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 7
Showing 1-28 articles out of 28 articles from the selected issue
  • Akihiro Kushima, Masaya Takahashi
    2013 Volume 33 Issue 7 Pages 1083-1087
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    We evaluated the age, sex, body mass index, site of onset, diagnosis, anesthesia method, approach, repair of the hernia orifice, presence or absence of intestinal resection, outcomes, recurrence, and contralateral onset in 28 obturator hernia patients, who underwent surgery at our hospital from June 1989 to July 2011. The mean patient age was 84 years, and all were female. From 1995, it was possible to make a correct diagnosis in 96% cases based on CT scan imaging. From 2000, 23% patients underwent surgery through a low abdominal median incision, whereas 77% patients underwent the inguinal approach, and repair of the hernia orifice was performed in 95% cases using meshes. Ipsilateral recurrence occurred in 12% cases, and contralateral recurrence occurred in 7.7% cases. The recurrence rate was 29% in cases that did not undergo repair of the hernia orifice with meshes and 4.8% in cases that did. Although no surgical procedure has been established for incarcerated obturator hernia, the method of closing the hernia orifice via the placement of meshes in the preperitoneal space using the inguinal approach could be beneficial in many cases.
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  • Naoki Hashizume, Tomomitsu Tsuru, Kiyotoshi Hanashiro, Naruki Higashid ...
    2013 Volume 33 Issue 7 Pages 1089-1092
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    [Introduction] Pediatric patients with liver injury after blunt abdominal trauma at our institute were clinically investigated and assessed. [Subjects and methods] An investigation was carried out regarding 15-year-old or younger patients with liver injury among patients with an average age of 15.5 yr that were transported to the ER due to blunt abdominal trauma. [Results] There were 39 cases of liver injury. Regarding the severity, there were 30 cases of subcapsular injuries, 2 cases of superficial injuries, and 7 cases of severe injuries. Transcatheter arterial embolization (TAE) was carried out on 9 cases (5 cases of extravasation, 3 cases of pseudoaneurysm, 1 case of arteriovenous fistula), with hemostasis successful in all cases, leading to conservative therapy being carried out. Delayed intraperitoneal bleeding was observed in 1 case during conservative therapy, however there were no cases requiring surgery or cases of death due to liver damage. [Conclusion] Stable non-surgical management was possible by carrying out TAE on liver trauma-associated vascular injuries.
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  • Yukiko Ogura, Kazuma Yamazaki, Masaaki Kodama, Satoru Kondho
    2013 Volume 33 Issue 7 Pages 1093-1096
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    (Purpose) We clinically reviewed patients with obturator hernias who were treated in our hospital. (Subjects and Methods) The subjects were 14 patients who underwent surgery in our hospital between 2000 and 2012. The mean age was 82.8 years old, and all patients were females. The mean BMI was 18.2 kg/m2. The majority of the chief complaints was vomiting or abdominal pain, and the Howship-Romberg sign was observed in 5 cases. Preoperative CT scan revealed obturator hernia in 12 patients. Preoperative duration from onset was 1-18 days. Emergency surgery was performed with the open method in all cases. (Results) Seven of the 14 patients underwent partial resection of the small intestine and the other 7 patients were saved from intestinal resection, the mean preoperative duration in whom was 4.7 days and 1.1 days, respectively. In patients with intestinal perforation, the preoperative duration was more than 3 days. The hernia hilus in 6 cases was closed with simple closure, and with artificial mesh in 6 cases. Twelve of the 14 patients were discharged or transferred to another hospital. (Conclusion) All the patients with obturator hernia were elderly females who were slender. An early CT scan should be performed for an accurate diagnosis, because early diagnosis and surgery were important to avoid intestinal resection.
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  • Izuru Ohtsubo, Tetsuo Ajiki, Taro Okazaki, Kenta Shinozaki, Yuko Yoshi ...
    2013 Volume 33 Issue 7 Pages 1097-1102
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    Recently, the age of the general population is increasing and many patients taking orally antithrombogenic drugs undergo cholecystectomy. We retrospectively reviewed the patients with cardiovascular diseases who had undergone cholecystectomy and examined the problems of the intake of antithrombogenic drugs in these patients. We performed laparoscopic cholecystectomy (Lap-C) in 151 patients and open cholecystectomy (OC) in 50 patients during the period from 2009 to 2011. Among 31 patients (20.5%) who were taking antithrombogenic drugs orally, 19 underwent Lap-C and 12 underwent OC. Intraoperative bleeding was not significantly different between patients with or without antithrombogenic therapy. No severe complications were seen in patients who underwent Lap-C, but 1 patient who underwent OC had cardiac arrest during induction of anesthesia. No patient died within the perioperative period. Bridging anticoagulation with heparin was performed in 11 patients (Lap-C 5, OC 6) and these patients had a longer hospitalization than those without heparinization. Even in patients who took antithrombogenic drugs orally, cholecystectomy was safely performed with careful perioperative management.
