Preemptive thoracic endovascular aortic repair (TEVAR) has been used increasingly for uncomplicated type B aortic dissection (TBAD); however, its optimal indications remain controversial, particularly when the proximal landing zone involves the aortic arch. We evaluated the long-term outcomes of aortic arch preemptive TEVAR for uncomplicated TBAD. Between July 2004 and January 2026, 473 patients with acute TBAD were treated at our institution and affiliated hospitals, 351 of whom completed initial medical therapy (follow-up, 1–241 months). Preemptive TEVAR was performed in 52 patients and 299 were managed medically. The subjects of this study were 41 patients who underwent preemptive TEVAR with a proximal landing zone in Zone 2 or 3. We compared the outcomes and aortic morphology on serial computed tomography (CT) of these 41 patients with those of 41 propensity-matched patients who did not undergo TEVAR. Before matching, the TEVAR group had a higher prevalence of patent false lumen and a larger false lumen diameter. Freedom from aortic adverse events was higher in the TEVAR group during long-term follow-up, although the difference was not significant (P = 0.065). There were no aortic-related deaths after TEVAR, and CT demonstrated favorable aortic remodeling. Aortic arch preemptive TEVAR was associated with favorable aortic remodeling and a trend toward improved long-term aortic outcomes.
The Warshaw procedure, a spleen-preserving distal pancreatectomy with splenic vessel ligation, is associated with splenic infarction and gastric varices. We evaluated the risk factors and clinical impacts of these conditions. We retrospectively analyzed 65 patients who underwent minimally invasive spleen-preserving distal pancreatectomy between 2014 and 2024. The outcomes were compared between the Warshaw (n = 40) and Kimura (n = 25) groups. The risk factors for splenic infarction and gastric varices were evaluated. Grade 2 splenic infarction was subdivided into 2a (50–89
INTRODUCTION:The optimal source-control strategy for gangrenous acute cholecystitis in patients with profound thrombocytopenia remains unclear. Moreover, infection-associated and immune thrombocytopenia may be difficult to distinguish during the acute phase. CASE PRESENTATION:A 76-year-old man with hypertension, diabetes mellitus, and a history of open distal gastrectomy for gastric cancer presented with gangrenous acute cholecystitis and profound thrombocytopenia (2000/μL). Infection-associated consumptive thrombocytopenia was initially considered, and emergency open cholecystectomy was performed following platelet transfusion. Thrombocytopenia persisted despite source control, and the response to platelet transfusion was suboptimal. The overall clinical course, exclusion of alternative causes, and preserved trilineage hematopoiesis on bone marrow examination supported a clinical diagnosis of immune thrombocytopenia. Treatment with dexamethasone, Helicobacter pylori eradication therapy, prednisolone, and rituximab resulted in platelet recovery. The patient was discharged on POD 16. CONCLUSIONS:This case highlights the necessity of balancing urgent source control against substantial bleeding risk in gangrenous acute cholecystitis with profound thrombocytopenia. Persistent thrombocytopenia following surgical source control, particularly with a suboptimal response to platelet transfusion, should prompt reassessment of the underlying etiology, including immune thrombocytopenia.
INTRODUCTION:The double-flap technique (DFT) is an established anti-reflux reconstruction method after proximal gastrectomy (PG) and may be advantageous for mediastinal reconstruction because of its low incidence of anastomotic leakage. However, thoracoscopic DFT reconstruction remains technically demanding because flap-related procedures increase procedural complexity. The non-flap tunnel technique (NFTT) has recently been introduced as a simplified alternative to DFT, but its application in thoracoscopic mediastinal reconstruction has not been reported. CASE PRESENTATION:A 56-year-old man with Siewert type II esophagogastric junction cancer required a high intramediastinal anastomosis because a proximal submucosal tumor necessitated extended esophageal resection. After laparoscopic PG and lower esophagectomy, a seromuscular tunnel was created extracorporeally on the remnant stomach. The remnant stomach was elevated into the mediastinum, and thoracoscopic reconstruction was performed in the prone position. Following fixation of the remnant stomach to the esophagus and rotation of the esophagogastric axis, esophagogastrostomy was completed using hand-sewn sutures, followed by seromuscular roof closure over the anastomosis. Reconstruction was completed in 60 minutes. A contrast study on POD 5 demonstrated no anastomotic leakage or reflux. The patient resumed oral intake on POD 6 and was discharged on POD 11 without complications. CONCLUSIONS:Thoracoscopic reconstruction using the NFTT is feasible and may represent a practical and technically simplified alternative to thoracoscopic DFT in selected patients requiring high intramediastinal anastomosis.
