We examined the efficacy of endoscopic band ligation(EBL), as compared to the clip method, for the treatment of colonic diverticular hemorrhage. Colonic diverticular hemorrhage was defined as evidence of active bleeding or a visible nonbleeding vessel in a diverticulum on endoscopy. A total of 37 patients were treated by EBL (EBL group) and 11 patients by the clip method(Clip group). The rate of transfusion was 37.8% in the EBL group and 54.5% in the Clip group. The duration of hospitalization was 6.6 days in the EBL group and 11.5 days in the Clip group. On follow-up endoscopy, the rate of disappearance of the diverticulum was 81% in the EBL group. Rebleeding occurred in 2 patients(5.4%) of the EBL group and 4 patients(36.4%) of the Clip group. The hospitalization cost was 375,570 yen per patient in the EBL group and 617,060 yen per patient in the Clip group. The rebleeding rate was low due to the disappearance of the diverticulum in the EBL group, and the medical costs were reduced by the shorter duration of hospitalization. Thus, EBL may be the treatment procedure of first choice for colonic diverticular hemorrhage.
[Introduction] The disadvantage of laparoscopic appendectomy is that it is a complicated method requiring a complete set of endoscopic surgical equipment. In order to establish a stylized method based on the idea that “simple is best”, we have introduced laparoscopic surgery, as a general rule, for all cases since 2013. ［Surgical Methods］The surgery is performed by two surgeons；a young surgeon as the operator and supervisor surgeon as the assistant. A three-port surgical procedure, involving the insertion of a 12-mm port from the umbilicus along with 5-mm ports from the midline of the lower abdomen and upper right abdomen, is adopted. The appendicular root is dissected using an ultrasonic incision and coagulation instrument after ligation with an endoloop. Since this is a simple method, we believe that it is applicable to all cases. As a further contrivance, the dissected appendix is collected using a cleaning method utilizing a uniquely devised string-attached retrieval bag, a catheter chip, and a 5-mm port, enabling performance of an effective massive lavage within a short period of time. ［Conclusion］Laparoscopic appendectomies were introduced to general municipal hospitals with only standard facilities by devising simple surgical methods.
Herein, we review the data of 14 cases of intestinal perforation caused by seatbelt injury sustained in a road traffic accident. Our subjects consisted of 11 men and 3 women, with an average age of 49 years. In all the cases, the accident occurred while the patient was riding in a four-wheeled vehicle；in all the cases, the subjects wore a seatbelt. The“seatbelt sign” was recognized in 10 of the patients. Five of the patients were in shock at the time of arrival at the hospital because of abdominal hemorrhage caused by mesenteric vessel injury. Two cases developed delayed perforation. We could not detect free-air in the abdominal cavity on the computed-tomographic (CT) images in these two cases. All the patients required open surgery. Five patients were diagnosed as having a single intestinal perforation, while 9 had multiple injury. There was one death. Our findings suggest a strong association between the occurrence of intestinal perforation and wearing of a seatbelt. In some cases, free air in the abdominal cavity could not be detected at the time of the initial CT, or the；patients developed intestinal perforation after a time lapse. On the basis of our findings, we would like to emphasize that doctors should be careful when diagnosing cases of blunt abdominal trauma. In addition, the intestinal perforations tend to multiply, and care should be taken not to overlook this while undertaking surgical treatment.
In 2000, we introduced laparoscopic appendectomy for the treatment of appendicitis at our hospital. In 2013, we began to perform extracorporeal closure of the appendicular stump during single-incision transumbilical laparoscopic-assisted appendectomy. In this study, we retrospectively analyzed the effectiveness of this method. We compared the two methods of appendicular stump closure in patients who underwent laparoscopic appendectomy at our hospital between January 2010 and October 2015, namely, intracorporeal closure (first 17 months, 69 cases) and extracorporeal closure (last 32 months, 250 cases). There were no significant differences in the operation time or length of hospitalization between the 2 methods. The latter was associated with a significantly higher incidence of wound infections, but with lower surgical costs. The findings of this study suggest that appendectomies can be performed more efficiently, safely and economically using the extracorporeal method for appendiceal stump closure.
