Nihon Fukubu Kyukyu Igakkai Zasshi (Journal of Abdominal Emergency Medicine)
Online ISSN : 1882-4781
Print ISSN : 1340-2242
ISSN-L : 1340-2242
Volume 33 , Issue 5
Showing 1-26 articles out of 26 articles from the selected issue
  • Naoki Tomizawa, Kazuhisa Arakawa, Tatsumasa Ando, Katsumi Kobayashi, R ...
    2013 Volume 33 Issue 5 Pages 793-801
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    Objectives and Methods: Treatment of traumatic type IIIb pancreatic injury is a clinically challenging problem. We examined reviewed 10 cases of type IIIb pancreatic injury managed at our institution. Diagnosis and Treatments: In cases where the pancreatic injury was severe, we attempted stent insertion into the pancreatic duct by ERP. Results: We performed ERP in three cases and inserted a stent in two cases. For the five cases with pancreatic body and tail injury, pancreas body and tail excision was performed. Extensive pancreatosplenectomy, bile drainage+pancreatic duct stenting, and the Letton&Wilson procedure were performed in one case each of the three patients with pancreatic head injury. PD was performed in two IIIb+D cases and one case was lost to MOF. A stent could confirm even the example which the crush of the pancreas was strong in operation, and identification and suture/ligation of the pancreatic duct were possible in all cases. Six cases showed pancreatic juice leakage after the operation, which was relieved by conservative treatment in all six cases. Conclusions: Preoperative ERP was useful for grasping the site and type of injury in patients with type IIIb pancreatic injury. In the strong case of the pancreas crush Even in cases with severe crush injury of the pancreas, insertion of a stent was effective for identification of the pancreatic duct. Damage control surgery may be recommended for poor-risk cases of pancreatic type IIIb injury.
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  • Hiroki Otani, Masatoshi Kubo, Tetsunobu Udaka, Kazutoyo Shirakawa
    2013 Volume 33 Issue 5 Pages 803-808
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    We report on 10 case sdiagnosed as having fish bone perforation of the gastrointestinal tract at our institution between 1999 and 2011. The mean age was 70 ± 10 years, and there were eight and two cases, respectively, with the acute inflammation type and chronic inflammation type of perforation? In nine cases, the fish bone could be detected on the CT obtained at admission. The site of perforation was the stomach in one case, small bowel in four cases, and sigmoid colon in two cases. The site of perforation could not be identified in the two cases of with the chronic inflammation type of perforation. In the four cases in which the CT revealed free air in the abdomen, surgery was performed and the fish bone was identified and removed from the abdominal cavity. In two of the five cases with the acute inflammation type of perforation in whom the CT did not show free air, the fish bone and site of perforation could not be identified. In one case that was managed conservatively, the fish bone was found to have disappeared in the examination conducted after a month. It is important in cases of fish bone perforation of the gastrointestinal tract to decide the therapeutic strategy according to the abdominal symptoms and findings on CT.
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  • Fumitake Hata, Hidefumi Nishimori, Morifumi Akiyama, Shinichiro Ikeda, ...
    2013 Volume 33 Issue 5 Pages 809-813
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    We retrospectively examined the effect of hyperbaric oxygen (HBO) therapy in 56 patients with postoperative intestinal obstruction seen at our institution from July 2009 through August 2010. The patients were 33 men and 23 women, with a mean age of 68.4 years. HBO therapy was performed once daily, and a set of 7 sessions was considered as one term of therapy. The therapy was discontinued when the obstruction resolved. HBO therapy needed to be interrupted in 5 patients due to choking, claustrophobia, etc. Twenty cases underwent in HBO therapy combined with a short or long tube. The recovery rate after HBO therapy was 89.3% (50/56), the average number of times of enforcement was 5.22 (range 1 to 7). HBO therapy failed in 4 patients (7.8 %), excluding those patients in whom the therapy was interrupted, and the average number of times of enforcement in these patients was 6 (range 3 to 7). In spite of additional medical treatment, these 4 patients ultimately required surgery. It is suggested that surgery should be considered in patients when conservative therapy combined with HBO is not effective.
