A stent-graft technique was developed by Parodi et al. and has been used clinically for thoracic endovascular aortic repair (TEVAR) since the 1990s. We evaluated how the new stent-graft technology contributed to expanding aortic surgery and improving surgical outcomes of aortic surgery. TEVAR was performed in a limited number of institutes in the early 2000s and was greatly enhanced by the approval of commercially available stent grafts in 2008. Its performance increased steadily thereafter, with 0 cases performed in 1999, 1658 in 2009, and 6461 in 2019. The ratio of TEVAR was 0% in 1999, which increased to 13.9% in 2009 and 28.5% in 2019, respectively. TEVAR has greatly contributed to the improvement of surgical outcomes, especially in non-dissection ruptured aneurysms and type B acute aortic dissection. TEVAR was performed in 53% of ruptured aneurysms, and the 30-day mortality rate improved to 13.9% in 2019 due to a 30-day mortality rate of 12.5% in TEVAR. The effect of TEVAR was more remarkable in patients with acute type B aortic dissection, where the 30-day mortality rate was 5.7%, and the procedure was performed in 75% of cases. The overall 30-day mortality rate improved to 7.0% for all patients with type B acute aortic dissection in 2019. The expansion of TEVAR using stent grafts greatly increased the number of aortic surgeries and played a significant role in improving surgical outcomes. Stent-graft technology has influenced the field of aortic surgery.

INTRODUCTION: Walthard cell nests are benign urothelial-like rests whose cystic transformation results in Walthard cysts. Their occurrence in male paratesticular structures is rare and can mimic urothelial or mesothelial disease.

CASE PRESENTATION: An 85-year-old male with a history of left inguinal hernia repair presented with a 33-mm whitish cyst adherent to the hernia sac. Ultrasonography revealed a well-defined, hypoechoic mass without internal vascular flow. Non-contrast CT revealed a lobulated, hyperattenuating lesion (~196 HU); in contrast, MRI showed intermediate-to-slightly high T1 and low T2 signals without diffusion restriction, consistent with a protein-rich cyst. Intraoperatively, the cyst ruptured, releasing whitish turbid fluid, and was excised en bloc during mesh plug repair. Cytology revealed crystalline material without cells, and cultures were negative. Histologic examination showed a thin-walled fibrous cyst lined by multilayered transitional-type epithelium without atypia. Immunohistochemistry demonstrated positivity for CK5/6, CK7, GATA3, p63, and WT1; negativity for CK20, uroplakin III, PAX8, calretinin, and OCT3/4; and a Ki-67 index of <1%.

CONCLUSIONS: This case represents the 2nd full-length, peer-reviewed report of a spermatic cord/inguinal canal Walthard cyst of this size. Compared with previous reports, our case uniquely offers comprehensive CT/MRI correlation, a complete immunophenotypic profile—including WT1 positivity with CK20 and uroplakin III negativity—and precise size documentation, thereby aiding in the prevention of misdiagnosis and overtreatment of cystic lesions in the inguinal canal of males.

INTRODUCTION: Recent advances in immune checkpoint inhibitor (ICI) therapy have made conversion surgery possible in selected patients with unresectable hepatocellular carcinoma (uHCC); however, outcomes in cases with extrahepatic spread remain unclear.

CASE PRESENTATION: A 77-year-old man with hepatitis B-associated uHCC presented with a 60 mm tumor in the posterior section of the liver with several daughter nodules and multiple enlarged para-aortic lymph nodes (PALNs). Durvalumab plus tremelimumab was chosen over atezolizumab plus bevacizumab because of the patient’s concurrent anticoagulant therapy for atrial fibrillation, which raised concerns about bleeding risk. Tumor markers (alpha-fetoprotein and protein induced by vitamin K absence or antagonist-II) returned to normal after three cycles, and imaging demonstrated significant shrinkage of both the primary tumor and the lymph nodes. After nine treatment cycles, the primary tumor had further decreased to 25 mm without daughter nodules; however, two PALNs demonstrated regrowth. The patient subsequently underwent a subsegmentectomy of segment 6 and lymphadenectomy of the PALNs. Histopathological examination revealed a complete pathological response (pCR) in the liver tumor, with no viable tumor cells. However, metastatic lymph nodes contained viable undifferentiated carcinoma cells that were negative for hepatocellular markers (HepPar-1 and arginase-1) but positive for CAM5.2 and vimentin, indicating a treatment-resistant component. Twelve months postoperatively, the patient remained recurrence-free with preserved liver function and good general condition.

CONCLUSIONS: This case demonstrates a discrepant therapeutic response, with a pCR in the liver contrasted with residual undifferentiated carcinoma in the PALNs. To our knowledge, this is the first reported HCC case demonstrating hepatic pCR after ICI therapy with residual undifferentiated carcinoma confined to the PALNs, highlighting immune-resistant extrahepatic clones and the diagnostic–therapeutic value of conversion surgery.

INTRODUCTION: In recent years, HER2-low breast cancer has emerged as a distinct subtype, and the anti-HER2 antibody–drug conjugate trastuzumab deruxtecan (T-DXd) has become a promising treatment option. We report the case of an older patient with advanced HER2-low breast cancer resistant to endocrine therapy, who demonstrated a favorable clinical response to the early introduction of T-DXd.

CASE PRESENTATION: A 70-year-old woman was diagnosed at the age of 64 years with stage IV right breast cancer (invasive lobular carcinoma; T1cN1M1 with pleural effusion positive for malignant cells). The patient received endocrine therapy and a CDK4/6 inhibitor; however, disease progression was observed, including increased pleural and ascitic effusion. Cytotoxic chemotherapy was discontinued owing to adverse events and impaired activities of daily living (ADL). Low HER2 expression was confirmed in ascitic cell block specimens, and T-DXd therapy was initiated. After 4 courses of T-DXd, the pleural and ascitic effusions were almost resolved, and no further paracentesis was required. The patient’s ADL improved, and she experienced clinical benefit for 15 months without any severe adverse events.

CONCLUSIONS: T-DXd is potentially a safe and effective treatment option for older patients with HER2-low breast cancer and for those with impaired ADL. Further accumulation of cases and investigations of long-term outcomes are warranted.

INTRODUCTION: Capivasertib, a protein kinase B (AKT) inhibitor, has demonstrated robust efficacy against hormone receptor–positive, human epidermal growth factor receptor type 2–negative advanced breast cancer, particularly in patients with AKT pathway mutations. However, serious metabolic complications such as hyperglycemia and diabetic ketoacidosis (DKA) have been reported. This case report describes capivasertib-induced hyperglycemia to support the development of safe treatment and monitoring strategies. The case is notable because early detection and timely intervention following the rapid onset of grade 4 hyperglycemia resulted in a favorable clinical course without long-term glycemic complications.

CASE PRESENTATION: A 69-year-old woman without diabetes developed grade 4 hyperglycemia (522 mg/dL) on day 2 after receiving capivasertib in combination with fulvestrant therapy. Pretreatment glucose tolerance test results were normal. Continuous insulin infusion was promptly initiated in response to the rapid increase in blood glucose levels to prevent ketosis. Her blood glucose levels improved within half a day, and she was discharged on day 6. She did not require further insulin or hypoglycemic agents thereafter.

CONCLUSIONS: Inpatient glucose monitoring enabled prompt detection of rapid glucose elevation and early intervention before the onset of DKA, resulting in a favorable outcome. Further clinical evidence is required to define optimal intervention strategies for grade 4 hyperglycemia associated with capivasertib therapy.

INTRODUCTION: Esophageal squamous cell carcinoma is an aggressive malignancy often diagnosed at an advanced stage. Immune checkpoint inhibitors (ICIs), such as pembrolizumab, have shown promising outcomes for improving survival. Although rare, immune-related adverse events (irAEs) associated with ICI therapy, such as pneumatosis intestinalis (PI) and portal venous gas (PVG), can be fatal.

CASE PRESENTATION: A 60-year-old man with unresectable advanced esophageal squamous cell carcinoma received cisplatin, 5-fluorouracil (FP), and pembrolizumab. Three days after treatment initiation, the patient experienced abdominal pain and hypotension. Imaging revealed extensive PI and PVG, with no signs of bowel ischemia. Emergency laparotomy confirmed PI involving the entire length of the small intestine, with no visible perforations. Symptoms resolved with conservative management. After benefits and potential adverse events of the current chemotherapy regimen were explained, the patient chose to continue pembrolizumab-based chemotherapy. In the second and third courses, the doses of cisplatin and 5-FU were reduced to 75% (cisplatin 60 mg/m², 5-FU 600 mg/m²), while the dose of pembrolizumab was maintained (200 mg). No major adverse events occurred, and follow-up CT scans showed shrinkage of the primary lesion, and PI did not recur during this period. However, 26 days after the 3rd treatment course, the patient developed sudden-onset abdominal pain, shock, more severe PI, and PVG. Despite receiving intensive care, the patient died the following day. Autopsy revealed diffuse intestinal erosion with a CD8-positive lymphocytic infiltration and histologically confirmed pneumatosis intestinalis extensively involving the small intestine and colon.

