibrosis with no viable tumor cells. Adjuvant chemotherapy with the same regimen was continued for 1 year. At the time of this writing, the patient had remained recurrence-free for more than 2 years postoperatively.

Conclusions: We report a rare case of GAED with multiple liver metastases successfully treated with aggressive surgical resection following systemic chemotherapy. Trastuzumab-based chemotherapy may be a viable treatment option for HER2-overexpressing GAED. In addition, radical surgery for GAED with liver metastases might prolong the survival if the chemotherapeutic regimen was effective.

Introduction: Thromboangiitis obliterans (TAO) has become increasingly uncommon in Japan due to declining smoking prevalence. However, in advanced cases with severely compromised distal vasculature, achieving durable limb salvage remains a formidable surgical challenge.

Case presentation: A 51-year-old man with a 12-year history of TAO presented with rest pain and a necrotic ulcer on the 2nd toe. He had recently ceased smoking after a 31-year history. Imaging demonstrated complete occlusion of the popliteal and tibial arteries, with foot perfusion reliant on corkscrew collaterals. The ankle-brachial index was 0.43, and skin perfusion pressure (SPP) was critically low. A severely diseased plantar artery was identified as a potential distal target. Given the high risk of graft failure, a hybrid strategy combining in situ bypass and surgical distal venous arterialization (DVA) was preoperatively planned. To mitigate perioperative vasospasm, a lumbar sympathetic block was administered 1 week prior to surgery. An in situ bypass using the ipsilateral great saphenous vein was constructed from the superficial femoral artery to the plantar artery. DVA was established via retrograde puncture of the plantar vein, balloon angioplasty for valve sites, and end-to-side anastomosis to the bypass graft. Early duplex ultrasonography revealed anastomotic stenosis at the DVA site as well as stenosis at valve sites, both of which were successfully managed with a single endovascular procedure. The toe stump healed completely within 3 months. The graft remained patent for 2 years, and SPP was preserved even after graft occlusion. Notably, graft failure coincided with DVA occlusion, suggesting its critical role in maintaining flow. At 42 months postoperatively, the patient remained ulcer-free with favorable perfusion, pain-free ambulation, and full return to work.

Conclusions: Preoperatively planned surgical DVA, in conjunction with sympathetic modulation and timely postoperative intervention, may offer a durable limb salvage strategy in advanced TAO with limited distal targets.