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: 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.

INTRODUCTION: Autoimmune neutropenia (AIN) is a rare disease that causes neutropenia due to autoantibodies directed against neutrophils. Neutropenia is associated with an increased risk of infection, such as surgical site infection or febrile neutropenia. To our knowledge, however, there are few reports of surgical or neoadjuvant chemotherapeutic treatments for colorectal cancer with AIN. Herein, we present a case with AIN undergoing multidisciplinary treatment of cecal cancer and metachronous liver metastases.

CASE PRESENTATION: A 74-year-old woman with AIN presented to our hospital with epigastric pain lasting for 3 weeks. Abdominal CT showed obstructive cecal cancer and swollen regional lymph nodes. She had been under observation for primary AIN in the hematology department in our institution. The blood test revealed white blood cell count of 2300/μL, neutrophil count of 19.4%, and thus absolute neutrophil count of 446/μL. Granulocyte-colony stimulating factor (G-CSF; filgrastim 75 μg) was administered to lower the risk of infectious complications before surgery. After the absolute neutrophil count levels increased sufficiently, laparoscopic ileocecal resection was performed. Pathological findings showed T3N1aM0, pStage IIIB (UICC 8th edition), HER2 score 0, and a RAS codon 12S mutation. Six months after curative surgery, multiple liver metastases appeared. A total of 8 cycles of mFOLFOX6 with bevacizumab, combined with G-CSF (filgrastim 75 μg) were administered. After preoperative chemotherapy, the patient underwent right anterior sectionectomy and partial resection of segment 6. She was uneventful in the postoperative course. Throughout the perioperative period and chemotherapy, no infectious complications were observed.

CONCLUSIONS: The administration of G-CSF to prevent neutropenia allowed the patient with AIN to safely undergo multidisciplinary treatment.

INTRODUCTION: Gastroschisis is almost always a small, right-sided, periumbilical, abdominal wall defect, and its occurrence on the left side of the umbilicus is extremely rare. Furthermore, omphaloceles and gastroschisis usually do not co-occur. The present report is the 2nd worldwide to describe the co-occurrence of an omphalocele and left gastroschisis-like abdominal wall defect.

CASE PRESENTATION: A 32-year-old pregnant woman (gravidity 2 and parity 1) was referred to our center because gastroschisis was detected in her fetus at 15 weeks and 3 days of gestational age. At 33 weeks and 3 days of gestational age, cesarean section was performed to deliver the female infant after a premature rupture of membranes. Her birth weight was 1368 g, and her Apgar scores were 8 at 1 min and 9 at 5 min. At birth, a macroscopic examination revealed an omphalocele with liver prolapse and a large, left-sided, epigastric, abdominal defect with an associated prolapse of the liver, spleen, stomach, and intestine. The patient had 2 very challenging conditions, namely, an early delivery with immature lung function and 2 large abdominal defects, for which a staged operation was performed using a combination of techniques involving the application of an artificial patch to close the abdominal wall temporarily, a hydro-fiber dressing to promote epithelization, and component separation to close the rather large defect permanently. Contrast CT revealed a defect in the lower costal cartilage and hypoplasia of the upper left abdominal wall. The peripheral part of the left superior epigastric artery was unclear in the imaging study.

CONCLUSIONS: The abdominal wall defect might have differed from other cases of left-sided gastroschisis in terms of its pathogenesis in the upper left abdomen. The presence of lower left hypoplastic thorax strongly suggested that dysfunction of the left superior epigastric artery had caused the abdominal wall defect. There is no standard treatment for this extremely rare, congenital malformation. Thus, its treatment requires the application of several techniques, each to address different aspects of the condition at the corresponding, surgical stage.

INTRODUCTION: Simultaneous liver–intestine transplantation is indicated for intestinal failure associated liver disease (IFALD), which can be caused by conditions such as intestinal motility disorders or short bowel syndrome. Currently, the most common grafts for liver–intestine transplantation are multivisceral transplantation (MVT) grafts consisting of the liver, stomach, duodenum, pancreas, small intestine, and colon, or liver–intestine grafts derived from the MVT graft but without the stomach. However, at the time of transplantation in the present case, Japanese regulations did not permit simultaneous pancreas transplantation in a non-diabetic recipient, which is generally required for this type of graft. Therefore, in the 2 previously reported domestic cases, the liver and intestine grafts were transplanted separately as non-composite grafts. Early in the development of MVT, liver–intestine grafts, excluding the stomach, duodenum, and pancreas, were used. We adopted this graft configuration for a 14-year-old female with megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) complicated by IFALD and performed, for the 1st time in Japan, a composite liver–intestine transplantation under existing regulations.

CASE PRESENTATION: The patient was a 14-year-old female who was maintained on minimal enteral feeding via an intestinal stoma and parenteral nutrition because of MMIHS. Since approximately year X-7, her IFALD progressed, leading to portal hypertension with gastrointestinal bleeding and hypersplenism, which led to a significant decline in her quality of life. She was listed for deceased donor liver–intestine transplantation and a suitable donor became available in December X. The stomach, duodenum, and pancreas of the donor were resected in situ, and a descending aortic graft was interposed at the caudal side of the superior mesenteric artery; arterial anastomosis was performed on the recipient’s infrarenal abdominal aorta. The hepatic vein was anastomosed using the piggyback technique. Although a small amount of parenteral nutrition was still required because of colitis, the patient was gradually progressing toward complete enteral nutrition. No evidence of rejection was observed, and the patient was discharged.