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  • Teppei Yamada, Yasuhide Fuchino, Kaori Nii, Kenji Maki, Hiroki Tani, S ...
    2013 Volume 33 Issue 5 Pages 815-820
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    Preventive appendectomy in cases of asymptomatic appendiceal diverticulosis is controversial, whereas appendiceal diverticulitis is associated with a high perforation rate. We conducted a retrospective analysis of all appendectomy specimens received at our hospital, and encountered 27 cases of diverticulosis of the appendix among the 1,004 patients in whom appendectomy was performed appendectomy specimens examined from 1993 to 2010. The average age of the patients was 49.4 years old, and the sex ratio was 16: 11 (male: female). The average period from onset to the first medical examination was 2.8 days. Only two patients of the 27 had received the correct diagnosis preoperatively. All patients were treated by laparotomy. In the postoperative pathological study, all cases had pseudodiverticulosis, associated with diverticulitis in 26 cases and with perforation in 9 cases (33.3%). The perforation rate in cases of appendiceal diverticulitis was statistically significantly higher than that in cases of acute appendicitis (3.0%) (p<0.0001). In regard to the postoperative course, there were significant differences in the number of cases with abscess formation, operations for peritonitis, and length of hospitalization between the perforation group and the non-perforation group. The risk of perforation in cases of appendiceal diverticulitis was 10 times that in cases of acute appendicitis. When the disease is detected incidentally, strict follow-up of the clinical course is essential, and in cases where diverticular inflammation is suspected, prompt surgical resection is recommended.
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  • Shunsuke Otani, Shigeto Oda, Eizo Watanabe, Ryuzo Abe, Taku Oshima, No ...
    2013 Volume 33 Issue 5 Pages 823-827
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    Normal intra-abdominal pressure (IAP), usually measured indirectly as intra-bladder pressure, is in the range of 5-7 mmHg. Sustained high IAP (≥12 mmHg) is termed intra-abdominal hypertension (IAH), and the abdominal compartment syndrome (ACS) is defined as sustained IAH (>20 mmHg) complicated by novel organ failure or dysfunction. ACS is categorized according to the cause into three types; primary, secondary, and recurrent ACS. Primary ACS is of abdominal origin, such as that caused by blunt abdominal trauma and acute pancreatitis. Secondary ACS is of extra-abdominal origin, such as that caused by severe burns, multiple trauma requiring massive fluid and blood administration, etc. Recurrent ACS occurs following closure of the distended abdomen due to primary or secondary ACS. A stepwise approach has been suggested for the management of ACS; 1) emptying of the gastrointestinal tract, 2) drainage of intra-abdominal fluids, 3) improvement of the abdominal wall compliance, 4) optimization of fluid administration, and 5) adjustment of local and systemic tissue perfusion. For refractory ACS, aggressive open abdominal management is warranted. Recently, damage control resuscitation, or restrictive fluid management to avoid ACS has been recommended, especially for cases of ACS complicating abdominal trauma. Novel closure methods for open abdomen have also been proposed to avoid recurrent ACS.
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  • Norio Sato, Shinichiro Shiraishi, Shiei Kin, Kenichiro Omoto, Takayuki ...
    2013 Volume 33 Issue 5 Pages 829-835
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) occur in the presence of acute pancreatitis, ruptured abdominal aortic aneurysm, major burn and major trauma etc. Critically ill patients such as potentially cause ACS and IAH must be treated in the intensive care unit (ICU). Nutritional guidelines in the ICU including acute pancreatitis, major burn recommend early enteral nutrition for those patients. However practical difficulties are sometimes encountered if the patient has IAH. We retrospectively summarized our experience with early enteral nutrition for severe acute pancreatitis and we suggest that the strategy of enteral nutrition for patients which potentially cause ACS.