An 81-year-old man consulted a neighborhood clinic complaining of pain on the right side of the abdomen. Examination revealed tenderness and rebound tenderness in the right abdomen. A plain CT revealed an increase of the fat density in the greater omentum and the patient was referred to our hospital with suspected acute peritonitis. After close examination, including a contrast-enhanced CT, we made the diagnosis of omental infarction. Although conservative management was attempted initially, emergency operation was conducted on the second day after admission because of worsening of the patient’s symptoms. Laparoscopic examination revealed necrosis of the omental tissue, and the necrotic tissue was excised. Omental infarction is a rare cause of acute abdomen. Although conservative treatment is successful in many cases, operation is indicated when the symptoms continue to worsen or omental torsion is noted. Minimally invasive laparoscopic surgery is useful in the surgical treatment of omental infarction.
Superior mesenteric venous thrombosis (SMVT) is a relatively rare condition that causes intestinal congestion and/or liver dysfunction by impairing mesenteric venous return， and the reported mortality rate is 0 to 23％. The condition can be severe in some cases, and be occasionally accompanied by intestinal necrosis. Therefore, appropriate initial treatment is essential. A 32-year-old woman was transferred to our institution with a history of vomiting, fever and abdominal pain, persisting despite antibiotic treatment. Based on the findings of contrast-enhanced abdominal computed tomography (CT) acute appendicitis was suspected. The CT images also revealed thrombus formation from the ileocolic vein to the superior mesenteric vein. Thus, under the diagnosis of acute appendicitis complicated by SMVT, emergency appendectomy was performed. Postoperatively, the patient received systemic anticoagulant therapy and was discharged 8 days after the surgery without any complications. The findings of this case suggest that when SMVT occurs concordantly with acute appendicitis, appendectomy should be performed first so as to eliminate the etiology of the thrombosis, and then anticoagulant therapy should be administered in order to prevent progression of the SMVT.
A 70-year-old drunk man who had stumbled and fallen into a canal was brought to our hospital. CT revealed a lumbar fracture, therefore, the patient was admitted to the orthopedics department. However, he developed abdominal pain on the following day, which persisted until the day after. A repeat abdominal CT revealed duodenal perforation and a retroperitoneal abscess. Emergency operation was performed. Intraoperative findings revealed a perforation about 5 mm in diameter in the third portion of the duodenum and widespread right retroperitoneal cavity. Simple closure with catheter jejunostomy was performed with abdominal drainage. Suture leakage occurred 9 days after the surgery. Manual lavage and drainage were performed for about half a year. Traumatic injury of the duodenum is often difficult to diagnose quickly, however, with delayed surgery, the risk of leakage and the associated morbidity and mortality are high. Various sophisticated procedures (pyloric exclusion, duodenal diverticulization and so on) have been performed. However, more recent reports show that sophisticated procedures are not required even in patients with severe injuries. In this paper, we present our experience of a case of traumatic duodenal injury and retroperitoneal abscess, together with a review of the literature.
A 38-year-old woman presented to us with a history of acute onset of severe left hypochondrial pain, and was admitted to the hospital. Contrast-enhanced CT revealed a hematoma in front of the spleen. After admission, the patient remained in stable general condition and the left hypochondrial pain gradually improved. The hematoma also seemed to be disappearing. Electively, we performed an angiography, which revealed a left gastroepiploic artery aneurysm measuring about 3mm in diameter. We speculated that the hematoma was caused by rupture of this aneurysm, and performed transcatheter arterial embolization（TAE）. At present, four years since the TAE, the ruptured aneurysm can no longer be visualized.
We report two rare cases of true diverticulosis of the appendix. Case 1: A 65-year-old man visited our hospital complaining of right lower abdominal pain. Abdominal computed tomography (CT) showed swelling of the appendix and the patient was admitted with the suspected diagnosis of acute appendicitis. On the 2nd hospital day, emergency laparoscopic appendectomy was performed, because antibiotic therapy proved ineffective. Case 2: A 56-year-old man with complicated appendicitis was transferred to our hospital from another hospital because of worsening of the condition over a period of eight days. He complained of right lower abdominal pain and examination revealed muscle guarding. Abdominal CT revealed appendicitis with abscess formation and emergency open appendectomy was performed. In both cases, the resected specimen showed diverticulosis and pathological examination indicated acute inflammation of the true diverticula. Especially in Case 2, histopathological examination revealed diverticulitis with perforation. A review of the literature revealed that true diverticulosis of the appendix is rare, with only 16 cases reported in Japan. Although these previous reports suggested that diverticulosis of the appendix is highly prone to perforation in the presence of acute inflammation, we considered that differential diagnosis from acute appendicitis is difficult preoperatively in the presence of complicating diverticulitis.