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  • Go Hoshino, Yoshiyuki Ishii, Hirotoshi Hasegawa, Takashi Endo, Koji Ok ...
    2013 Volume 33 Issue 7 Pages 1103-1108
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    The purpose of this study was to clarify the usefulness of predictive scoring systems for the postoperative mortality of patients with colorectal perforation using the Acute Physiological and Chronic Health EvaluationII (APACHEII), Sequential Organ Failure Assessment (SOFA), Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), and the Mannheim Peritonitis Index (MPI). A total of 54 patients with colorectal perforation underwent a surgical procedure in our hospital between 2006 and 2011. The score of each risk assessment was retrospectively calculated, and the association between each score and mortality was evaluated in these patients. Furthermore, optimal cut-off values for the mortality were determined by Receiver Operating Characteristics (ROC) curve analysis for each system. The each risk assessment score was significantly higher in the non-survivors than in the survivors. According to the optimal cut-off values for the mortality, the APACHEII system had the highest sensitivity (100%), and the SOFA system had the highest specificity and accuracy (90% and 89%) among the four risk assessment systems. In conclusion, APACHEII and SOFA systems were useful for predicting postoperative mortality in patients with colorectal perforation.
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  • Chikara Kunisaki, Hirochika Makino, Jun Kimura, Takashi Oshima, Ryo Ta ...
    2013 Volume 33 Issue 7 Pages 1111-1117
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    In Japan, Many surgeons do not pay attention to prophylaxis against venous thromboembolism (VTE) after gastroenterological surgery. However, the incidence of VTE in Japan is regarded to be almost the same as in Western countries. Moreover, deep vein thrombosis (DVT) sometimes induces fatal pulmonary thromboembolism (PE), therefore, it is necessary to perform optimal prophylaxis against VTE according to the risk stratification after surgery. For example, we recommend low-molecular weight heparin combined with mechanical prophylaxis using elastic stockings or intermittent pneumatic compression (IPC) for middle-aged or elderly patients having gastroenterological cancer. Moreover, it is necessary to consider the balance of the values and preferences of prophylaxis against VTE, and toxicities such as bleeding complications when we perform pharmacologic prophylaxis by estimating the operative method and background in each patient.
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  • Nobuhiro Kurita, Mitsuo Shimada, Takashi Iwata, Hirohiko Sato, Kozo Yo ...
    2013 Volume 33 Issue 7 Pages 1119-1124
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    Purpose: A randomized study using three anticoagulants for prevention of venous thromboembolism (VTE) was designed to clarify the utility and adverse events for high risk patients after major abdominal-pelvic surgery. Based on the results of a random clinical trial (RCT), Enoxaparin has been provided for high risk patients after major abdominal-pelvic surgery since April, 2012 and clinical outcomes were evaluated. Patients and methods: RCT protocol: Three hundred and three high risk patients who underwent major abdomino-pelvic surgery were randomly divided into three groups as follows: Enoxaparin 2,000 IU×2/day 7 days: Group E (n=99), Fondaparinux 2.5 mg×1/day 7 days: Group F (n=101), and unfractionated heparin 5000 U×2/day 7 days: Group H (n=103). All patients received unfractionated heparin 5000 IU intravenously for 24 hours just after the operation. The clinical outcomes were recorded in the 152 high risk patients who underwent abdomino-pelvic major surgery and who had received Enoxaparin (2000 IU×2/day 7 days). Results: RCT: Symptomatic VTE was not confirmed in any of the three groups. Anti-coagulant therapy was interrupted by hemorrhagic adverse events in Groups E, F, H as follows: n=9 (9.1%), n=9 (8.9%), and n=11 (10.7%), respectively, including one re-operation in Group H. No epidural catheter was inserted in patients from Group F based on the instructions of the Department of Anesthesiology. Conclusion: All three drugs were useful to prevent VTE. Based on our results, Enoxaparin could become a first choice drug.
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  • Masataka Ikeda, Masato Sakon, Taishi Hata, Mamoru Uemura, Jyunichi Nis ...
