We analyzed the clinical characteristics of 96 patients with colorectal perforation who underwent emergency surgery at our hospital between January 2008 and December 2015. Of the total, 11 patients died during hospitalization and 10 patients (10.4%) died of complications associated with the acute clinical state. We also analyzed the preoperative prognostic factors. Multivariate analysis identified preoperative PLT<100,000/μL, preoperative hemodialysis and preoperative shock as independent adverse prognostic factors. The SOFA score was significantly higher in the non-survivor group than in the survivor group. A comparison of the SOFA parameters showed that the preoperative coagulation, cardiovascular and renal scores were significantly higher in the non-survivor group than in the survivor group. Colorectal perforation is often associated with poor outcomes；therefore, early detection of patients with a poor predicted prognosis and prompt intensive treatment are important.
The concept of interval appendectomy (IA) has become popular as an elective surgical strategy for acute appendicitis, because it is less invasive, is associated with fewer postoperative complications, and is cosmetically advantageous. Although IA is performed after the inflammation has subsided with conservative initial treatment in the acute stage, it is still under debate as to which approach, emergent or interval appendectomy, is the better treatment strategy for patients with acute appendicitis. The aim of this study was to conduct a retrospective comparison of the clinical data of patients who had undergone laparoscopic IA (LIA, n=37) and those who had undergone laparoscopic emergency appendectomy (LEA, n=13), and to establish a new scoring system IA scoring system to predict the potential success of LIA. The WBC count and serum CRP were significantly lower in the LIA group (P=0.004 and 0.020), whereas the pelvic abscess cavity size, intestinal ectasia and ascites were significantly more severe in the LEA group (P=0.007, 0.023 and 0.022). Logistic regression analysis was performed using the above five factors, and a scoring system to predict the potential success of LIA was established using each regression coefficient with approximate proportion (WBC count: 0 or 2 points; serum CRP and intestinal ectasia: 0-1 point; abscess cavity: 0-2 points; and ascites: 0-3 points). An IA score of ≤4 was associated with a 91.9% of sensitivity, 90.9% of specificity and 91.7% of accuracy for potentially successful LIA.
There has been much debate about the indications for damage control surgery (DCS). We analyzed the data of trauma patients who underwent laparotomy from the Japan Trauma Data Bank, and discovered many differences in the vital signs on arrival at the ER between the DCS group (n=532) and the no -DCS group (n=3915). The positivity rate of FAST, the blood transfusion rate, and the mortality rate were also significantly different between the groups. Logistic regression analysis identified the heart rate, level of consciousness, body temperature and injury mechanism as independent predictors of DCS. By categorizing and weighting of these predictors, we developed a prediction score for DCS, named the damage control indication detecting score (DECIDE score). The DECIDE score consists of three predictors (body temperature, level of consciousness and injury mechanism) and was found to be correlated with the mortality. With a cutoff value of the score of 5, the mortality rate, sensitivity and specificity were calculated to be 30.8%, 64.8% and 70.0%, respectively. The DECIDE scale enables prediction of DCS in the pre -hospital condition also, because only physical findings and clinical information are needed to calculate the score. Further validation study is warranted for the DECIDE score.
<Method> We classified a total of 150 patients with splenic trauma who had undergone treatment at our institution over the past 29 years into 3 groups according to the management strategy: G-Ⅰ, consisting of 40 cases (1988-1995: principally laparotomized), G-Ⅱ, consisting of 41 cases (1996-2002: aggressive transcatheter arterial embolization (TAE)), and G-Ⅲ, consisting of 69 cases (2003-2016: early laparotomy intended at salvage surgery). The validity of the strategy in each group was judged by the rate of success and the splenic salvage rate. <Results> Conversion of the management strategy was required in 7, 17 and 9% of patients in G-Ⅰ, G-Ⅱ and G-Ⅲ, respectively. In G-Ⅱ, 5 of the 11 patients who had been treated by TAE as the initial management strategy subsequently required total splenectomy. All of these 5 cases showed extrasplenic extravasation of contrast on the initial CT. Moreover, among all the 11 patients, one patient needed continuous epidural anesthesia for pain control, and another patient required readmission for splenic infarction, abscess and pleural effusion. In G-Ⅲ, early laparotomy was adopted for cases who showed hemodynamic instability and extrasplenic extravasation on CT. The splenic salvage rate in G-Ⅰ, G-Ⅱ and G-Ⅲ were 43, 51 and 78%, respectively. <Conclusion> The present strategy performed in G-Ⅲ can lower the strategy conversion rate and yield the highest splenic salvage rate, in my experience.