CONCLUSIONS: We report successful composite liver–intestine transplantation using a graft that excluded the stomach, duodenum, and pancreas, which led to good clinical outcomes.

INTRODUCTION: Partial pulmonary torsion is extremely rare.

CASE PRESENTATION: A 29-year-old man was initially treated with antibiotics for presumed bacterial pneumonia. Despite treatment, his inflammatory condition did not improve, and increasing pleural effusion was suggestive of empyema, leading to referral to our department. Following drainage, the patient’s condition did not improve. CT showed an increase in pleural effusion, with infiltrative shadows remaining within a clearly demarcated area, along with emphysematous changes in both lungs. He was diagnosed with lung abscess and empyema, and surgery was performed. Intraoperatively, the peripheral lingular segment appeared dark reddish, firm, and hyperlobulated. The affected area could be bluntly dissected, with its central portion narrowed but continuous with the central lingular segment, which rotated at least 360°. Peripheral pulmonary torsion was diagnosed, and a partial resection was performed. Postoperative recovery was uneventful.

CONCLUSIONS: Given the extreme rarity of peripheral pulmonary torsion, this case highlights the importance of considering torsion in persistent localized infiltrates unresponsive to treatment.

INTRODUCTION: Bile duct injury is a rare but serious complication of laparoscopic cholecystectomy (LC), particularly in patients with biliary anomalies such as accessory hepatic ducts (AHDs). Indocyanine green (ICG) fluorescence imaging has recently been recognized as a valuable tool for intraoperative visualization of biliary anatomy. However, its application in Type I AHDs, as classified by Hisatsugu, has not been previously reported.

CASE PRESENTATION: A 35-year-old male was referred for elective LC following successful conservative treatment for mild acute cholecystitis. Preoperative magnetic resonance cholangiopancreatography revealed that the cystic duct drained into a posterior AHD arising from segment 6, consistent with a Type I anomaly according to the Hisatsugu classification. At anesthesia induction, 2.5 mg of ICG was administered intravenously, and near-infrared fluorescence imaging enabled clear identification of the biliary anatomy, including the AHD. Despite mild chronic inflammation, Calot’s triangle was safely dissected, and the gallbladder was successfully removed. Post-resection ICG imaging confirmed the integrity of the AHD, with no evidence of injury or stricture. The operative time was 3 h and 30 min, and the patient was discharged without complications on POD 3.

CONCLUSIONS: Intraoperative ICG fluorescence imaging allowed for safe and accurate identification of biliary anatomy in a patient with a Type I AHD anomaly. This technique may help reduce the risk of bile duct injury during LC in patients with complex biliary variations.

INTRODUCTION: Insulinomas are rare tumors resulting in hyperinsulinemic hypoglycemia. Insulinomas are usually seen in adults, and are very rare in the pediatric population. A total of 10% of insulinomas that occur are associated with multiple endocrine neoplasia type 1, and overall, 10% are malignant.

CASE PRESENTATION: A 12-year-old boy suffered from an absence-like condition, 4 years before presentation. It was later discovered that this was due to hypoglycemia. His fasting blood glucose level was normal (93 mg/dL), but his insulin level was 60.8 μIU/mL, and his C-peptide level was 4.25 ng/mL, at the first visit. Abdominal CT and MRI showed a 6-cm nodular lesion in the anterior part of the pancreatic tail. Somatostatin receptor scintigraphy revealed radiotracer accumulation in the tumor. There was no evidence of lymphadenopathy or distant metastasis. He underwent laparoscopic spleen-preserving distal pancreatectomy. Pancreatic pathology revealed a grade 2 neuroendocrine tumor and malignant insulinoma. Postoperatively, the patient had no further hypoglycemia. At 9 months after the operation, he was under careful follow-up observation.

CONCLUSIONS: We present a pediatric case of a malignant insulinoma that was preoperatively diagnosed as benign and subsequently treated by minimally invasive surgery. There is no clear treatment strategy for pediatric malignant insulinomas. We suggest that—even if malignant insulinoma has been treated by minimally invasive surgery—follow-up with surveillance imaging is acceptable if curative resection has been achieved; however, further surgical intervention may be warranted in selected cases.

INTRODUCTION: Based on the results of the JCOG0802 study, segmentectomy is now considered the standard treatment for early-stage lung cancer. However, segmentectomy for right basal segment lesions remains technically challenging because of the complexity of B7 branching. B7 demonstrates 3 distinct branching patterns based on its anatomical relationship with the basal vein (BV): ventral, bilateral, and dorsal. Herein, we report a successful S10+S7b complex segmentectomy for S10 lung cancer with a bilateral B7 branching pattern using a pulmonary ligament (PL) approach.

