Thoracoscopic and laparoscopic approach for pleuroperitoneal communication under peritoneal dialysis: a report of four cases.

BACKGROUND: Pleuroperitoneal communication (PPC) is a rare complication of continuous ambulatory peritoneal dialysis (CAPD) and often forces patients to switch to hemodialysis. Some efficiencies of video-assisted thoracic surgery (VATS) for PPC have been reported recently; however, there is no standard approach for these complications. In this case series, we present a combined thoracoscopic and laparoscopic approach for PPC in four patients to better assess its feasibility and efficiency. CASE PRESENTATION: Clinical characteristics, perioperative findings, surgical procedures, and clinical outcomes were retrospectively analyzed. We combined VATS with a laparoscopic approach to detect and repair the diaphragmatic lesions responsible for PPC. We first performed pneumoperitoneum in all patients following thoracoscopic exploration. In two cases, we found bubbles gushing out of a small pore in the central tendon of the diaphragm. The lesions were closed with 4-0 non-absorbable monofilament sutures, covered with a sheet of absorbable polyglycolic acid (PGA) felt, and sprayed with fibrin glue. In the other two cases without bubbles, a laparoscope was inserted, and we observed the diaphragm from the abdominal side. In one of the two cases, two pores were detected on the abdominal side. The lesions were closed using sutures and reinforced using the same procedure. In one case, we failed to detect a pore using VATS combined with the laparoscopic approach. Therefore, we covered the diaphragm with only a sheet of PGA felt and fibrin glue. There was no recurrence of PPC, and CAPD was resumed at an average of 11.3 days. CONCLUSIONS: The combined thoracoscopic and laparoscopic approach is an effective treatment for detecting and repairing the lesions responsible for PPC.

A Case of Intractable Lung Abscess Following Dropped Gallstone-Induced Subphrenic Abscess: A Rare Postoperative Complication Caused by Dropped Gallstone During Laparoscopic Cholecystectomy.

Dropped gallstones into the abdominal cavity due to perforation of the gallbladder occasionally occur during laparoscopic cholecystectomy. Abscess formation caused by residual gallstones is one of the late postoperative complications after laparoscopic cholecystectomy. Most of them are intra-abdominal abscesses; however formation of intra-thoracic abscesses, in particular, lung abscess, is less described, and surgery for an intra-thoracic abscess is rarely performed. We describe a case of intractable lung abscess following dropped gallstone-induced subphrenic abscess caused by a residual gallstone after laparoscopic cholecystectomy.

A case of pleuroperitoneal communication in which establishing a laparoscopic pneumoperitoneum was useful for the detection of a fistula.

BACKGROUND: Pleuroperitoneal communication (PPC) is rarely observed, accounting for 1.6% of all patients who undergo continuous ambulatory peritoneal dialysis (CAPD). Although there have been several reports concerning the management of this condition, we have encountered several cases in which control failed. We herein report a valuable case of PPC in which laparoscopic pneumoperitoneum with video-assisted thoracic surgery (VATS) was useful for supporting the diagnosis and treatment. CASE PRESENTATION: The patient was a 58-year-old woman with chronic renal failure due to chronic renal inflammation who was referred to a nephrologist in our hospital to undergo an operation for the induction of CAPD. Post-operatively, she had respiratory failure, and chest X-ray and computed tomography (CT) showed right-sided hydrothorax that decreased when the injection of peritoneal dialysate was interrupted. Therefore, PPC was suspected, and she was referred to our department for surgical repair. We planned surgical treatment via video-assisted thoracic surgery. During the surgery, we failed to detect any lesions with thoracoscopy alone; we therefore added a laparoscopic port at her right-sided abdomen near the navel and infused CO2 gas into the abdominal cavity. On thoracoscopy, bubbles were observed emanating from a small pore at the central tendon of the diaphragm, which was considered to be the lesion responsible for the PPC. We closed it by suturing directly. CONCLUSIONS: VATS with laparoscopic pneumoperitoneum should be considered as an effective method for inspecting tiny pores of the diaphragm, especially when the lesions responsible for PPC are difficult to detect.

Unusual giant multilocular mesothelial cyst of mediastinum.