【Introduction】Damage control surgery (DCS) has played a key role in recent management of traumatic massive hemoperitoneum (tMH), but advances in medical technology enable primary hemostasis for tMH.【Methods】We retrospectively reviewed the data of patients who underwent laparotomy for tMH with hemodynamic instability from 2006 to 2015. We classified the cases treated before the last case of gauze packing (until September 2012) as the previous group, and the subsequently treated cases as the latter group.【Results】There were a total of 94 cases in the previous group and a total of 35 cases in the latter group. There were no significant differences in the age, ISS, injured organs, injury-to-start of laparotomy time or operative time between the two groups. The preoperative CT performance rate was high in both groups. The mortality rate was significantly lower in the latter group.【Conclusion】The results confirmed the validity of the strategy directed towards mandatory preoperative CT and primary definitive hemostasis for tMH with hemodynamic instability.
Our strategy for the treatment of hemorrhagic shock associated with abdominal organ injuries is as follows. If the patient is hemodynamically stable and a suitable candidate for enhanced CT, it is possible to take into account the findings of angiography and TAE. If the patient is hemodynamically unstable, or has gradually worsening hemorrhage, it is an absolute indication for Damage Control Surgery (DCS), and an ER laparotomy should be scheduled as soon as possible. Our three years’ experience of trauma laparotomy includes 104 cases, of which 42 underwent DCS. We conducted a retrospective analysis of the vital signs, management strategy, time management, and outcomes of these cases. The RTS was significantly lower, the ISS significantly higher, and the Ps significantly lower in the cases that had undergone DCS than in those in which DCS had not been performed. The most severe trauma group in our experience was the group of “Damage Control Resuscitation (DCR) with DCS” cases. The urgency was greater, the time duration from ER arrival to laparotomy was shorter, and the severity was greater in the ERL group than in the ORL group, although there were no significant differences among the groups. There were 8 unexpected survivors during this period, including 4 cases of aortic cross clamp for impending cardiac arrest. Our strategy for severe abdominal injury was properly complied with, and our clinical outcomes could be considered as acceptable.
There has been a significant shift to non─operative management (NOM) in the management of abdominal trauma patients requiring hemostasis control of hemorrhage, however, NOM is not always possible in all cases, and the choice of therapeutic intervention is important. With a view to identifying any problematic issues in our strategies for hemostasis the control of hemorrhage, we investigated the data of abdominal trauma patients who required hemostasis. Methods：The data of all intraabdominal hemostasis patients who were admitted to our institute intraabdominal trauma patients admitted to our institute who underwent interventions for hemostasis between January 2006 and June 2013 were retrospectively reviewed. Results：Of the 84 patients who required hemostasis, 8 patients (9.5%) died. Of the 59 patients who required intraabdominal hemostasis alone, 2 patients (3.4%) who underwent surgery alone died, and all patients who were treated by transcatheter arterial embolization (TAE) survived. In all, 18 patients required pelvic hemostasis, of whom 5 (27.8%) died, the mortality rate in this group being significantly higher than that in the other groups. Conclusion：Control of pelvic hemorrhage is of critical importance in the management of abdominal trauma patients.