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  • -Efficacy of Vacuum Packing Closure-
    Hirotaka Yamamoto, Hiroaki Watanabe, Yasuaki Mizushima, Tetsuya Matsuo ...
    2013 Volume 33 Issue 5 Pages 837-840
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    Background: Abdominal compartment syndrome (ACS) may lead to multiple organ failure if left undiagnosed, therefore, intra-abdominal pressure monitoring is recommended for high-risk patients. However, currently, epidemiologic factors predicting the development of ACS remain elusive, and no guidelines exist for selecting a method for temporary abdominal closure (TAC) after decompressive laparotomy (DL). We analyzed ACS patients treated at our institute to clarify the risk factors for the development of ACS. In addition, we examined trauma patients who underwent damage control surgery (DCS) and evaluated the advantage of vacuum packing closure (VPC). Methods:Medical records of ACS patients treated at our institute since 2004 were reviewed. Trauma patients who underwent DCS between 1994 and 2011 were categorized into two groups according to the method of TAC, namely VPC and skin closure, and evaluated the efficacy of VPC. Results: Massive fluid resuscitation, coagulopathy and metabolic acidosis were commonly seen among all ACS patients. Hypothermia and abdominal/pelvic trauma were also commonly seen in the trauma patients. After DCS, postoperative ACS was less frequent among the patients in the VPC group. Conclusion: Patients receiving massive fluid resuscitation, coagulopathy and metabolic acidosis should be monitored for the development of ACS. After DL, VPC is an excellent method for TAC.
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  • Hiroyuki Koami, Tsutomu Isa, Shinichiro Kameyama, Tomonari Ishimine, T ...
    2013 Volume 33 Issue 5 Pages 843-848
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    We have had several opportunities to perform open abdominal management (OAM) at the Urasoe General Hospital. We evaluated the data of 4 of our consecutive severe trauma cases (mean age 25.8 years; male 75%) who received OAM between April 2009 and October 2011. The major characteristic features of our OAM were “silo closure with a continuous suction system” and the “simple pulling-up method”. All patients were diagnosed as having severe abdominal trauma with hemorrhagic shock, the trauma sustained in a motor vehicle accident in 2 cases, by fall from a height in 1 case, and by crush injury in 1 case. Emergent operation as well as interventional radiology (IVR) was performed in 3 patients. The indications for OAM were primary ACS (1 case), difficulty in wound closure (1 case), and damage control surgery (2 cases). It was possible to close the abdominal fascia in 3 patients, and 2 of the patients were still surviving at 30 days. OAM is available method feasible for general surgeons, moreover, it is often necessary to undertake OAM to prevent ACS.
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  • Shokei Matsumoto, Nao Hiroe, Masayuki Shimizu, Motoyasu Yamazaki, Yuki ...
    2013 Volume 33 Issue 5 Pages 849-854
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    Background: In recent years, damage control surgery has been widely used, and as such, the number of patients with abdominal compartment syndrome has been increasing. Under this circumstance, it is often impossible to close the abdomen using standard methods. We often use the Wittman patch for these cases. Indication: Candidates for the Wittman patch are those who still have an open abdomen five days or more after temporary abdominal closure. We use vacuum pack closure for temporary abdominal closure. If the intra-abdominal pressure rises over 12 mm Hg after abdominal closure, use of the Wittmann patch is preferable to forcing abdominal closure. Every second day, the patch is closed as much as is tolerated in the ICU. The ability to sequentially approximate the abdominal wall prevents significant loss-of-domain and enables definitive abdominal closure. Results: We managed eight cases of open abdomen. It was possible to achieve definitive abdominal closure in a mean of 6.5 days (4^8 days). Definitive abdominal closure could be performed in all patients. None of the patients developed ventral hernia. Conclusion: It is possible to safely perform definitive abdominal closure using the Wittmann patch and measuring the intra-abdominal pressure.