A 65-year-old man was referred to our hospital with a history of right lower quadrant pain. The patient had not been abroad or engaged in homosexual behavior. Abdominal computed tomographic examination revealed a tumor of the cecum, and colonoscopic examination showed a type 2 tumor of the cecum and multiple small ulcers in the whole colon. With the suspected diagnosis of multiple malignant lymphoma, the patient was admitted to the hospital. The following day, the patient complained of severe abdominal pain, and was diagnosed as having peritonitis associated with colonic penetration. Emergency surgery was performed, which revealed penetration at the cecum. Ileocecal resection and intraperitoneal drainage were performed. The resected specimen showed multiple ulcers with necrotic tissue. On day 7 after the operation, Entamoeba histolytica was identified in the resected specimen. The patient was then treated with metronidazole, and discharged home without any complications. Follow-up examinations at 2, 6 and 10 months after the operation revealed rapid healing of the ulcers following the treatment, although the erythema persisted for a relatively long time.
An 85-year-old man, treated nine days earlier by transcatheter arterial embolization for a ruptured hepatocellular carcinoma, presented to us complaining of abdominal pain and went into shock. Based on the findings of abdominal contrast-enhanced CT, we suspected nonocclusive mesenteric ischemia（NOMI） and performed angiography for confirmation and intervention. The angiography revealed neither vasospasm nor any other obstructive findings. Nonetheless, we diagnosed the patient as having NOMI and immediately started him on intra-arterial papaverine infusion therapy. Eight days after the start of this therapy, the patient showed significant recovery and was transferred from the ICU to the ward. Thus, continuous intra-arterial papaverine infusion therapy appears to be beneficial for NOMI patients who do not exhibit the typical angiographic findings.
With the increasing frequency of non-operative managements due to technological progress in the field of interventional radiology, the number of trauma surgeries is decreasing. As a result, preoperative training and simulation for trauma surgery have become more difficult, and it takes longer for young trauma surgeons to acquire surgical skills in their field. Off-the job training courses using live animals and human cadavers have been developed to address this problem. A wearable camera enables novel operative field recording, and can be of great help in trauma surgery training.
The patient was an 80-year-old woman (multipara 3) who presented to a neighborhood hospital with a few days' history of fever and loss of appetite. CT examination revealed findings suggestive of gastrointestinal perforation. Therefore, the patient was transported by ambulance to our emergency unit for further examination and treatment. CT revealed free air in the peritoneal cavity, and small amounts of air and liquid were also noted in the uterus. The patient was diagnosed as having peritonitis secondary to uterine perforation or gastrointestinal perforation, and emergency laparotomy was performed. Intraoperatively, a 20/30 mm perforations were identified in the uterine fundus, associated with purulent ascites. We resected the uterine body, and performed peritoneal lavage, followed by drainage. Histopathological examination of the resected lesion revealed no evidence of any neoplasm or malignancy. After the surgery, the patient could not be weaned off the ventilator and died of kidney failure on postoperative day 15. Spontaneous perforation is an extremely rare complication of pyometra. We report this rare case of spontaneous rupture of the uterus with free air in the peritoneal cavity.
A 79-year-old man was transported to our emergency department with disturbance of consciousness and melena, and was admitted to the hospital. Metabolic acidosis and hypovolemia were noted on admission. Since non-occlusive mesenteric ischemia (NOMI) was suspected from the CT findings, emergency laparotomy was performed, and a necrotic segment of the small intestine and colon was resected. During the second-look operation, necrotic mucosa was observed in the colon and the resectional range was determined by colonoscopy. It is thought that intraoperative endoscopy is useful for assessment of the intestinal viability and making a decision in regard to the extent of bowel resection in patients with mesenteric ischemia.
A 21-year old man was brought to the emergency room with injuries sustained in a car accident；at the time of the accident, the patient was sitting in the front passenger seat wearing a three-point seatbelt. On examination at admission, the oblique seatbelt sign was observed and there was severe tenderness in the right upper abdomen. Abdominal computed tomography revealed scattered free air in the upper abdomen and a swollen transverse colonic wall in the region of the hepatic flexure. Under the suspicion of perforation of the transverse colon caused by the shoulder belt, emergency surgery was performed. Intraoperatively, while no colonic perforation identified, perforation of the anterior wall of the first portion of the duodenum was observed. The duodenal perforation was treated by single closure surgery. After the surgery, the abdominal tenderness promptly disappeared, and the patient was discharged on postoperative day 12.