[Background] Computed tomography (CT) and transcatheter arterial embolization (TAE) are useful in patients with blunt abdominal trauma. [Purpose] The aim of this study was to investigate the adaptation and limitations of TAE according to the CT findings. [Materials and Methods] We enrolled and retrospectively reviewed the data of all the patients who were diagnosed with liver injury between 2011 and 2015. The patients were classified according to the guidelines of the Japanese Association for the Surgery of Trauma. In addition, they were also classified according to whether extravasation of the contrast medium was seen on CT or not. Variations in the initial treatment and the success rate were clarified. [Results] Among the 50 cases of liver injury, 33 were non-operatively managed, with any additional treatment provided as required. Fourteen patients underwent TAE, and two among them underwent laparotomy after the TAE：one for abdominal compartment syndrome (ACS) and one for hemodynamic instability. Furthermore, two patients were treated by planned surgery plus TAE. [Discussion] Adoption of TAE is useful in patients showing extravasation of the contrast medium on CT, but the decision to convert TAE to operative management because of ACS or hemodynamic instability should not be delayed.
Blunt pelvic trauma is a severe condition that is often associated with massive hemorrhage and high mortality and morbidity rates. Pelvic radiographic imaging is a useful screening tool to rapidly determine the need for immediate intervention. Computed tomography is the mainstay for assessing pelvic fractures and retroperitoneal hematomas. Multimodality therapies, including external pelvic stabilization, transcatheter arterial embolization and extra─peritoneal pelvic packing are useful adjunctive procedures that require appropriately trained and immediately available personnel. Transcatheter arterial embolization has advanced remarkably. The clinical usefulness of this procedure for the control of traumatic bleeding is now well established. It is important to have a sound understanding of the diagnostic and treatment strategies for pelvic trauma. This review article focuses on the radiologic findings and technical aspects of emergent interventional radiology for pelvic trauma.
A 90-year-old male with the chief compliant of abdominal pain was referred to our hospital. Abdominal contrast-enhanced CT revealed extensive dilatation of the small intestine with poor enhancement, a positive whirl sign, and massive ascites. Under the presumed diagnosis of strangulated ileus, we performed emergency laparotomy. Strangulation due to knotting between two loops of the small intestine was confirmed intraoperatively. We performed resection of the involved small intestinal segments after first unknotting the knotted intestines. The residual length of the small intestine was approximately 300 cm. The postoperative course of the patient was uneventful and he was transferred to receive rehabilitation on the 19th postoperative day. In the majority of cases of the intestinal knot syndrome, the knotting occurs between the ileum and the sigmoid colon. Herein, we report a very rare case of an ileoileal-type intestinal knot syndrome (true knot).
We report a rare case of recurrent abdominal bleeding from a mesenteric hematoma. A 61-year-old man was referred to our hospital with abdominal pain and vomiting, and the patient went into sudden shock during a physical examination. Initial CT showed abdominal hemorrhage with a mesenteric hematoma. Emergency laparotomy revealed a ruptured mesenteric hematoma with abdominal bleeding. We excised the mesentery with the hematoma and the jejunum. About 30 hours after the surgery, the patient went into shock again. Abdominal CT showed another new hematoma, which was suspected as having been caused by postoperative bleeding. However, re-operation revealed a new hematoma in the mesentery of the descending colon, which was not found in the previous surgery, which was treated by left hemicolectomy. There was no evidence of any factors predisposing to hemorrhage in the patient, such as trauma, arteriopathy, coagulopathy, etc. Therefore, we diagnosed the patient as a case of spontaneous mesenteric hematoma. Although spontaneous mesenteric hematoma is a rare disease of unknown etiology, there has been no report of recurrence in the literature. This case report, of a patient who developed a recurrent spontaneous mesenteric hematoma, is the first report in Japan.
A 76-year-old woman with a 2-month history of lower abdominal discomfort and nebulous urine presented to us with melena of sudden onset and was admitted to our hospital. Abdominal CT showed multiple diverticula and a 30-mm linear hyperdensity in the sigmoid colon. The CT scan also showed fistula formation between the sigmoid colon and the urinary bladder. We diagnosed the patient as having colovesical fistula caused by diverticulitis of the sigmoid colon and performed resection of the sigmoid colon with partial resection of the urinary bladder. The perforation site in the sigmoid colon was identified and abscess formation around the perforation was confirmed. In addition, a 30-mm-long fish bone was also identified in the bowel lumen at the site of perforation. The patient’s postoperative course was uneventful, and she was discharged on the 11th postoperative day. Colovesical fistula caused by a fish bone is rare, and we report our case with a discussion of the literature.