CONCLUSIONS: The patient experienced two episodes of PI and PVG with distinct clinical courses. Although the exact cause of the first episode remains unclear, the fatal recurrence suggests that rechallenging with suspected causative agents carries a significant risk, even after dose reduction. While ICI-based chemotherapy for esophageal cancer was highly effective, this case highlights the importance of continuously reassessing the risk–benefit balance during treatment. Discontinuation of ICIs should be considered when serious irAE are suspected.

INTRODUCTION: Moyamoya disease is an occlusive cerebrovascular disorder in which maintaining cerebral blood flow during cardiac surgery is challenging. No reports have described Bentall surgery in such patients. We present a successful case using an integrated brain protection strategy combining intra-aortic balloon pumping (IABP)-induced pulsatile flow, carbon dioxide management, and moderate hypothermia.

CASE PRESENTATION: A 51-year-old male with symptomatic moyamoya disease was referred for severe aortic regurgitation due to left coronary cusp leaflet shortening and a sinus of Valsalva aneurysm (50.7 mm) with cardiac dysfunction and left ventricular enlargement. Selective carotid angiography revealed poor visualization of the circle of Willis, including the anterior and middle cerebral arteries, along with the presence of moyamoya vessels. Oxygen PET imaging revealed Powers Stage II, indicating a high risk of cerebral infarction and intracranial hemorrhage. To maintain cerebral blood flow during cardiopulmonary bypass (CPB), intra-aortic balloon pumping was used to induce pulsatile flow, with moderate hypothermia for brain protection. Continuous monitoring of the partial pressure of carbon dioxide in the oxygenator exhaust gas allowed timely management of the arterial carbon dioxide during CPB, and cerebral oxygen saturation was used to optimize cerebral blood flow. Under this comprehensive brain flow management strategy, Bentall surgery was successfully performed. Postoperative MRI revealed no evidence of brain hemorrhage or infarction, and the patient was discharged without any neurological symptoms.

CONCLUSIONS: This case demonstrates that IABP-induced pulsatile flow, PexCO₂-guided CO₂ management, and moderate hypothermia can effectively preserve cerebral circulation during CPB. This integrated approach enabled the safe and successful completion of Bentall surgery in a patient with moyamoya disease.

INTRODUCTION: Anterior mediastinal germ cell tumors are uncommon in children, and mixed germ cell tumors containing malignant components are particularly rare. These tumors may occasionally present with endocrine manifestations such as gonadotropin-independent precocious puberty caused by ectopic human chorionic gonadotropin (hCG) secretion. Complete resection is the mainstay of treatment, and extended thymectomy is recommended when the tumor involves or is inseparable from the thymus. Minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS) have been increasingly applied, and in some adult cases, a cervical incision has been combined to ensure removal of the cranial thymic extension. However, pediatric reports of VATS combined with a cervical incision for extended thymectomy are lacking.

CASE PRESENTATION: We report a 9-year-old boy who presented with gonadotropin-independent precocious puberty characterized by suppressed gonadotropins, elevated serum testosterone, and increased hCG and alpha-fetoprotein levels. Imaging demonstrated a 45 × 25-mm anterior mediastinal mass with features suggestive of teratoma and suspicious cranial solid components. The tumor displaced the thymus cranially into the lower cervical region, prompting the decision for extended thymectomy via a combined thoracoscopic and cervical approach. A small transverse cervical incision was used to mobilize the cranial thymus, and thoracoscopic dissection allowed safe control of thymic veins and arteries and complete en bloc resection of the thymus and tumor. The specimen measured 6 × 5 × 3 cm and weighed 53 g. Histopathology revealed a mixed germ cell tumor composed of mature teratoma and seminoma. The postoperative course was uneventful, tumor markers normalized, and the patient subsequently received adjuvant cisplatin-based chemotherapy. He remains disease-free at follow-up.

CONCLUSIONS: To our knowledge, this case represents the 1st pediatric anterior mediastinal mixed germ cell tumor treated with thoracoscopic extended thymectomy combined with a cervical incision. The approach allowed safe and complete resection despite cranial displacement of the thymus, while avoiding sternotomy. Recognition of endocrine manifestations such as hCG-induced precocious puberty is essential for early diagnosis. This case demonstrates that minimally invasive extended thymectomy with cervical extension is feasible in children and may be applied to achieve radical resection of complex anterior mediastinal tumors.

INTRODUCTION: Occult breast cancer (OBC) is defined as metastatic breast carcinoma without detectable breast lesions on clinical or imaging evaluation. Most cases are diagnosed from axillary lymph node metastasis (ALNM), while presentation from other sites is rare.

CASE PRESENTATION: A 49-year-old woman with prior gastric cancer developed a 20-mm scalp mass, which was surgically excised. Pathology and immunohistochemistry confirmed metastatic breast carcinoma (hormone receptor-positive and HER2-negative). No breast or axillary lesions were detected by imaging, including PET-CT scan. She was diagnosed with OBC without ALNM and started endocrine therapy with anastrozole.

CONCLUSIONS: We report a rare case of OBC diagnosed based on a solitary scalp metastasis without ALNM. OBC without ALNM appears to favor luminal type and distinct metastatic sites, but further cases are needed to establish treatment strategies.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) can arise anywhere along the gastrointestinal tract. When they originate outside the gastrointestinal tract, they are referred to as extragastrointestinal stromal tumors (EGISTs), which are rare. In particular, EGISTs arising in the perianorectal region are extremely rare. We report the case of a primary perianorectal EGIST, which was initially diagnosed preoperatively as a rectal GIST.

CASE PRESENTATION: A 74-year-old woman presented with a palpable mass on her left buttock. Histopathological analysis of the biopsy specimen confirmed the diagnosis of GIST. MRI revealed a 46 × 28 mm mass on the left dorsolateral aspect of the lower rectum, which was preoperatively diagnosed as rectal GIST. Partial resection of the rectum via a posterior approach was planned. Intraoperatively, however, no continuity between the tumor and rectal wall was observed. Based on pathological and operative findings, the tumor was diagnosed as a perianorectal EGIST, and complete resection was achieved without rectal resection.

CONCLUSIONS: This case underscores the clinical significance of considering EGIST as a differential diagnosis for anorectal GIST lacking clear continuity with the intestinal wall. Furthermore, our experience suggests that posterior approach is less invasive, facilitates anus preservation, and should be considered for resection of both rectal GISTs and perianorectal EGISTs.

INTRODUCTION: A bronchopleural fistula (BPF) is a serious and potentially life-threatening complication of pulmonary resection, with a particularly high incidence following pneumonectomy. Although surgical repair is the mainstay of treatment, conservative management with bronchoscopic intervention also results in complete resolution in some cases. Spontaneous closure of the BPF, especially after full dehiscence of the bronchial stump, remains exceptionally uncommon.

CASE PRESENTATION: A 60-year-old man with diabetes mellitus and interstitial pneumonia underwent right upper lobectomy for suspected lung cancer. The tumor adhered to the superior vena cava, requiring pericardial dissection and phrenic nerve resection. The bronchial stump was sutured and covered with a free pericardial fat pad. Postoperative recovery was initially uneventful; however, on POD 18, the patient presented with dyspnea and was diagnosed with right lower lobe pneumonia. On POD 31, he spat out all suture material and fat tissue with hemosputum. Imaging findings confirmed the presence of a BPF at the bronchial stump without pneumothorax or empyema. He was then conservatively managed with antibiotics and glycemic control. The hilar air space gradually decreased over the following weeks, and CT confirmed complete spontaneous closure of the fistula by POD 151.

CONCLUSIONS: Our case highlights that, under selected conditions—such as absence of empyema, confined necrosis of the bronchial stump, and reduced residual pleural space due to phrenic nerve paralysis and adhesions surrounding the hilum—spontaneous closure of a BPF without a surgical or bronchoscopic intervention is possible. Conservative management with careful monitoring may be a feasible option in selected patients.

INTRODUCTION: Airway foreign bodies are time-sensitive otolaryngologic emergencies that can occur in persons of any age. We describe a unique case of complete aphonia caused by the impaction of a crayfish (Procambarus clarkii) claw at the level of the vocal cords.