BACKGROUND: Intrathoracic mesothelial cysts are congenital lesions induced by the abnormal development of the pericardial coelom. There have been a few reports of giant mesothelial cyst of the superior mediastinum, but the preferred treatment remains a controversial topic. We herein report a rare case of successful removal of giant mesothelial cyst that was incidentally detected during a medical checkup. CASE PRESENTATION: A 53-year-old man with a feeling of mild chest tightness was referred to our hospital for the evaluation of an abnormal shadow of the mediastinum on chest X-ray. Computed tomography showed a multilocular, homogenous, large cyst in the superior mediastinum measuring 18 cm in size without contrast enhancement and with spotty calcification, and magnetic resonance imaging showed a low intensity on T1-weighted images and high intensity on T2-weighted images. Therefore, a cystic thymoma, thymic cyst, lymphangioma, cystic teratoma or pericardial cyst was suspected as the preoperative diagnosis. Despite mild symptoms, the patient underwent total thymectomy under median sternotomy for an appropriate diagnosis and treatment. The pathological diagnosis was giant multilocular mesothelial cyst. CONCLUSIONS: Intrathoracic mesothelial cyst is a benign cyst and generally asymptomatic, but can sometimes induce critical chest clinical symptoms if untreated, depending on its size. In our case, complete surgical resection and a detailed pathological evaluation was effective for making the appropriate diagnosis and delivering treatment. In addition, an immunohistological evaluation is effective for diagnosing mesothelial cysts when it is difficult to distinguish the cyst from other cystic lesions.

Multifocal cholesterol granulomas of the anterior mediastinum.

BACKGROUND: Cholesterol granuloma in the mediastinum is rarely observed, accounting for 1% of all mediastinum tumors. There have been only a few reports of multifocal cholesterol granulomas of the thymus. We herein report a rare case of multifocal cholesterol granuloma in the thymus that was incidentally detected during follow-up of an aortic aneurysm. CASE PRESENTATION: The patient was a 70-year-old man with dyslipidemia and hypertension who was referred to our hospital to undergo an operation for chest aortic aneurysm. Preoperative computed tomography (CT) showed 4 lesions in the anterior mediastinum measuring up to 4 cm in size with slight contrast enhancement and spotty calcification. Therefore, a thymoma, bronchogenic cyst, or lymphangioma were considered as the preoperative diagnosis. The patient underwent total thymectomy under thoracotomy followed by aortic arch replacement for the aortic aneurysm. The pathological diagnosis was multifocal cholesterol granulomas in the thymus. CONCLUSIONS: Cholesterol granulomas should be included in the differential diagnosis of cystic tumor in the mediastinum, especially in patients with basal disease such as dyslipidemia and hypertension, which may lead to aortic aneurysm. Furthermore, complete surgical resection and a detailed histological evaluation are important for the accurate diagnosis and treatment.

Superior vena cava replacement combined with venovenous shunt for thymic carcinoma.

INTRODUCTION: Advanced-stage thymic malignancies are a heterogeneous group of mediastinal tumors that include thymoma and thymic carcinoma infiltrating the surrounding thoracic structures. When the tumor infiltrates the superior vena cava (SVC), radical resection can be selectively achieved via en bloc SVC resection and its prosthetic conduit replacement. We herein report a case of SVC replacement for thymic carcinoma en bloc radical resection. CASE PRESENTATION: A 75-year-old Japanese man presented at our hospital due to progressive dyspnea and edema of his face and upper extremities. CT showed a 55 × 40 × 38-mm tumor located at the anterior mediastinum lesion. This tumor had invaded the superior vena cava and both brachiocephalic veins. We performed surgical resection for the thymic carcinoma located at the mediastinum that invaded the superior vena cava and both brachiocephalic veins. The surgery was performed through a full median sternotomy and transmanubrial approach without using an artificial heart and lung. The tumor involved the SVC, right brachiocephalic vein (RBCV) and left brachiocephalic vein (LBCV). We performed SVC replacement for thymic carcinoma en bloc radical resection. DISCUSSION: This report has two important implications. First, a venovenous shunt (VVS) from the distal LBCV to the right auricle was very useful and safe before performing an SVC complete clamp. The second implication of our study was that using a PTFE with a large inner diameter may prevent thrombus occlusion. CONCLUSIONS: We experienced SVC replacement for thymic carcinoma en bloc radical resection. We were able to safely performed this surgery using our usual approach.

Mediastinal lymph node metastases in lung cancer presenting as pure ground-glass nodules: A surgical case report.