CASE PRESENTATION: A 70-year-old woman presented with a 15-mm partially solid nodule in the right S10 segment (cT1miN0M0, cStage IA1). 3D-CT revealed bilateral B7 branches crossing the BV. A preoperative bronchoscopic marking with indigo carmine was conducted to guide the intersegmental plane. Three-port video-assisted thoracic surgery was performed via the PL approach. Following V7b dissection, the crossing of B7a and B7b over the BV was clearly identified. The dorsal branch of the B7 (B7b), located ipsilateral and central to the B10, was first divided. Sequential dissections of the veins, bronchi, and arteries at S10 and S7b were then performed. The intersegmental plane was stapled according to the preoperative bronchoscopic markings to ensure adequate margins. The postoperative course was uneventful, and the patient was discharged on POD 6. The pathological examination revealed adenocarcinoma (pT1miN0M0, pStage IA1) with negative margins (20 mm).

CONCLUSIONS: This case may serve as a reference for surgical planning in segmentectomy for right basal lesions according to B7 branching patterns. Even in complex cases with bilateral B7 branching patterns, initial B7b dissection facilitates access to the B10. The PL approach provides not only direct access to the basal segment vasculature and bronchi but also superior visualization of the anatomy of B7 branching.

INTRODUCTION: Gastric cancer often presents with metastases at diagnosis, but simultaneous metastases to both the small and large intestines are extremely rare and may be misinterpreted as synchronous primary intestinal cancers, particularly when preoperative imaging is inconclusive.

CASE PRESENTATION: A 78-year-old male receiving cabozantinib for hepatocellular carcinoma with vertebral metastasis presented with anorexia, epigastric discomfort, and melena. Endoscopy revealed an ulcerative gastric lesion, and colonoscopy showed irregular ulcerative lesions in the ascending and transverse colons. The patient underwent laparoscopic distal gastrectomy, right hemicolectomy. During surgery, a small intestinal tumor was suspected, prompting an additional partial resection. Histopathology and immunohistochemistry (CK7, CK20, CDX2, SATB2, Arginase-1) confirmed that the intestinal lesions were metastases from gastric cancer rather than synchronous primary colorectal cancers.

CONCLUSIONS: This case suggests that preoperative and intraoperative imaging may not detect rare metastatic patterns, and that immunohistochemical analysis may help estimate tumor origin. Careful differentiation between true synchronous colorectal cancer and gastric cancer with intestinal metastases may help guide treatment decisions.

INTRODUCTION: Primary colonic leiomyosarcoma (LMS) accounts for only 0.12% of colonic malignancies. However, it is highly aggressive and associated with a poor prognosis. While radical surgical resection is considered the mainstay of treatment, the optimal surgical approach and the role of adjuvant chemotherapy remain unclear due to the small number of reported cases.

CASE PRESENTATION: A 45-year-old, male patient presented with hematochezia. Colonoscopy revealed a 40-mm, type 1 tumor in the sigmoid colon. Immunohistochemical analysis of a biopsy specimen found atypical spindle cell proliferation, positivity for desmin and h-caldesmon, and negativity for CK AE1/AE3, indicating smooth muscle differentiation. Contrast-enhanced CT demonstrated a 40-mm, enhancing mass without a lymph node or distant metastasis. The patient underwent a laparoscopic sigmoidectomy with lymph node dissection. Pathological examination confirmed a 40 × 42 × 35 mm, French Federation of Cancer Centers (FNCLCC) grade 2 leiomyosarcoma with partial serosal exposure, negative margins, and no nodal involvement (0/42). Immunohistochemistry revealed positivity for α-SMA, desmin, h-caldesmon, and calponin, with a Ki-67 index of 60%–80%. Postoperatively, the patient received six cycles of adjuvant chemotherapy with doxorubicin and ifosfamide. A follow-up examination at 3 years and 6 months found no recurrence.

CONCLUSIONS: This report underscores the potential efficacy of minimally invasive surgery and adjuvant chemotherapy in some patients with primary colonic LMS, which in the present case was successfully managed with laparoscopic resection followed by adjuvant chemotherapy. More evidence is needed to establish a standard treatment strategy.

INTRODUCTION: Paraesophageal mixed hiatal hernia is a rare entity in neonates, that occasionally induces near-complete esophageal or gastric obstruction, and its diagnosis is sometimes difficult. Furthermore, its management remains controversial. This case provides new insights into the diagnosis and treatment strategies of neonatal paraesophageal mixed hiatal hernias.

CASE PRESENTATION: The case was a 4-day-old female infant who had frequent emesis after feeding. Plain radiography showed a “coiled-up sign” of an orogastric tube at the level of the diaphragm. CT indicated that the upper half of the stomach protruded into the mediastinal space. In the upper gastrointestinal study, the abdominal esophagus and cardia were compressed and bent, causing the contrast material to stagnate. Thus, she was diagnosed with paraesophageal mixed hiatal hernia. The enteral tube was advanced to the level of the jejunum by insufflating the stomach and returning it to the abdominal cavity under fluoroscopy. After feeding via an enteral tube during the neonatal period, the patient underwent radical surgery at 37 days old. We performed laparoscopic procedures involving pulling the stomach down, approximating the widened hiatus, and Toupet fundoplication to prevent postoperative gastroesophageal reflux.

CONCLUSIONS: The “coiled-up sign” of the gastric tube at the level of the diaphragm in neonates suspected with upper gastrointestinal obstruction or stenosis should raise suspicion of a paraesophageal mixed hiatal hernia and an upper gastrointestinal contrast study is useful for the diagnosis. Insertion of a feeding tube may allow for elective radical surgery while avoiding life-threatening complications.

