Journal of Nippon Medical School最新文献

Introduction: Because of its lower risk of mediastinal complications, the retrosternal route is commonly used for reconstruction after subtotal esophagectomy. However, cases of postoperative gastric conduit obstruction at the thoracic inlet have been reported, as has passage disturbance at the feeding jejunostomy site. These obstructions are often managed by surgical treatment, but few reports have described endoscopic treatment.

Case presentation: A 75-year-old man with advanced mid-thoracic esophageal cancer underwent three courses of DCF chemotherapy, followed by robotic esophagectomy with gastric conduit reconstruction via the retrosternal route and feeding jejunostomy. Preoperative CT showed no thoracic inlet stenosis. On postoperative day (POD) 7, a barium swallow test revealed cervical esophageal dilation and narrowing of the gastric conduit due to external compression at the thoracic inlet. In addition, a passage disturbance at the feeding jejunostomy site developed later. Endoscopic balloon dilation was performed at both sites on POD 26 and 31, resulting in resolution of both obstructions. The patient resumed adequate oral intake and was discharged without the need for reoperation.

Conclusions: This case suggests that endoscopic balloon dilation is an effective, minimally invasive alternative to surgery for managing postoperative gastric conduit and jejunostomy obstructions after esophagectomy.

Leptomeningeal metastasis (LM) from colorectal cancer is rare. LM is characterized by rapid progression, making diagnosis and treatment challenging, and are associated with a poor prognosis. A 63-year-old man undergoing chemotherapy with bevacizumab for colorectal cancer was admitted to our hospital with loss of appetite. On admission, he experienced frequent episodes of loss of consciousness. Imaging to identify the underlying cause revealed no abnormalities. Cytological examination of cerebrospinal fluid confirmed LM. Because of worsening symptoms, the patient had difficulty communicating, thus preventing continuation of chemotherapy. He died at 3 weeks post-admission. In patients with cancer who exhibit central nervous system symptoms without abnormal imaging findings, LM should be considered even if the primary tumor is in the transverse colon. In such cases, cytological examination of cerebrospinal fluid and imaging studies should be conducted. This rare case of LM from colorectal cancer after resection and chemotherapy with molecularly targeted agents yielded insights that might guide future treatment strategies.

A transgender (trans) man is a trans person who was assigned female sex at birth. Some trans men undergo gender-affirming surgical procedures, particularly mastectomy. We present a case of keloid formation after gender-affirming mastectomy that highlights the importance of choosing the most appropriate mastectomy technique in patients at risk of keloid and the most effective therapeutic strategies for anterior-chest keloids. A 40-year-old Japanese trans man developed keloids along inverted-T mastectomy-induced anterior-chest scars. The keloids were completely excised, and the defects were closed by primarily using a layered technique. Starting the next day, the wounds were treated with radiotherapy over 3 consecutive days. The wounds/scars were carefully monitored and treated with continuous taping fixation for 1 year. There was no recurrence, and aesthetic outcomes at 18 months were good. To prevent keloids after gender-affirming mastectomy, surgeons must estimate individual risk of keloid formation. If the patient is young, of Asian or African descent, or has a personal or family history of keloids, surgical methods that leave long lateral scars on the anterior chest (e.g., the inverted T procedure) should be avoided. Tensionless or tension-reducing surgical techniques should also be used, along with postoperative radiotherapy, long-term taping or compression, close follow-up to detect early signs of keloid formation, and referral to a plastic surgery department if any scar induration or elevation is observed. Surgeons performing gender-affirming mastectomy can potentially reduce the risk of keloid formation by carefully considering these factors.