INTRODUCTION: Generally, lung cancer representing as Ground-glass nodules is associated with an early stage and good prognosis. However, we herein report a rare case of pure ground-glass nodules with mediastinal lymph node metastases. PRESENTATION OF CASE: A 69-year-old man underwent video assisted thoracic surgery right upper lobectomy with mediastinal lymph node dissection due to multifocal Ground-glass nodules in the right upper lobe of the lung. Histopathologically, six lung adenocarcinomas were present simultaneously. Furthermore, we detected mediastinal lymph nodes metastases that contain micropapillary component. The lung lesion containing micropapillary component was a pure Ground-glass nodule that adjoining pulmonary bulla on CT findings. DISCUSSION: Generally, lung cancer presenting as pure ground-glass nodules is associated with an early stage and good prognosis. However, the necessity of evaluating the mediastinal lymph nodes in pure ground-glass nodules is controversial. It is reported that lung cancer adjoining the wall of a bulla tends to have a poor prognosis, even when small in size. Therefore, Ground-glass nodules with metastases might have a different pathogenesis than other nodules. CONCLUSION: Adenocarcinoma appearing as pure Ground-glass nodules is associated with early stage lung cancer and a good prognosis. However, the findings in our patient indicate the importance and necessity of evaluating the mediastinal lymph nodes for metastases intraoperatively.

A minimally invasive and safe surgical approach to resect anterior superior sulcus tumors.

INTRODUCTION: Superior sulcus tumors (SSTs) are a wide range of tumors invading a section of the apical chest wall called the thoracic inlet. The unique characteristics of SSTs lie in the anatomy of the region where these tumors occur. For this reason, a surgical approach to treating these tumors is technically demanding, and complete resection may be difficult to accomplish. CASE PRESENTATION: A 71-year-old Japanese man presented at our hospital due to left anterior chest pain and an abnormal chest CT scan showing a 40 × 33 × 30-mm tumor located in the left anterior apex of the thoracic inlet. This tumor had invaded the first and second rib and was located near the subclavian vein. There was no significant distant metastasis. Therefore, we performed surgical resection. The surgical procedure included three steps. First, we performed VATS observation via the left thoracic cavity. Second, via the transmanubrial approach, we obtained tumor-free margins of the anterior cervical structures. Third, through VATS in the left lateral decubitus position, we performed left upper lobectomy and mediastinal lymph node dissection. This surgery was successful, with no postoperative complications. DISUCUSSION: This surgical approach was effective and safe for treating a superior sulcus tumor located the anterior apex of the thoracic inlet. Next, VATS lobectomy is minimally invasive and safe after the transmanubrial approach for managing anterior superior sulcus tumor. CONCLUSION: We experienced a case of locally advanced superior sulcus tumor located at the anterior apex of the thoracic inlet and performed complete resection.

Two extremely rare cases of extrapleural hematoma.

BACKGROUND: Extrapleural hematoma is uncommon. However, according to the size of hematoma and/or the progression of anemia, surgical treatment to control bleeding might be necessary because a huge hematoma can cause ventilator and circulatory disturbances to press heart and lung. We present two unusual cases of huge extrapleural hematoma in an anticoagulated patient with no apparent history of trauma or otherwise traumatic episodes. CASE PRESENTATION: Case 1: A 78-year-old man presented to our emergency department with pain in his right shoulder and disturbance of consciousness. He had no apparent history of trauma. Computed tomography (CT) of the chest revealed the presence of a huge lens-like encapsulated lesion measuring 220 × 90 mm in the right thoracic cavity. These findings all supported a diagnosis of extrapleural hematoma with hemothorax. Case 2: A 73-year-old man was brought to our hospital by ambulance after bruising his back in his house. CT of the chest revealed the presence of a huge lens-like encapsulated lesion measuring 230 × 70 mm in the left thoracic cavity. Hemorrhagic effusion was obtained by thoracocentesis, and the lesion was suspected of being a hematoma. In both two cases, we performed video-assisted thoracic surgery (VATS), which was minimally invasive and effective. These two patients were cured and discharged smoothly after surgery. CONCLUSIONS: We reported two rare cases of extrapleural hematoma. This disease requires close attention when it manifests in patients undergoing anticoagulation therapy. Regarding treatment, VATS was particularly effective in these cases.