    2013 Volume 33 Issue 7 Pages 1125-1129
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    Background: We herein introduce our program for the prevention of venous thromboembolism (VTE) in patients with malignant diseases. Methods: All patients (1,408 males and 750 females) elected to undergo surgery in our Department were surveyed. Surveillance was conducted three times a week, and data were collected prospectively. Results: The mean age of patients was 63, and the mean body mass index (BMI) was 22.2. Open and laparoscopic surgery were performed on 1,311 and 847 patients, respectively. The mean operation time was 306 min. Elastic stocking and/or an intermittent pneumatic compression (IPC) device was used in 99% of patients for one day after the operation. Pharmacological VTE prophylaxis was performed in 6.2% of patients. Symptomatic VTE was detected preoperatively in 3 patients (0.14%), and postoperatively in 4 patients (0.19%). No fatal VTE was detected. Conclusion: The ratio of pharmacological VTE prophylaxis remains low compared to the mechanical prophylaxis. Appropriate VTE prophylaxis according to the risk of VTE may reduce the incidence of symptomatic VTE.
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  • Takashi Yazawa, Tsutomu Takenami, Tomoyuki Ono, Tomochika Tachibana, A ...
    2013 Volume 33 Issue 7 Pages 1131-1136
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    Introduction: The incidence of deep vein thrombosis (DVT) after gastric surgery in Japan has not been adequately studied. We assessed the incidence of DVT using our strategy for the diagnosis of DVT and the efficacy of fondaparinux for the prophylaxis against DVT after gastric cancer surgery. Patients and Methods:Two hundred and seventy-three gastric cancer patients underwent ultrasonography of the lower limbs for the detection of DVT. D-dimer levels were measured 4 times: before surgery, 1, 4, 7 and 14 days after surgery. Patients who were admitted after October 2010 received fondaparinux 2.5 mg subcutaneously once-daily. We examined the incidence of DVT between patients with and without fondaparinux. Results: The DVT incidence was 21%. According to receiver operating characteristic curve analysis, the resulting cut-off value of the D-dimer level 7 days after surgery was 11.0 μg/mL (sensitivity 68%; specificity 75%). DVT was detected in 15% of patients in the fondaparinux group and 28% in the control group. Conclusion: We assessed strategies for diagnosis of DVT combining the use of D-dimer and ultrasonography. Fondaparinux 2.5 mg/day may be a valuable therapeutic option for preventing DVT after gastric surgery.
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  • : Safety of our Protocol Using Fondaparinux
    Hiroshi Yamaguchi, Tomohisa Furuhata, Kenji Okita, Toshihiko Nishidate ...
    2013 Volume 33 Issue 7 Pages 1137-1144
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    We applied a new protocol for thromboprophylaxis using Fondaparinux in 74 patients who underwent laparoscopic colorectal cancer surgery. In our protocol, Fondaparinux was injected subcutaneously once per day from postoperative day 1, at least 24 hours after the end of surgery, to postoperative day 5. Epidural tubes were removed at least 24 hours after the final administration of Fondaparinux. Compliance with the protocols was excellent. There were no complications associated with epidural tubes. Only 1 patient developed a symptomatic venous thromboembolism at postoperative day 14. Postoperative complications including bleeding did not increase in these 74 patients when compared retrospectively with our historical cases before applying this new protocol. Therefore, we suggest our new protocol for thromboprophylaxis can be safely applied to patients after laparoscopic colorectal cancer surgery. Additionally, we observed a perioperative transition of serum D-dimer concentrations and divided the patients into two groups. The group in which the serum D-dimer concentration continued to increase after surgery had more risk factors associated with venous thromboembolism than the other group in which the serum D-dimer concentration did not continue to increase post-surgery.
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  • Keishi Nakamura, Hideto Fujita, Toshifumi Watanabe, Sachio Fushida, Ta ...
    2013 Volume 33 Issue 7 Pages 1145-1152
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    [Purpose] The aim of this study was to investigate the incidence and risk factors of deep vein thrombosis (DVT) in colorectal cancer patients during the perioperative period. [Methods] We retrospectively reviewed 114 patients, who had undergone colorectal surgery at Kanazawa University Hospital between September 2010 and August 2013. The assessment of DVT in the lower extremities was performed using ultrasonography. [Result] The incidence of DVT in the perioperative period was 26.3%. The incidence of DVT before and after surgery was 18.4% and 23.7%, respectively. The significant variables identified by multivariate analyses were sex and previous venous thromboembolism (VTE) as an independent risk factor of preoperative DVT. The significant variables during the postoperative period were organ/space surgical site infection (SSI) and DVT diagnosed preoperatively as an independent risk factor of postoperative DVT. [Conclusion] We should perform screening for DVT during the perioperative period for colorectal cancer patients having several risk factors.