INTRODUCTION: Patent ductus arteriosus in adults is rare, and is commonly recommended to be closed due to the possibility of cardiac complications. Patent ductus arteriosus closure has been often performed using endovascular devices or patches. However, the use of these closure devices in the presence of active infection is controversial, and patch closure procedure along with other cardiac surgery could make it more complicated. We report a case in which we successfully treated infective endocarditis with temporary occlusion of a patent ductus arteriosus in an 80-year-old woman.

CASE PRESENTATION: An 80-year-old woman with a medical history of total left hip arthroplasty, patent ductus arteriosus, and mild aortic, mitral, and tricuspid valve regurgitation was admitted to another hospital with recent symptoms of general fatigue and lower limb edema. Laboratory blood tests revealed elevated C-reactive protein levels and white blood cell counts. CT revealed fluid accumulation around the left artificial hip joint and multiple embolisms in the lungs and kidneys. MRI revealed microbleeds in the brain. Transthoracic echocardiography revealed severe aortic regurgitation and large vegetations on both the aortic and mitral valves. Streptococcus sanguinis was detected by both blood and fluid culture examinations. She was transferred to our hospital for surgical treatment under the diagnosis of infective endocarditis. Aortic and mitral valve replacement with cardiopulmonary bypass was scheduled; however, preoperative and intraoperative closure of the patent ductus arteriosus was not planned considering potential risks. A percutaneous balloon catheter was placed in the pulmonary artery through the patent ductus arteriosus, and temporary occlusion was achieved. During the aortic and mitral valve replacement procedure, blood flow from the pulmonary vein was well controlled. After cardiopulmonary bypass was weaned off, the balloon was deflated and removed. The postoperative course was uneventful, and the patient was transferred to another hospital for further rehabilitation.

CONCLUSIONS: The successful outcome of the present case shows that temporary occlusion of the patent ductus arteriosus during cardiac surgery with cardiopulmonary bypass may be a useful treatment option for patients with patent ductus arteriosus and infective endocarditis.

INTRODUCTION: Acinar cell carcinomas are rare pancreatic neoplasms, accounting for approximately 1% of all exocrine pancreatic tumors. We describe a case of a cystic variant with intracystic hemorrhaging that was difficult to differentiate from a pseudocyst due to its morphology.

CASE PRESENTATION: A 54-year-old man was admitted with severe left upper quadrant abdominal pain. Imaging studies showed a 7.0-cm internal heterogeneous cystic lesion with a splenic artery pseudoaneurysm near the lesion. Transarterial embolization of the splenic artery was performed, but rebleeding occurred 1 month later. Distal pancreatectomy with partial resection of the stomach revealed internal nodular lesions on the resected specimen. Microscopically, the cystic mass was composed of neoplastic tissue with papillary and tubular structures. The tumor was diagnosed as acinar cell carcinoma since immunohistochemical examination showed tumor cells positive for BCL10, lipase, and trypsin. The patient experienced local recurrence 6 months postoperatively, received chemotherapy with gemcitabine followed by S-1, underwent a 2nd resection at 18 months, and has remained recurrence-free for 15 years.

CONCLUSIONS: Acinar cell carcinoma rarely presents with a cystic structure and may be accompanied by a pseudoaneurysm, which can complicate differentiation from a pancreatic pseudocyst, highlighting the importance of careful differential diagnosis for appropriate treatment.

INTRODUCTION: Here, we report a very rare case of chronic expanding hematoma presenting as a gradually enlarging subcutaneous pulsatile mass detected 24 years after a Konno procedure.

CASE PRESENTATION: A 37-year-old man, who had undergone a Konno procedure at the age of 13 for severe aortic stenosis caused by a bicuspid aortic valve, presented with a pulsatile subcutaneous mass that had gradually increased in size over a 4-month period. CT revealed a large mediastinal mass compressing the right ventricular outflow tract, and a transthoracic echocardiogram showed an elevated pressure gradient between the right ventricle and pulmonary artery. Surgical resection of the mass and reconstruction of the right ventricular outflow tract were performed. The mass was completely excised, and the outflow tract was reconstructed using a short valved composite graft. The patient had an uneventful postoperative course.

CONCLUSIONS: This case underscores the importance of considering chronic expanding hematoma in the differential diagnosis of new pulsatile masses in patients with a history of cardiac surgery and demonstrates that timely surgical intervention can be performed safely and effectively.

INTRODUCTION: Richter’s hernia is a rare type of hernia in which only a part of the intestinal wall becomes entrapped, often leading to ischemia and necrosis. In rare cases, it can result in spontaneous formation of an intestinal-cutaneous fistula. Herein, we report a rare case of an intestinal-cutaneous fistula caused by incarceration of a Richter’s femoral hernia. Additionally, we present a brief literature review to highlight the diagnostic and therapeutic challenges associated with this condition.