Unlike Langerhans cell histiocytosis (LCH) involving the skull, LCH of the vertebrae and lungs requires careful long-term follow-up because of the risks of motor and respiratory dysfunction; however, few reports have addressed this issue. A boy aged 7 years 7 months presented with bilateral shoulder pain and neck pain. Initial imaging revealed C6 vertebral bone lysis, a mass spanning C5-C7, C6 vertebral body flattening, and epidural extension. Chest radiographs and CT scans showed diffuse reticular and funicular shadows, ground-glass opacities, interlobular septal thickening, and swollen hilar lymph nodes. Bone scintigraphy showed cervical accumulation, while gallium scintigraphy revealed diffuse lung uptake. Lung biopsy confirmed LCH (CD1a, S-100, langerin positivity), confirming a diagnosis of multisystem LCH involving lung, bone, skin, and soft tissue. Treatment with cytarabine, vincristine, and prednisolone, in accordance with the Japan LCH Study Group-02 protocol, resulted in rapid respiratory improvement, withdrawal of oxygen, and resolution of neck pain. Seven years after completing chemotherapy, the patient had no neck discomfort and satisfactory cervical motion, normal respiratory function, and no respiratory symptoms. A cervical MRI scan at 1.5 years after the end of chemotherapy showed persistent C6 vertebral flattening from the compression fracture, which remained clinically stable throughout follow-up, with no herniation, mass formation, or epidural recurrence. Chest imaging at a 7-year follow-up examination showed no abnormalities. These findings suggest that timely diagnosis and appropriate chemotherapy yield favorable long-term outcomes in multisystem LCH with vertebral and pulmonary involvement, and avoid major sequelae.

A 76-year-old woman was referred to our hospital for evaluation of markedly high intraocular pressures (IOPs): ≥40 mmHg in both eyes. No intraocular inflammation, pseudoexfoliation, or glaucomatous optic neuropathy was observed on ophthalmological examination. The 24-hour IOP fluctuations, measured with a Goldmann tonometer in the sitting position at 8, 12, 16, 20, and 24 o'clock, were 22/17, 33/28, 41/33, 30/22, and 30/24 mmHg, respectively, and showed a peak in the afternoon. The patient was diagnosed with ocular hypertension, and microhook trabeculotomy (μLOT) (right eye with lens reconstruction, left eye initially pseudophakic) was performed. After μLOT surgery in both eyes (4 days postoperatively in the right eye and 1 day postoperatively in the left eye), IOP decreased in both eyes to 12/15, 11/14, 12/15, 10/11, and 10/10 mmHg, and the fluctuation range was suppressed. At 3 months postoperatively (measured at 8, 12, 16, 20, 24, and 4 o'clock), the effect was maintained at 14/15, 15/19, 14/19, 11/12, 13/14, and 13/13 mmHg, respectively, but was slightly attenuated. In a patient with marked 24-hour IOP fluctuation, μLOT was effective in reducing IOP values and fluctuation.

A 38-day-old infant was referred to our hospital for evaluation of apnea, fever, and pyuria. Invasive bacterial infection, including meningitis, was suspected because of the presence of apnea. A contrast-enhanced CT scan revealed acute localized bacterial nephritis, and meningitis was ruled out. Gram-positive cocci and Gram-negative rods, ie, Enterococcus raffinosus and Escherichia coli, were isolated from a urine culture at the referring hospital. This case report describes the youngest case of E. raffinosus infection. Apnea was the main complaint, but the origin of fever was infant acute focal bacterial nephritis (AFBN) with mixed infection. In infants, bacterial infections, especially invasive bacterial infections, can result in poor outcomes and require careful evaluation and treatment. Furthermore, the possibility of AFBN should not be overlooked, because bacteriuria or leukocyturia may be absent and can flare up if antimicrobials are not administered for an adequate duration. Although ampicillin-susceptible E. raffinosus infection in our patient responded well to treatment, there have been reports of vancomycin-resistant enterococci, which highlights the importance of proper use of antimicrobial agents to avoid producing drug-resistant bacteria.

