Between 2009 and 2015, we experienced 8 cases of torsion of the gallbladder. Here, we examined the utility of various findings in terms of preoperative diagnosis. Patients with torsion of the gallbladder were more likely to be skinny and elderly, compared with patients with acute cholecystitis who underwent a cholecystectomy during the same period. All eight patients with torsion of the gallbladder were underweight, with a body mass index (BMI) of less than 18.5. Underweight cases with a BMI of less than 18.5 accounted for 8.1% of all cases of acute cholecystitis cases, and 34.8% of them had gallbladder torsion. Thus, a low BMI could be a useful finding for preoperative diagnosis. Regarding imaging findings, direct findings suggesting torsion (such as a twisted gallbladder structure) were considered to be more important than indirect findings accompanying torsion (such as a remarkable thickening or poor contrast or high-density area of the gallbladder wall) for preoperative diagnosis. In acute cholecystitis cases with a low BMI, the possibility of gallbladder torsion should be kept in mind when determining the preoperative diagnosis.
About 301 elderly patients over 80 years of age who had undergone emergency abdominal surgery were treated at the Hyogo Prefectural Awaji Medical Center during the six years between April 2008 and March 2014. We examined the causative diseases, mortality rate, period of hospitalization, and so on. The average patient age was 85.6 years old (the oldest patient was 99 years old). Ileus was the common causative disease (85 cases). It became 85% of the all cases when ileus, hernia, gastrointestinal tract perforation and appendicitis totaled. Fifty-two cases were oncology-related emergencies, most of which were caused by colon cancer. Ninety-nine cases had postoperative morbidities, and there were 30 deaths. The mean hospitalization period was 26.1 days. The occurrence of a postoperative complication prolonged the hospitalization period. In Japan's aging society, an increase in elderly patients requiring emergency abdominal surgery is an unavoidable reality, and the characteristics of such cases must be understood.
Transomental hernia is a rare disease, since it is a type of intra-abdominal hernia that forms as a result of incarceration through an abdominal greater omental hiatus. This disease lacks specific physical features, making its preoperative diagnosis difficult. Between 2009 and 2016, we encountered ten cases of transomental hernia in which MD-CT was helpful for preoperative diagnosis. The patients ranged in age from 58 to 83 years old (average：67 years old), and the male-to-female ratio was 6 to 4. The preoperative diagnoses were transomental hernia in 6 and intra-abdominal hernia in 4, based on MD-CT findings. MD-CT showed a dilated small intestine on the ventral side of the ascending colon and the transverse colon through the omental hiatus, a closed loop, and the convergence of a mesentery or the small intestine. The possibility of transomental hernia should be considered when treating patients with an obstruction who have no history of a laparotomy. MD-CT with multiplanar reconstruction (MPR) is useful for the preoperative diagnosis of trans-omental hernia.
The Practice Guidelines for Primary Care of Acute Abdomen 2015 (hereinafter referred to as GL) seeks to scientifically propose appropriate management strategies for acute abdomen. Within this process, the GL can be used to identify life-threatening diseases such as ischemic disease, bleeding diseases, and diffuse peritonitis in patients with abdominal pain. The “initial diagnosis and treatment algorithm” described in the GL was prepared to provide appropriate treatment without overlooking life-threatening clinical states. As a result, a 2-step method was adopted. In Step 1, urgent diseases that produce abnormalities in vital signs are identified, and appropriate resuscitation and curative treatment methods are recommended. Patients who do not exhibit abnormal vital signs then proceed to Step 2 in the diagnostic and treatment algorithm, where diseases that may require emergency surgery (bleeding, ischemia of an internal organ, panperitonitis, and acute inflammation of an organ) are identified. Herein, we clarify the aims of the “Initial Diagnosis and Treatment Algorithm.”