A 41-year-old woman visited a local doctor with the chief complaint of massive melena. Upper and lower gastrointestinal endoscopy as well as abdominal computed tomography failed to reveal the source of the bleeding. Therefore, she was transferred to our hospital for more detailed evaluation. A double-balloon endoscopy was performed under the suspicion of small intestinal hemorrhage, which revealed a minute submucosal tumor with a visible vessel was observed in the middle part of the ileum. After tattooing, laparoscopy-assisted partial resection of the small intestine was performed. Immunohistopathological analysis of the resected tissue revealed that the tumor was a leiomyoma of the small intestine. While preoperative diagnosis of the source of hemorrhage from the small intestine is thought to be difficult, some cases of successful preoperative diagnosis have been reported in recent years because of the popularization of double-balloon endoscopy and capsule endoscopy. We report a case of leiomyoma of the small intestine, that was successfully identified by double-balloon endoscopy；the tumor was subsequently resected by laparoscopic surgery.
A 90-year-old woman with suspected sigmoid colon cancer and multiple liver metastases was referred to our hospital. Lower gastrointestinal endoscopy showed advanced type-2 circumferential cancer in the sigmoid colon. The endoscope could not be passed further up, and CT revealed multiple liver metastases. Therefore, a colonic stent (Wallflex metallic stent, 22 mm×9 mm) was inserted for symptomatic relief. Three days after the stent insertion, the patient developed nausea and abdominal pain. CT showed free air and ascites in the abdominal cavity, suggesting gastrointestinal perforation. Therefore, emergency surgery was performed. At the surgery, it was noticed that the intestinal wall at the proximal and distal ends of the stent had become thin and perforated. We considered that the sigmoid colon cancer had invaded and adhered to the small intestinal mesentery and curved, and the axial force exerted by the stent expansion caused sigmoid colon perforation at the stent end. The bending and reduced mobility of the bowel due to the invasion of adjacent organs by the cancer were considered to be probably responsible for the delayed perforation. Thus, the possibility of such a complication should be kept in mind when placing a colonic stent.
A 64-year-old female patient presenting to us with the complaint of abdominal pain after she sustained blunt abdominal trauma was admitted to our hospital. Abdominal CT revealed bilateral cystic tumors with fatty deposits and calcification in the peritoneal cavity. The bulky tumor in the right ovary appeared to have collapsed, and rupture of the tumor capsule was suspected. The sebaceous material that had spilled out of the tumor was considered. It was suspected that sebaceous material had spilled out of the tumor into the abdominal cavity. Emergency surgery was performed under the diagnosis of chemical peritonitis caused by rupture of a mature cystic teratoma, and the patient recovered. Histopathological examination of the resected specimen revealed a mature cystic teratoma with malignant transformation to squamous cell carcinoma. Rupture of an ovarian tumor following abdominal trauma is rare. Hence, we report this case, in which the typical CT findings enabled us to make an accurate diagnosis, together with some reference to the literature.
Blunt isolated pancreatic injury is relatively rare. We report our use of the Letton-Wilson procedure for isolated pancreatic injury in two cases. Case 1: A 17-year-old man sustained blunt injury in the epigastric region while playing basketball. The patient presented on the day after the injury with worsening abdominal pain. Abdominal CT showed a low-density area in the pancreatic body. The findings of ERP led to the diagnosis of Type Ⅲ pancreatic injury, and emergency surgery was performed. At surgery, complete rupture of the pancreatic parenchyma ventral to the portal vein was observed. We performed the Letton-Wilson procedure to preserve the pancreas, because the patient was young and otherwise healthy. Case 2: A 22-year-old man sustained blunt abdominal injury when he collided with another player during a baseball game. The patient was diagnosed as having sustained Type Ⅲb pancreatic injury by abdominal CT and ERP, and emergency surgery was performed. This patient was also found, like Case 1, to have complete rupture of the pancreatic parenchyma. We reconstructed the pancreas by the Letton-Wilson procedure. Both patients were discharged after the wounds healed, without any serious complications. It is necessary to choose the appropriate operative procedure in each individual case of pancreatic injury. When a patient is young and the pancreas can be expected to be preserved, the Letton-Wilson procedure may be considered as the appropriate operative procedure.