CASE PRESENTATION: A 65-year-old man developed abrupt throat discomfort and loss of voice while eating crayfish. Indirect laryngoscopy showed a foreign body resting across the vocal cords with absent vibration. Cervical CT demonstrated a tubular hyperdense structure within the glottic region, and flexible transoral bronchoscopy confirmed a mucus-coated object adherent to the vocal cords. The object was removed en bloc with grasping forceps under topical anesthesia, after which phonation returned immediately. The patient was discharged the next day without complications. The retrieved foreign body was identified as a crayfish claw.

CONCLUSIONS: Crayfish claw impaction at the vocal cords is an exceedingly rare cause of aphonia. Incorporating a targeted dietary history—particularly of regional or seasonal foods—can expedite the diagnosis and management of unusual airway foreign bodies.

INTRODUCTION: Fournier’s gangrene is a rapidly progressive necrotizing fasciitis affecting the external genitalia and perineal region, with a poor prognosis and mortality rate of up to 20%. Prompt infection control, typically through extensive debridement, is essential for survival but may impair anal sphincter function and patient’s QOL. In the present case, infection control and anal sphincter preservation were successfully achieved using the loop drainage as the initial treatment strategy.

CASE PRESENTATION: A 77-year-old man with a history of alcoholic liver cirrhosis and cerebral infarction presented with fever, redness, and swelling around the anus. Fournier’s gangrene was diagnosed based on physical examination and imaging findings, and emergency debridement was performed. A loop drainage technique using Penrose drains was used around the anus to preserve anal function. Postoperatively, additional debridement and drainage procedures resulted in successful infection control. No postoperative defecatory dysfunction was observed, and the patient was discharged with a preserved QOL.

CONCLUSIONS: The loop drainage technique using Penrose drains may be an effective therapeutic option for perianal involvement in Fournier’s gangrene.

INTRODUCTION: The accidental ingestion of fish bones is a common clinical occurrence, especially in regions with high fish consumption. While most foreign bodies pass uneventfully or are removed endoscopically, sharp objects such as fish bones may perforate the gastrointestinal tract and migrate to adjacent organs, occasionally leading to severe complications. Migration into the lung parenchyma is extremely rare.

CASE PRESENTATION: An 80-year-old woman presented with a 5-year history of intermittent hemoptysis following an episode initially diagnosed as bacterial pneumonia. CT revealed a linear hyperdense structure suggestive of a retained fish bone that had penetrated the esophageal wall and migrated into the peripheral left lower lobe. The foreign body had gradually shifted peripherally over time. Video-assisted thoracoscopic surgery (VATS) was performed, and the fish bone, measuring 4 cm, was successfully extracted through a small incision in the lung parenchyma without the need for lobectomy. The postoperative course was uneventful, and follow-up imaging showed resolution of the surrounding inflammation.

CONCLUSIONS: This case highlights an extremely rare instance of a fish bone that remained in the lung for 5 years after esophageal perforation. It underscores the importance of considering retained foreign bodies in the differential diagnosis of unexplained pulmonary symptoms and imaging findings. Furthermore, it demonstrates that even long-standing foreign bodies may be managed effectively with a minimally invasive, lung-preserving approach when preoperative evaluation is carefully conducted.

INTRODUCTION: Antiphospholipid syndrome (APS) is a multisystem autoimmune disorder of hypercoagulability, characterized by arterial and venous thrombosis, recurrent fetal losses, thrombocytopenia, and circulating antiphospholipid antibodies. Among valvular manifestations associated with APS, mitral regurgitation (MR) is the most common, followed by aortic regurgitation. Surgical interventions for APS-related valvular diseases carry high perioperative morbidity and mortality. There are no established guidelines regarding the surgical management of APS-related MR.

CASE PRESENTATION: A 46-year-old man underwent mitral valve repair for severe MR. Histopathological examination of the vegetation on the mitral valve revealed nonbacterial thrombotic endocarditis, and in combination with laboratory findings, the MR was diagnosed as associated with APS. Leaflet thickening and fusion progressed postoperatively, leading to moderate-to-severe MR and mitral stenosis within 2 years.

CONCLUSIONS: In cases where MR is the initial presentation of APS, preoperative diagnosis of APS can be challenging. Detailed, frame-by-frame transesophageal echocardiographic evaluation may aid in the preoperative identification of subtle valvular abnormalities suggestive of APS. When thrombocytopenia and a prolonged activated partial thromboplastin time (APTT) are identified during preoperative evaluation for valvular heart disease, tests for lupus anticoagulant, anticardiolipin antibody, and anti-β2 glycoprotein I antibody should be performed, and consultation with hematologists is recommended. Valve repair for MR associated with APS, which preserves valvular tissue that may become diseased in the future, is likely to result in poor outcomes.

INTRODUCTION: Endoscopic treatment frequently results in minimal gastrointestinal content leakage and mild symptoms. However, surgical intervention may become necessary when the patient’s general condition is unstable. Further management of the underlying disease is required in cases where esophageal perforation occurs during endoscopic treatment. This report presents a case of esophageal perforation that occurred during the treatment of achalasia, underscoring the success of a two-stage laparoscopic approach.

CASE PRESENTATION: A 72-year-old male with a history of esophageal achalasia underwent treatment. Abdominal pain developed during pneumatic dilation. As the pain intensified, imaging studies revealed esophageal perforation. On admission, his vital signs were consistent with shock, and he was diagnosed with localized esophageal rupture. A two-stage laparoscopic surgery was performed, starting with closure of the 3.5-cm perforation and the creation of a jejunostomy for nutrition. Before the second surgery, the patient received a 10-day enteral nutrition and a laparoscopic Heller–Dor procedure, which was successfully completed without complications. On hospital day 22, the patient was discharged following a stable recovery without perioperative complications.

CONCLUSIONS: This case emphasizes the successful management of esophageal perforation following achalasia treatment through a minimally invasive surgery. The patient underwent curative surgery for esophageal achalasia during a short hospital stay.

INTRODUCTION: Chylopericardium is a rare but serious complication after thoracic surgery, caused by injury to thoracic duct tributaries during procedures like lymph node dissection. It leads to chylous fluid in the pericardial cavity. Prompt diagnosis is vital to prevent cardiac tamponade, malnutrition, and immunosuppression due to disrupted lymphatic drainage.

CASE PRESENTATION: A 74-year-old man presented with neck discomfort, and a CT scan incidentally revealed a part-solid ground-glass nodule (GGN) in the right upper lung lobe, raising suspicion of primary lung cancer. Thoracoscopic lobectomy was performed, followed by mediastinal dissection, during which a small pericardial perforation occurred. On POD 4, the patient developed sudden obstructive shock secondary to cardiac tamponade. After consultation with the cardiology, cardiac surgery, and radiology departments, aortic dissection was initially suspected as the most likely cause. As a result of exploratory thoracotomy via cardiac surgery, no aortic dissection was found. Chylous fluid was found in the pericardial space and was thought to be the cause of cardiac tamponade. Conservative management of the chylous effusion was unsuccessful, and thoracoscopic ligation of the lymphatic vessels was required. No reaccumulation of the chylous pericardial fluid was observed after the intervention.

CONCLUSIONS: Following lung surgery, particularly when lymph node dissection or unintentional pericardial breach is performed, chylous pericardial effusion accompanied by cardiac tamponade may occur. Therefore, this complication should be considered.

INTRODUCTION: Amebic liver abscess is a parasitic infection caused by Entamoeba histolytica, which reaches the liver via the portal circulation after invading the colon. While it typically presents with fever, right upper quadrant pain, and elevated inflammatory markers, its clinical and radiologic features can resemble those of bacterial liver abscesses. In patients with structural liver abnormalities, such as polycystic liver disease, symptoms may be atypical and delay diagnosis.

CASE PRESENTATION: We report the case of a 75-year-old woman with autosomal dominant polycystic kidney disease and multiple liver cysts, who presented with abdominal distension and gastrointestinal symptoms. MRI revealed multiple liver cysts, including a large lesion with heterogeneous signal intensity, initially suspected to represent intracystic hemorrhage. The patient underwent open cyst fenestration and deroofing. Postoperatively, she developed persistent ascitic fluid drainage and acute kidney injury requiring dialysis. Despite elevated inflammatory markers, she remained afebrile, and bacterial cultures from blood and ascitic fluid were negative. Histopathological analysis of the resected cyst wall revealed numerous trophozoites consistent with E. histolytica, and subsequent stool and ascitic fluid antigen tests confirmed the diagnosis. The patient was treated with a 16-day course of metronidazole followed by 7 days of paromomycin, resulting in clinical improvement and eventual discharge.

