Spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support: a case report.

BACKGROUND: Intercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage. CASE PRESENTATION: A 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful. CONCLUSION: We report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.

Metastatic lung tumor from hepatocellular carcinoma with tumor thrombus invasion in the pulmonary vein: a case report.

BACKGROUND: Metastatic lung tumor with a tumor thrombus in the peripheral pulmonary vein is very rare. We present a case of a metastatic lung tumor from hepatocellular carcinoma (HCC) with tumor thrombus invasion in the pulmonary vein that was diagnosed preoperatively and underwent complete resection by segmentectomy. CASE PRESENTATION: A 77-year-old man underwent laparoscopic lateral segment hepatectomy for HCC eight years ago. Protein induced by vitamin K absence or antagonist-II remained elevated from two years ago. Contrast-enhanced chest computed-tomography (CT) showed a 27 mm nodule in the right apical segment (S1). He was pathologically diagnosed with a metastatic lung tumor from HCC via transbronchoscopic biopsy. We planned to perform right S1 segmentectomy. Before surgery, contrast-enhanced CT in the pulmonary vessels phase for three-dimensional reconstruction showed that the tumor extended into the adjusting peripheral pulmonary vein, and we diagnosed tumor thrombus invasion in V1a. The surgery was conducted under 3-port video-assisted thoracic surgery. First, V1 was ligated and cut. A1 and B1 were cut. The intersegmental plane was cut with mechanical staplers. Pathological examination revealed moderately-differentiated metastatic HCC with tumor thrombus invasions in many pulmonary veins, including V1a. No additional postoperative treatments were performed. CONCLUSIONS: As malignant tumors tend to develop a tumor thrombus in the primary tumor, it might be necessary to perform contrast-enhanced CT in the pulmonary vessel phase to check for a tumor thrombus before the operation for metastatic lung tumors.

Colonic varices treated with embolization after pancreatoduodenectomy with portal vein resection: a case report.

BACKGROUND: Pancreatoduodenectomy with resection of the portal vein or superior mesenteric vein confluence has been safely performed in patients with pancreatic head cancer associated with infiltration of the portal vein or superior mesenteric vein. In recent years, left-sided portal hypertension, a late postoperative complication, has received focus owing to increased long-term survival with advances in chemotherapy. Left-sided hypertension may sometimes cause fatal gastrointestinal bleeding because of the rupture of gastrointestinal varices. Here, we present a case of colonic varices caused by left-sided portal hypertension after pancreatoduodenectomy with portal vein resection. CASE PRESENTATION: A 69-year-old man diagnosed with pancreatic head cancer was referred to our department for surgery after undergoing chemotherapy with nine courses of gemcitabine and nab-paclitaxel. Computed tomography showed a mass 25 mm in diameter and in contact with the portal vein. He had undergone subtotal stomach-preserving pancreatoduodenectomy with portal vein resection. Four centimeters of the portal vein had been resected, and end-to-end anastomosis was performed without splenic vein reconstruction. We had to completely resect the right colic vein, accessary right colic vein, and middle colic vein due to tumor invasion. The pathological diagnosis was ypT3, ypN1a, ypM0, and ypStageIIB, and he was administered TS-1 as postoperative adjuvant chemotherapy. Seven months after therapeutic radical surgery, he presented with melena with progressive anemia. Computed tomography revealed transverse colonic varices. He was offered interventional radiology. Trans-splenic arterial splenic venography showed that transverse colonic varices had developed as collateral circulation of the splenic vein and inferior mesenteric vein system. An embolic substance was injected into the transverse colonic varices, which halted the progression of the anemia caused by melena. Fifteen months after therapeutic radical surgery, local recurrence of the tumor occurred; he died 28 months after the surgery. CONCLUSIONS: When subtotal stomach-preserving pancreatoduodenectomy with portal vein resection is performed without splenic vein reconstruction, colonic varices may result from left-sided portal hypertension. Interventional radiology is an effective treatment for gastrointestinal bleeding due to colonic varices, but it is important to be observant for colonic necrosis and new varices.

Minimally invasive surgery for esophageal cancer after esophageal perforation.

Both esophageal rupture and esophageal cancer are life-threatening diseases. We report a case of esophageal cancer that occurred after esophageal rupture was treated with thoracoscopic and laparoscopic surgery. A 76-year-old man presented with vomiting followed by epigastric pain and was diagnosed with spontaneous esophageal rupture. Laparoscopic and thoracoscopic surgery were performed. Primary closure was completed with a fundic patch, and thoracic lavage was performed. Ten months later, his condition was diagnosed as squamous cell carcinoma of the abdominal esophagus. He underwent thoracoscopic esophageal resection in the prone position, and a gastric conduit was created laparoscopically. The pathological finding was superficial esophageal carcinoma without lymph node metastasis. The patient's postoperative course was uneventful, and there was no recurrence at 21 months of follow-up.

