Introduction: Abdominoperineal resection is performed using laparoscopic techniques at many institutions. Few institutions construct the terminal stoma using the extraperitoneal route, mainly because of the difficulty of this approach. However, the extraperitoneal route for terminal stoma might be associated with a lower rate of complications when compared with the transperitoneal route. We construct the terminal stoma via the extraperitoneal route using Nelaton’s catheter. Materials and Surgical Technique: We call this technique the “Nelaton’s Catheter Hauling Technique”, which involves: 1) dissection of the extraperitoneal space using a intestinal spatula, 2) insertion of Nelaton’s catheter into the abdominal space via the extraperitoneal route, 3) capture of the tip of Nelaton’s catheter and pull it to the outside, 4) tying of the threads of the stump of the colon and the tip of Nelaton’s catheter, and 5) pulling up on Nelaton’s catheter to move the stump of the colon outside via the extraperitoneal route. Discussion: We believe that the use of this technique will contribute to the reduction of stoma-related complications.
Although dysphagia is a common complication after radiotherapy (RT) for head and neck cancer, its pathogenesis is not completely understood because the swallowing function is affected by complex factors. Appropriate swallowing pressure is an important factor in normal swallowing. When the radiation field includes the pharyngeal segment, intrabolus pressure may be affected. The purpose of this study is to examine the long-term influence of RT on swallowing pressure. Ten patients undergoing treatment for early-stage laryngeal squamous cell carcinoma were included in this study. Sufficient nutritional intake was maintained through oral feeding alone throughout the study period in all of the patients. A high-resolution manometry system with 36 circumferential sensors spaced 1 cm apart was positioned through the nose to record the maximum pressures at the mesopharynx, hypopharynx and the upper esophageal sphincter. The pressures were recorded before and at 6 and 12 months after treatment. There was no statistically significant chronological change in pressures either at meso-, hypopharynx or the upper esophageal sphincter. Even though radiation field includes a part of pharyngeal segment, intrabolus pressure was not found to be affected by the treatment. Despite the disadvantages of RT, the current study did not demonstrate RT had a quantitative influence on swallowing pressure. Further studies are required to clarify the relationship between pharyngeal pressure and the dysphagia induced by RT.
A 20-year-old woman presented to the Department of Obstetrics and Gynecology of our hospital for a prenatal checkup at 33 weeks’ gestation. No abnormalities had been ever found in routine urine testing at school health checkups. Blood tests revealed renal impairment, with a creatinine level of 1.77 mg/dL, and she was referred to our department. Hematuria and proteinuria were not found; therefore, she was allowed to continue the pregnancy while being followed for renal function. Renal biopsy was performed after delivery. Pathological examination revealed irregular renal tubular dilatation and atrophy associated with thickening, thinning, and disruption of the tubular basement membrane and diffuse fibrosis and cell infiltration in the interstitium. Based on these findings, nephronophthisis was suspected. Genetic analysis revealed complete homozygous deletion of NPHP1, and nephronophthisis was definitively diagnosed. Currently, the only curative treatment available for nephronophthisis is renal transplantation, and thus, symptomatic treatment for chronic kidney disease eventually becomes necessary. Because nephronophthisis lacks clear clinical symptoms, early diagnosis is difficult. Thus, if young patients present with renal impairment, a detailed examination is necessary to consider nephronophthisis in the differential diagnosis.
This is a case study on a 72-year-old man receiving continuous outpatient treatment since 2008 after a diagnosis of chronic renal failure due to diabetic nephropathy. In August 2010, he underwent pylorus-preserving pancreaticoduodenectomy for a middle bile duct carcinoma. He was transferred to our department at 39 days after surgery because of exacerbation of renal function, as well as prolonged ascites and anorexia after the surgery. The tests for malignant tumor, bacterial infection, tuberculosis, and ascitic fluid due to cirrhosis, done after his transfer, all showed negative results. Postoperative lymphorrhea was diagnosed on the basis of his clinical course and the feature of the ascites being similar to serum. Because the exacerbation of renal function was thought to be caused by a reduction of renal blood flow due to lymphorrhea, cell-free and concentrated ascites reinfusion therapy (CART) was performed for a total of two times. Consequently, the patient showed an increase in urine volume and improvement of renal function: creatinine was decreased to 1.99 mg/dL from 3.86 mg/dL. His course of ascites was observed conservatively with CART treatment, and the ascites gradually decreased and disappeared. We report a case that validates the usefulness of CART for treating exacerbation of chronic renal failure caused by lymphorrhea after surgery.