CONCLUSIONS: For high-risk patients with complex hepatic cysts of uncertain cause, begin with percutaneous aspiration and targeted fluid analyses—including testing for E. histolytica—before invasive surgery; this lowers operative risk and aids detection of amebic liver abscess in atypical or culture-negative presentations.

INTRODUCTION: Cardiac calcified amorphous tumors (CAT) are non-neoplastic cardiac lesions composed of calcified nodules. These lesions are associated with underlying factors such as hypertension, diabetes mellitus, and end-stage renal dysfunction. However, its association with infective endocarditis remains unclear.

CASE PRESENTATION: The patient was a 72-year-old woman with a medical history of diabetes mellitus, hypertension, and ossification of the posterior longitudinal ligament. However, no renal dysfunction was observed. For the past 2 months, she had been prescribed antibiotics for low-grade fever. The patient exhibited signs of cerebral and splenic infarctions, along with a vegetative mitral valve apparatus. Cardiac CT showed a posterior leaflet with a tumor-like appearance and calcification. Intraoperative findings revealed no calcification of the mitral annulus. However, the mitral valve leaflets were markedly thickened, with a vegetate attached to the posterior leaflet. The vegetation was then removed and the anterior leaflet was easily excised. The posterior leaflet, which was markedly thickened with calcification, was excised using a No. 15 scalpel and incised along its border with the left ventricular posterior wall. After irrigation, the left ventricular posterior wall and mitral annulus were covered with bovine pericardium and a 25-mm biological valve was implanted in the supra-annular position. The results of pathological and bacterial examinations were consistent with those of a case of CAT complicated by infective endocarditis. The patient’s postoperative course was uncomplicated.

CONCLUSIONS: We encountered a rare case of CAT complicated by infective endocarditis. Complete resection of the CAT in combination with pericardial patch reconstruction of the left ventricular posterior wall, mitral annulus, and mitral valve replacement using a bioprosthesis yielded favorable results.

INTRODUCTION: Pectus excavatum (PE) is the most common anterior chest wall deformity, but surgical intervention during infancy is rarely indicated. In patients with complex congenital heart disease (CHD), however, PE may severely compromise mediastinal capacity, particularly after repeated sternotomies. Although delayed sternal closure is a standard approach to address postoperative hemodynamic instability, in cases where chest wall deformity directly compresses the heart, definitive thoracic reconstruction may be required.

CASE PRESENTATION: We report a 9-month-old boy with right atrial isomerism, single atrium, single ventricle, and total anomalous pulmonary venous connection (TAPVC). After initial TAPVC repair with pulmonary artery banding at 2 months of age, he developed progressive PE. At reoperation for pulmonary venous stenosis release and pulmonary artery re-banding, correction of mediastinal rotation returned the enlarged heart to the midline. Attempts at chest closure resulted in abrupt elevation of central venous pressure and systemic hypotension due to direct cardiac compression by the sternum and costal cartilages. Temporary skin-only closure was performed. Definitive thoracic reconstruction was undertaken 48 hours later using a modified Rehbein technique with a bioabsorbable poly-L-lactic acid (PLLA) mesh plate, molded into a convex shape and fixed anterior to the sternum. This approach increased mediastinal volume and allowed stable chest closure. Postoperatively, right phrenic nerve palsy required noninvasive ventilatory support for 3 weeks. The patient recovered and was discharged 2 months later in good condition.

CONCLUSIONS: This case demonstrates that in infants with complex CHD, severe PE may render chest closure impossible, leading to life-threatening hemodynamic compromise. Thoracic reconstruction using an absorbable PLLA mesh plate provided temporary but effective external fixation, securing mediastinal space without impairing growth. This growth-sparing strategy may represent a valuable salvage option when conventional closure fails in pediatric cardiac surgery.

INTRODUCTION: Neuroblastoma is commonly seen in children younger than 5 years but is extremely rare in adults. There are only 23 reported cases of mediastinal neuroblastoma in adults, and no standard treatment strategy has been established.

CASE PRESENTATION: A 79-year-old man was referred to our hospital for the investigation of an abnormal shadow observed on a routine chest radiograph. CT revealed a 5.5 × 5.0-cm mass in the anterior mediastinum, and fluorodeoxyglucose-PET demonstrated increased fluorodeoxyglucose uptake. Surgical resection was performed to obtain a definitive diagnosis and local control. Histopathological examination confirmed that the mass was a poorly differentiated neuroblastoma with invasion into the surrounding mediastinal fat. Postoperative radiotherapy was administered. The patient remains alive without recurrence at more than 5 years after surgery.

CONCLUSIONS: Neuroblastoma arising in the anterior mediastinum of adults is extremely rare and the long-term prognosis remains unclear. Complete resection followed by radiotherapy may contribute to prolonged disease-free survival in selected adult patients.

INTRODUCTION: Pulmonary cavernous hemangioma (PCH) is extremely rare and, due to the lack of specific radiological characteristics, is often misdiagnosed as other pulmonary diseases, including metastatic tumors. Here, we report a case of multiple PCH lesions with concomitant hepatic cavernous hemangioma (HCH), emphasizing the diagnostic implications of imaging findings.

CASE PRESENTATION: A 57-year-old man presented with fever. CT revealed numerous well-circumscribed pulmonary nodules and multiple low-density hepatic lesions. Dynamic contrast-enhanced CT demonstrated mild, nonspecific enhancement of the pulmonary nodules, whereas the hepatic lesions showed enhancement from the center to the periphery. Serum tumor markers were within normal limits, and PET-CT revealed no abnormal fluorodeoxyglucose uptake in any of the lesions. Although the hepatic lesions appeared suggestive of hemangioma on imaging, the possibility of malignancy, such as hepatic angiosarcoma and its pulmonary metastases, could not be completely ruled out. Therefore, both hepatic and pulmonary biopsies were performed, and histopathological examination confirmed cavernous hemangioma in both organs.

CONCLUSIONS: PCH is a rare benign tumor lacking distinctive imaging characteristics; therefore, differentiation from metastatic pulmonary tumors is often challenging and represents a key diagnostic issue. Although definitive diagnosis currently relies on surgical biopsy, combining suggestive imaging findings—such as the presence of microcalcifications within nodules and the absence of fluorodeoxyglucose uptake on PET-CT—may help avoid unnecessary invasive procedures.

INTRODUCTION: Pulmonary artery intimal sarcoma (PAIS) is a rare vascular malignancy. Complete surgical resection is crucial for favorable outcomes; however, intraoperative delineation of the tumor extent poses a significant challenge.

CASE PRESENTATION: A 63-year-old woman with suspected PAIS underwent a left pneumonectomy under cardiopulmonary bypass. Despite macroscopically clear margins, histopathological examination of the pulmonary artery (PA) stump exhibited tumor infiltration, necessitating reevaluation. We identified multiple skip-like intraluminal nodules along the PA and performed resection and subsequent reconstruction utilizing an autologous pericardial patch. The final pathology demonstrated not only nodular lesions but also creeping intimal infiltration in segments without gross abnormalities.

CONCLUSIONS: Although PAIS typically exhibits contiguous spread along the intima, the presence of skip-like nodules and subtle creeping infiltration is rare, complicating intraoperative assessment. Comprehensive intraoperative and pathological assessments are essential to achieve a complete resection.

INTRODUCTION: Partial splenic torsion in polysplenia syndrome is an extremely rare condition. We encountered and performed surgery for a case of partial splenic torsion in a patient with polysplenia syndrome coexisting with agenesis of the dorsal pancreas.

CASE PRESENTATION: A 30-year-old woman with heterotaxy syndrome presented with intermittent epigastric and right lateral abdominal pain persisting for 2 weeks. She was referred to our hospital. Abdominal contrast-enhanced CT revealed multiple spleens on the right side, a right-sided stomach, and agenesis of the dorsal pancreas. One of the 5 spleens showed no contrast enhancement. Suspecting torsion or infarction, we opted for surgical intervention. Intraoperative findings revealed a small spleen with poor coloration and 180-degree torsion, which we removed. Additionally, we identified another poorly anchored spleen and performed splenopexy to secure this wandering spleen.