Many patients with emergency gastrointestinal diseases require emergency operations and are intolerant of enteral nutrition thereafter. We evaluated nutritional management after emergency operations in patients with emergency gastrointestinal diseases. We retrospectively studied the postoperative fasting period, intensive care unit (ICU) admission, and quantity of nutrients consumed as of postoperative day 7 in 550 abdominal emergency patients. Sixty-seven patients were managed using total parenteral nutrition for more than seven postoperative days, including 25 patients who were treated in the ICU. There were no significant differences in the mortality rate or the length of the hospital stay whether treated in the ICU or not. The fasting period was 8 days in both groups, and the quantity of nutrients administered on postoperative day 7 was below 500 kcal in both groups. Many patients with emergency gastrointestinal diseases require intensive care after presenting with peritonitis and sepsis. Permissive underfeeding is better than full feeding only during the early postoperative period. In conclusion, the route and quantity of nutrients to be administered should be carefully decided because inappropriate nutritional support can adversely affect a patient's nutritional status.
【Aim】The usefulness of water-soluble contrast agents (WSCA) for the diagnosis and treatment of small bowel obstruction (SBO) was investigated. 【Methods】Between January 2008 and December 2015, 878 consecutive patients with SBO received WSCA and were included in the study. Abdominal X-rays were taken 5 hours after the administration of 100mL of WSCA and were classified into four types: type Ⅰ/Ⅱ, corresponding to the absence of contrast agent in the colon with/without the detection of a complete obstruction point; and type ⅢA/ⅢB, an incomplete obstruction group corresponding to the presence of contrast agent in the colon with/without a dilated small intestine. Surgery was recommended for type Ⅰ/Ⅱ SBO, while conservative therapy was recommended for type ⅢA/ⅢB SBO. The medical records of the patients were retrospectively analyzed. 【Results】Types Ⅰ, Ⅱ, ⅢA, and ⅢB were identified in 37, 98, 399, and 344 patients, respectively. The duration from hospital admission until surgery was 2.1 days. The time until oral intake and the length of the hospital stay were 2.6 and 10.6 days, respectively, for type ⅢA and 2.1 and 8.5 days, respectively, for type ⅢB. 【Conclusions】WSCA aids the management of SBO. WSCA reduces the duration until operation and the time until the resolution of the obstruction, as well as the length of the hospital stay.
The Practice Guidelines for Primary Care of Acute Abdomen 2015 (GL) has been published, but for these guidelines to be useful, the GL must be universally recognized. We performed a questionnaire survey exploring to what extent the GL is presently recognized. All 38 doctors at our hospital completed the questionnaire. Five doctors (13%) knew about the GL; of these doctors had learned about the GL 2 months after its publication, and 3 of them had learned about the GL after participating in a GL-related workshop that was conducted at our hospital. The remaining 33 doctors (87%) were unaware of the GL. Six doctors belonged to five societies that participated in the development of the GL; the Japanese Society for Abdominal Emergency Medicine, the Japan Radiological Society, the Japan Primary Care Association, the Japan Society of Obstetrics and Gynecology, and the Japanese Society for Vascular Surgery. However, only 2 of these doctors knew about the GL. Thus, the GL is not yet widely known. To raise awareness of the presence of the GL and develop the usefulness of the GL, must be further publicized. Hospital workshops are effective for promoting recognition of the GL. Furthermore, the number of doctors who belonged to the five societies involved in the formulation of the GL was not very large, and cooperation with a larger number of associations might be useful.
【Purpose】In an educational clinical question (number 107) of the Practice Guidelines for Primary Care of Acute Abdomen 2015, it is mentioned that although the AbdEMeT course is being held, the resulting improvement in clinical abilities has not yet been reported. The aims of the present study are (1) to evaluate the impact of this publication on the educational course and (2) to extract evaluation items (competency) to verify improvements in clinical ability. 【Methods】①The course instruction guidelines before and after the publication were compared. ②An interim questionnaire survey exploring 23 kinds of abdominal clinical abilities was conducted for subjects at different stages of their medical career. 【Results】①Policies regarding analgesic use and others were added after the publication. ②The average scores (maximum score: 108 points) of medical 5th or 6th year students, residents, senior residents, general internal medicine/specialists other than digestive diseases, and gastroenterologists were 30.7, 48.8, 56.0, 51.1 and 71.5, respectively. The largest difference between gastroenterologists and others was obtained for abdominal ultrasound performance. Furthermore, some low performance items of gastroenterologists, such as inquiries regarding menstruation, were also identified. 【Conclusion】The course instruction guideline was revised after the publication, and the adequacy of interim evaluation items for abdominal clinical abilities was confirmed. Improvement of the evaluation items and confirmation of the improved abilities of trainees will be future topics of study.