CASE PRESENTATION: An 81-year-old male with severe dementia presented with fecal leakage from the right groin. Physical examination revealed a 5-mm skin defect with stool discharge, and contrast-enhanced CT confirmed a small bowel skin fistula secondary to an incarcerated Richter’s femoral hernia. Given the patient’s stable condition and absence of peritoneal signs, initial conservative management was chosen. However, surgical intervention was performed because there was no improvement. Due to difficulty in dissection, an intraperitoneal approach was required. The affected bowel was resected, a functional end-to-end anastomosis was performed, and the hernial orifice was closed using a combined approach. The patient recovered uneventfully and was discharged.

CONCLUSIONS: Prompt recognition and appropriate management are essential to improving outcomes in cases of Richter’s hernia complicated by intestinal-cutaneous fistula formation in the aging population.

INTRODUCTION: We encountered a case in whom ventricular septal rupture (VSR) repair was performed only through right atriotomy. A few cases of VSR repair using the right atrial approach have been reported in the literature. We report our experiences with focusing on the surgical technique.

CASE PRESENTATION: The patient was a 79-year-old woman who was admitted to the emergency room with dizziness and vomiting. Echocardiography showed inferior myocardial infarction and posterior VSR. Emergency percutaneous coronary artery intervention was performed on the proximal right coronary artery and recanalization was achieved. Delayed surgery was planned because of the stability of her hemodynamics. Sandwich repair using two bovine pericardial patches was performed only through right atriotomy on the 14th day of hospitalization under intra-aortic balloon pumping (IABP). The location of the VSR was identified by saline injection through the left ventricular vent. A VSR 18 mm in length was observed after resection of several trabeculae. A 3.5 × 2.5 cm oval patch of bovine pericardium was placed on the left side of VSR and another patch was attached to the right side to cover the VSR with 8 pieces of monofilament-interrupted U sutures. She was discharged from the hospital on the 108th POD after long ventilatory management and temporary hemodialysis.

CONCLUSIONS: VSR of the posterior interventricular septum due to inferior myocardial infarction is a good candidate for the right atrial approach. It is important to diagnose the location and shape of the VSR in advance. The location of the VSR can be identified by saline injection through the left ventricular vent and resection of several trabeculae is essential to expose the whole VSR. The right atrial approach can minimize impairment of the ventricular function and may be a promising approach for VSR repair.

INTRODUCTION: Obstructive fibrinous tracheal pseudomembrane, an extremely rare but potentially fatal complication of tracheal intubation, occurs several days after intubation and is characterized by central airway obstruction due to the formation of a fibrinous pseudomembrane. Early diagnosis is crucial. Treatment typically involves bronchoscopic removal of the pseudomembrane. Herein, we describe a patient whose pseudomembrane was successfully cored out using fiberoptic intubation after achieving preoxygenation with high-flow nasal cannula oxygen therapy.

CASE PRESENTATION: An 83-year-old woman (height 146 cm, weight 38 kg) underwent left lower lobe lobectomy with left atrial resection for squamous cell carcinoma (cT4N1M0, Stage IIIA). The surgery was completed successfully with no immediate complications. On POD 3, she developed prolonged expiration and inspiratory wheezing that was unresponsive to steroid inhalation. Her condition progressively worsened with stridor, labored breathing, and inability to lie supine. Bronchoscopy revealed 90% circumferential subglottic stenosis. High-flow nasal cannula oxygen therapy significantly improved her respiratory distress, enabling her to lie supine. Fiberoptic intubation was then performed under conscious sedation with spontaneous breathing, and the circumferential membranous structure was cored out by the intubation tube. Pathological examination confirmed fibrinous exudate with atypical cells, establishing a diagnosis of obstructive fibrinous tracheal pseudomembrane.

CONCLUSIONS: Obstructive fibrinous tracheal pseudomembrane, a rare condition, causes upper airway obstruction within days after extubation. Preoxygenation with high-flow nasal cannula oxygen therapy, followed by coring the pseudomembrane out with an intubation tube, may be an effective, rapid, and minimally invasive means of treatment in selected patients with a subglottic, obstructive, fibrinous tracheal pseudomembrane.

INTRODUCTION: Intrapulmonary schwannoma is a rare benign tumor that often presents diagnostic and therapeutic challenges due to its nonspecific radiological findings and central location. Establishing a histological diagnosis before surgery is crucial to avoid unnecessary extensive lung resection.

CASE PRESENTATION: A 46-year-old non-smoking woman presented with an incidental 2.4 cm pulmonary nodule centrally located in segment 10 (S10) of the left lower lobe. CT showed the tumor compressing the bronchus and pulmonary artery without direct airway communication, making transbronchial biopsy unfeasible. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) successfully obtained tissue samples, and histopathological examination revealed spindle cells with diffuse S100 protein positivity, confirming the diagnosis of an intrapulmonary schwannoma. Given the benign nature of the tumor, an S10 segmentectomy was planned. Preoperative 3D CT suggested that while the pulmonary vein (V10) could be approached posteriorly, the artery (A10) and bronchus (B10) would require an interlobar approach due to the tumor’s central location. Intraoperative findings confirmed this, and the tumor was successfully resected. The patient had an uneventful recovery and was discharged on POD 4. Final pathology confirmed the diagnosis of an intrapulmonary schwannoma and negative margin.

