In a study of 29 cases of obturator hernia that we have experienced in our department from 2006 until 2016, the perioperative outcomes and therapeutic methods were retrospectively examined. The median patient age was 87 years, the median BMI was 16.7kg/m2, and the male-to-female ratio was 2：27. The majority of patients were thin, elderly females. In all the cases, the diagnosis was determined based on abdominal computed tomography (CT) findings, and the patients were treated by emergency surgery. The cases were divided into two groups：an intestinal resection group containing 13 patients, and a non-resection group containing 16 patients. The findings showed that in the intestinal resection group, the preoperative CRP levels were significantly higher, the period of time from the onset of disease until surgery was significantly longer, the incidence of postoperative complications was significantly higher, and the postoperative hospital stay was significantly longer. Next, the methods used for the repositioning of the incarcerated intestines were compared for 12 cases treated using the traction method and 9 cases treated using the water pressure method. Our findings showed that the rate of intestinal resections and the rate of intestinal injury during hernia reduction were lower in the water pressure method group. Our study suggested that early diagnosis and early surgery are important for preventing intestinal perforation and avoiding the resection of the incarcerated intestine, that the water pressure method offered more protection during the repositioning of the incarcerated intestine, and that it the water pressure method lead to a lower rate of intestinal resections as well as a better postoperative course.
The ethics committee of the “Japanese Society for Abdominal Emergency Medicine (JSAEM)” has created ethical guidelines for medical and health research. Members of this society should observe these guidelines when presenting research at official meetings and when contributing articles to the official journal. These guidelines consist of original ethical guidelines developed by this society, with clinical applications based on both the “Declaration of Helsinki” and the “Japanese Ethical Guidelines for Medical and Health Research Involving Human Subjects.” Clinical studies involving human subjects are divided into studies requiring ethical review, such as observational or interventional studies, and studies that do not require ethical review, such as case reports. With the permission of the facility president, opt─out and inclusion agreements were obtained as transition measures, limiting the need for this society to perform ethical reviews only for observational studies from institutions that do no have ethical committees.
A woman in her 50s who was suffering from intermittent abdominal pain was referred to our hospital. The presence of ileoileal intussusception was suspected based on a computed tomography scan. However, the abdominal pain improved by itself. A trans-anal double balloon enteroscopy revealed a tumor-like lesion covered with intestinal mucosa at 60cm proximal to the terminal ileum. Ulcer and redness were observed at the tip of the lesion. Based on these findings, the patient was diagnosed as having a recurrent ileoileal intussusception caused by an inverted Meckel's diverticulum. Elective laparoscopic surgery was scheduled. Intraoperatively, the orifice of the inverted Meckel's diverticulum was easily identified. Since a reduction of the inverted diverticulum was not possible, a partial ileal resection was performed. The histopathological findings revealed ectopic pancreatic and gastric tissue in the ulcerative part of the diverticulum. In the present case, a double balloon enteroscopy was useful for the differential diagnosis of intermittent abdominal pain. An appropriate diagnosis enabled an adequate preoperative evaluation and a less-invasive surgical treatment.
The patient was a man in his fifties who had suffered from schizophrenia for over 2 decades. He had been convinced that magnets would protect him, so he had been swallowing magnets for one month. He was admitted to our hospital complaining of abdominal pain. He had rebound tenderness across his entire abdomen. In addition, an abdominal X-ray showed a cluster of magnets and enlarged intestinal gas. He underwent an emergent operation for a perforation of the intestinal tract. A cluster of 55 magnets was found in the upper jejunum, consisting of 2 magnet groups and 3 holes in the jejunum. He underwent a partial resection of the jejunum. Postoperatively, he developed severe sepsis but recovered and was discharged from hospital 5 weeks later. Swallowing magnets results in various symptoms arising from internal fistulas through the intestinal tract, intestinal obstruction, and/or perforation. When a cluster of magnets is found in the gastrointestinal tract, it should be removed immediately before the case progresses to severe complications, as in the present case.