【Background】Since the pathogenesis of bowel strangulation (BS) involves bowel ischemia, contrast-enhanced computed tomography (CECT) is important for the diagnosis of BS. However, which CECT findings are most useful for an accurate diagnosis remain unclear. 【Method】The characteristics of 21 patients with necrotic BS and 33 patients with non-necrotic BS were examined. 【Results】A beak sign, a thick intestinal wall, and mesenteric edema were observed in over 70% of the patients with both necrotic and non-necrotic BS. Hypo-enhancement of the bowel wall was observed in 71% of the patients with necrotic BS and 18% of the patients with non-necrotic BS. 【Discussion】For the early diagnosis of BS, greater importance should be placed on the presence of a beak sign, thick intestinal wall, and mesenteric edema, with hypo-enhancement of the bowel wall being a lesser consideration.
A 24-year-old woman with no past medical history was admitted to our hospital because of abdominal pain and vomiting. A multi-detector computed tomography (MDCT) examination showed a blind congested intestinal tract in the pelvis and an expanded small intestine. The patient was diagnosed as having ileus in Meckel's diverticulum. After decompression of the small bowel using a long tube, an emergency laparoscopic surgery was performed. Laparoscopic exploration revealed that a band had adhered from Meckel's diverticulum to the ileal mesenterium, and a hernia orifice had formed between the band and the mesenterium. The neighboring ileum had become incarcerated into the hernia orifice and presented as an inner hernia. We separated the band and performed a wedge resection that included Meckel's diverticulum. Histopathologic examination of the resected band revealed a mesodiverticular band. Ileus at Meckel's diverticulum is difficult to diagnose because of the variety of symptoms. However, MDCT has contributed to an improvement in diagnosis. A surgical field can be difficult to secure during laparoscopic surgery for cases with ileus, but decompression using a long tube seems to be a safe maneuver in patients with ileus in Meckel's diverticulum.
A 58-year-old woman presented with a right lumbar area pain, a thigh pain, and a purulent discharge with a fecal odor. A blood examination revealed elevated serum inflammatory data, such as a white blood cell count of 19,800/μL and a c-reactive protein level of 28.5mg/dL. A CT scan showed a retroperitoneal abscess from the level of the right kidney to the thigh. Under general anesthesia, emergency drainage using an extraperitoneal approach was performed. After the operation, an exploratory examination showed a perforated appendix and abscess ; therefore, a single incision laparoscopic appendectomy was performed on the 11th day thereafter. A pathological diagnosis of a penetration of the appendiceal diverticulum was made. The patient gradually recovered and was discharged. We herein report that laparoscopic surgery was possible using primary drainage even in a case with a huge retroperitoneal abscess.
A 53-year-old man was admitted to our institution because of upper abdominal pain. A physical examination revealed signs of peritoneal irritation in the right upper quadrant, and abdominal computed tomography revealed thrombi in the superior mesenteric vein and in an ischemic segment of the small bowel. Emergency surgery was performed. An intraoperative examination revealed an area of necrosis extending for approximately 70 cm; the necrotic area was removed by a partial resection of the intestine. A thrombectomy was not performed because the venous congestion in the mesentery had not diffused. The absence of a blood coagulation disorder confirmed a diagnosis of idiopathic superior mesenteric venous thrombosis. After the operation, the patient was continuously treated with heparin, which was then switched to oral anticoagulation therapy with warfarin. This patient is currently under observation and has not shown any recurrence of symptoms.