CONCLUSIONS: Preoperative histological diagnosis of an intrapulmonary schwannoma by EBUS-TBNA is both feasible and clinically advantageous, enabling a limited anatomical resection. A preoperative strategy that incorporates both the tumor’s benign nature and its central location is essential for achieving optimal surgical outcomes.

INTRODUCTION: Juvenile polyposis syndrome (JPS) is a rare disease characterized by multiple hamartomatous polyps in the gastrointestinal tract that may cause protein-losing gastroenteropathy. In such cases, symptoms such as hypoalbuminemia and anemia are often difficult to manage. Although clinical guidelines provide recommendations for diagnosis and management, standardized treatment strategies remain to be fully established.

CASE PRESENTATION: A 40-year-old man underwent laparoscopic total gastrectomy for protein-losing gastroenteropathy secondary to gastric polyposis. He had a history of colorectal polyposis associated with an SMAD4 mutation and had previously undergone subtotal colectomy. The patient developed worsening anemia and hypoproteinemia. Upper gastrointestinal endoscopy revealed an increase in both the size and number of gastric polyps. Protein-losing gastroenteropathy was diagnosed using technetium-99m human serum albumin scintigraphy. Laparoscopic total gastrectomy with Roux-en-Y reconstruction was performed to control hypoproteinemia and eliminate the risk of malignant transformation of the polyps. Postoperatively, the symptoms resolved, and oral intake improved. He remained in good health and has continued a normal daily life without symptom recurrence for 4 years postoperatively.

CONCLUSIONS: We present a case of JPS with an SMAD4 mutation causing protein-losing gastroenteropathy and refractory anemia, successfully treated with laparoscopic total gastrectomy. The patient’s sustained nutritional status suggests that total gastrectomy may be an effective treatment option for gastric JPS with protein-losing gastroenteropathy.

INTRODUCTION: Laparoscopic sleeve gastrectomy is the most common metabolic bariatric surgery performed in Japan. Nevertheless, concerns persist regarding its long-term efficacy, which is considered inferior to that of procedures involving gastrointestinal bypass. In response to these concerns, a modified approach known as the “sleeve plus procedure” has been introduced and is now covered by insurance for patients with severe obesity and type 2 diabetes mellitus (T2DM). We successfully performed proximal jejunal bypass with sleeve gastrectomy (PJB-SG), a variant of this approach, marking the first documented case of its kind in Japan. This report presents the clinical outcomes of this procedure along with a review of the relevant literature.

CASE PRESENTATION: A 50-year-old female patient with a body mass index of 46.9 kg/m² presented with obstructive sleep apnea and T2DM. The patient exhibited resistance to pharmacological treatment, including glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors. Fifteen months after the initial consultation, she opted for PJB-SG. The operation lasted 207 min, with 18 mL of blood loss. At 252 days postoperatively, the patient had achieved a total weight loss of 18.0% and a hemoglobin A1c level of 6.0% while continuing a minimal dose of SGLT2 inhibitors. No adverse events related to the bypass procedure, such as diarrhea or liver dysfunction, were observed.

CONCLUSIONS: To our knowledge, this is the first reported case of PJB-SG conducted in Japan. This procedure may represent a promising alternative for patients with severe obesity and T2DM in Japan.

INTRODUCTION: Primary gastric carcinosarcoma is extremely rare. Herein, we report a case of primary gastric carcinosarcoma with small intestinal intraluminal metastasis.

CASE PRESENTATION: The patient was a 77-year-old man who was referred to our hospital for further examination of occult fecal blood. At this time, the patient reported lightheadedness, and severe anemia was confirmed, with a hemoglobin level of 6.5 g/dL. Upper gastrointestinal endoscopy revealed a mass with bleeding spots in the middle 3rd of the stomach, which was thought to be the cause of the anemia. The patient’s overall condition was poor; therefore, we decided to limit the surgery to local resection of the primary lesion as palliative treatment, with the main goal of controlling bleeding. The final pathological diagnosis was gastric carcinosarcoma. Postoperatively, the progression of anemia stopped, the patient was able to eat without any problems, and he was discharged home. However, 9 days later, the patient visited the emergency department complaining of abdominal pain. He was diagnosed with intestinal obstruction and underwent surgery. During surgery, a hard mass was palpable in the small intestine, and the lesion was resected. The pathological findings of the small intestinal mass were identical to those of the gastric tumor, and the patient was diagnosed with small intestinal intraluminal metastasis of the gastric carcinosarcoma. Eight months after surgery, pulmonary metastasis was detected by a CT scan. Chemotherapy with capecitabine and irinotecan was initiated, and tumor reduction was achieved.

CONCLUSIONS: Primary gastric carcinosarcoma may present with intraluminal metastasis of the small intestine, and clinicians should make a note of this when treating such patients.

INTRODUCTION: Bladder irritation after inguinal hernia repair is typically associated with mesh migration into the bladder. Notably, no previous cases have described bladder irritation symptoms in the absence of direct mesh penetration. This report presents a rare instance of bladder symptoms caused by a folded mesh, despite normal cystoscopic and cystographic findings.