Acute arterial occlusion of the extremities usually manifests with symptoms of ischemia, namely, pain, pallor and paralysis. We encountered a case of blunt abdominal trauma without symptoms of ischemia of the lower extremities, and could not diagnose occlusion of the iliac artery by the initial reading of the whole-body CT. A 55-year-old man was transported to our hospital with a history of having sustained blunt abdominal trauma. On presentation to our hospital, examination revealed severe abdominal tenderness, but no signs of ischemia of the lower extremities. We detected intra-peritoneal bleeding and bowel perforation on the initial CT, and performed emergent laparotomy. At laparotomy, occlusion of the left iliac artery was detected, and revascularization was performed. Systematic CT interpretation has been shown to be necessary to prevent missed injuries, and to provide the right therapeutic intervention at the right time. Good intra-hospital teamwork, like in the case shown, is also necessary for trauma care. The “Three-step evaluation of trauma pan-scan, starting with Focused Assessment with CT for Trauma (FACT)” is valuable obtaining information efficiently from the initial CT reading in trauma care.
A 83-year-old man visited our emergency room complaining of right lower abdominal pain. Physical examination revealed tenderness in the right lower abdomen. Abdominal enhanced CT revealed cystic dilatation of the appendix to 50×32 mm. The patient was diagnosed as having a mucocele of the appendix or gangrenous appendicitis, and emergency operation was performed. At laparotomy, the appendix was found to be swollen, necrotic, and twisted clockwise by about 720 degrees at its root. Appendectomy was performed after releasing the torsion. The resected specimen showed the appendix to be filled with mucin. The histopathological diagnosis was low grade appendiceal mucinous neoplasm. The patient’s postoperative course was generally uneventful.
A 74-year-old man diagnosed as having rectal cancer with multiple liver and lymph node metastases underwent Miles operation. On postoperative day 4, we recognized sanguineous drainage and abdominal CT showed intraperitoneal bleeding and extravasation of contrast material to intraperitoneal cavity. We made the diagnosis rupture of hepatic metastasis and intraperitoneal bleeding. Emergency TAE was performed, and no further intraperitoneal bleeding was recognized. Rupture of metastatic hepatic tumors, especially of digestive tract origin, is rare as compared to rupture of hepatic cell carcinoma, because of their avascularity and hard capsule. We report a first case of a Ours is the first report of rupture of a hepatic metastasis from rectal cancer colorectal liver metastasis. In this particular case, we suspected that the rupture was caused by severed vessels or rupture of the capsule associated with rapid growth and increased internal pressure of the tumor.
We report the case of a patient with a hepatic artery pseudo-aneurysm secondary to a liver abscess. A 60-year-old man presented to us with the chief complaint of anorexia. On admission, abdominal computed tomography revealed multiple liver abscesses. The patient was treated with intravenous antibiotics and recovered uneventfully. Two weeks later, enhanced computed tomography showed a hepatic artery aneurysm measuring 20 mm in diameter in a branch of the right hepatic artery in segment 6. Emergency percutaneous trans-arterial embolization with steel coils was successfully performed. The patient recovered and was discharged from the hospital on day 14 after the intervention. Attention should be paid to the possible occurrence of a hepatic artery pseudo-aneurysm secondary to liver abscess, even if the patient’s clinical course is uneventful.
A 36-year-old woman was referred to our hospital for further examination of a liver tumor. Abdominal contrast-enhanced CT and ultrasound revealed a mass approximately 50 mm in size in the S4 segment of the liver that was suspected to be a hepatocellular adenoma, although the possibility of hepatocellular carcinoma could not be ruled out. Immediately after these examinations, the patient developed high grade fever （39℃） that persisted for several days. The fever did not improve with conservative treatment, while the tumor also continued to increase in size. Partial hepatectomy was performed for both diagnostic and therapeutic purposes. Histopathological examination revealed the diagnosis of inflammatory pseudotumor. The fever resolved immediately after the surgery, the patient's subsequent course was uneventful, and she was discharged six days after the surgery. Inflammatory pseudotumor of the liver is a benign lesion with no characteristic imaging findings, and is frequently difficult to diagnose. In cases such as this one, in which a tumor is believed to be benign but biopsy is not feasible, the mass is found to be growing rapidly, and the patient is symptomatic, surgery for diagnosis and therapy is an option that should be considered.