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  • Futoshi Ogawa, Kosuke Nakano, Kohei Yonezawa, Masaki Koide, Kotaro Hos ...
    2013 Volume 33 Issue 5 Pages 855-863
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    We studied the abdominal closure method for cases in whom open abdominal management was undertaken for the abdominal compartment syndrome. For 88 patients in whom open abdominal management was undertaken at our department of emergency and critical care medicine over the past 10 years, I examined the abdominal closure method and patient characteristics between the earlier 5-year period and latter 5-year period. In typical abdominal closure There were no significant differences in the patient characteristics between the 40 patients managed in the earlier 5-year period and 48 patients managed in the latter 5-year period. In atypical abdominal closure, free skin grafting and the bilateral anterior rectus abdominal sheath turnover flap method were performed and abdominal closure was completed after the abdominal wall was covered with granulation tissue. In the latter period, a lot of component separation methods are performed within 14 days, and the intra-abdominal pressure and peak airway pressure at abdominal closure were high however, there were few serious complications, and the prognosis was good. It was thought that the component separation method was useful to avoid rise of intra-abdominal pressure for atypical abdominal closure in the acute phase. Atypical abdominal closure taking into account the intra-abdominal pressure was effective as an abdominal closure method after open abdominal management.
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  • Hidetoshi Akashi, Seiji Onitsuka
    2013 Volume 33 Issue 5 Pages 865-870
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    Results of open repair for ruptured AAA (rAAA) are still not satisfactory, because of the high risk of multiple organ failure (MOF) due to the abdominal compartment syndrome (ACS). A recent study has reported an open management technique offering the potential for reduced mortality (10^20%). After open repair of an rAAA, tight surgical closure of the abdominal wall can result in the ACS because of severe edema of the intestine resulting from excessive? fluid resuscitation, intra-abdominal hematoma formation and reperfusion injury. Numerous studies since the 1990s have reported the effectiveness of open management, or delayed closure, for the prevention of ACS in patients with rAAA. We suggest that an intra-abdominal pressure ≥ 20 mmHg should lead to a decision of open management and delayed closure in patients with rAAA. Early introduction of open management, delayed closure and vacuum-assisted closure (VAC) techniques offer promise for decreased morbidity and mortality.
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  • Masaki Imaeda, Akira Ishikawa, Seiji Ogiso, Kenji Sakaguchi, Takashi K ...
    2013 Volume 33 Issue 5 Pages 871-874
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    A 79-year-old woman was admitted with a 2-day history of vomiting and epigastric pain. The patient was fully conscious and the vital signs were stable. She complained of spontaneous abdominal pain and a mild swelling was observed in the upper abdomen; however, there was no tenderness or other evidence of peritoneal irritation. MDCT-MPR images revealed the extended, small intestine on the ventral side of the transverse colon, a positive beak sign and mesenteric convergence. Based on the findings, we made the diagnosis of transomental hernia. CT revealed no ischemic changes, and since the abdominal findings also tended to subside, we started conservative medical treatment with ileus tube insertion. Decompression of the upper small intestine was achieved successfully, however, the incarcerated hiatal hernia was not released. We conducted laparotomy on day 5. The jejunum was found to be invaginated in the abnormal omental hiatus, however, the intestinal segment was not ischemic. The diagnosis of transomental hernia must be kept in mind in patients with no history of laparotomy presenting with ileus. MDCT-MPR may be useful for the diagnosis.