A 50-year-old female patient was hospitalized at our gynecological clinic because of abdominal distention and vomiting after an operation for uterine cancer. After hospitalization, she was diagnosed as having a paralytic ileus and was treated with a nasogastric tube to reduce the pressure. However, no improvement in the patient's condition was seen. She was transferred to our department and was initially treated with a long intestinal tube and continuous suction to reduce the pressure. Three days after the insertion of the long intestinal tube, the patient's vomiting began to reoccur and the patient complained of abdominal pain. A CT scan showed a concentric circular multilayered structure at the small intestine near a point around the middle of the long intestinal tube; this structure was caused by the mesentery and small intestine invaginating into the jejunum. The patient was diagnosed as having intussusception, and an operation was conducted. The proximal jejunum was invaginated by 10cm at a point near the Treitz ligament. Moreover, we observed that the terminal ileum had adhered to and looped around the retroperitoneum, which we determined to be the cause of the ileus. This report summarizes and discusses several cases of intussusception involving the use of a long intestinal tube.
Although about 10% of all cases of bowel obstruction are caused by internal hernias, internal hernia through the broad ligament of the uterus is a rare cause of internal hernias. Preoperative diagnosis has long been difficult, but advanced imaging techniques, such as CT, can now enable a correct preoperative diagnosis. We experienced five cases of internal hernia through the broad ligament of the uterus that were diagnosed using CT before surgery between 2010 and 2016. All the cases came to our hospital with abdominal pain. The abdominal CT examinations showed a dilated small intestine loop in the pelvic cavity that was compressing the uterus. A reduced enhancement of the intestine wall was not observed；thus, we considered the possibility of intestinal necrosis to be low. We diagnosed the cases as having an internal hernia through the broad ligament of the uterus, and emergency surgery was performed. Three cases underwent laparoscopic surgery. Since intestinal necrosis had not developed, none of the cases required intestinal resection, and the postoperative courses were all uneventful. CT is useful for the diagnosis of internal hernia through the broad ligament of the uterus, and laparoscopic surgery offers great potential for a successful treatment.
A 58-year-old-man was diagnosed as having an adenocarcinoma (p-T2aN2M0, p-Stage Ⅲa) in the right superior lobe of the lung. The patient underwent the resection of the right superior lobe; 23 months later, he was diagnosed as having lymph node metastases. Multiple lung metastases were subsequently observed. Accordingly, systemic chemotherapy and radiation treatment were initiated. Three years and nine months after the initial surgery, the patient visited our hospital complaining of epigastric pain and dyspnea. An abdominal computed tomography examination revealed the presence of free air. We suspected an upper gastrointestinal perforation and performed a gastrectomy. A histopathological examination confirmed the presence of adenocarcinoma and a metastatic gastric tumor; immunohistochemical test results showed that the metastases had originated from the lung cancer. The patient died 1 month after a gastrectomy. Here, we report a rare case of a perforated metastatic gastric tumor originating from lung cancer. As the prognosis of patients with perforated metastatic gastric tumor originating from lung cancer is relatively poor, the patient's individual characteristics should be carefully considered when devising a treatment strategy.
A 79-year-old woman was admitted to our hospital with a right upper quadrant pain 7 days before admission. Abdominal contrast-enhanced CT revealed a large distended gallbladder with an edematous wall without a lack of contrast and a whorled appearance at the neck of the gallbladder; the neck of the gallbladder was situated dorsal to the common bile duct. We suggested the possibility of a floating gallbladder with torsion of the gallbladder, and an emergency cholecystectomy was performed. The operative findings showed a Gross type Ⅱ floating gallbladder that had adhered to the transverse colon, duodenum, greater omentum, and hepatoduodenal ligament with herniation through Winslow's foramen and a 360-degrees counterclockwise torsion at the neck duct of the gallbladder. A histological examination of the gallbladder revealed partial necrosis of the epithelium. The possibility of gallbladder necrosis arising from torsion of the gallbladder should be kept in mind, and emergency surgery should be promptly performed. The further development of gangrenous cholecystitis is possible in patients with a floating gallbladder that exhibits both internal herniation and torsion of the gallbladder.