A 46-year-old woman was diagnosed as having a large bowel obstruction caused by sigmoid colon cancer. She went into cardiopulmonary arrest while undergoing conservative medical treatment with a trans-anal ileus tube. She was resuscitated by defibrillation, but remained in a coma. During therapeutic hypothermia, the tumor perforated. A Hartmann's operation was performed, and she recovered with no neurological damage. Metastatic tumors in the liver and lung were treated using surgery and chemotherapy, and she survived for 4 years and 8 months after the first operation.
Recently, the number of cases of lumbar hernia repaired using artificial materials has increased based on the concept of tension-free repair, as has been widely applied for inguinal hernia repair. Herein, we report the case of a superior lumbar hernia repaired using the ULTRAPRO plug(UPP). An 87-year-old woman complaining of a left lower back mass was referred to our hospital. On physical examination, a soft and painless mass, 7×5 cm in diameter, was confirmed in her left lower lumbar area. Manual reduction of the hernia content was possible. An abdominal computed tomography scan revealed that the descending colon had prolapsed into the extraperitoneal fat layer through a left lumbar muscle defect, which was diagnosed as a superior lumbar hernia. Operative findings revealed a hernia sac under the broadest muscle of back. The hernia orifice was confirmed as the superior lumbar triangle surrounded by the 12th rib, the serratus posterior inferior, the internal oblique muscle, and the quadratus lumborum muscle. The hernia orifice measured 3.5 cm in diameter. Hernia repair was performed using a UPP. The postoperative course was uneventful, and the patient was discharged on the 3rd post-operative day. The patient has been in good health without signs of recurrence for 2 years since the surgery. Because a partially absorbable soft mesh, such as a UPP, can be easily adjusted to the hernia orifice without causing postoperative pain, UPP appears to be useful for the repair of superior lumbar hernias.
We report two cases of Petersen's hernia occurring after a laparoscopy-assisted total gastrectomy (LATG). Case 1 was a 73-year-old man who had undergone an LATG for early gastric cancer 15 months prior to the development of a sudden abdominal pain. He was diagnosed as having an intestinal obstruction, and his severe condition necessitated emergency surgery. The intraoperative findings showed that almost all the small intestine had penetrated through a Petersen's defect (an unclosed meso-transverse orifice formed for the placement of the jejunum in a Roux-en-Y bypass), and torsion of the intestine was observed at the site, leading to the diagnosis of Petersen's hernia. The penetrating intestine was pulled out, and the Petersen's defect was closed with a suture. The patient recovered uneventfully and was discharged from hospital on postoperative day 7. Case 2 was a 68-year-old man who had undergone an LATG 24 months prior to the development of a severe abdominal pain and a visit to an outpatient clinic. The patient underwent an emergent celiotomy based on a diagnosis of strangulated ileus. The intraoperative findings showed a 1-m loop of the ileum impacted within a Petersen's defect and resulting in an intestinal obstruction (i.e., a Petersen's hernia). The involved intestine was pulled out, and the Petersen's defect was subsequently closed with a suture. The patient recovered uneventfully and was discharged on postoperative day 9.
A 61-year-old man visited our hospital with a three-week history of abdominal pain. An abdominal enhanced computed tomography examination revealed arterial bleeding as a localized accumulation of contrast material extravasation near the blood vessels of a dilated right gastroepiploic artery. A ruptured aneurysm of the right gastroepiploic artery was suspected. Abdominal angiography revealed multiple aneurysms of the right gastroepiploic artery. Although massive contrast extravasation was not demonstrated from the gastroepiploic artery, continuous bleeding was suspected. Transarterial embolization was performed, but hemostasis was not achieved. The ruptured aneurysm of the right gastroepiploic artery was resected, and the patient had an uneventful postoperative course. A histopathological examination revealed a ruptured aneurysm of the right gastroepiploic artery caused by segmental arterial mediolysis.