Traumatic pancreatic injuries are uncommon but challenging to manage. This study aimed to clarify the clinical characteristics of traumatic pancreatic injury and explore the role of early endoscopic retrograde pancreatography (ERP) as a diagnostic and therapeutic approach. We reviewed 14 patients with traumatic pancreatic injuries treated between 2007 and 2025. Injuries were classified according to the Japanese Association for the Surgery of the Trauma System. Clinical outcomes were analyzed according to early ERP use (≤ 24 h after injury). Three patients had a type I injury, one had a type II injury, five had a type IIIa injury, and five had a type IIIb injury. Patients with a type IIIa/b injury had higher serum amylase levels at 24 and 48 h, as well as higher secondary intervention rates and longer hospital stays. Among five patients who underwent early ERP, the main pancreatic duct injury was successfully bridged in one patient with a type IIIb injury, enabling non-operative management. There were no significant differences in clinical outcomes between the early ERP and delayed/no ERP groups. Appropriate management of traumatic pancreatic injuries resulted in favorable outcomes. Further studies are required to clarify the clinical importance of early ERP.
This prospective single-arm multicenter phase 2 trial investigated the efficacy and safety of chemoradiotherapy with gemcitabine (GEM) + S-1 (GSRT) in patients with locally advanced pancreatic ductal adenocarcinoma (PDAC) (BR + UR-LA). Forty patients with locally advanced PDAC based on imaging findings were enrolled at three high-volume centers in Japan (April 2013–December 2018). The patient received full-dose GSRT concurrent with 50.4 Gy of radiation therapy. After chemoradiotherapy completion, the patients were reevaluated for surgical eligibility, and resection was performed if the tumors were considered resectable. In patients with unresectable tumors, chemotherapy was continued for over 6 months, and resection was performed if the tumors were considered resectable during the treatment course. The primary endpoint was the 1-year survival rate. Thirty-nine patients received GSRT, and their 1-year survival rate, median overall survival time, and median progression-free survival time were 64.1
Resternotomy during total arch replacement surgery is associated with adverse outcomes. We aimed to determine the accuracy of this statement. From January 2008 to February 2021, 384 consecutive total arch replacement surgeries were performed at our institution. Resternotomy was performed in 53 (14
INTRODUCTION:Chronic expanding hematoma (CEH) is a slowly enlarging hematoma that persists for more than 1 month after the initial hemorrhagic event. Intrathoracic CEH is rare and often requires technically demanding surgery because of dense adhesions and the risk of massive intraoperative bleeding. We report a case of giant intrathoracic CEH managed using a surgical strategy that included preoperative selective transcatheter arterial embolization (TAE). CASE PRESENTATION:A 49-year-old man with a history of tuberculous pleuritis approximately 10 years earlier was referred to our hospital because of a gradually enlarging asymptomatic right intrathoracic mass. Contrast-enhanced CT revealed a 95-mm heterogeneous mass with peripheral enhancement, consistent with CEH. Selective embolization of the right 8th to 11th intercostal arteries was performed on the day before surgery. Through a posterolateral thoracotomy with resection of the 7th and 8th ribs, the hematoma was completely resected with partial resection of the right lower lobe. Additional procedures, including decortication, adhesiolysis, and chest wall plasty, were performed to facilitate lung re-expansion and reduce the residual thoracic cavity. Although prolonged postoperative air leakage required pleurodesis on POD 10, the patient was discharged on POD 12 without major complications. No recurrence has been observed during follow-up. CONCLUSIONS:Preoperative selective TAE, combined with an appropriate surgical strategy, may reduce intraoperative bleeding and enable safe and controlled radical resection of intrathoracic CEH. Careful preoperative planning, including bleeding control and optimization of the surgical approach, is essential for successful treatment.