A 51-year-old man was referred to our hospital because of a stomachache and vomiting. Contrast-enhanced abdominal computed tomographic imaging revealed intestinal intussusception, a low-absorption tumorous lesion, and a spirally revolving small intestine. We diagnosed the patient as having a small bowel volvulus and intestinal intussusception caused by a small bowel adipose tumor and performed emergency surgery. The laparotomy findings revealed a 270-degree torsion of the mesentery of the small intestine on the oral side at a point 70 cm from the ligament of Treitz and ischemic changes of the intestinal tract. Intestinal intussusception was also observed. During the reduction of the intussusception using Hutchinson's method, we felt a tumor of approximately 4 cm in the foward part. We performed a partial resection of the small intestine including the intussuscepted intestinal tract. The specimen revealed a yellowish pedunculated tumor in the jejunum, and a histopathological diagnosis of adipose tumor was made. The postoperative prognosis was good, and the patient was discharged on postoperative day 8. Only a few case reports have described secondary small bowel volvulus in which adult intestinal intussusception was triggered by a small bowel adipose tumor, making this particular case relatively rare.
We describe 2 patients with transanal foreign bodies. Patient 1 was a 62-year-old man who consulted our hospital because he could not remove a foreign body that had been inserted into his rectum two days earlier. A plain abdominal radiograph revealed a cylindrical body. The object could not be removed because a computed tomography examination showed that the apex of the foreign body had reached rectosigmoid. An emergency laparotomy was performed with a combined spinal-epidural anesthesia. The aerosol can was removed transanally. Patient 2 was a 26-year-old man who presented with a rectal foreign body. The object could not be removed, so emergency surgery was performed using a combined spinal-epidural anesthesia. A vibrator was removed transanally. Transanal foreign bodies should be carefully treated based on the medical history and diagnostic imaging studies.
A 55-year-old man was admitted to the hospital because of abdominal pain and vomiting after he had eaten sliced raw fish 3 days previously. A sharp tenderness and distension was present in the middle abdomen, but the presence of peritoneal irritation was unclear. A plain abdominal X-ray showed signs of ileus. A computed tomography (CT) examination of the abdomen revealed partial wall thickening and stenosis of the small intestine with wall enhancement, dilatation of the proximal small intestine, and the accumulation of ascites. On the same day, he underwent hyperbaric oxygen therapy (HBOT) with a primary diagnosis of small bowel anisakiasis and bowel obstruction. On the day after HBOT, his abdomen was no longer distended and the abdominal tenderness had disappeared. An abdominal X-ray examination showed no signs of ileus, such as air-fluid levels. An abdominal CT examination demonstrated an improvement in wall thickening and stenosis of the small intestine and the disappearance of ascites. His post-HBOT course was favorable, and he was discharged 8 days after HBOT without requiring a surgical operation. We confirmed the diagnosis based on an elevated serum anti-anisakiasis-specific IgE antibody level. Anisakiasis of the small intestine is relatively rare; however, we should keep in mind that anisakiasis can develop into bowel obstruction. Though anisakiasis can generally be treated conservatively, HBOT is an extremely useful treatment for small bowel anisakiasis that has developed into bowel obstruction.
We report a case of artery pseudoaneurysm and portal vein thrombosis following a pancreaticoduodenectomy (PD) that was treated using an interventional radiological technique. A 67-year-old female underwent a PD for the treatment of pancreatic cancer. A pancreatic fistula was diagnosed on postoperative day (POD) 14, and an intraabdominal hemorrhage occurred on POD 16. An emergency angiography showed a pseudoaneurysm at the gastroduodenal arterial stump. Subsequently, a covered stent was placed to prevent rupture of the artery pseudoaneurysm. Thereafter, intraabdominal hemorrhage via an artery pseudoaneurysm occurred on POD 38, 51, and 75. For these artery pseudoaneurysms, stent placement with coil embolization was repeatedly performed. Furthermore, portal vein thrombosis occurred, and a stent was also placed in the portal vein. Finally, the portal vein stent became occluded, but the hepatic artery flow was maintained. Therefore, liver failure did not occur postoperatively. The patient was discharged on POD 146 without any adverse vascular events.