An 80-year-old man visited our hospital complaining of right lower quadrant abdominal pain and abdominal fullness. An abdominal CT examination showed a lobulated tumor 14 cm in diameter in the pelvic cavity. Endoscopy and irrigoscopy showed a compression phenomenon toward the sigmoid colon by the tumor. We diagnosed the patient as having subileus and performed an emergency operation. A pelvic tumor connected with the sigmoid colon and infiltrating the mesentery was found, so a partial resection of the sigmoid colon and small intestine was performed. Peritoneal disseminations were observed in the abdominal cavity and were removed. A pathological examination showed c-kit positivity, and high-risk gastrointestinal stromal tumor (GIST). GIST derived from the large intestine accounts for 5% of all GISTs. Thus, GIST derived from the colon is relatively rare. We report a case of GIST derived from the sigmoid colon that presented as subileus and describe the characteristics of GISTs derived from the colon.
A 53-year-old woman complained of epigastric discomfort after awakening, followed by abdominal pain and vomiting. She was admitted to our hospital as an emergency patient. Her abdominal findings were positive for muscular guarding and rebound tenderness, and an abdominal computed tomography examination was performed, suggesting strangulation of the small bowel. We performed an emergency laparotomy, and a mobile food lump was palpated in the jejunum at a point 140cm anal from the ligament of Treitz, with intestinal dilatation. A jejunotomy was placed on the food lump, which was identified as a jellyfish. Postoperatively, the patient was found to have boiled and eaten a dried jellyfish the day before the emergency procedure. Her postoperative course was unremarkable, and she was discharged on the 10th hospital day. Small bowel obstruction caused by food is relatively rare, and to the best of our knowledge, jellyfish has not been previously reported as a cause of small bowel obstruction.
A 79-year-old man was admitted for abdominal pain, nausea and vomiting；an enhanced computed tomography (CT) examination revealed superior mesenteric and portal vein thrombosis. Since the CT examination also showed thickened small-intestine walls and ascites, but not intestinal necrosis, conservative therapy was started systemically. Anticoagulation therapy using heparin relieved the symptoms and reduced the thrombus, but one month later, the patient vomited because of intestinal stenosis. An enterography showed cicatricial stenosis at the upper jejunum and an intestine-intestine fistula. He was discharged 52 days after admission.We then conducted a partial intestine resection with an end-to-end anastomosis.The postoperative course was uneventful, and no recurrence was seen after subsequent edoxaban therapy. Superior mesenteric vein thrombosis is a comparatively rare disease, but intestinal stenosis can sometimes occur with conservative therapy. We controlled the ileus conservatively and performed surgery electively.
Since the first report of their use in 1990, self─expandable metallic stents (SEMS) have been used to treat obstructive colorectal cancer. Numerous cases were treated with SEMS placement after SEMS treatment for obstructive colorectal cancer was included under the national insurance program in Japan. Since 2014, a total of 28 SEMS placements have been performed as “bridges to surgery” in our hospital, with technical and clinical success rates of 100% and 82％, respectively, and a complication rate of 7%. Twenty-five laparoscopic-assisted operations have also been performed. SEMS placement is considered a safe and feasible decompression method for the treatment of obstructive colorectal cancer.
The patient was an 81-year-old woman who had been diagnosed as having adult-onset Still’s disease and was taking oral steroids. She arrived at our hospital with chief complaints of abdominal pain and a fever of 38℃. An examination of blood samples showed a high-grade inflammatory reaction. Abdominal computed tomography findings were suggestive of a tumor in contact with the uterus within the pelvis, and air was observed in the bladder. A vesical fistula caused by the tumor was therefore suspected. No abnormal endometrial findings were observed, and lower gastrointestinal endoscopy findings did not lead to a diagnosis of cancer. The gastrointestinal contrast enema revealed the presence of rectovesical and rectoenteric fistulas. The diagnosis was challenging, but findings suggestive of an abscess in the posterior wall of the uterine cervix were observed on a pelvic MRI. White pus was drained after incision. HE stains showed filamentous gram-positive bacilli, leading to a diagnosis of actinomycosis. High-dose penicillin therapy was administered. We constructed an artificial anus to repetitive urinary tract infection. Here, we report a case of pelvic actinomycosis that was difficult to differentiate from a malignant tumor and presented with concomitant rectovesical and rectoenteric fistulas. We have also included a short discussion of the relevant medical literature in our report.