Prognostic factors of advanced or postoperative recurrent non-small cell lung cancer targeted with immune check point inhibitors.

BACKGROUND: Although immune checkpoint inhibitors (ICIs) for non-small cell lung cancer (NSCLC) have been established as one of standard therapy, the prognostic factors of ICIs remain unclear, aside from the programed cell death-ligand 1 (PD-L1) expression of tumor cells. The aim of this study was to determine the prognostic factors of ICIs. METHODS: We analyzed the clinicopathological data of 44 cases of advanced NSCLC targeted with ICIs in our hospital, between February 2016 and February 2018, in order to determine the prognostic factors of ICIs. We also reviewed the literature regarding ICIs. RESULT: We retrospectively analyzed the 44 cases (26 nivolumab and 18 pembrolizumab cases). These patients were 38 men and 6 women, comprising 13 cases of adenocarcinoma, 29 squamous cell carcinoma and 2 unclassified types. Seven patients were using first-line therapy and while the others were using second-line therapy or later. Epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) mutations were negative in all the cases. The response rate and disease control rate were 20.5% and 51.3%, respectively. The median progression-free survival time and median survival time were 146 days and 257 days, respectively. We observed five severe adverse effects (AEs) (three cases of interstitial pneumonia, one of liver dysfunction and one of adrenal failure), that were resolved by steroid pulse therapy. In multivariate analyses, the Eastern Cooperative Oncology Group performance status (ECOG PS), pathological type, standardized uptake value (SUV) on positron emission tomography (PET), white blood cell (WBC) count, neutrophil, neutrophil-to-lymphocyte ratio (NLR), lactate dehydrogenase (LDH) and albumin were independently prognostic factors. There were no significant differences in the prognosis between nivolumab and pembrolizumab. CONCLUSIONS: ICIs were effective in 44 treated NSCLC cases. Our analysis suggests that while ICIs are effective in treating patients, candidates must be carefully selected and cautiously observed.

Thymic papillary adenocarcinoma coexisting with type A thymoma: A case report.

INTRODUCTION: Thymic papillary adenocarcinoma is rare. Further, thymic papillary adenocarcinoma coexisting with type A thymoma is extremely rare. Surgery remains the only effective treatment for this disease. PRESENTATION OF CASE: An 84-year-old Japanese woman presented to our institute due to abnormal chest computed tomography (CT) findings showing a 45 × 40 × 40-mm tumor located in the anterior mediastinum. A malignant tumor was suspected based on the CT findings and high serum levels of carcinoembryonic antigen. Mediastinal tumor resection was performed via video-assisted thoracic surgery through the left thoracic approach. This patient was discharged from our institute without any problems at six days post-operation. DISCUSSION: This report has three major implications. First, one of the tumors was papillary adenocarcinoma. Primary papillary adenocarcinoma of the thymus is exceedingly rare. Second, papillary adenocarcinoma and type A thymoma coexisted in this tumor. Third, epithelial thymic tumor should be resected completely, since complete resection has been reported to be associated with an improved prognosis. CONCLUSION: We encountered a rare case of thymic papillary adenocarcinoma coexisting with type A thymoma.

Detection of circulating tumor cells with a novel microfluidic system in malignant pleural mesothelioma.

Detection of rare tumor cells circulating in the blood (CTCs) presents technical challenges. CellSearch, the only approved system for clinical use, fails to capture epithelial cell adhesion molecule-negative CTCs such as malignant pleural mesothelioma (MPM). We have developed a novel microfluidic device (CTC-chip) in which any Ab to capture CTCs is conjugated. The CTC-chip was coated with an Ab against podoplanin that is abundantly expressed on MPM. Circulating tumor cell-detection performance was evaluated in experimental models in which MPM cells were spiked in blood sampled from a healthy volunteer and in clinical samples drawn from MPM patients. The CTC-chip showed superior CTC-detection performance over CellSearch in experimental models (sensitivity, 63.3%-64.5% vs 0%-1.1%; P < .001) and in clinical samples (CTC-positivity, 68.8% vs 6.3%; P < .001). A receiver operating characteristic (ROC) analysis showed that the CTC test provided a significant diagnostic performance in discrimination of unresectable disease from resectable disease (area under the ROC curve, 0.851; P = .003). The higher CTC count (≥2 cells/mL) was significantly associated with a poor prognosis (P = .030). The novel CTC-chip enabled sensitive detection of CTCs, which provided significant diagnostic and prognostic information in MPM.