This study aimed to evaluate the effect of small intestine arrangement on the bowel function after laparoscopic colectomy. A total of 160 patients were randomly divided into two groups. The control group received conventional treatment, while the experimental group underwent small intestine arrangement. The primary outcome was the time to initial postoperative gas discharge. The experimental group showed a significant difference in the time of initial postoperative gas discharge compared to the control group (45.2 ± 19.7 vs. 54.9 ± 21.8 h, P = 0.004). Additionally, the experimental group had a significantly shorter time to first tolerability of liquid food (64.4(43.0,68.3) vs. 67.5(60.5,86.8) hours, P = 0.005). One case involved the identification of a Meckel’s diverticulum and a small intestinal stromal tumor through intervention. Arranging the small intestine may promote the postoperative intestinal function and improve the detection of complications, thereby avoiding the potential risk of reoperation. NCT05485857.
INTRODUCTION:Colonic lipomas are benign mesenchymal tumors composed of mature adipocytes and are most commonly located in the submucosal layer. They are usually asymptomatic and are often managed conservatively. Although adenomas arising overlying colonic lipomas have been reported, the coexistence of adenocarcinoma directly overlying a lipoma is extremely rare. The pathogenic relationship between submucosal tumors and epithelial malignancies remains unclear. CASE PRESENTATION:A 76-year-old man was diagnosed with a lipoma in the descending colon (diameter, approximately 30 mm) and was managed with surveillance. After 26 months of follow-up, colonoscopy revealed a newly developed small type 2 ulcerative lesion located directly over the lipoma. A biopsy confirmed adenocarcinoma. Endoscopic ultrasonography demonstrated a homogeneous hyperechoic lesion in the 3rd layer consistent with a lipoma, along with focal thickening of the 2nd layer, without evidence of deep invasion. CT and MRI showed imaging features characteristic of a lipoma, with a peripheral component suspicious for malignancy. The patient was diagnosed with descending colon cancer (cT2N0M0, Stage I) and underwent laparoscopic left hemicolectomy with lymph node dissection. A histopathological examination revealed a lipoma extending from the submucosa into the muscularis propria, while the carcinoma was confined to the mucosa and muscularis propria overlying the lipoma, without invasion into the lipomatous tissue. No histological findings indicative of chronic inflammation were observed. CONCLUSIONS:We report a rare case of adenocarcinoma developing directly over a colonic lipoma during surveillance. Although chronic inflammation has been proposed as a possible mechanism linking submucosal tumors to epithelial malignancies, no such features were identified in this case, and a causal relationship could not be established. While colonic lipomas are generally managed conservatively, careful endoscopic surveillance may be considered in selected patients with relatively large lipomas requiring long-term follow-up.
INTRODUCTION:Pancreatoduodenectomy (PD) for pancreatic head malignancies can be complicated by coexisting vascular anomalies. Median arcuate ligament syndrome (MALS), occurring in 2.1%-7.6% of PD cases, causes celiac artery (CA) stenosis and poses a significant risk of ischemic complications. While division of the median arcuate ligament (MAL) may restore blood flow in some cases, arterial reconstruction is occasionally necessary. We report a challenging case of pancreatic head adenocarcinoma with MALS requiring emergent intraoperative arterial reconstruction. CASE PRESENTATION:A 69-year-old man presented with a 31-mm pancreatic head tumor in contact with the superior mesenteric artery (SMA) and complete CA occlusion due to MALS. Preoperative imaging revealed well-developed collateral circulation via the dorsal pancreatic artery (DPA). After 6 cycles of neoadjuvant chemotherapy with gemcitabine plus nab-paclitaxel, the tumor decreased to 18 mm. Anticipating the potential need for arterial reconstruction during PD, preoperative simulations were conducted with the vascular surgery team. Intraoperatively, MAL division was performed, and a gastroduodenal artery (GDA) clamp test confirmed adequate hepatic arterial flow via the DPA. However, hepatic arterial flow ceased during subsequent surgical manipulation, requiring emergent arterial reconstruction. Initial middle colic artery-GDA anastomosis was complicated by repeated thrombosis; definitive reconstruction using a lesser saphenous vein graft successfully restored hepatic arterial flow. Pathological examination revealed a complete pathological response. The patient was discharged on POD day 18 without major complications and remains recurrence-free at 22 months. CONCLUSIONS:This case demonstrates that in PD for patients with concomitant MALS, collateral circulation may be disrupted by intraoperative manipulation, potentially necessitating emergent arterial reconstruction. Therefore, meticulous preoperative imaging evaluation, vigilant intraoperative monitoring of hepatic arterial flow, and thorough preparation for vascular reconstruction are essential for the safe management of these complex cases.