A 63-year-old male with epigastric pain was diagnosed as having severe acute pancreatitis (CT grade 2) and hospitalized. On the 6th hospital day, the intra-abdominal pressure increased to 25 mmHg and the patient was diagnosed as having Abdominal Compartment Syndrome (ACS). Subcutaneous anterior abdominal fasciotomy was performed, with dissection between the posterior rectus abdominal sheath and the peritoneum. Thereafter, the pressure decreased to 11 mmHg and open abdominal management (OAM) with vacuum packing closure was started. On the 18th postoperative day, we applied a combination of the bilateral anterior rectus abdominal sheath turnover flap method and the components separation method (CSM) for repairing the fascia defect, which was 200 mm in length and 90 mm in width. On the 2nd postoperative day, a part of the skin became necrotic due to the tension of the suture, however, the patient did not develop recurrent ACS or ventral hernia. Use of a combination of the bilateral anterior rectus abdominal sheath turnover flap method and the CSM has not been reported before for abdominal closure after OAM reported, but proved effective in our case.
An 86-year-old man with a one-month history of right lower abdominal pain and fever, visited our hospital because of persistent anorexia. Although abdominal CT suggested the presence of an appendiceal mass, the patient was considered as a suitable candidate for interval laparoscopic appendectomy （ILA） after detailed examination, because of the possibility of a neoplasm. Then, 11 days later, he visited our hospital again with fever. Laboratory tests showed liver dysfunction and increased levels of inflammatory markers. Abdominal CT showed a liver abscess located in segment 6, therefore, we treated the liver abscess before treating the appendicitis. ILA was performed after improvement of the inflammatory reaction. Nowadays, liver abscess secondary to appendicitis caused by transmission of infection through the portal system is rare. Herein, we report a case of liver abscess detected during the course of observation of an appendiceal mass prior to interval appendectomy.
We report a case of acute perforated peritonitis secondary to rupture of a pyometra associated with a rectovaginal fistula. A 72-year-old woman who had been under follow-up for a rectovaginal fistula with pyometra caused by insertion of a pessary was admitted to our hospital with the complaint of abdominal pain. Physical examination revealed tenderness and muscle guarding in the lower abdomen. Transvaginal US examination revealed a fluid-filled uterus. CT examination showed ascites and a distended fluid-filled uterus. In addition, free air was detected in the abdominal and uterine cavities. We diagnosed the patient as a case of acute perforated peritonitis and performed emergency laparotomy. At laparotomy, a perforation was found in the anterior wall of the uterine body. Therefore, total abdominal hysterectomy, bilateral salpingo-oophorectomy and resection of the rectovaginal fistula were performed. In elderly female patients, peritonitis caused by rupture of a pyometra should be considered in the differential diagnosis of acute abdomen.
A 26-year-old woman with a history of anorexia, abdominal pain and fever on day 4 of menstruation was referred to our hospital. She had a history of sometimes experiencing right lower abdominal pain with menstruation. An abdominal ultrasound and computed tomography revealed enlargement of the appendix. We performed appendectomy under the assumed diagnosis of acute appendicitis. Macroscopic examination of the resected specimen revealed partial enlargement and induration in the distal part of the appendix. On histopathological examination, endometrial tissue was found in the muscular and subserosal layers. On the basis of these findings, a diagnosis of acute appendicitis with endometriosis of the appendix was made. It was presumed that the thickened endometrial tissue had caused luminal obstruction of the appendix. The patient's right lower abdominal pain resolved after the surgery, and no recurrence of the endometriosis was observed at the 12 -month follow -up after the operation. Appendiceal endometriosis is a rare disorder characterized by enlargement and induration or flexion of the appendix in its distal part. Histopathological examination is important for its diagnosis. Here, we present this rare case, together with a review of the literature.