An 87-year-old woman underwent a laparoscopic distal gastrectomy for early gastric cancer. During the surgery, a part of the transverse mesocolon approximately 10 mm in diameter was injured, but we decided that restoration of this defect was not necessary because the injured area was tiny and was unlikely to cause complications. Three months after the surgery, the patient complained of nausea and underwent a computed tomography examination, which revealed an ileus caused by an internal hernia of the small intestine into the transverse mesocolon; emergency surgery was subsequently performed. Intraoperatively, a hernia orifice in the transverse mesocolon and invagination of the small intestine were observed. The invaginated intestine was withdrawn, and the hernia orifice of the mesocolon was closed with sutures. The internal hernia was shown to have been caused by mesenteric injury at the first surgery because the identified hernia orifice was at the same site as the mesenteric defect during the laparoscopic distal gastrectomy. It is very important to recognize that injury of the transverse mesocolon during surgery can lead to an internal hernia as a postoperative complication and that the repair of mesocolon damage is indeed required. Furthermore, precautions to avoid this complication should be taken.
The patient was a 32-year-old woman who had previously undergone a laparoscopic ovarian cystectomy for endometriosis. At 7 weeks and 3 days of pregnancy, she was brought to our hospital for emergency treatment because of abdominal pain and vomiting. An abdominal ultrasonography revealed the presence of a keyboard sign, and an abdominal radiography revealed a‘niveau’. Based on the imaging results, the patient was diagnosed as having an intestinal obstruction. Blood examination findings were not suggestive of intestinal necrosis ; therefore, conservative management consisting of the placement of a gastric tube and non-oral food intake was performed. However, no improvement in the symptoms was noted following hospital admission. The following day, we performed an abdominal computed tomography scan, and an ileus tube was inserted under endoscopic assistance. Thereafter, the abdominal pain and other symptoms decreased. Despite the improvement in the pain and other symptoms, no decrease in fluid discharged from the ileus tube was observed. Thus, on day 10 of hospitalization, we performed surgery to remove the intestinal obstruction. The intraoperative findings revealed fibrotic adhesions between the small intestine and the mesentery proper, which was considered to be the cause of the intestinal obstruction. The adhesion was removed, thereby completing the operation. No postoperative complications occurred, and the patient was discharged on postoperative day 10. Following discharge, the pregnancy progressed without complications, and at 38 weeks and 6 days of pregnancy, the patient transvaginally delivered a baby weighing 2840g. A delayed diagnosis of intestinal obstruction during pregnancy is fatal for both the mother and fetus. Thus, a precise diagnosis that avoids unnecessary radiation exposure is needed.
A 75-year-old woman was admitted to a clinic because of hematemesis. Endoscopic findings revealed an ulcerative lesion in the descending portion of the duodenum, with bleeding. A CT scan showed a tumor on the pancreatic head that had extended to the duodenum. As a result, we considered the tumor to be a pancreatic head cancer that had infiltrated the duodenum. The patient was immediately transferred to our hospital for treatment. Although she developed hemorrhagic shock because of massive hematemesis, she recovered from a severe state after receiving intravenous fluid resuscitation and blood transfusion. After the above treatment, a pancreaticoduodenectomy was performed. Pathologically, the tumor was diagnosed as a poorly differentiated tubular adenocarcinoma with duodenal infiltration. Since hemorrhagic shock arising from pancreatic cancer with duodenal infiltration is rare, we report the present case along with a literature review.
A 62-year-old woman was admitted to our department with an intermittent abdominal pain that had begun two days previously. Abdominal ultrasonography and contrast-enhanced computed tomography revealed an intussusception of the transverse colon. A colonoscopy revealed erosion on the side of the intussusception closest to the anus, but no neoplastic lesions were observed. After a Gastrografin® enema was attempted, the intussusception was successfully reduced. A colonoscopy that was performed 7 days later revealed only the presence of circular ulcers along the area affected by the intussusception. Thus, the patient was diagnosed as having adult idiopathic intussusception. The intussusception has not recurred in the nine years since diagnosis. Adult idiopathic intussusception is relatively rare and does not require further treatment if the absence of organic disease can be confirmed after reduction. If intussusception is diagnosed, endoscopic and enema examinations should be performed whenever possible.