INTRODUCTION:Anti-Yo antibody-associated paraneoplastic neurological syndrome (PNS) is a rare immune-mediated disorder that often presents with subacute cerebellar symptoms and is frequently associated with breast and gynecological malignancies. CASE PRESENTATION:A woman in her 50s developed subacute progressive neurological symptoms, including dizziness, diplopia, dysphagia, gait disturbance, ataxia, and nystagmus. Brain MRI showed no obvious abnormalities. Although Miller-Fisher syndrome was initially suspected, intravenous immunoglobulin therapy had limited efficacy, and serum anti-Yo antibodies were subsequently detected. Further investigation revealed human epidermal growth factor receptor 2-positive breast cancer with axillary lymph node metastasis. Because her neurological symptoms rapidly progressed and her performance status deteriorated, neoadjuvant chemotherapy was considered difficult. Left mastectomy with axillary lymph node dissection was therefore performed as prompt tumor-directed treatment. The final pathological stage was pT1aN1aM0, stage IIA. Postoperatively, additional immunomodulatory treatments and rehabilitation were provided for the neurological deficits. CONCLUSIONS:This case highlights the importance of considering anti-Yo antibody-associated PNS in patients with unexplained subacute progressive neurological symptoms, even when brain imaging shows no clear abnormalities. Early recognition of PNS and prompt screening for an underlying malignancy, including breast cancer, are essential to allow timely tumor-directed treatment before severe neurological deficits become established.
Tolvaptan sodium phosphate (TSP) is an intravenous aquaretic agent that is rapidly converted to tolvaptan after administration. This study aimed to evaluate the safety and efficacy of TSP in open-heart surgery cases. This study included 103 patients (31 women; mean age, 70.5 ± 10.8 years) who received intravenous TSP following open-heart surgery. The urine output was measured hourly from 1 h before to 6 h after administration, and time-dependent changes were assessed. The magnitude of the response was defined as ΔU1–6 = (U1+U2+U3+U4+U5+U6) – U-1. Patients were ranked according to ΔU1–6, and the top 25 (marked responders) and bottom 25 (poor responders) were compared. The urine output was significantly increased within 1–3 h after TSP administration, peaked at 2–3 h, and remained above the baseline through 6 h (all p < 0.05). In a multivariable linear regression analysis, the serum sodium level at the time of TSP administration was independently associated with ΔU1–6 (p=0.018). The serum sodium levels at TSP administration were lower in marked responders (p=0.033). No TSP-related adverse events were observed in any of the cases. Intravenous TSP can induce a rapid and sustained diuretic response following open-heart surgery, and the serum sodium levels determine the magnitude of the aquaretic response to intravenous TSP.