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  • Takao Yamamoto
    2013 Volume 33 Issue 5 Pages 875-878
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    We report a case of GIST of the duodenum with bleeding, in which pancreaticoduodenectomy (PD) was successfully performed after hemostasis was first accomplished by TAE. A 39-year-old female was admitted to our hospital with a history of melena. Abdominal CT revealed a hypervascular tumor measuring 40 mm in diameter in the medial part of the second portion of the duodenum. Upper gastrointestinal endoscopy showed bleeding from an exposed vessel in an ulcerated area of the submucosal tumor 2 cm distal to papilla Vater. The patient had previously undergone enucleation of a duodenal GIST at another hospital 7 years earlier, therefore, a recurrent duodenal GIST was suspected. Hemostasis was accomplished by local injection of some a hypertonic saline-epinephrine solution on the ulcer. Rebleeding occurred 7 days after the endoscopic treatment, therefore, TAE was attempted. PD was then performed safely 3 days after the TAE. The resected tumor was pathologically diagnosed as a GIST. TAE is considered to be effective pretreatment for bleeding duodenal GISTs in cases where a major surgical procedure like PD is required for resection of the tumor.
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  • Kenichiro Omoto, Takehiro Shimada, Takashi Ohishi, You Isobe, Sumio Ma ...
    2013 Volume 33 Issue 5 Pages 879-882
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    We report on a case of splenic injury in an 85-year old man following a diagnostic colonoscopy. The patient was sedated with intravenous midazolam and pethidine hydrochloride. The colonoscopic examination was completed uneventfully and the endoscopic findings were normal. Approximately 30 minutes after the procedure, the patient complained of left upper abdominal pain and went into a state of shock. An abdominal CT revealed hemo peritoneum. As the patient stabilized hemodynamically and the pain reduced in severity, we selected non-operative management. On the third day after admission, he complained of severe abdominal pain of acute onset and went into a state of shock again. Abdominal CT revealed extravasation, therefore, we performed transcatheter arterial embolization, however, the bleeding was venous therefore, we immediately performed open splenectmy. The patient made an uneventful recovery and was discharged home on the 19th day after admission to the hospital. Splenic injury following colonoscopy is rare, however, a delay in the diagnosis could be fatal. Endoscopists should therefore pay close attention when patients complain of abdominal pain after a colonoscopy.
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  • Mariko Furukori, Kimiharu Hasegawa, Kei Ohara, Tomokazu Hoshi, Masahik ...
    2013 Volume 33 Issue 5 Pages 883-886
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    An 18-year-old man was brought to our hospital by ambulance with a 2-day history of persistent fever and abdominal pain. The abdominal wall was rigid and there were strong signs of peritoneal irritation Contrast-enhanced abdominal CT revealed free air and a part for the blind end which continued from small intestine, and we diagnosed peritonitis due to perforation of a Meckel's diverticulum. An emergency laparoscopy-assisted operation was performed. Dirty ascitic fluid and perforation of a Meckel's diverticulum were found, and a wedge resection and peritoneal irrigation were performed. Histopathology revealed perforation of a Meckel's diverticulum near its tip and advanced inflammatory cell infiltration and necrosis. No ectopic tissues were detected. With the recent advances in diagnostic imaging, the preoperative diagnosis rate of Meckel's diverticulum is increasing. In the differential diagnosis of acute abdomen, it is important to carefully evaluate CT images of the abdomen taking into consideration the possibility of Meckel's diverticulum.
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  • Hidehisa Yamada
    2013 Volume 33 Issue 5 Pages 887-890
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    A 66-year-old male who had been diagnosed as having an intraperitoneal foreign body at another clinic was admitted to our hospital with acute abdominal pain and vomiting. An abdominal X-ray revealed small bow el obstruction. Abdominal computed tomography revealed a globular mass measuring 4 cm in diameter compressing the jejunum. An ileus tube was inserted to relieve the obstruction conservatively. We made the diagnosis of bowel obstruction caused by jejunal diverticulitis with an enterolith. Laparoscopic partial resection of the jejunum was performed. The jejunal diverticulum including the enterolith was present on the mesenteric side of the jejunum. On histopathological examination, a true diverticulum of the jejunum was diagnosed, along with inflammatory changes. Surgical treatment should be considered for a jejunal diverticulum with an enterolith because of the risk of diverticulitis, intestinal obstruction, and perforation.