Subcarinal node is the significant node that affects survival in resected small cell lung cancer.

PURPOSE: Our aim was to clarify the significance of surgery and the prognostic factors in patients with small cell lung cancer (SCLC). METHOD: A retrospective review of 50 patients with limited SCLC who underwent a pulmonary resection and mediastinal nodal dissection during the 10-year period from 1988 to 1997 was undertaken. The TNM classification was applied to all cases of SCLC. RESULTS: A Cox regression multivariate analysis indicated lymph node metastasis (P = 0.0117) and adjuvant therapy (P = 0.0429) to be independent prognostic factors in SCLC patients. Concerning the patients with lymph node metastasis, the prognosis was related only to the involvement of the subcarinal node (station 7). Although no patient with lymph node involvement in station 7 could be a 2-year survivor, in the case of patients with lymph node involvement except in station 7, 47.1% of them were 2-year survivors and 25.1% were 4-year survivors. Among the patients with lymph node metastasis, a univariate analysis indicated the prognosis to be significantly poorer in patients with station 7 involvement than in those without station 7 involvement (P = 0.0224). CONCLUSION: Involvement in the subcarinal node might be a prognostic factor for SCLC.

Successful resection of a recurrent mediastinal liposarcoma invading the pericardium: report of a case.

Primary liposarcoma of the mediastinum is rare, but cases of recurrence have been reported in the English literature. We successfully resected a recurrent pericardial liposarcoma, detected 5 years after the initial resection of a liposarcoma of the anterior mediastinum invading the pericardium. Routine follow-up computed tomography showed the recurrence and suggested invasion of the pericardial cavity, which was supported by the findings of transesophageal ultrasonography. As cine-magnetic resonance imaging suggested that the tumor was resectable, an operation was performed. Histopathology confirmed the diagnosis of recurrent liposarcoma and showed clear surgical margins.

Spontaneous pneumothorax secondary to radiographically occult lung metastasis from parapharyngeal synovial sarcoma: report of a case.

This report describes a case of secondary pneumothorax caused by a radiographically occult lung metastasis from parapharyngeal synovial sarcoma, a relatively rare tumor known to be highly metastatic to the lung. Although chest X-ray and thoracic computed tomography scan failed to detect the metastatic nodule in the right lung, the surgically resected specimen proved to be a 3-mm lung metastasis. To our knowledge, only eight cases of lung metastases from synovial sarcoma causing pneumothorax have ever been reported. In most of these cases, the lung metastases were detected by radiographical examinations. However, in this patient, the metastatic lesion was not detected during examination. It is speculated that secondary pneumothorax caused by synovial sarcoma may occur during the early stages of lung metastasis. Therefore, if pneumothorax occurs in a patient with a synovial sarcoma, the possibility of lung metastasis should be carefully considered, even if it is undetectable on radiological examinations.

Wedge resection of the portal bifurcation concomitant with left hepatectomy plus biliary reconstruction for hepatobiliary cancer.

BACKGROUND/PURPOSE: We report our experience performing wedge resection of the portal bifurcation and transverse suture closure in patients undergoing left hepatectomy and caudate lobectomy plus biliary reconstruction for hepatobiliary cancer. METHODS: The procedure was performed in three patients with hilar or intrahepatic cholangiocarcinoma. After confirming that tumor invasion of the portal bifurcation was not circumferential, the portal trunk and the right posterior and right anterior portal branches were isolated and clamped. Wedge resection of the portal bifurcation was performed, taking care to secure a clear surgical margin. The edges of the portal vein were approximated, using guy-sutures in the dorsal and ventral edges and a temporary central guy-suture, and portal reconstruction was carried out using a continuous transverse suture. After unclamping, good portal flow was confirmed by color Doppler ultrasonography. RESULTS: The procedure was completed successfully in all three patients; the average time of portal vein occlusion was 15 min. Two patients had postoperative complications: bile leakage and wound infection, but no patient developed postoperative hepatic failure or died. The three patients are alive without recurrence at 2, 11, and 22 months after the operation. CONCLUSIONS: Wedge resection of the portal bifurcation is easier and simpler than using a venous patch or performing segmental resection.