A septuagenarian male was diagnosed as having an acute superior mesenteric artery （SMA） embolism and was transferred to our hospital. About 2 days had passed since the onset of symptoms；however, no obvious signs of intestinal necrosis were present. The patient underwent an angiography that revealed the occlusion of the SMA by a thrombus in the truncus. The thrombus was injected with urokinase and was suctioned with an aspiration catheter. Intestinal blood flow was restored after the procedure, obviating the need for intestinal resection. Early diagnosis and endovascular treatment can lead to intestinal preservation in patients with SMA embolism.
A 25-year-old pregnant woman presented at the trauma center with an abdominal gunshot injury during her 6th month of pregnancy. On arrival, her consciousness level was clear, her blood pressure was 120/60mmHg, and her heart rate was 140/min. A gunshot entry wound was found in the epigastric region, and the omentum had prolapsed from the wound. A gunshot exit wound was found in the left subcostal region, and the small intestine had prolapsed from that wound. The abdomen was distended, and diffuse tenderness was detected. The fetal head was palpable under the abdominal wall. A fetal ultrasound examination revealed the arrest of the fetal heart. An emergency operation was performed under a diagnosis of uterine rupture caused by an abdominal gunshot injury. An exploration revealed a jejunal injury and a complete uterine rupture at the fundus site. The uterus was well contracted, and no active bleeding was detected. A partial jejunectomy was performed, and the ruptured uterine wall was repaired using double-layer suturing. Her postoperative course was uneventful, and the patient was discharged on the 7th postoperative day.
A 73-year-old female patient with an untreated and enlarging umbilical hernia for over 20 years experienced sudden, intense abdominal pain and was taken to an emergency department by ambulance. An umbilical mass with a diameter of 20 cm and a length of 10 cm was observed, and the presence of ischemia was assumed. An enhanced computed tomography examination showed an umbilical hernia with a prolapsed intestine and edematous ischemia-related changes in the small intestine in the abdominal cavity. Based on a diagnosis of strangulated ileus caused by the torsion of the small intestine and mesentery at the hernia orifice, emergency surgery was performed. In the hernia sac, the intestine was ischemic but not necrotic. In the abdominal cavity, 100 cm of the ileum was necrotic and was thought to have been segmentally perfused by the mesentery incarcerated at the hernia orifice. The necrotic intestine was resected, and an anastomosis was created. The hernia orifice was repaired by direct suturing of the muscle and fascia. The patient made steady progress and was discharged from hospital 11 days after the surgery.
A 76-year-old woman was admitted to our emergency center with back pain and nausea. She had undergone a laparoscopic distal gastrectomy with an antecolic Billroth Ⅱ reconstruction for gastric cancer two years previously. An abdominal computed tomographic scan revealed an internal hernia and volvulus of the efferent loop. Ascites were also observed. We performed an emergency operation. The intraoperative findings showed chylous ascites and torsion of the efferent loop into the space between the mesentery of the B-Ⅱ limbs and the transverse mesocolon. We released the strangulation of the efferent loop. Because the intestinal blood flow was good, we finished the operation without performing an intestinal resection. Internal hernia with chylous ascites after gastrectomy is rare, especially in cases with a Billroth Ⅱ reconstruction. Although an emergency operation is needed for the correction of an internal hernia and volvulus with ascites, the intestinal blood flow is often preserved if chylous ascites are observed. Thus, the presence of chylous ascites might be an indicator that intestinal resection is unnecessary.