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  • Akifumi Nakagawa, Hideo Yamamoto, Tatsuyoshi Yamamoto, Masato Momiyama ...
    2013 Volume 33 Issue 5 Pages 891-894
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    A-59-year-old woman who presented with anemia and massive intestinal bleeding was admitted to our hospital for further examination. Upper and lower gastrointestinal endoscopic examinations revealed no abnormal findings. Contrast-enhanced abdominal computed tomography revealed a tumor measuring about 2 cm in diameter in the proximal jejunum, which was well-stained in the arterial phase. Emergency operation was performed because of progressive anemia, based on the diagnosis of massive bleeding from a GIST of the small intestine. Laparotomy revealed an extramurally growing tumor in the small intestine, 30 cm from the Treitz's ligament. Partial resection of the small intestine was performed. Histopathological examination of the resected specimen revealed a low-grade GIST measuring 20×15mm diameter arising from the jejunum. The postoperative course was uneventful, and the patient remains healthy, without any evidence of recurrence. Among the cases of GIST with massive intestinal bleeding reported in Japan, the tumor diameter in the present case was the smallest. GIST usually grows extramurally and is asymptomatic when it is small in size. However, it must be borne in mind that small GISTs can also occasionally cause massive intestinal bleeding.
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  • Nozomi Ito, Hironori Tsujimoto, Isao Kumano, Satoshi Maejima, Hiroyuki ...
    2013 Volume 33 Issue 5 Pages 895-899
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    A man in his 50s who had undergone laparoscope-assisted distal gastrectomy with antecolic Roux-en Y reconstruction for early gastric cancer was admitted urgently with severe abdominal pain on the 122nd postoperative day. Physical examination revealed no signs of peritonitis. Abdominal CT showed a small amount of ascites, dilatation of a part of the jejunum, and edema of the mesentery. Emergency surgery was performed under the suspected diagnosis of strangulated ileus with internal hernia. Almost the entire jejunum was impacted in the space between the transverse colon and the elevated jejunum via the antecolic pathway, consistent with Petersen's hernia. Ischemic changes were found in the herniated jejunum, which disappeared immediately after manual reduction of the herniated jejunum. Thereafter, the defect of the mesentery was closed. The patient was discharged on the 7th postoperative day. This case underscores the importance of bearing in mind the possibility of occurrence of internal hernia in patients undergoing laparoscope-assisted gastric resection with Roux-en Y reconstruction.
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  • Taizan Minami, Eiji Nakamura, Toshio Morita, Atsuo Nakamura, Shinjiro ...
    2013 Volume 33 Issue 5 Pages 901-904
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    The patient was a 65-year-old woman. She suddenly appeared for abdominal pain who presented with abdominal pain of acute onset. Based on the physical examination and abdominal computed tomography (CT) findings, we suspected strangulated ileus. Emergency laparotomy was performed, which showed a tumor in the abdominal cavity and pooling of bloody ascites. Because abnormal omental hiatus had been adherent to the tumor, small intestine had been fitted into the same site The intestine had herniated through an abnormal omental hiatus formed by the adherent tumor. We finally diagnosed transepiploic hernia by the operation findings On the basis of the operative findings, we finally diagnosed transepiploic hernia and performed reduction of the hernia. Closure of the hernial. orifice was performed without resection of the intestine, because the herniated intestinal segment showed only congestion, with no evidence of necrosis or perforation. Transepiploic hernia is a relatively rare condition, and a number of causes of this type of hernia have been recognized, including trauma, inflammation and steroid usage. We report a rare case of transepiploic hernia which was considered to be caused by an inflammatory tumor.
