松本 志郎

We report a case of acquired hemophilia A (AHA) after esophageal resection. The patient was an 80-year-old woman whose preoperative activated partial-thromboplastin time (APTT) was well within the normal range, at 34.9 s. She underwent thoracic esophagectomy and gastric pull-up for superficial esophageal cancer (operative time, 315 min; intraoperative blood loss, 245 ml). Intrathoracic and subcutaneous bleeding occurred spontaneously on postoperative day (POD) 39. The APTT was prolonged, at 140 s, and factor VIII inhibitor was 36 Bethesda U/ml. Treatment with recombinant activated factor VII, prednisolone, and cyclophosphamide resulted in remission within 2 months. This case supports an association between surgery and the triggering of factor VIII inhibitors. The diagnosis of AHA requires clinical acumen and must be considered in any patient with bleeding and a prolonged APTT.

We present three patients with T2 acinar cell carcinomas (ACC) (two of which were small) and discuss their clinical and pathological features. Case 1: A 34 year-old woman had a 2.6 cm iso- or hyperdense tumor. Enucleation was performed but final diagnosis was ACC and a pylorus preserving pancreaticoduodenectomy was performed. Case 2: A 35 year-old woman was found to have a 4.5 cm hypervascular tumor in the tail of the pancreas. Distal pancreatectomy was performed. Case 3: A 61 year-old man suffered from acute pancreatitis and was found to have an encapsulated 2.5 cm hypervascular tumor in the head of pancreas. Pylorus-preserving pancreaticoduodenectomy was performed. These three patients with T2 ACCs had common characteristics including well-demarcated exophytic tumors with slow and limited progress, distinctively different from large ACCs and pancreatic ductal adenocarcinomas. ACCs are important in the differential diagnosis of homogeneously or heterogeneously enhancing small pancreatic tumors.

Several options exist for reconstruction after total esophagectomy in patients with esophageal carcinoma. However, the options for a major resection after previous head and neck surgery in these patients are extremely limited. The procedure performed in 2 patients requiring esophagectomy after resection for previous head and neck malignancies is described. Both patients underwent previous chemoradiation therapy and free jejunal transfer for hypopharyngeal squamous cell carcinoma. Esophagectomy and reconstruction with a cervical gastrojejunal anastomosis combined with deltopectoral flaps were performed after the diagnosis of esophageal disease. Soft tissue defects were closed with a modified deltopectoral flap using de-epithelization. The deltopectoral flap is effective not only for cutaneous resurfacing, but also to promote delayed wound healing after radiation therapy. This report demonstrates a useful multidisciplinary approach for resection and reconstruction in patients after a previous free jejunal transfer.