CASE PRESENTATION: A 49-year-old woman presented with urinary urgency, incontinence, and chronic right inguinal pain for 3 years, 8 years after undergoing inguinal hernia repair using the modified Kugel method. Although cystoscopy and cystography revealed no abnormalities, pelvic CT and MRI demonstrated a curved fatty tissue protruding toward the bladder. Laparoscopic exploration confirmed the presence of a folded mesh adjacent to the bladder wall. The mesh was successfully removed and a new mesh was placed, resulting in complete resolution of the urinary symptoms and pain without postoperative complications.

CONCLUSIONS: In patients presenting with bladder symptoms after inguinal hernia repair, mechanical irritation of the bladder wall by mesh should be considered—even when cystoscopic and radiographic findings are normal.

INTRODUCTION: While surgical treatment for partial atrioventricular septal defect (AVSD) is commonly performed in pediatric patients, its application is relatively rare in older patients.

CASE PRESENTATION: A 73-year-old woman was referred to our hospital for evaluation of shunt blood flow caused by a partial atrioventricular septal defect and left atrioventricular valve regurgitation that caused right heart overload and cardiomegaly. She underwent minimally invasive atrial septal defect closure and left atrioventricular valve repair through right-sided thoracotomy.

CONCLUSIONS: We report a successful case of minimally invasive surgery in an older patient with a partial atrioventricular septal defect.

INTRODUCTION: Stomach-partitioning gastrojejunostomy (SPGJ) is widely performed for malignant gastric outlet obstruction; however, its utility may be limited when the obstruction is located in the distal duodenum, where digestive fluid stasis can become problematic. We devised a novel modification, termed dual-outlet stomach-partitioning gastrojejunostomy (DO-SPGJ), to address this limitation by adding a 2nd gastrojejunostomy distal to the gastric partition.

CASE PRESENTATION: A 67-year-old man with a tumor in the 3rd portion of the duodenum was diagnosed with squamous cell carcinoma without distant metastasis. The tumor was deemed unresectable due to invasion of the superior mesenteric artery. After 2 months of systemic chemotherapy, the patient developed symptoms of gastric outlet obstruction. A laparoscopic modified SPGJ was performed, involving a standard proximal gastrojejunostomy and an additional distal anastomosis between the gastric antrum and jejunum. The postoperative course was uneventful, and oral intake was successfully resumed.

CONCLUSIONS: This dual-anastomosis approach allows for both food bypass and drainage of digestive secretions, addressing the limitation of conventional SPGJ in cases of distal duodenal obstruction. The technique may also mitigate complications related to fluid stagnation, such as cholangitis or pancreatitis. This novel technique may represent a viable surgical option for select patients with unresectable malignant obstruction of the distal duodenum, especially when fluid stasis is a concern.

INTRODUCTION: Occult breast cancer (OBC) is a rare subtype of breast cancer, typically presenting as axillary lymph node metastasis without an identifiable primary tumor in the breast. Axillary lymphadenopathy requires differential diagnosis, including OBC. However, in patients undergoing treatment for another malignancy, distinguishing OBC from axillary metastasis of the known primary cancer can be challenging. Immune checkpoint inhibitors (ICIs) have extended survival in advanced non-small cell lung cancer (NSCLC), potentially allowing time for 2nd primary cancers to develop and be detected.

CASE PRESENTATION: A 71-year-old woman underwent right upper lobectomy for stage IIIA lung adenocarcinoma. Four months postoperatively, CT revealed a right chest wall mass and right axillary lymphadenopathy, which was interpreted as recurrence. Systemic therapy was administered, and third-line atezolizumab monotherapy led to complete remission of the chest wall mass; however, progressive enlargement of the axillary lymph nodes was subsequently observed. Imaging showed no detectable lesion in the breast, but core needle biopsy of the axillary node revealed metastatic invasive ductal carcinoma, negative for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) with a Ki-67 index of 80%. Immunohistochemistry was positive for GATA3 and negative for thyroid transcription factor-1 (TTF-1), consistent with OBC. The patient underwent axillary lymph node dissection, and postoperative observation without additional treatment was selected due to comorbidities. She has remained disease-free for 1 year.

CONCLUSIONS: This case illustrates that axillary lymphadenopathy during treatment for another malignancy may represent a 2nd primary cancer such as OBC. As ICI therapy prolongs survival, clinicians should pay attention for new malignancies, including breast cancer, even in the absence of breast lesions.

INTRODUCTION: Carbon-ion radiotherapy (CIRT) for pelvic recurrent rectal cancer has recently attracted attention due to its excellent therapeutic outcomes. A spacer is often inserted before CIRT to ensure a certain distance between the recurrent lesion and the adjacent intestine. We report a case of hydronephrosis due to ureteral stenosis after laparoscopic insertion of a polyglycolic acid (PGA) spacer.

CASE PRESENTATION: A 58-year-old man underwent laparoscopic abdominoperineal resection and right lateral lymph node dissection after neoadjuvant chemoradiotherapy. He had been free of recurrence for 4 years. PET-CT 4.5 years after surgery revealed a 9-mm lymph node enlargement with an SUVmax = 2.88 in the left lateral region. Laparoscopic left lateral lymph node dissection was performed due to suspicion of recurrence, but removal was difficult due to severe fibrosis after previous radiation therapy. Definitive diagnosis of recurrence had not been made, so the patient was observed without treatment, but PET-CT 7 years after the initial surgery showed that the lymph node had enlarged to 25 mm with uptake of SUVmax = 8.06. Recurrence was strongly suspected, so we planned CIRT, and PGA spacer insertion was performed laparoscopically in advance. CT 3 days after insertion of the PGA spacer revealed hydronephrosis due to ureteral stenosis, which was thought to be caused by compression from the PGA spacer. Follow-up CT taken 7 days after surgery showed no improvement, so a ureteral stent was placed. Ureteral stenosis has persisted, so the ureteral stent has been replaced every 3 months. Regarding the recurrent lesions after CIRT, a tendency for them to shrink was observed on CT taken 1.5 years after the procedure.