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  • Yukiko Ogura, Kazuma Yamazaki, Masaaki Kodama, Satoru Kondoh
    2013 Volume 33 Issue 5 Pages 905-908
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    The patient was a 36-year-old male who visited our hospital with the chief complaint of abdominal distention. Massive ascites with a high ADA level of the ascitic fluid and CT evidence of smooth uniform peritoneal thickening were observed, with no specific findings on bacteriological examination of the ascitic fluid. Because of the strong suspicion of tuberculous peritonitis, a diagnostic laparoscopy and biopsy were performed to obtain an accurate diagnosis. The diagnosis of tuberculous peritonitis was confirmed by histopathological examination of biopsy specimens obtained from the tiny white nodules on the peritoneum, which showed epithelioid cell granulomas with Langhans’ giant cells. The patient was successfully treated and cured with a 6-month regimen of isoniazid (INH), rifampicin (RHP), ethambutol (EB) and pyrazinamide (PZA). Although early diagnosis of tuberculous peritonitis is important for effective treatment and reducing the mortality, it is often difficult to make a precise diagnosis from the clinical findings and examinations. An exploratory laparoscopy with biopsy is useful for obtaining an accurate diagnosis.
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  • Tomoko Tohma, Yoshikazu Yamamoto, Satoru Takaishi
    2013 Volume 33 Issue 5 Pages 909-912
    Published: July 31, 2013
    Released: September 27, 2013
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    A 69-year-old male with Crohn's disease presented with abdominal pain. He had a 35-year history of Crohn's disease involving the small intestine, and had been treated with 5-ASA. A CT examination showed hepatic portal venous gas (HPVG). A follow-up CT performed six hours later revealed complete resolution of the portal venous gas, however, the patient's abdominal examination findings remained unchanged. We performed laparotomy. Obstruction of the small bowel was found, however, no necrotic changes were observed. HPVG, occurring both spontaneously and following colonoscopy, has been reported previously in Crohn's disease patients. Herein, we report a case of Crohn's disease in which the initial presentation included HPVG. Pertinent literature on HPVG associated with Crohn's disease is also reviewed.
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  • Nobutoshi Hagiwara, Takeshi Matsutani, Tsutomu Nomura, Masao Miyashita ...
    2013 Volume 33 Issue 5 Pages 913-917
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    A 62-year-old man underwent a subtotal esophagectomy via laparotomy and right thoracotomy for advanced esophageal cancer. Reconstruction was performed with a gastric conduit through the posterior mediastinal route, with jejunostomy. On postoperative day 7, anastomotic leakage was caused by necrosis of the gastric conduit. After resection of the partially necrotic segment of the gastric conduit the distal gastric conduit was placed on the antethoracic subcutaneous portion. Esophagostomy was performed through the reopened cervical wound. The patient was referred to our hospital for reconstruction after stabilization of the general condition. Reconstruction was performed using a gastric conduit and a free jejunal graft with microvascular anastomosis. On postoperative day 4, the patient complained of abdominal pain and vomiting. An abdominal CT showed hepatic portal venous gas in the left lobe of the liver and pneumatosis cystoides intestinalis in the wall of the small intestine. The emergency operative findings showed adhesion of the jejunum on the anal side of the jejunostomy to the peritoneum. The distal small intestinal loop was impacted between this adhesion and the jejunostomy as an internal hernia. However, since no circulatory disturbance of the small intestine was observed, the small intestine was not resected. The postoperative course was uneventful, and the patient was discharged from our hospital on postoperative day 21. We report this rare case of hepatic portal venous gas and pneumatosis cystoides intestinalis resulting from internal hernia after esophageal cancer surgery.
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  • Kazuhiro Toyota, Yuji Sugawara
    2013 Volume 33 Issue 5 Pages 919-921
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    The patient was an 81-year-old male who had undergone endoscopic resection of a polyp in the ascending colon in August 2010. At the end of April 2012, he visited our hospital with the complaint of localized, progressively worsening right lower abdominal pain, and was diagnosed as having appendicitis and hospitalized. An X-ray examination revealed two clips used for the endoscopic therapy overlapping in a V formation in the right lower abdomen, and CT showed the clips at the tip of the appendix. Emergency laparotomy was performed. The appendix was found to be thickened and surrounded by an abscess; therefore, appendectomy and drainage were performed. Two clips arranged in a V formation were found to be stuck in the appendix, perforating it. It is rare for endoscopic clips to cause harm; however, as in this case, multiple clips can together cause perforation.