Background: Ulcerative colitis (UC) typically develops in the rectum and progresses proximally. Segmental UC is a rare condition that is often difficult to diagnose. We present a case of segmental UC mimicking colon cancer that developed in the transverse colon. Case presentation: An 83-year-old woman with abdominal pain visited our hospital. Total colonoscopy revealed a granular mass with stenosis in the transverse colon. Biopsy specimen showed infiltration of inflammatory cells. No mucosal inflammation was evident on the anal side of the colon and rectum. Abdominal computed tomography showed enhanced mural thicknening in the transverse colon. Enlarged regional lymph nodes were apparent. Although no malignancy was evident, cancerlike stenosis and swollen lymph nodes were identified, so colectomy with regional lymph node resection was performed. The resected specimen showed near-circumferential thicknening. Aggregated small polypoid lesions and a mucosal bridge were also revealed. Histological findings showed a wide range of crypt abscess. No cellular atypia was found. We finally diagnosed segmental UC. The patient was subsequently followed closely without treatment, and abdominal distension developed one and a half years later. Total colonoscopy showed mucosal redness and erosion in the residual transverse colon. Pharmacotherapy immediately improved symptoms. As of 10 years postoperatively, she has experienced no further recurrence. Conclusion:We encountered a rare case of segmental UC in the transverse colon. UC does not always develop from the rectum and progress towards the oral side. Early definitive diagnosis can achieve good results for treatment and the clinical course.
A case of 68-year-old woman. The patient was scheduled for laparoscopic transverse colectomy, due to early colorectal cancer diagnosis. Right after the surgery began, electrocardiogram showed a R-on-T phenomenon premature ventricular contraction leading to ventricular tachycardia and ventricular fibrillation. Although chest compression and electric defibrillation made the rate come back to sinus rhythm, we used emergency coronary angiography after halting the surgery since an elevation in ST segment had been confirmed in precordial leads on 12-lead electrocardiogram. As there was complete occlusion in left anterior descending coronary artery (LAD), the patient appeared to have a high-grade stenosis before surgery. Placing a stent on LAD, we carried out laparoscopic transverse colostomy once again at a later date. In this case, given that the coronary artery had had a high-grade stenosis before the surgery, it is highly likely that some kind of disruption in the myocardial oxygen balance caused myocardial ischemia, but that was difficult to predict by preoperative assessment. However, we successfully resuscitated the patient through swift and proper treatments and the case successful ended up being radical operation without any after effects thanks to a proper judgment made by cooperation between surgeons and internal cardiologists. (195 words)
Osteomyelitis pubis in athletes is very rare. This pathology is often confused with osteitis pubis, and delays in treatment may lead to residual sequelae. We encountered a case of osteomyelitis pubis in a 16-year-old high school soccer player. Despite early diagnosis, starting treatment, and subsidence of infection, the patient was unable to return to competitive sports. We report this case and discuss the relevant literature.
We report a case of Fournier's gangrene in a patient with underlying untreated diabetes. A 42-year-old woman noticed induration of the left vulva and was prescribed antibiotics by a local physician. However, symptoms were unimproved, so she was transferred for further evaluated in the Department of Obstetrics and Gynecology at our hospital. A soft tissue infection was suspected, and she was referred to our department. The patient had a temperature of 38.8°C, examination revealed erythema and swelling extending from the left vulva to the left medial thigh, and blood tests indicated a high degree of inflammation. Plain radiography showed gas formation in the left inguinal region, and magnetic resonance imaging (MRI) revealed necrotizing fasciitis. Fournier's gangrene was diagnosed, and emergency debridement was performed. The infection subsided with antibiotic therapy and repeated debridements. Fournier's gangrene can be fatal if diagnosed late. Early diagnosis by MRI, defining the extent of necrosis, and early debridement are useful. Negative pressure wound therapy (NPWT) was useful to treat the open wound after debridement.
The patient was a 54-year-old woman undergoing steroid treatment as a maintenance therapy of remission for minimal change nephrotic syndrome (MCNS). After pain appeared in her right-lower abdomen, an abdominal contrast computed tomography scan revealed thrombosis of the right ovarian vein. Laboratory evaluation on admission revealed proteinuria (3.5 g/ day) and decreased serum total protein (4.9 g/dL) and albumin (2.4 g/dL) levels, indicating nephrotic syndrome recurrence. Leukocyte and C-reactive protein levels were elevated; over 100 leukocytes/high power field were detected in the urine, and E. coli was detected in both blood and urine cultures, indicating septicemia due to pyelonephritis. The thrombosis disappeared after approximately 27 weeks of heparin and warfarin treatment. The MCNS recurrence was treated with an increased steroid dose; after about 6 weeks, the patient was negative for urinary protein. Her pyelonephritis improved with antibiotic treatment. The patient was discharged in good condition on day 55 after admission. When patients with nephrotic syndrome complain of abdominal pain, venous thrombosis in the abdominal cavity should be considered.
The aim of this study was to establish a method for observing vocal fold vibration using a transnasal flexible fiberoptic endoscope and a high-speed camera for clinical use. We assembled a high-speed digital imaging system with an ordinary flexible endoscope and a highly sensitive high-speed camera (HAD-D71; DITECT Corporation, Tokyo, Japan) with ISO 5,000,000. The camera had an 8-GB internal storage memory for video capture of up to 7.0 s with the usual setting of 640 × 480 pixels at 4000 fps. Using the nasal route, the system enabled us to observe vocal fold vibration during running speech with adequate brightness and good image quality. Our high-speed digital imaging system with a flexible endoscope can be a useful option to observe vocal fold vibration during running speech and is an alternative to difficult transoral rigid endoscopy in patients complaining of voice problems.