CONCLUSIONS: Polysplenia syndrome is a rare condition involving multiple spleens in the setting of heterotaxy syndrome—a defect in the left–right axis of the thoracic or abdominal organs without a complete mirror image. Several reports have described polysplenia syndrome coexisting with agenesis of the dorsal pancreas. Including our case, 11 instances of splenic torsion associated with polysplenia syndrome have been reported in English, with the current patient being the oldest. Furthermore, this is the 1st reported case of splenic torsion occurring in the context of polysplenia syndrome with agenesis of the dorsal pancreas. Our patient had 2 notable anatomical characteristics: first, a vascular variation in which the right celiac artery lacked a common hepatic artery and instead formed a common trunk with the superior mesenteric artery and common hepatic artery, resembling Adachi type VI (group 24); and second, a centrally located, unfixed dorsal spleen that underwent torsion. We hypothesize that splenic torsion occurred due to the central spleen’s mobility and its slightly elongated splenic artery.

INTRODUCTION: Situs inversus totalis (SIT) is a rare congenital condition characterized by a complete mirror-image reversal of thoracic and abdominal organs. This anatomic anomaly poses technical challenges in abdominal surgery, particularly in oncologic procedures requiring precise orientation and dissection. Robot-assisted surgery (RS) offers advantages such as stable visualization and enhanced dexterity, which may facilitate safe and effective surgery even in patients with reversed anatomy. However, reports of using RS for colorectal cancer in the setting of SIT remain scarce.

CASE PRESENTATION: A 75-year-old man was referred to our department for evaluation and management of an anal fistula. A comprehensive diagnostic workup revealed carcinoma with cutaneous invasion arising from the anal fistula in the context of SIT. Because of the cutaneous invasion, curative resection was indicated, and the patient underwent robot-assisted abdominoperineal resection (RAPR). To accommodate the mirror-image anatomy, the surgical setup—including the positioning of robotic arms, monitors, surgeon, assistant, and scrub nurse—was reversed relative to the standard configuration. Lymphadenectomy and vascular ligation were performed using a medial-to-lateral approach adapted in a left-right inverted fashion. While pelvic dissection and lateral mobilization were conducted using the surgeon’s right hand in a standard manner, cranial-side medial dissection and vascular handling were performed using the surgeon’s left hand after instrument exchange. The operative time was 334 min, there was minimal blood loss (15 mL), and the patient’s postoperative course was uneventful.

CONCLUSIONS: RS is a feasible and safe option for patients with SIT undergoing colorectal cancer resection. This case highlights the adaptability of robotic platforms in facilitating unique techniques in the setting of complex anatomical variations. It supports their utility in achieving precise and complication-free oncologic surgery in rare scenarios. Further accumulation of similar patient reports is warranted to establish standardized strategies and validate outcomes.

INTRODUCTION: Wernicke encephalopathy (WE) is a potentially life-threatening neurological disorder caused by a thiamine deficiency, most commonly associated with alcoholism or malnutrition. Although its occurrence after gastrointestinal surgery has been increasingly recognized, WE following thoracic surgery remains extremely rare and is often underrecognized by thoracic surgeons. Given that neurological symptoms of WE can mimic those of cerebral infarction, a timely diagnosis is challenging, especially when complicated by postoperative nausea and vomiting (PONV).

CASE PRESENTATION: We report a rare case of WE following a pulmonary lobectomy in a severely malnourished 75-year-old woman with a history of recurrent thyroid cancer. A 1.6-cm pulmonary nodule was incidentally detected during routine follow-up, and a diagnosis of a primary lung adenocarcinoma was established. The patient underwent a right upper lobectomy and mediastinal lymph node dissection without intraoperative complications. Persistent PONV developed immediately postoperatively, necessitating peripheral parenteral nutrition without vitamin supplementation. On POD 3, the patient developed ataxia, dysmetria, and saccadic eye movements. Although a cerebral infarction was initially suspected, brain magnetic resonance imaging revealed hyperintense signals in the periaqueductal region, suggestive of WE. Intravenous thiamine replacement with fursultiamine led to the gradual resolution of the neurological symptoms and nausea. The patient resumed oral intake on POD 7 and was discharged on day 10 without any neurological sequelae.

CONCLUSIONS: This case highlighted the importance of considering WE as a differential diagnosis in malnourished patients presenting with neurological symptoms and PONV after a pulmonary resection, even in the absence of alcohol use. Early recognition and empiric thiamine supplementation are crucial to prevent irreversible neurological damage. Thoracic surgeons should maintain a high index of suspicion for WE, particularly in at-risk patients, to avoid a delayed diagnosis and improve clinical outcomes.

INTRODUCTION: Schwannomas are benign tumors originating from peripheral nerve sheaths and are most commonly found in the head, neck, and extremities. Intrathoracic schwannomas, particularly those arising from the vagus nerve, are relatively rare. Despite their benign nature, schwannomas often exhibit fluorodeoxyglucose (FDG) uptake on PET scans, potentially leading to diagnostic confusion. This report presents a case initially suspected to be a metastatic lymph node but later diagnosed as a schwannoma from the intrathoracic vagus nerve, highlighting the diagnostic challenges associated with thoracic nodal lesions.

CASE PRESENTATION: A 36-year-old woman with a history of cryptogenic optic neuritis presented with a posterior mediastinal nodule discovered on chest CT. FDG-PET/CT revealed uptake in the nodule, initially raising suspicion of metastatic lymphadenopathy. A repeat CT scan showed that the nodule had shifted medially, suggesting a pedunculated lesion rather than lymphadenopathy. Thoracoscopic findings revealed a 2-cm nodule arising from the vagus nerve and exhibited mobility due to its pedunculated growth. The tumor was enucleated, preserving the main nerve trunk. Histopathological examination confirmed the diagnosis of schwannoma.

CONCLUSIONS: Schwannomas originating from the thoracic vagus nerve can exhibit pedunculated growth and positional migration, posing diagnostic challenges. Mobile mediastinal nodules should prompt consideration of vagal nerve schwannomas in the differential diagnosis. Recognizing that benign schwannomas can accumulate FDG on PET scans is crucial to avoid misdiagnosis as malignancy. This case underscores the importance of comprehensive imaging analysis and clinical correlation in the evaluation of mediastinal masses, potentially alleviating unnecessary psychological burden on patients due to the suspicion of malignancy.

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: The location and size of our patient’s hepatic artery aneurysm might suggest the possible inadequacy of endovascular treatment (EVT) only. We therefore devised a hybrid operation that included microscopic arterial reconstruction after dividing the hepatic artery with simultaneous EVT.

CASE PRESENTATION: A 69-year-old man had multiple abdominal artery aneurysms that were derived from segmental arterial mediolysis. The main aneurysm, which was in the common-proper hepatic artery, was >3 cm in diameter. Complete coiling of the aneurysm might have resulted in hepatic ischemia, so we planned a simultaneous hybrid operation that comprised both hepatic artery reconstruction and EVT. First, the radiologists catheterized the common hepatic artery in preparation for aneurysm rupture. Then, hepato-biliary-pancreatic surgeons encircled and clipped 4 outflow arteries from this aneurysm: the gastroduodenal artery, right gastric artery, and the right and left hepatic arteries. Subsequently, with the help of plastic surgeons, left hepatic artery reconstruction was performed using the middle colic artery to ensure blood flow to the liver. Finally, the radiologists were able to perform coil embolization without fear of aneurysm rupture or dislocation of coils. The operation and EVT time was totaled to 567 min. The patient was discharged after 18 days without postoperative complications. Eighteen months after the operation, there has been no recurrence or regrowth of this treated aneurysm or growth of other aneurysms. Considering segmental arterial mediolysis as multiple visceral aneurysms, we performed MRA to confirm the absence of intracranial aneurysms.

CONCLUSIONS: With cooperation between hepato-biliary-pancreatic surgeons, plastic surgeons, and radiologists, we performed a hybrid operation that included microscopic arterial reconstruction after simultaneously dividing both hepatic arteries and performing EVT for the hepatic artery aneurysm to avoid liver ischemia. A flexible treatment plan that draws upon a breadth of knowledge, techniques, and devices, and involves the cooperation of multiple clinical departments, is suggested to be helpful in the treatment of difficult abdominal aneurysms.

INTRODUCTION: Intraoperative asystole is a rare but potentially life-threatening complication of lung cancer surgery. Various factors, including cardiac conditions, hemorrhage, anesthetic effects, and neural reflexes, may contribute to this phenomenon. Herein, we report a case of intraoperative asystole triggered by a vagal reflex during thoracoscopic left upper lobectomy.