Mesenteric panniculitis is a non-specific inflammatory disease with a good prognosis. Herein, we report the case of a 41-year-old woman who was diagnosed as having mesorectal panniculitis with abscesses. The patient presented to a neighborhood hospital with a 3-day history of lower abdominal pain, and laboratory tests revealed elevated levels of inflammation markers. Contrast-enhanced computed tomography revealed an edematous rectum surrounded by abscesses, therefore, she was referred to our hospital for further management. As she presented with acute abdomen and elevated levels of inflammation markers, even though the cause of the abscesses was unclear, emergency surgery was performed. Laparotomy revealed normal uterine adnexa, but an edematous rectum, mesenteric panniculitis and supralevator abscess, and we drained the abscess. Until now, 7 months since the surgery, there has been no evidence of recurrence. Thus, surgeons should bear in mind that mesorectal panniculitis with severe inflammation sometimes presents with a supralevator abscess.
A 75-year-old man was transported to our hospital from another hospital complaining of abdominal pain. He had no history of laparotomy. Computed tomography showed massive ascites, distended loops of the small intestine, and convergence of the mesentery of the small intestine. An emergency laparotomy was performed, and the patient was diagnosed as having strangulated ileus caused by internal herniation. The operative findings were strangulation and necrosis of a segment of the small intestine caused by herniation through a defect in the greater omentum on the right side. The defect of the greater omentum was opened, and an approximately 200-cm segment of the herniated small bowel was resected. The postoperative course was uneventful. Transomental hernia, a kind of intra-abdominal hernia is rare, therefore, we report this case with a review of the literature.
A 21-year-old woman was admitted to our hospital with a history of lower abdominal pain. She had previously been receiving treatment at another hospital for anorexia nervosa. Peripheral blood examination revealed pancytopenia, and abdominal computed tomography showed free air around the rectum. The patient was diagnosed as having rectal perforation and diagnostic laparoscopy with closure of the defect with sutures was performed. Postoperatively, the patient developed disseminated intravascular coagulation. In addition, laboratory tests revealed hypophosphatemia, considered to be associated with the anorexia nervosa. Phosphate supplementation was initiated, and fortunately, the patient did not develop any dangerous arrhythmias because of the administered phosphate. On the 29th day after surgery, she was transferred from the hospital for continuation of the treatment for anorexia nervosa. A follow-up at six months after the operation revealed no signs of relapse. This is the sixth case report of idiopathic perforation of the gastrointestinal tract in patients with anorexia nervosa.
We encountered a case in which soluble fibrin monomer complex (SFMC) measurement in the plasma was useful for the diagnosis of perioperative critical pulmonary thromboembolism (PTE). A man in his 70s with a high fever and weakness of the limbs was referred to our hospital. Blood tests showed elevated levels of creatine phosphokinase. The patient was diagnosed as having an infection of unknown origin with rhabdomyolysis. Whole-body computed tomography (CT) revealed thickening of the wall of the ascending colon. Colonoscopy showed an elevated lesion in the ascending colon. Endoscopic biopsy specimens revealed the diagnosis of colonic adenocarcinoma. Based on these findings, a diagnosis of ascending colon cancer was made, and right hemicolectomy was scheduled. During induction of anesthesia for the surgery, the blood pressure and peripheral arterial oxygen saturation suddenly decreased. The surgery was, however, continued as the blood pressure and oxygen saturation improved with blood transfusion and catecholamine infusion. A blood test revealed elevation of the plasma SFMC level to 129.8μg/mL (reference value ≤7.0μg/mL), and acute pulmonary embolism was suspected. However, transesophageal echocardiography did not reveal either severe right ventricular hypokinesis or persistent pulmonary hypertension. Postoperative measurement revealed further elevation of the SFMC level (361.6μg/mL)；therefore, emergency CT was performed, which revealed pulmonary embolism and left femoral vein thrombosis. An inferior vena cava (IVC) filter was placed immediately. Anticoagulant therapy was started from the day after the surgery. The IVC filter was removed after 2 weeks, and the patient was discharged on day 31 after the operation. This case report indicates the usefulness of plasma SFMC measurement for early diagnosis of PTE in perioperative patients.