Effect of erlotinib plus bevacizumab on brain metastases in patients with non-small cell lung cancer.

BACKGROUND: The standard therapy for brain metastasis (BM) in non-small cell lung cancer (NSCLC) is radiation therapy (RT), although it is associated with complications such as leukoencephalopathy. In the current report, we retrospectively review data from eight patients who had NSCLC and harbored epidermal growth factor receptor (EGFR) mutations, and who were received erlotinib plus bevacizumab (E+B) as first-line therapy for BM. METHODS: Patients were given E+B as first therapy for BM until August 2017 at our institution. Patients receiving local therapy for BM, such as surgery or radiotherapy, were excluded. Patients were administered erlotinib orally (once daily at 150 mg/body) plus bevacizumab by intravenous infusion (15 mg/kg on day 1 of a 21- or 28-day cycle). RESULTS: Eight NSCLC patients who were diagnosed with BM received E+B, including 2 men and 6 women with a median age of 65 years (range, 46-84 years). Four patients had an L858R EGFR mutation, while the other four had an exon 19 deletion. Seven patients had a partial response to E+B treatment, and one had a complete response. The 2-year survival rate was 62.5%. Three patients who were pre-treated with gefitinib had an E+B treatment duration of less than 1 year. At the time of this analysis, four patients had BM-related neurologic symptoms and multiple BMs, and were still receiving E+B with no evidence of treatment failure after more than 1 year. CONCLUSIONS: E+B can be used as first-line therapy for BM, even in patients with BM-related neurologic symptoms and multiple BMs.

Complete resection of an anterior mediastinal tumor by total arch replacement and pulmonary artery trunk plasty with a pericardial patch: A case report.

INTRODUCTION: Patients with undiagnosed anterior mediastinal tumors commonly undergo surgery for diagnosis and treatment. However, determining the optimal therapeutic strategy is difficult for tumors with substantial invasion, such as lesions touching the aortic arch (AA). CASE PRESENTATION: A 76-year-old man of Asian descent presented to our hospital because chest computed tomography (CT) revealed an anterior mediastinal tumor. This tumor surrounded the left subclavian vein and touched the AA. We suspected the tumor to be malignant. We therefore decided to resect the tumor with preparation for total arch replacement (TAR). The operation was performed in three steps. First, we performed a mediastinal sternotomy. However, the tumor had invaded the subclavian vein, so we resected this vein after adding a transmanubrial approach. However, because of invading the AA we needed next step. Second, we shifted the patient to the right lateral decubitus position. We performed partial resection of the left upper lobe and exfoliated the distal AA. Third, we shifted the patient to the dorsal position and implanted an artificial cardiopulmonary device, after which we performed TAR, and pulmonary artery (PA) trunk plasty with a pericardial patch. The operation was successful, with no major adverse events. Pathologically, the tumor was diagnosed as diffuse large B-cell lymphoma. DISCUSSION: If oncologically complete resection is preferable for tumors with substantial invasion, complete resection should be attempted even if the surgery is difficult. CONCLUSION: We performed complete resection of an anterior mediastinal tumor with TAR and PA trunk plasty using a pericardial patch.

Outcomes of patients undergoing surgery for thymic carcinoma: a single-center experience.

BACKGROUND: Thymic carcinoma is uncommon, presents locally at an advanced stage, and behaves aggressively. The optimum treatment for advanced thymic carcinoma is controversial. We retrospectively reviewed our institutional experience with patients with thymic carcinoma. METHODS: We analyzed the clinical data of six patients who underwent total thymectomy for thymic carcinoma at our institution from 2006 to 2016. Variables analyzed included sex, age, histological classification, Masaoka staging, postoperative treatment, and recurrence. RESULTS: The clinical characteristics of the six patients with thymic carcinoma (median age, 56 years; five men and one woman) were as follows: squamous cell carcinoma (n=5); sarcomatoid carcinoma (n=1); Masaoka stages II (n=1), III (n=2), IVa (n=1), and IVb (n=2). Four patients underwent combined pulmonary resection (66.7%) as a component of en bloc resection due to suspicion of pulmonary invasion. Four patients (66.7%) received postoperative therapy, and complete resection was achieved for four patients. There were no perioperative deaths. One patient experienced a recurrence. CONCLUSIONS: Complete resection for thymic cancer improved the prognosis of our patients, indicating that robust studies will be required to confirm our findings.