CONCLUSIONS: In this case, a PGA spacer was inserted laparoscopically and hydronephrosis occurred early due to ureteral stenosis. Although the ureteral stenosis in the early postoperative period was thought to be caused by the PGA spacer, the persistence of ureteral stenosis was thought to be a late adverse event of CIRT. In cases where the ureter is exposed, such as after lateral lymph node dissection with neoadjuvant chemoradiotherapy, prophylactic ureteral stenting before inserting a PGA spacer may be considered.

INTRODUCTION: Although iatrogenic left ventricular pseudoaneurysm (LVPA) is rare, its treatment strategy needs consideration. We report a case in which postoperative initiation of rivaroxavan led to iatrogenic LVPA, which resolved spontaneously after drug cessation.

CASE PRESENTATION: A 69-year-old man was diagnosed with a 76-mm saccular aortic arch aneurysm. He underwent urgent total aortic arch replacement with a frozen elephant trunk. A left ventricular apex injury due to intraoperative vent insertion was repaired, and postoperative CT revealed no problems. While hospitalized, he developed atrial fibrillation and started taking rivaroxavan. At 3 months postoperatively, an LVPA, 10 mm in diameter, developed at the intraoperative repair site. The LVPA resolved spontaneously following discontinuation of rivaroxaban, thereby avoiding the need for reoperation.

CONCLUSIONS: This case illustrates the potential for anticoagulation-associated LVPA formation in surgically repaired myocardium and supports the consideration of conservative management in selected cases.

INTRODUCTION: The integrity and stability of the chest wall (CW) are major factors that ensure the protection of the thoracic organs and proper respiratory function. In cases requiring extensive CW resection for tumor control, reconstruction using autologous tissue or synthetic materials is often performed. However, the optimal approach remains undetermined. We report a case of successful CW reconstruction using a combination of a titanium mesh plate and a dual-surface expanded polytetrafluoroethylene (ePTFE) sheet.

CASE PRESENTATION: A man in his 70s presented for referral with a CW tumor in the left anterior chest. The tumor was located in the left anterior CW and was suspected to have pulmonary, thymic, and pectoralis major and minor invasions. Surgical resection included removal of the 2nd through the 4th ribs, partial left upper lobectomy, and partial thymectomy. The large CW defect was reconstructed via rigid reconstruction using a titanium mesh plate with a dual-mesh ePTFE sheet sewn inside. Pathological examination revealed a sarcomatoid malignant pleural mesothelioma. Three years after surgery, the patient remained recurrence-free. Despite radiographic evidence of titanium plate cracking, the pulmonary function and thoracic mechanics were preserved.

CONCLUSIONS: The combination of ePTFE sheets, which have a smooth surface to protect the lungs and excellent tissue affinity, and titanium mesh plates, which are sufficiently rigid to maintain thoracic function, is an excellent method of rigid reconstruction that takes advantage of the strengths of each material. This technique is feasible and versatile and ensures short-term postoperative stability. Nevertheless, the long-term safety and potential complications warrant further clinical evaluation.

INTRODUCTION: Duodenal gastrointestinal stromal tumors (D-GISTs) are rare neoplasms that pose surgical challenges, particularly when located near critical structures such as the ampulla of Vater or the pancreatic head. Although pancreaticoduodenectomy (PD) is often required in such cases, it is associated with significant morbidity. Neoadjuvant chemotherapy (NAC) with imatinib has emerged as a strategy to downsize tumors, thereby enabling organ-preserving resections. Laparoscopic and endoscopic cooperative surgery (LECS), initially developed for gastric submucosal tumors, has been adapted for duodenal lesions (D-LECS) in selected cases. Here, we present a case in which neoadjuvant imatinib therapy enabled local resection using the D-LECS approach.

CASE PRESENTATION: A 67-year-old man was diagnosed with a 55-mm D-GIST involving the duodenal bulb and descending portion, located near the ampulla of Vater and pancreatic head. NAC with imatinib (400 mg/day) was administered for 2 months, resulting in significant tumor shrinkage to 27 mm, without invasion of adjacent structures. D-LECS was performed using an endoscopic submucosal incision followed by laparoscopic full-thickness resection. After laparoscopic suturing, minor leakage at the end of the suture line was reinforced using the reopenable-clip over line method. The procedure was completed safely with negative margins and no complications. The patient was discharged on POD 14, and remained recurrence-free at 12 months.

CONCLUSIONS: Neoadjuvant imatinib effectively downsized a locally advanced D-GIST, enabling safe, minimally invasive resection via D-LECS. This case highlights the potential of NAC and D-LECS as a less invasive alternative to PD in anatomically challenging D-GISTs.