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of many cancers, including cancers of the head and neck. Despite the promising therapeutic efficacy of ICIs, immune-related adverse events (irAEs) are a major concern. Acute tubular injury and interstitial nephritis are the most common irAEs involving the kidneys. The present patient was diagnosed as having advanced papillary squamous cell carcinoma of the head and neck. After failure of the initial treatments, including chemotherapy, nivolumab (programmed death-1 inhibitor) was introduced. Shortly after initial administration of nivolumab, the patient developed acute kidney injury with hematuria and proteinuria. A renal biopsy and his clinical course indicated a diagnosis of ICI-related IgA nephropathy. Although glomerular involvement in irAEs is rare and challenging to treatment, the present patient was successfully treated with steroids, which improved kidney function and led to complete remission, as confirmed by urinalysis.

A rectovaginal fistula (RVF) is an abnormal tract between the rectum and vagina, which requires surgical intervention in many cases. Although there are many different therapeutic approaches for RVF depending on the patients' condition, there are no established guidelines for the care of RVF. This study aimed to evaluate the results of laparoscopic colostomy in advanced cancer patients with RVF, and the safety and efficacy of this surgery. In this study, seven female advanced cancer patients with RVF were hospitalized and successfully treated with laparoscopic colostomy from 2015 to 2018 at our university hospital. Their data were retrospectively evaluated from their medical records. The early use of diverting stomas facilitated timely resumption of cancer treatment and enabled early treatment with chemotherapy or radiotherapy. Although vaginal stool leakage affected three patients, all patients recovered, experiencing neither pain nor infection during their cancer treatment. While colostomy was physically and mentally taxing for the patients, it improved the infection and pain caused by the RVF. We conclude that the early use of diverting stomas had two effects: a significant improvement in infection management and facilitation of the rapid resumption of cancer treatment.

Anisakiasis is a parasitic infection affecting the human gastrointestinal tract. It is caused by the consumption of contaminated, raw or inadequately cooked fish or squid, which is typically used for making sushi and sashimi. Most cases involve gastric anisakiasis, whereas intestinal anisakiasis is rare. This report describes the case of a 63-year-old Japanese woman with a history of raw fish consumption who presented with acute-onset abdominal pain and vomiting. Abdominal computed tomography (CT) demonstrated thickened small bowel loops and ascites on the liver surface. The patient was admitted for supportive care. On the second day of hospitalization, contrast-enhanced abdominal CT revealed that the ascites had moved from the liver surface to the pouch of Douglas. On the fifth day of hospitalization, the patient was discharged with a substantial improvement in abdominal pain. Five days after the discharge, her eosinophil count was elevated, and parasitic disease was therefore suspected. Anti-Anisakis IgG/A and IgE (RAST) antibody levels were elevated, confirming the diagnosis of intestinal anisakiasis. A review of 51 reported cases of intestinal anisakiasis suggests that the presence of ascites and measurement of anti-Anisakis antibody titers are helpful for diagnosis in cases presenting with nonspecific abdominal symptoms after consumption of raw or undercooked fish.

Nasogastric tube syndrome (NGTS) is a complication of NGT placement that can cause sore throat, bilateral vocal cord paralysis, and airway constriction. Although rare, this condition should be known by all physicians because it is sometimes fatal. We report a case of NGTS that was successfully diagnosed and debrided with a rigid curved laryngoscope. A 79-year-old man was referred to our department for evaluation of persistent pharyngeal pain and dysphagia after thoracic aortic aneurysm surgery. He had restricted bilateral vocal fold abduction, and the NGT had been placed for nearly 120 days. After induction of general anesthesia, the patient underwent laryngeal examination using a rigid curved laryngoscope, which revealed ossified cricoid cartilage in the postcricoid area, leading to confirmation of NGTS. The NGT was removed, and the protruding bony lesion was debrided. Subsequently, the patient underwent gastrostomy to improve his nutritional status. One month later, the postcricoid lesion improved, and the patient was able to tolerate an oral diet. The pathophysiology of NGTS is thought to involve ulceration of the postcricoid mucosa and injury of the posterior cricoarytenoid muscle by contact with the NGT. Although the treatment has not been established, early removal of the NGT is important. In the present case, the rigid curved laryngoscope was useful for resection of the bony lesion, which contributed to early epithelialization and symptom improvement.