INTRODUCTION:Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm that most commonly arises in the pleura but can occur at virtually any anatomical site, including the abdominal cavity. Although rupture of SFT has occasionally been reported, most such cases involve intrathoracic tumors presenting with hemorrhage, and peritonitis caused by rupture of an intra-abdominal SFT is exceedingly rare. CASE PRESENTATION:A man in his 70s was referred to Hokkaido University Department of Gastroenterological Surgery II after contrast-enhanced CT revealed a 12 × 9-cm heterogeneous pelvic mass with poor enhancement accompanied by ascites. Endoscopic US-guided fine-needle aspiration had been performed at the previous hospital but failed to yield a definitive diagnosis, and elective tumor resection was planned. One week after the initial visit, the patient was brought to our hospital with abdominal pain. Emergency CT showed slight enlargement of the tumor, intratumoral fluid collection, and increased fat stranding around the tumor. Conservative management with intravenous antibiotics was initiated because there were no overt signs of generalized peritonitis. However, inflammatory markers worsened and fever developed, prompting emergency surgery on hospital day 2. Laparotomy revealed partial rupture of the tumor wall with leakage of contaminated intratumoral fluid into the peritoneal cavity. The tumor pedicle was identified at the base of the sigmoid mesocolon, and complete resection was achieved. The operative time was 124 min, and the estimated blood loss was 1100 mL. Histopathological examination revealed a patternless proliferation of spindle cells within a fibrous stroma with staghorn-like vasculature. Immunohistochemistry showed nuclear positivity for signal transducer and activator of transcription 6 and positivity for CD34, confirming the diagnosis of SFT. According to the modified Demicco model, the tumor was classified as intermediate risk. The patient was discharged on POD 31. CONCLUSIONS:When managing a large intra-abdominal tumor whose growth rate cannot be reliably assessed, the possibility of rupture should be kept in mind, and emergency surgery should not be delayed when abdominal findings worsen. Although the prognostic impact of tumor rupture in SFT remains unclear, this event may justify closer postoperative surveillance than that indicated by existing risk classification schemes.
INTRODUCTION:Obturator hernia is a rare cause of small-bowel obstruction and is frequently associated with strangulation. Even after successful reduction, bowel ischemia-reperfusion injury may occur and result in life-threatening metabolic complications. CASE PRESENTATION:An 87-year-old woman presented with a 3-week history of nausea and vomiting. CT revealed a right obturator hernia with incarceration of a small-bowel loop. US-guided manual reduction was successfully performed. Contrast-enhanced CT obtained immediately after reduction demonstrated preserved bowel-wall enhancement with circumferential mural thickening. The serum potassium level at presentation was 4.6 mmol/L. Despite apparently preserved bowel perfusion on CT, she continued to experience abdominal pain, tachypnea, and progressively deteriorating consciousness. Approximately 5 h after reduction, she developed sudden bradycardia followed by cardiac arrest. Continuous electrocardiographic monitoring showed progression from sinus rhythm to loss of P waves, QRS widening, and finally a sine-wave pattern. Laboratory testing during resuscitation revealed severe hyperkalemia (8.5 mmol/L). Despite intensive resuscitative efforts, the patient died. CONCLUSIONS:Preserved bowel-wall enhancement after reduction of a strangulated obturator hernia does not necessarily indicate bowel viability. A prolonged clinical course, persistent symptoms or systemic abnormalities, and residual CT abnormalities such as bowel-wall thickening and ascites should be considered together when assessing bowel viability after reduction. Such findings should prompt careful reassessment, close monitoring, and consideration of early surgical exploration despite preserved bowel-wall enhancement.