CASE PRESENTATION: A 53-year-old man with left upper lobe adenocarcinoma of the lung (cT1cN0M0, Stage IA3) underwent video-assisted thoracoscopic surgery. During blunt dissection along the posterior surface of the left superior pulmonary vein, severe bradycardia rapidly progressed to asystole. Surgical manipulation was discontinued immediately, and spontaneous circulation returned within 40 s without pharmacological intervention. As the event resolved immediately upon cessation of surgical stimulation, it was considered a transient reflex response. The surgery was resumed and completed without complications. The patient’s postoperative course was uneventful.

CONCLUSIONS: Although rare, vagal reflex–induced asystole should be considered during manipulation of the left pulmonary hilum. Therefore, surgeons and anesthesiologists must be vigilant and prepared for immediate resuscitative measures to ensure patient safety.

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: Liver resection has rarely been reported as a cause of chylous ascites. Such ascites, consisting mainly of hepatic lymph, is usually caused by injury to the lymphatic system between the hepatic hilum and the hepatoduodenal ligament. We report a patient who developed chylous ascites after liver resection and required a peritoneovenous shunt.

CASE PRESENTATION: An 80-year-old man with a liver tumor diagnosed as cholangiocarcinoma underwent an extended right hemihepatectomy with lymphadenectomy following right portal vein embolization. Postoperatively, he developed chylous ascites that resolved with dietary measures, bowel rest, and administration of octreotide. However, he was readmitted a month after discharge with abdominal distension and dyspnea from massive ascites and pleural effusion. Abdominal paracentesis confirmed chylous ascites, showing a triglyceride concentration of 614 mg/dL. After failure of conservative therapy, including dietary and pharmacologic interventions, peritoneovenous shunting was performed. Clinical status improved after shunting, with no adverse events except for transient fever.

CONCLUSIONS: Refractory chylous ascites after liver resection should be treated promptly with surgical measures such as peritoneovenous shunting to maintain the patient’s general condition.

INTRODUCTION: Situs inversus totalis (SIT) is a rare congenital condition characterized by mirror-image transposition of the thoracic and abdominal viscera. Herein, we report a rare case of laparoscopic common bile duct exploration with choledochotomy and stone extraction in a patient with SIT and a history of total gastrectomy with Roux-en-Y (R-Y) reconstruction.

CASE PRESENTATION: A 70-year-old woman with SIT and a history of total gastrectomy with R-Y reconstruction presented with recurrent cholangitis caused by choledocholithiasis. Conservative therapy led to temporary improvement, but symptoms recurred after 2 months. Percutaneous transhepatic gallbladder drainage was followed by laparoscopic cholecystectomy and laparoscopic common bile duct exploration (LCBDE) one week later. Dense adhesions along the midline and right upper quadrant prevented standard port placement, so all maneuvers were confined to the left abdomen. A 3-cm umbilical minilaparotomy accommodated a Lap Protector with two 5-mm working ports, and additional 5-mm ports were inserted in the left lower abdomen for the camera, in the left upper abdomen for the assistant, and above the choledochotomy site for choledochoscope access. CT confirmed complete SIT and an 18-mm common bile duct (CBD) stone with upstream dilation. Endoscopic retrograde cholangiopancreatography was impossible because the long Roux limb and adhesions limited endoscopic access. Choledochotomy was aided by traction sutures; the impacted stone was fragmented intraductally and retrieved with basket forceps. The CBD was closed primarily without drainage. The postoperative course was uneventful, and the patient was discharged on day 8. No complications occurred during the 4-week follow-up.

CONCLUSIONS: This case emphasizes the technical challenges of laparoscopic biliary surgery in patients with situs inversus and a history of R-Y reconstruction. The key points include individualized port placement, surgeon positioning, traction, and secure primary closure. LCBDE is feasible in patients with SIT and prior R-Y reconstruction if surgical strategies are individualized based on anatomical variation and surgical history.

INTRODUCTION: Tumor rupture with neuroblastoma is an uncommon but serious complication, particularly in high-risk cases involving MYCN amplification. When rupture occurs soon after induction chemotherapy is initiated, rapid deterioration and abdominal compartment syndrome (ACS) may develop. Early identification of high-risk patients and their readiness for surgical management are essential to optimizing outcomes.

CASE PRESENTATION: A 4-year-old girl presented with a large left adrenal mass and elevated neuroblastoma markers. Imaging showed a heterogeneous 11 × 9.5 × 17-cm tumor encasing the renal hilum. Because of intratumoral hemorrhage, biopsy was deferred and induction chemotherapy was initiated. Seven days later, sudden abdominal distension and severe anemia developed. Contrast-enhanced CT confirmed intraperitoneal bleeding from the ruptured tumor. Transarterial embolization, including occlusion of the left renal artery, achieved temporary hemostasis; however, intra-abdominal pressure increased to 20 mmHg, thus meeting the ACS criteria. Emergency laparotomy revealed extensive hemorrhagic ascites and a ruptured tumor capsule. En bloc resection of the tumor and left nephrectomy were performed over 4 hours, and total blood loss of 2968 mL occurred. Histopathology confirmed MYCN-amplified neuroblastoma invading the adjacent renal parenchyma, which was classified as high risk by the International Neuroblastoma Risk Group. Postoperatively, the chylous ascites resolved by day 11, and multimodal therapy, including chemotherapy, autologous stem cell transplantation, proton beam radiotherapy, and anti-GD2 antibody therapy, was completed. Remission has been maintained for 2 years.

CONCLUSIONS: Embolization alone may not prevent ACS in patients with MYCN-amplified neuroblastoma and chemotherapy-induced rupture. Prompt surgical resection can be life-saving when anatomically feasible. A pretreatment risk assessment, cautious initiation of chemotherapy, vigilant monitoring, and early surgical preparedness are critical for managing high-risk neuroblastoma.

INTRODUCTION: Ovarian cancer remains a leading cause of cancer-related mortality. Although the peritoneum and abdominal lymph nodes are the most common sites of metastasis, duodenal metastasis is extremely rare. We report a rare case of duodenal metastasis from ovarian clear cell carcinoma (OCCC) that initially presented with gastrointestinal bleeding and was successfully treated with curative resection.

CASE PRESENTATION: A 52-year-old woman with a history of OCCC (International Federation of Gynecology and Obstetrics stage IIA) underwent total hysterectomy with bilateral salpingo-oophorectomy and partial omentectomy, followed by adjuvant platinum-based chemotherapy. During follow-up, routine blood tests revealed marked anemia. Contrast-enhanced CT and MRI demonstrated a 30-mm tumor in the second portion of the duodenum with pancreatic invasion. Upper gastrointestinal endoscopy revealed a type II ulcerative tumor with peripheral bleeding, and biopsy confirmed clear cell carcinoma. Given the anemia caused by tumor bleeding, pancreaticoduodenectomy was performed with curative intent. Histopathological findings were consistent with metastatic OCCC. The patient has remained recurrence-free for 30 months postoperatively.

CONCLUSIONS: We present a rare case of platinum-resistant OCCC with duodenal metastasis that was successfully managed with pancreaticoduodenectomy, resulting in long-term survival. Although the role of surgical resection in such cases remains uncertain, this case suggests that curative surgery may be beneficial in selected patients.

INTRODUCTION: Immaturity of ganglia (IG) is a rare disease and is classified as a type of allied disorders of Hirschsprung’s disease (HSCR). Recently, familial occurrence of HSCR has often been reported. However, there have been very few reports of familial occurrence of IG. We report 3 cases of intrafamilial occurrence of IG.

CASE PRESENTATION: Case 1 was an older brother. He was born vaginally at 40 weeks and 6 days of gestation, weighing 3658 g. No prenatal diagnosis was made. On the day of birth, abdominal distention appeared, and a gastric tube was inserted. On the 1st day of life, colonography showed microcolons throughout the colon. We diagnosed gastrointestinal obstruction or Hirschsprung’s disease and performed surgery on the same day. Cases 2 and 3 were monozygotic twins. They were born vaginally at 37 weeks and 0 days, weighing 2778 and 2810 g, respectively. Neither of them had a prenatal diagnosis. On the 1st day of life, abdominal distention, malfeeding, and delayed evacuation of feces were observed, and colonography was performed. Due to the presence of microcolons throughout the colon, we decided to operate on them. In all 3 cases, ileostomies were created, and the stomas were closed after 6 months. They began oral intake and infusion early on, and anal defecation was established. Also, immature ganglion cells were confirmed by HuC/D staining during the 1st operation. At the time of stoma closure, we confirmed that ganglion cells had matured.

CONCLUSIONS: IG, like HSCR, may have intrafamilial onset. Therefore, early diagnosis and treatment planning are important. Also, a careful explanation to the family is essential.