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  • Yosuke Kato, Kaeko Oyama, Keiko Murasugi, Toshiyuki Okuda, Naohiro Ota ...
    2013 Volume 33 Issue 5 Pages 923-926
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    We encountered 2 cases of acute cholecystitis in which the condition developed after coronary artery bypass grafting (hereinafter, CABG) using the right gastroepiploic artery (hereinafter, RGEA). Case 1 was a 70-year-old male who was diagnosed as having perforated acalculous cholecystitis, and emergency abdominal surgery was performed after first confirming running RGEA grafted blood vessels upon blood flow in the grafted RGEA by CT imaging. Case 2 was a 72-year-old male who underwent conservative therapy after being diagnosed as having mild acute cholecystitis. Running RGEA grafted blood vessels were Blood flow in the grafted RGEA was confirmed by vascular reconstruction 3D-CT, and laparoscopic surgery was electively performed. In both cases, RGEA grafted blood vessels blood flow in the grafted RGEA was intraoperatively confirmed with no injuries, and the patients were discharged from the hospital with no complications. It was possible to perform cholecystectomy by either laparotomy or laparoscopic surgery; however, considering that it is invasive and allows safe confirmation of the blood flow in the grafted blood vessels, it is believed that endoscopic surgery would be highly advantageous. With respect to acute cholecystitis following CABG using an RGEA graft, it is believed that further safety can be ensured by avoiding emergency surgery in such cases as much as possible and performing surgery after sufficient preoperative planning.
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  • Takahiro Toyokawa, Hitoshi Teraoka, Kishu Kitayama, Shinya Nomura, Isa ...
    2013 Volume 33 Issue 5 Pages 927-931
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    A 64-year old man was transferred to the emergency department of our hospital because of loss of consciousness. On arrival, he was conscious, but in a state of shock. Although his blood pressure improved with our treatment, he complained of progressively worsening lower abdominal pain, and signs of peritoneal irritation became apparent the following morning. Abdominal CT showed moderate ascites and pneumatosis in the wall of the small intestine. Emergency operation was performed under the tentative diagnosis of nonocclusive mesenteric ischemia. Intraoperatively, we found a necrotic lesion approximately 10 cm in diameter about 15 cm proximal to the distal ileum; the damaged segement of the ileum was partially resected. Histopathology confirmed the diagnosis of necrotic-type ischemic enteritis. The postoperative course was uneventful and the patient was discharged 9 days after the operation. Since necrotic-type ischemic enteritis is rare, we report this case with a review of the literature.
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  • -A Case Report-
    Hideaki Murase, Ryo Oono, Kenta Kobayashi, Yoshihiro Ueda, Megumu Enjo ...
    2013 Volume 33 Issue 5 Pages 933-935
    Published: July 31, 2013
    Released: September 27, 2013
    JOURNALS FREE ACCESS
    A 67-year-old woman diagnosed as having advanced gastric cancer was treated by distal gastrectomy after three courses of neoadjuvant chemotherapy with docetaxel, cisplatin and S-1 (DCS). She was initiated on treatment with S-1 as postoperative chemotherapy, however, the occurrence of anorexia as a severe adverse event necessitated discontinuation of S-1 after the first course. Three months after surgery, the patient was admitted again with anorexia and nausea. Abdominal CT scan showed gas within the bladder wall and emphysematous cystitis was diagnosed. The condition improved after urinary drainage and antibiotic therapy. To the best of our knowledge, 9 cases of emphysematous cystitis with cancer have been reported in Japan. In our case, the emphysematous cystitis was associated with anorexia after gastrectomy for gastric cancer.
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