We report the case of a patient with intraperitoneal bleeding probably caused by segmental arterial mediolysis(SAM)of the right colic artery, as suggested by postoperative three-dimensional computed tomography-angiography(3D-CTA). A 58-year-old man with a history of abdominal pain and sudden transient loss of consciousness was referred to our hospital. The symptoms recurred at our hospital, and computed tomography revealed a massive intraperitoneal fluid collection and extravasation of contrast medium from the right colic artery. Emergency laparotomy was performed to identify the cause of the intraperitoneal bleeding. 3D-CTA performed on postoperative day 2 revealed multiple bead-like dilatations of the residual branch of the right colic artery, which was found to have disappeared spontaneously in a CT repeated 10 months later. On the basis of the findings, the patient was diagnosed as a case of SAM. With the spread of the disease concept of SAM, the number of case reports is increasing. On the other hand, the pathogenetic mechanism is yet to be clearly elucidated. 3D-CTA is a useful for screening and following up the characteristics of SAM.
We present the case of an 86-year-old woman who was diagnosed as having strangulated bowel obstruction. The patient presented with signs of localized peritonitis, and an abdominal CT revealed distended small bowel loops in a localized area. Strangulated bowel obstruction was suspected, and emergency laparotomy was performed. The jejunum was occluded by an intraluminal mass with intestinal torsion at that site. The mass was extracted through an enterotomy, and identified as a knotted piece of sea tangle. On postoperative questioning, the patient admitted to having eaten a sea tangle without adequately chewing it first. In an estimated 0.3-1.0％ of cases of bowel obstruction, the obstruction is caused by food. Bowel obstruction due to a sea tangle has been reported in 10-12％ of cases of food-induced bowel obstruction. Diagnosis of this type of bowel obstruction is difficult and urgent operation is often needed, as it is difficult to treat this condition non-operatively. It is important to review the patient’s food intake in detail to make the correct diagnosis, and to be aware of the appropriate timing for deciding on the need for surgical intervention.
A 72-year-old man was admitted to our hospital with the complaints of severe right lower abdominal pain and abdominal distension. Physical examination revealed rebound tenderness without muscle guarding. Plain abdominal radiographs showed signs of small bowel obstruction. Abdominal computed tomography showed ascites around the liver and in the abdominal cavity, localized thickening of the intestinal wall with good contrast enhancement, and no signs of a closed loop. Emergency surgery was performed because of the small bowel obstruction of uncertain etiology. Laparoscopically, we located a significant, locally edematous lesion near the terminal ileum. There was no internal hernia or strangulation. We made a small incision and resected the edematous ileum, which was regarded as the cause of the obstruction. The histopathological examination showed an anisakis body in the submucosal layer and a parasitic granuloma. The cause of the small bowel obstruction was considered to be ileal edema caused by anisakiasis of the ileum.
Pyogenic liver abscesses can occur from a variety of causes. There are few reports of liver abscess developing in patients with colon cancer. Herein, we report the case of a 64-year-old man with ascending colon cancer who developed a pyogenic liver abscess during chemotherapy. The patient was referred to our hospital for a mass lesion in the ascending colon, and was diagnosed as having advanced ascending colon cancer. He was treated with capecitabine/oxaliplatin plus bevacizumab in an attempt to reduce the risk of postoperative recurrence. During the third course of chemotherapy, the patient developed fever, although his general condition remained good. After 4 courses of chemotherapy, enhanced computed tomography revealed an abscess in the right lobe of the liver. After percutaneous transhepatic drainage of the abscess followed by antibiotic therapy, the patient's condition improved. The causative pathogen was Streptococcus anginosus. In conclusion, although pyogenic liver abscesses rarely develop during chemotherapy for colon cancer, the possibility should be borne in mind.
A 76-year-old man visited our emergency room complaining of epigastric pain. He was found to be in peripheral circulatory shock and abdominal examination revealed signs of peritoneal irritation. Abdominal CT revealed hepatic portal venous gas. From these findings, intestinal necrosis was suspected, and emergency surgery was performed. Blotchy, dark red discoloration of the serous surface of the ileum was noted 30-50cm from the ileocecal valve, based on which we diagnosed non-occlusive mesenteric ischemia (NOMI). Despite the absence of intestinal necrosis, we decided to perform a second-look operation and a re-celiotomy was performed 12 hours later. The color of the bowel had improved, so we did not carry out any bowel resection. The patient was discharged on postoperative day 15, however, he presented again with recurrent pain and vomiting. Another exploratory laparotomy was performed on postoperative day 31, which revealed a narrowed ileal segment approximately 5 cm in length, and partial resection of the small bowel was performed. Histopathologic examination of the resected bowel segment revealed fibrosis affecting all the layers, and we concluded that the ischemia had led to gradual narrowing of the lumen. Late-onset intestinal narrowing in cases of NOMI is rare. We discuss our case in light of the available literature on this uncommon clinical entity.