A 64-year-old man was admitted to the hospital with abdominal distension. Laboratory examination revealed elevation in the levels of the inflammatory markers. Abdominal CT revealed a high-density line-like structure in the horizontal portion of the duodenum, and air around the mesentery of the jejunum. As the patient gave a history of having consumed fish, we made the diagnosis of a fish bone penetrating the horizontal portion of the duodenum. Emergency upper GI endoscopy revealed the fish bone. We introduced a stomach tube into the horizontal portion of the duodenum under fluoroscopic guidance, and performed continuous suction. The patient was discharged from the hospital after 12 days. Penetration of the duodenum by a fish bone is rare. Only 25 cases of perforation/penetration of the duodenum by a fish bone have been reported in the Japanese literature； furthermore, only 8 cases of penetration of the horizontal portion of the duodenum have been reported. Ours is the only one of these patients who recovered with conservative treatment alone. Endoscopic extraction and continuous suction with a stomach tube were useful.
A 49-year-old woman presented to us with a 10-year history of recurrent lower abdominal pain associated with right thigh pain, and was diagnosed as having right-sided sciatica. She was admitted to our hospital with severe abdominal pain and right-sided sciatica. Digital rectal examination suggested the presence of an extrinsic rectal tumor associated with the sciatica. Computed tomography (CT) revealed herniation of the small intestine through the sciatic foramen. On the basis of these findings, we made the diagnosis of bowel obstruction due to incarcerated sciatic hernia, and performed emergency operation. The small intestine was incarcerated into the right sciatic foramen, as a Richter's hernia. The incarcerated intestine was manually repositioned. Ileal resection was not needed as the bowel was viable, and the foramen defect was repaired directly by suturing the right ovary. After the operation, the lower abdominal pain with the right-sided sciatica disappeared altogether. Sciatic hernia is rare, and entrapment of the sciatic nerve is unusual. Although CT may provide a diagnosis of sciatic hernia, digital rectal examination may be useful for suspecting the diagnosis in patients presenting with abdominal pain associated with chronic thigh pain.
We report a case of vaginal cuff dehiscence developing after total vaginal hysterectomy. The patient was a 71─year─old woman who had been treated by total vaginal hysterectomy for prolapse of the uterus. Nine months later, she presented with vaginal dehiscence, and emergency laparotomy was performed. We reduced the eviscerated small intestine into the peritoneal cavity and closed the dehiscent vaginal cuff. Six months later, the patient presented again with recurrent vaginal dehiscence, which necessitated another emergency laparotomy. We speculated that the recurrent vaginal cuff dehiscence in this patient may be due to the steroid and methotrexate treatment that she was receiving. Vaginal cuff dehiscence is rare complication, however, patients undergoing vaginal hysterectomy should be carefully followed up, especially those receiving steroid therapy.
The patient was an 83-year-old man, who was admitted with the complaint of bloody bowel discharge. CT revealed a giant colonic diverticulum in the ascending colon measuring 50 mm in diameter. The patient improved with conservative treatment instituted for diverticular bleeding. One year later, the patient presented with a history of abdominal pain. CT revealed free air in the abdominal cavity and a giant colonic diverticulum measuring 67 mm×50 mm in size with inflammatory changes. Emergency surgery was performed under the diagnosis of perforation of a giant diverticulum in the ascending colon. Right hemicolectomy was performed. Examination of the resected specimen revealed the diverticulum measuring 65×72 mm in external diameters; it also contained a huge fecalith. Histopathologic examination revealed the lack of a proper muscle layer in the diverticulum. The patient was discharged on the 13th day after the surgery, after an uneventful postoperative course. Giant diverticulum of the colon is a relatively rare disease, and is associated with a risk of perforation and intraperitoneal abscess formation. When we compared an emergency surgical group with an elective surgical group reported in the Japanese literature, the mortality and complication rates were higher in the emergency surgical group. We believe that elective operation is desirable for patients who can tolerate surgery.