A 66-year-old woman presented at the hospital complaining of fatigue, lower abdominal pain, and a neck pain that had begun one week previously. The patient was being treated with steroids for microscopic polyangiitis (MPA). Although the abdominal pain was slight and not severe, massive subcutaneous emphysema was observed from the neck to the precordia region. An investigational computed tomography examination was performed, revealing an abscess within the sigmoid mesocolon and emphysema within the retroperitoneum, mediastinum, and neck. An emergency operation was performed under a diagnosis of “perforated diverticulum of the sigmoid colon with severe retroperitoneal, mediastinal and cervical emphysema.” The clinical symptoms of intestinal perforations toward the retroperitoneum are much milder than those of perforations located toward the abdominal cavity, making them more difficult to discover and diagnose. In addition, the presently reported patient was a long-term steroid user because of her current condition (MPA), which might have alleviated the clinical symptoms to a level where a diagnosis was difficult.
Spontaneous bladder rupture is less common than traumatic bladder rupture, but its incidence reportedly increases with aging. We encountered a case of spontaneous bladder rupture in a 101-year-old man. The patient visited our emergency department because of vomiting and a prominent lower abdominal pain. A ruptured bladder was found on a computed tomography examination, and we diagnosed the patient as having a spontaneous bladder rupture. We repaired the wound through an emergency surgery and enforced cystostomy. The postoperative course was uneventful, and the patient was transferred to another hospital 22 days postoperatively. The cause of the bladder rupture was thought to be the patient’s advanced age and chronic urinary retention resulting from prostatic hypertrophy. Since Japan is an aging society, the incidence of spontaneous bladder rupture is expected to increase in the near future. Bladder rupture should be considered as a possible cause of abdominal pain in older adults.
A 44-year-old woman was examined in our hospital after complaining of vomiting and abdominal pain. An abdominal contrast-enhanced computed tomography examination revealed a dilated intestine and a right-displaced uterus in the pelvic cavity. A long tube was inserted to decompress the dilated intestine, but her symptoms did not improve. An abdominal plain CT examination after an intestine series using a long tube showed the stenosis of the intestine in the left region of the uterus. Laparoscopic surgery was performed, and the ileum was found to have herniated into a defect of the left broad ligament of the uterus. The intestine had adequate blood flow, and the intestine was released and the defect of the broad ligament of the uterus was sutured without resecting the intestine. The patient had an uncomplicated postoperative course. We experienced a relatively rare case of an internal hernia through a defect in the broad ligament of the uterus. Laparoscopic surgery after decompression of the dilated intestine was minimally invasive and useful.
An 87-year-old woman was admitted to our hospital because of acute heart failure and the exacerbation of chronic renal failure 3 months previously. She was found to have stenotic lesions in her coronary arteries, so a percutaneous coronary angioplasty was performed and anticoagulant therapy was started. Hemodialysis was also initiated for chronic renal failure. She was discharged 2 weeks later but was readmitted to our hospital with abdominal pain. An abdominal computed tomography scan showed free air and ascites. She was diagnosed as having a gastrointestinal perforation and an emergency operation was performed. Two sites of perforation and multiple ulcers were identified in the small intestine, and a partial resection of the small intestine was completed. On postoperative day 4, we histologically diagnosed the patient as having perforations of small intestinal ulcers caused by cholesterol crystal embolization (CCE). The next day, we performed low-density lipoprotein apheresis (LDL-A) and started steroid pulse therapy. The skin lesions associated with CCE improved temporarily, but she died on postoperative day 16 because of an anastomotic leak or a new perforation.
We report three cases of splenic abscess managed by conservative therapy with/without percutaneous drainage. The mortality rate of patients with splenic abscess is high, but splenic abscess can be treated non─surgically, depending on the cause of the abscess and the condition of the patient. However, close management is necessary, because approximately one─third of cases undergoing percutaneous drainage subsequently require a splenectomy.