An acute abdomen is sometimes accompanied by ischemic heart disease. In such cases, doctors must determine the most suitable treatment policy while facing the difficulty of determining the level of priority required for the treatment of each condition. We report a case of acute cholecystitis accompanied by unstable angina in which the treatment plan was quite difficult to determine. A 79-year-old man presented with a chief complaint of chest pain while resting. Based on detailed laboratory investigations, he was diagnosed as having unstable angina and acute cholecystitis and was transferred to a specialized facility to prioritize the treatment of angina. However, based on various test results, the patient was found to be ineligible for emergency catheter testing; he was then re-transferred to our hospital to receive treatment for the acute cholecystitis first. An abdominal computed tomography scan revealed the presence of emphysema in the gallbladder and the biliary tract, and a diagnosis of emphysematous cholecystitis was confirmed. Emergency surgery was planned, and an open cholecystectomy was performed. During the postoperative period, multidisciplinary systemic management was initiated with the patient admitted to the intensive care unit. The patient's recovery was satisfactory, and he was discharged after his condition improved.
The patient was a 33-year-old man. He consulted the Emergency and Critical Care Center of our hospital complaining of an upper abdominal pain. A preoperative contrast-enhanced abdominal CT examination revealed torsion of a mucocele of the appendix, and an emergency laparoscopically assisted appendectomy was performed. The resected specimen suggested a swelling of the appendix (9.5×2.5cm), and a yellow-white, jelly-like substance was observed in the inner area. Pathologically, a diagnosis of a low-grade appendiceal mucinous neoplasm (LAMN) was made. The mucus had infiltrated the submucosal layer. LAMN is a newly classification of tumor in the Japanese Classification of Colorectal Carcinoma. A standard treatment for LAMN has not yet been established, but LAMN has both benign and malignant properties, and strict follow-up may be necessary after resection involving a sufficient margin. To our knowledge, only 15 case reports of LAMN torsion have been made in Japan. In addition, a diagnosis of torsion was made before surgery in 2 patients, including our patient. Such cases may be extremely rare.
A 104-year-old woman presented at a neighborhood hospital with a chief complaint of anorexia. She was suspected of having ileus and was referred to our hospital for a detailed investigation. Abdominal contrast-enhanced computed tomography showed a thickening of the sigmoid colon and the dilation of the oral colon. The patient was diagnosed as having ileus caused by colon cancer and the insertion of a self-expanding metallic stent. After 4 days, the patient developed abdominal pain. Abdominal contrast-enhanced computed tomography showed ileus caused by the impaction of a foreign body in the stent. The foreign body was removed endoscopically and was identified as a Japanese apricot pit. This is the first report of food-induced ileus after stent insertion and is a rare example of the endoscopic removal of a foreign body.
We report a case of strangulated ileus associated with an adult transmesenteric internal hernia. The patient was a 20-year-old man who presented with an upper abdominal pain and no history of surgery. The following day, the abdominal pain worsened, and the patient sought treatment at our hospital. Abdominal findings included tenderness in the right lower quadrant and severe spontaneous pain over the entire abdomen. A computed tomography examination showed the presence of ascites, a lack of enhancement in a portion of the small bowel, and an ileocecal artery with a course that included a sharp, right turn. We suspected a strangulated bowel obstruction and performed an emergency diagnostic laparoscopy, which revealed a necrotic gastrointestinal tract. The ileum had herniated through a 3-cm ileal mesenteric defect located 5 cm from the ileocecal junction. A gangrenous section of the ileum that was 45 cm in length was resected and was found to contain a mesenteric defect. Although only a few reports of transmesenteric hernia have been made in adults and such cases are difficult to diagnose preoperatively, a differential diagnosis for strangulated ileus should be considered when the patient does not have a history of surgery. Prompt surgery, including a laparoscopy, is important and could be useful for the diagnosis and treatment of transmesenteric internal hernia.
We report a case of fish bone penetration of the duodenum that was successfully treated using laparoscopic surgery. A 64-year-old man was admitted with epigastric pain persisting for 2 hours after a meal. Computed tomography showed a linear calcified body that appeared to have penetrated the horizontal portion on the right side of the superior mesenteric vein (SMV) of the duodenum. An emergency operation was performed. The fish bone was safely removed laparoscopically. The bone had penetrated the horizontal portion of the duodenum. Neither an abscess nor a hematoma was detected. The hole was sutured closed. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. Laparoscopic surgery enables an accurate diagnosis and a less invasive treatment for fish bone penetration of the duodenum.