Anatomical lung resection using the da Vinci SP system was recently introduced in Japan. We retrospectively evaluated our initial experience and analyzed the learning curve for the first 53 consecutive cases. Fifty-three patients with primary lung cancer underwent anatomical resection, including lobectomy and segmentectomy, using the da Vinci SP system. We reviewed the perioperative outcomes, including the operative time, console time, conversion rates, and complications. The learning curves for operative and console times were assessed using a cumulative summation analysis. The mean patient age was 71.5 years. Thirty-five and 18 patients underwent lobectomy and segmentectomy, respectively. The mean operative and console times were 207.1 min and 147.5 min, respectively. Two patients (4
This study retrospectively investigated the risk factors for postoperative pain after thoracoscopic surgery, with a particular focus on chest wall anatomical characteristics. We reviewed patients who underwent thoracoscopic surgery between August 2021 and June 2025 at our institution. At routine outpatient visits 2–3 weeks after discharge, postoperative pain was assessed using the Numerical Rating Scale. Patients were categorized into a pain group (score ≥ 3) and a low-pain group (score ≤ 2). Clinical variables, perioperative factors, and preoperative chest wall anatomy were compared using an imaging analysis workstation. Among the 149 patients, 62 (41.6
Distal pancreatectomy with celiac axis resection (DP-CAR) is performed for locally advanced pancreatic body cancers involving the common hepatic artery (CHA) and/or celiac axis (CA). This procedure becomes especially intractable in cases of portal vein (PV) invasion due to poor mobility around both the CA and PV. However, no previous reports have described the surgical strategies for such difficult situations. To overcome the difficulty of CA and PV invasion, we devised a novel procedure called "pre-resection portal vein reconstruction." In this procedure, PV reconstruction using an inferior mesenteric vein patch graft is implemented after division of the CHA and pancreatic neck. The greatest advantage of this procedure is improved mobility around the pancreatic body after PV reconstruction, thereby enabling a subsequent sequential approach around the superior mesenteric artery, abdominal aorta, and CA root. "Pre-resection portal vein reconstruction" is an option for locally advanced pancreatic body cancers with both CA and PV invasion.
INTRODUCTION:An extrahepatic biliary neuroendocrine tumor (EB-NET) is an extremely rare malignancy with a poor prognosis and no established standard of care. CASE PRESENTATION:We herein report the case of a 35-year-old Japanese woman with no significant past medical or family history who presented with epigastric and back pain and was diagnosed with an EB-NET after pylorus-preserving pancreaticoduodenectomy. Despite initial resection, she developed recurrent liver metastases that required repeated hepatic resections and multiple systemic therapies, including chemotherapy, somatostatin analogs, everolimus, and peptide receptor radionuclide therapy (PRRT). Eventually, owing to progressive liver metastasis, she underwent living-donor liver transplantation (LDLT) from her brother 6 years after the initial surgery. Post-transplantation, the patient has remained disease-free for >3 years while on maintenance immunosuppression. CONCLUSIONS:Multimodal treatment, including resection of metastases, PRRT, and LDLT, significantly prolonged survival. This case highlights the potential role of LDLT as a curative strategy for patients with EB-NETs and controlled extrahepatic disease following multimodal treatment. Our case suggests that liver transplantation may provide long-term survival even in cases of a rare primary EB-NET, prompting the consideration of broader transplant indications in selected patients.
INTRODUCTION:Entero-appendiceal fistula is an extremely rare entity, with very few cases reported in the literature. Most previously described cases presented with abdominal pain or were diagnosed incidentally. To our knowledge, there have been no reports of such a fistula presenting with overt gastrointestinal bleeding. CASE PRESENTATION:A 56-year-old man with a medical history of human immunodeficiency virus infection, alcoholic cirrhosis, and paroxysmal atrial fibrillation, who was under regular follow-up at our hospital, presented with a 4-day history of hematochezia that was occurring 3-4 times per day. He was found to have severe anemia with a hemoglobin level of 6.6 g/dL and was emergently hospitalized on the same day. Contrast-enhanced CT did not reveal active extravasation. Colonoscopy showed multiple diverticula but no clear bleeding source. Recurrent hematochezia prompted repeat imaging, and subsequent CT showed extravasation in the ileum. Colonoscopy again revealed blood originating from a segment proximal to the reach of the colonoscope, suggesting bleeding from a more proximal segment. Double-balloon enteroscopy revealed a hemorrhagic submucosal tumor-like lesion located approximately 100 cm proximal to the ileocecal valve. Biopsy was inconclusive, but surgical resection was indicated because of the ongoing bleeding and the need to exclude malignancy. Laparoscopic resection revealed that the tip of the appendix had formed a fistula into the ileal lumen. Histopathological examination confirmed a full-thickness fistula between the appendix and ileum, with no evidence of malignancy. CONCLUSIONS:This is the first reported case of an entero-appendiceal fistula presenting with overt gastrointestinal bleeding and endoscopic features mimicking a submucosal tumor. Although extremely rare, this condition should be considered in the differential diagnosis of small intestinal tumors, particularly in patients with a history of complicated appendicitis or immunosuppression.