INTRODUCTION: We herein report a case of presacral neuroblastoma (NB) with a rectobulbar urethral fistula. We successfully resected the tumor with a combined laparoscopic and posterior approach and simultaneously performed posterior sagittal anorectoplasty (PSARP).

CASE PRESENTATION: A 1-year-old boy underwent laparoscopic surgery. He had a surgical history of transverse colostomy for an imperforate anus (later diagnosed as a rectobulbar urethral fistula) on the 2nd day after birth. Before radical surgery for a rectobulbar urethral fistula at 1 year of age, an imaging study incidentally showed a 28 × 27-mm presacral tumor. After a detailed examination, the tumor was diagnosed as NB, International Neuroblastoma Risk Group (INRG) Stage L1. We decided to perform surgical resection using a combined laparoscopic and posterior approach. The main reason for using the laparoscopic approach was to reduce intraoperative bleeding by ligating the median sacral artery (tumor-feeding artery). We also planned to simultaneously perform PSARP. If PSARP is performed later, postoperative adhesions make it difficult to dissect the rectum and identify the levator ani muscles. Under general anesthesia, the median sacral artery was ligated laparoscopically. The patient was then placed in the jackknife position, and the tumor was completely resected using a posterior approach. PSARP was performed without complications. The pathological diagnosis was NB, a differentiating subtype with R0 resection. The final INRG risk classification was low-risk, and no additional treatments were required. Postoperative complications were not observed, with the exception of urinary incontinence. The patient was discharged on the 16th day after surgery. He had no recurrence for 3 years after surgery. His defecation was well controlled using glycerin enema without soiling. His self-catheterization for urinary incontinence once daily was continued for 1 year and stopped after confirming no residual urine.

CONCLUSIONS: In this study, we performed laparoscopic surgery combined with a posterior approach for a presacral NB and successfully resected the tumor with a good laparoscopic view. Furthermore, we simultaneously performed PSARP for the rectobulbar urethral fistula following tumor resection. This approach may be one of the options for treating presacral NB associated with a rectobulbar urethral fistula.

INTRODUCTION: In the 2019 World Health Organization (WHO) classification, tumors comprising ≥30% of both neuroendocrine and non-neuroendocrine components are defined as mixed neuroendocrine–non-neuroendocrine neoplasms (MiNENs). Acinar cell carcinoma (ACC) constitutes <1% of pancreatic tumors, while neuroendocrine carcinoma (NEC) accounts for 1%–2%, making MiNENs with both characteristics extremely rare. The role of surgical resection in resectable NEC remains unclear; however, it is generally recommended as part of multimodal therapy. This case presents a pancreatic mixed acinar–NEC successfully managed with multimodal therapy, including repeated liver metastasis resections, achieving long-term disease control.

CASE PRESENTATION: A 57-year-old woman presented with abdominal pain. Her symptoms improved with conservative treatment, but the patient returned to the emergency room 3 months later with abdominal pain. Hemorrhage from a pancreatic tail cyst and localized pancreatitis were suspected based on laboratory and imaging findings. As malignancy could not be ruled out, the patient was referred to our department and underwent laparoscopic distal pancreatectomy with splenectomy. Pathological examination revealed mixed acinar–NEC composed of 70% ACC and 30% NEC; later, liver metastasis was detected. While progression was observed after cisplatin plus etoposide combination therapy, stereotactic body radiation therapy led to a gradual reduction in the size of the liver tumor. Six months postoperatively, laparoscopic partial hepatectomy was performed. Despite adjuvant chemotherapy, a solitary liver tumor from ACC was detected 1 month after surgery. After FOLFIRINOX chemotherapy administration, another laparoscopic partial hepatectomy was performed. No recurrence has since been observed.

CONCLUSIONS: In cases where disease control is achieved via multimodal therapy, surgical resection of metastases may be considered to provide long-term survival.

INTRODUCTION: Coexisting bilateral intralobar and extralobar pulmonary sequestration has rarely been reported, with no previous reports indicating that simultaneous resection is necessary because of a common drainage vein.

CASE PRESENTATION: A 1-year-old boy was prenatally suspected to have right pulmonary sequestration. A preoperative contrast-enhanced CT scan revealed coexisting right intralobar and left extralobar pulmonary sequestrations. The left extralobar sequestration drained into the right inferior pulmonary vein, which was shared by the right intralobar sequestration. The patient had a history of infection with right intralobar pulmonary sequestration during infancy, so a right lower lobectomy was considered. Although an isolated right lower lobectomy would have resulted in congestion of the left sequestrated lung, simultaneous bilateral thoracoscopic surgery was performed. First, thoracoscopic resection of the left sequestrated lung and ligation of the right feeding artery of the right sequestrated lung were performed with right differential lung ventilation, followed by thoracoscopic right lower lobectomy with left differential lung ventilation after repositioning the patient. The intra- and postoperative courses were uneventful.

CONCLUSIONS: Simultaneous thoracoscopic surgery for bilateral pulmonary sequestration in infants with a common drainage vein is a reasonable strategy, as unilateral lesion resection may lead to postoperative complications.

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: 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: Left trisectionectomy with bile duct resection is a high-risk procedure that requires thorough preoperative evaluation to prevent postoperative liver failure. In addition, there are a few reports of highly invasive hepatectomy in cases where hepatic vein thrombosis is present preoperatively.

CASE PRESENTATION: In a 58-year-old man, papillary epithelium was detected in the left hepatic duct during a bile duct biopsy, and the anterior segment of Glisson's capsule was compressed by the cystic components. Left trisectionectomy with bile duct resection was planned, based on a diagnosis of intraductal papillary neoplasm of the bile duct (IPNB). In our department, portal vein embolization (PVE) is essential when considering left trisectionectomy with bile duct resection, so surgery was scheduled after PVE. However, CT after PVE showed thrombus formation in the right hepatic vein (RHV), which persisted despite the initiation of anticoagulant therapy. Owing to the absence of a major drainage vein and the risk of postoperative liver failure, the patient was treated with gemcitabine + cisplatin + S-1 therapy. CT after chemotherapy still showed RHV thrombosis, along with newly developed peripheral venous shunt formation between the obliterated RHV branches. After 6 months, the same findings were observed, and as the tumor had shrunk, the case was deemed resectable. Left trisectionectomy with bile duct resection was performed. Pathological diagnosis confirmed IPNB (pTisN0M0, pStage 0 according to the Union for International Cancer Control, 8th edition). Following adjuvant chemotherapy, the patient developed pulmonary metastases, which were surgically resected. As of 38 months post-hepatectomy, the patient remains cancer-free.

CONCLUSIONS: We encountered a case in which left trisectionectomy with bile duct resection was possible owing to the formation of an RHV shunt, enabling resection of both the primary and recurrent lesions. Continuous imaging is essential for the dynamic assessment of resectability.

INTRODUCTION: Esophageal penetration due to accidental foreign body ingestion is relatively rare but has a poor prognosis. Penetration into the left atrium is extremely rare, and only a few cases have been reported. A case of foreign body penetration into the left atrium is reported.

CASE PRESENTATION: The patient was a 75-year-old woman who was transferred to our hospital for surgery due to fish bone perforation from the lower esophagus into the left atrium on CT. Urgent surgery was performed with the diagnosis of sepsis due to a mediastinal abscess and esophageal penetration into the left atrium caused by accidental fish bone ingestion. At surgery, only the fistula of the penetration wound in the esophagus and the left atrium could be detected, but not the fish bone. On CT after surgery, a folded fish bone was seen at the pericardium close to the left atrium. It was considered unlikely that the heart would again be perforated due to the fish bone’s length, and it was decided to follow up with continued antimicrobial therapy.

CONCLUSIONS: A rare, successfully rescued case of esophageal penetration of an accidentally ingested fish bone into the left atrium by urgent surgery, with collaboration between gastrointestinal and cardiovascular surgeons, is reported.

INTRODUCTION: Hepatocellular carcinoma (HCC) presents as a hepatic mass and may involve vascular invasion or extrahepatic spread. However, intraductal growth within the intrahepatic bile duct is rare and is often associated with obstructive jaundice. HCCs confined to the intrahepatic bile duct without detectable hepatic mass or jaundice are rare, and diagnosis is often difficult due to clinical and radiological resemblance to perihilar cholangiocarcinoma. Moreover, such cases generally carry a poor prognosis. We report a rare case of HCC that developed exclusively within the intrahepatic bile ducts, without forming a detectable mass in the liver or causing jaundice.