Virtual-assisted lung mapping (VAL-MAP) shortened surgical time of wedge resection.

BACKGROUND: The detection of extremely small lung tumors has increased with the development of computed tomography. Resection of such tumors by thoracoscopy is often hindered due to the unclear location of the tumor. Various methods of preoperative determination of such lesions have been attempted, but without marked success. Here we used virtual-assisted lung mapping (VAL-MAP) to perform surgical resection of small lung lesions. METHODS: We selected patients with pulmonary tumors that we anticipated to be difficult to identify during thoracoscopy and/or decide the resection line for sub-lobar lung resection. The wedge resections in the VAL-MAP group were compared to a group of patients who underwent wedge resection without VAL-MAP in 2013. RESULTS: Surgery duration was significantly shorter in the VAL-MAP group (average: 76.4 min) than in the 2013 group (average: 108.6 min; P=0.000451), although the VAL-MAP group (average major axis: 9.6 mm) had smaller tumors (P=0.000032) and more pure ground-glass opacities (GGOs) (P=0.0000919) than the 2013 group (average major axis: 16.6 mm). CONCLUSIONS: The findings of this study indicate that VAL-MAP is efficacious. In particular, VAL-MAP resulted in a shorter surgery duration and has expanded the indications of resectable lesions.

Mediastinal Tracheostoma for Treatment of Tracheostenosis after Tracheostomy in a Patient with Mucopolysaccharidosis-Induced Tracheomalacia.

BACKGROUND: Treatment of tracheostenosis after tracheostomy in pediatric patients is often difficult. Mucopolysaccharidosis is a lysosomal storage disease that may induce obstruction of the airways. CASE PRESENTATION: A 16-year-old male patient underwent long-term follow-up after postnatal diagnosis of type II mucopolysaccharidosis. At 11 years of age, tracheostomy was performed for mucopolysaccharidosis-induced laryngeal stenosis. One week prior to presentation, he was admitted to another hospital on an emergency basis for major dyspnea. He was diagnosed with tracheostenosis caused by granulation. The patient was then referred to our institution. The peripheral view of his airway was difficult because of mucopolysaccharidosis-induced tracheomalacia. For airway management, a mediastinal tracheostoma was created with extracorporeal membrane oxygenation. To maintain the blood flow, the skin incision for the mediastinal tracheal hole was sharply cut without an electrotome. The postoperative course was uneventful, and the patient was weaned from the ventilator on postoperative day 19. He was discharged 1.5 months postoperatively. Although he was referred to another institution because of respiratory failure caused by his primary disease 6 months postoperatively, his airway management remained successful for 1.5 years postoperatively. CONCLUSION: Mediastinal tracheostomy was useful for treatment of tracheostenosis caused by granulation tissue formation after a tracheostomy.

Postoperative thoracic hemorrhage after right upper lobectomy with thoracic wall resection during rivaroxaban anticoagulant therapy for deep leg vein thrombosis: A case report.

INTRODUCTION: Postoperative pulmonary embolism (PE) is the one of the most important complications after thoracic surgery. This complicatin after the surgery is often treated by new anticoaglant drug, such as rivaroxaban, which dose not need to the monitoring of blood coaglation system. We experienced postoperative bleeding case during anticoaglant therapy using rivaroxaban. PRESENTATION OF CASE: The patient underwent a right upper lobectomy with lung and chest wall resection for lung cancer. On postoperative day (POD) 10, we started to use rivaroxaban to treat the deep vein thrombosis (DVT). Four days after starting the rivaroxaban treatment, severe surgical site hemorrhage occurred, which led to the need for the infusion of concentrated red cells (CRC). After stopping the rivaroxaban, the thoracic bleeding ceased. Because the event occurred so long after the surgery, and because the bleeding stopped after withdrawal of treatment, we believe that rivaroxaban induced the thoracic bleeding. CONCLUSION: Some reports in the field of orthopedics (Turpie et al., 2009) have noted that rivarxaban is effective to prevent postoperative DVT. However, there were few reports that invied the attention to postoperative bleeding be induced by rivarxaban. Thus, we describe this case in order to alert clinicians to the potential bleeding risks associated with the admistration of rivaroxaban postoperatively.