A 66-year-old woman fell down the stairs and visited our hospital. Radiography revealed fractures in the right humerus and the 7th-9th left ribs；thus, she was admitted to the Department of Orthopedic Surgery. Surgery for the humerus fracture was performed on the 11th hospital day. On the 12th hospital day, the patient's blood pressure decreased suddenly, and a laboratory examination showed the progression of anemia. An abdominal computed tomography (CT) examination revealed a hematoma around the spleen and the extravasation of contrast medium into the intraperitoneal space. We also identified a delayed splenic rupture with hemorrhagic shock. We confirmed the bleeding point of the distal splenic artery using angiography and performed a transcatheter angiographic embolization. When the course of this case was reviewed, the abdominal CT findings obtained on the 3rd hospital day revealed an intrasplenic pseudoaneurysm that might have led to the delayed splenic rupture.
An 83-year-old man developed diarrhea and severe vomiting. He was admitted to our hospital after arriving by ambulance. A computed tomography (CT) examination revealed air bubbles in the gastric wall and hepatic portal venous gas. He had no tenderness with peritoneal signs, and his general condition was stable. He was treated conservatively. A CT examination performed on the following day did not reveal any air bubbles in the gastric wall or hepatic portal venous gas. An upper gastrointestinal endoscopy revealed diffuse edematous changes in the greater curvature of the stomach. A mucosal culture of the stomach was negative. The patient's course was good. He was discharged on the 10th day. We present a case of gastric emphysema with hepatic portal venous gas that was cured with conservative treatment and review the relevant medical literature.
We report a rare case of a 64-year-old male with rectal cancer causing Founier's gangrene and progressing to septic shock. The patient visited our hospital because of diarrhea and a poor appetite. He had a high fever, and his blood data indicated a high level of inflammation. His perineum and inguinal region were remarkably swollen, and it had a grasping snow sign. A CT examination showed a widespread pneumoderma from his right femur to his trunk. A CT examination also revealed an irregular wall thickness in the rectum. A colonoscopic examination showed stenosis of the rectum as a result of a type 2 tumor. The pathological diagnosis of a biopsy specimen was adenocarcinoma. We diagnosed the patient as having rectal cancer causing Fournier's gangrene and progressing to septic shock. After intensive care for severe septic shock including the extended drainage of the gangrenous region and antibiotic therapy for 17 days, we performed an abdominoperineal resection. He was discharged without any complications at 21 days after the operation.
We report a case of mesenteric hernia of the ileum in an adult. The patient was a 54-year-old woman who presented with abdominal pain. Mild tenderness and mild rebound tenderness were observed in the abdomen. A whirl sign and ascites, with no enhancement in a section of the small bowel, were observed using abdominal computed tomography. Strangulation ileus was suspected, and an emergency operation was performed. A 100-cm length of the ileocolic segment was herniated through a small 3-cm mesenteric defect, which was located in the mesoileum. The necrotic ileum was resected. The postoperative course was uncomplicated, and the patient was discharged on postoperative day 10. Transmesenteric internal hernias in elderly patients are rare but should be considered during differential diagnosis to enable an immediate emergency operation, if necessary.
We report the surgical treatment of a 34-year-old woman with a rectal impalement injury. The injury occurred while she was taking a walk. While attempting to jump over a 1-meter-high garden plant, she fell and a branch pierced her right buttock. She visited her local doctor, who noticed blood and feces within the wound and suspected an intestinal injury. The woman was transported to our hospital in an emergency vehicle；upon admission, a 3-cm-diameter open wound was noted at 9 o’clock on her right buttock. A hematoma was observed, and the skin was stained with feces. Contrast-enhanced abdominal computed tomography revealed parenteral emphysema. There was no abdominal free air. Parenteral extravasation of the contrast agent was noted upon irrigoscopy. Under a diagnosis of traumatic rectal impalement injury, we performed emergency surgery. We identified the injured portion of the lower rectum anoscopically. We drained and debrided the area before closing the wound using simple sutures. The post-operative course was good, and the patient was discharged on post-operative day 19. Impalement injury is a penetration injury caused by a blunt-tipped object. Our experience illustrates the importance of early diagnosis and thorough surgical planning, even for emergency surgery, in cases with perineal impalement injuries.
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