CASE PRESENTATION: A 70-year-old man presented with right hypochondriac pain. Imaging revealed dilation of the intrahepatic bile ducts in the anterior sector and intraductal filling defects, particularly in the intrahepatic bile duct branch of segment 8, without a detectable hepatic mass. Alpha-fetoprotein and Duke pancreatic monoclonal antigen type 2 levels were elevated, whereas prothrombin induced by vitamin K absence-II, carbohydrate antigen 19-9, and carcinoembryonic antigen levels were within normal limits. Perihilar cholangiocarcinoma was suspected based on imaging. Right hepatectomy with extrahepatic bile duct resection was performed after preoperative portal vein embolization. Intraoperative ultrasonography and gross examination revealed no parenchymal mass. Histopathology showed atypical hepatocyte-like cell clusters with pleomorphic nuclei proliferating within the Glisson’s capsule and infiltrating the adjacent liver parenchyma in a trabecular pattern without fibrous capsule formation. Tumor infiltration into the bile duct epithelium was evident. Immunohistochemical staining was positive for HepPar1 and negative for cytokeratin 19, with a 40% Ki-67 labeling index, confirming HCC diagnosis. The patient remains recurrence-free at 2 years and 7 months postoperatively.

CONCLUSIONS: This case highlights a rare presentation of HCC without a hepatic mass or jaundice, confined to the intrahepatic bile duct. Most patients present with obstructive jaundice. Only two other English-language cases have no prior history of primary HCC, no hepatic mass, no jaundice, and disease confined to the bile duct. Although bile duct-invading HCC is generally associated with poor prognosis, our case suggests that early surgical intervention may lead to favorable long-term outcomes in select patients.

INTRODUCTION: Hypocalcemia is a common complication after total thyroidectomy, particularly in patients with Graves’ disease and high bone turnover. Preoperative vitamin D deficiency is a known risk factor for postoperative hypocalcemia; however, the effects of vitamin D supplementation remain controversial. This is the first study to document a paradoxical increase in parathyroid hormone (PTH) levels after preoperative vitamin D supplementation in a patient undergoing total thyroidectomy.

CASE PRESENTATION: We report the case of a 68-year-old woman with Graves’ disease and coexisting thyroid cancer who received native vitamin D (2000 IU/day) for 4 weeks before surgery. This unexpectedly resulted in a marked increase in PTH levels and bone formation markers, suggesting the worsening of secondary hyperparathyroidism. Interestingly, fibroblast growth factor 23 levels remained unchanged despite an increase in PTH and 1,25-dihydroxyvitamin D levels. Postoperatively, she developed transient hypoparathyroidism.

CONCLUSIONS: Native vitamin D supplementation may, paradoxically, worsen secondary hyperparathyroidism in some patients, highlighting the need for careful preoperative metabolic assessment and individualized management strategies.

INTRODUCTION: Encapsulated papillary carcinoma (EPC) is a relatively rare form of breast cancer and is often low grade. Even in cases of EPC with invasion, it rarely metastasizes. We herein report a case of EPC with invasion that presented with a cystic axillary lymph node metastasis that was highly characteristic on imaging.

CASE PRESENTATION: A 73-year-old woman presented with a mass in the right breast. Mammogram showed linear calcifications in the middle-outer region of the right breast and a lobulated mass in the lower region. Ultrasound revealed a cystic mass with extensive fluid formation in the breast and a hypoechoic mass with indistinct borders. Numerous cystic enlarged lymph nodes, similar in appearance to the intramammary mass, were detected in the ipsilateral axilla. Contrast-enhanced MRI also revealed multiple cystic enlarged lymph nodes in the axilla. Cytology of the axillary lymph nodes was suggestive of metastasis. The patient underwent a right mastectomy and axillary dissection, and histopathological examination confirmed a diagnosis of EPC with invasion (pT2N2aM0, Stage IIIA). The metastatic axillary lymph nodes contained cystic structures with papillary proliferation, closely resembling the primary EPC lesion. The patient was treated postoperatively with endocrine therapy alone, and to date, no recurrence has been observed 18 months after surgery.

CONCLUSIONS: This case highlights a rare instance of EPC with invasion presenting as cystic lymph node metastases, which was strikingly evident on imaging. Awareness of this unique metastatic pattern may be useful in daily clinical practice for facilitating accurate diagnosis and appropriate management of EPC.

INTRODUCTION: In this work, we describe an unusual presentation of a nuchal-type fibroma, presenting as a mass in the ischiorectal space in an adult male. Since this lesion was not palpable and was in close proximity to the anal sphincter complex, we describe a novel multidisciplinary approach using wire-needle localization with interventional radiology to allow for a directed dissection, similar to an approach used in breast partial mastectomy surgeries.

CASE PRESENTATION: A 56-year-old male presented with an incidentally found 2.1 × 2.7 × 1.8 cm ischiorectal mass that abutted the anal sphincter complex. Interventional radiology performed an ultrasound-guided wire needle localization which allowed for a directed dissection down to the lesion. Pathology was consistent with nuchal-type fibroma with negative margins. The patient now undergoes surveillance with semi-annual MRIs.

CONCLUSIONS: This case report describes a novel application of a hybrid surgical approach utilizing intraoperative image-guided localization for the safe excision of a rare soft tissue mass in an atypical, difficult-to-access location.

INTRODUCTION: Unilateral absence of the pulmonary artery (UAPA) is a rare congenital vascular anomaly, often diagnosed in childhood but sometimes remaining asymptomatic until adulthood. Its coexistence with primary lung cancer is exceptionally uncommon. Surgical resection in such cases poses risks due to absence of the pulmonary artery and hypertrophied systemic vessels, which may lead to bleeding or ischemic complications.

CASE PRESENTATION: A 69-year-old woman with a history of unilateral interstitial pneumonia was referred for evaluation of a growing nodule in the left lower lobe. She was asymptomatic, with no prior hemoptysis or infection. Imaging revealed left-sided UAPA with systemic collateral perfusion. Two 18F-fluorodeoxyglucose (FDG)-avid pulmonary nodules were detected, raising suspicion for stage IA3 (S9) and IA2 (S8) lung cancer. To avoid the high morbidity associated with pneumonectomy while achieving oncologic control, a left lower lobectomy was performed. Intraoperative findings included hypertrophied systemic vessels and absence of the pulmonary artery, which required conversion to thoracotomy due to bleeding from collateral vessels forming the fused fissure and anatomical complexity. The bronchial stump was reinforced with a free fat pad. Although the initial postoperative course was uneventful, bronchoscopy on POD 90 revealed a bronchopleural fistula. The patient was managed conservatively with close observation, during which bronchial epithelial perfusion gradually recovered, and she has remained clinically stable without additional intervention.

CONCLUSIONS: Management of asymptomatic adult UAPA complicated by ipsilateral lung cancer requires careful, case-specific surgical planning. Lobectomy was selected to reduce pneumonectomy-related risks. Implementing preventive measures—such as a pedicled muscle flap or pericardial fat pad for bronchial stump coverage—is advisable to reduce ischemic risk in such cases.

INTRODUCTION: Situs inversus totalis (SIT) is a rare congenital anomaly characterized by mirror-image reversal of the entire thoracoabdominal viscera. Right-sided round ligament (RSRL) is another rare congenital anomaly often associated with intrahepatic vascular variations. The coexistence of these 2 anomalies is extremely rare and presents a significant challenge for hepatectomy. Here, we report a case of anatomical hepatectomy performed in a patient with SIT and RSRL.

CASE PRESENTATION: A 50-year-old Japanese man was diagnosed with ascending colon cancer and multiple lung and liver metastases. CT revealed SIT and RSRL. The patient underwent laparoscopic colectomy followed by chemotherapy with XELOX plus bevacizumab. We planned a hepatectomy for the residual liver metastasis after 4 courses of chemotherapy. To assess the intrahepatic vasculature accurately, we horizontally flipped the CT and 3D images to correct the mirror-reversed orientation of the liver, creating standard anatomical images without SIT. We then standardized the anatomical terminology within the surgical team to prevent misinterpretation of structures during surgery. We performed anatomical hepatectomy of the dorsal area of the right paramedian sector to resect residual hepatic lesions after chemotherapy. The procedure was performed on the right side of the patient using a standard surgical approach. Histopathological examination identified a single viable nodule with hepatic metastasis, whereas the remaining nodules showed a pathological complete response. The patient recovered uneventfully and was discharged on POD 10. The patient remained alive without disease progression 84 months after hepatectomy.

CONCLUSIONS: We successfully performed anatomical hepatectomy in a patient with SIT and RSRL. Normalized imaging and standardization of anatomical terminology within the surgical team are key to ensuring surgical precision, preventing confusion during the operation, and avoiding potentially fatal complications of SIT and RSRL.