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  • So Yamaki, Hideyoshi Toyokawa, Sohei Satoi, Hiroaki Yanagimoto, Tomohi ...
    2013 Volume 33 Issue 7 Pages 1153-1156
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    In a retrospective study in our institution from January 2006 to March 2010, postoperative hypotension (systolic blood pressure of<90 mmHg) developed in 81 (42%) of 194 patients who underwent pancreaticoduodenectomy with epidural anesthesia and analgesia (EAA). Wound dehiscence occurred significantly more often in patients with postoperative hypotension (p=0.015). In June 2011, the transversus abdominis plane block with continuous fentanyl infusion was introduced for postoperative analgesia. Low-molecular-weight heparin was simultaneously administered for the prevention of postoperative venous thromboembolism. Only 5 patients (18%) developed postoperative hypotension, and no thromboembolic events occurred. In conclusion, postoperative hemodynamic instability due to EAA may lead to increased postoperative complications. Administration of low-molecular-weight heparin may be a safe method for the prevention of venous thromboembolism.
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  • Hiroki Hayashi, Takanori Morikawa, Fuyuhiko Motoi, Hiroshi Yoshida, Ta ...
    2013 Volume 33 Issue 7 Pages 1157-1164
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    Although chemical thromboprophylaxis after abdominal surgery is recommended for preventing postoperative venous thromboembolism (VTE), the use of such drugs after major hepatobiliary-pancreatic surgery is typically avoided due to the increased risk of hemorrhage. We analyzed the rates of postoperative bleeding events, VTE and morbidity to evaluate the safety and efficacy of chemical thromboprophylaxis in 466 patients who underwent major hepatobiliary-pancreatic surgery. Four thousand international units per day of enoxiaparin were administered for 90 patients, 2.5 mg/day and 1.5 mg/day of fondaparinux was administered for 125 and 58 patients, respectively. The remaining 193 patients did not receive any chemical prophylaxis. Chemical thromboprophylaxis was associated with a significantly increased rate and risk of overall bleeding events as compared to patients who did not receive chemical thromboprophylaxis. Most of the postoperative hemorrhage was minor and chemical prophylaxis did not increase the risk of major hemorrhage requiring blood transfusion or hemostatic intervention. The rate of VTE was decreased in the patients with chemical prophylaxis. We consider that chemical thromboprophylaxis is beneficial and can be safely used even after major hepatobiliary-pancreatic surgery.
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  • Takahiro Masuda, Fumiaki Yano, Hiroaki Aoki, Mitsumori Mitsumori, Nobu ...
    2013 Volume 33 Issue 7 Pages 1165-1168
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    A 59-year-old man was admitted to the emergency room with hematemesis, melena and general malaise. His hemoglobin was 6.2g/dL, for which a transfusion of 8 U of packed red blood cells was administered. He immediately underwent upper gastro-intestinal endoscopy and a hemorrhagic ulcer was confirmed at the posterior wall of the duodenal bulb, which was controlled by endoscopic hemostasis. Abdominal CT showed irregular swelling of the antral wall of the stomach and the duodenum, as well as portal vein thrombosis (PVT) with gas in the portal vein. On the next day, angiography was performed for persistent anemia, but no active bleeding from the duodenal ulcer was identified. On the same day, due to progressive anemia, he underwent emergency surgery. Due to poor visibility around the duodenum caused by bleeding, the anterior wall of the duodenum was opened and bleeding was confirmed to originate from a perforation of the portal vein due to the duodenal ulcer. The perforated portal vein wall was sutured with the surrounding tissue, then a distal gastrectomy and jejunostomy were performed. Immediately after the operation, liver damage due to PVT became evident. The patient died on the 12th post-operative day. Portal vein perforation due to duodenal ulcer is extremely rare.
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  • Hiroe Maeda, Naoya Aisu, Kazunosuke Yamada, Nobuhide Matsuoka, Tomoaki ...
    2013 Volume 33 Issue 7 Pages 1169-1172
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    A 66-year-old woman complaining of abdominal pain was transported to our hospital with a diagnosis of retroperitoneal hematoma. Contrast-enhanced computed tomography of the abdomen showed a retroperitoneal hematoma around the pancreas head. An angiogram revealed that there was an aneurysm 10 mm in diameter in the anterior inferior pancreaticoduodenal artery (AIPDA). The gastroduodenal artery (GDA) and the AIPDA were supplied from the superior mesenteric artery. A diagnosis was made of a ruptured AIPDA aneurysm due to celiac artery compression by the median arcuate ligament. Transcatheter embolization of the aneurysm was performed followed by the surgical decompression of the celiac artery. The patient is currently doing well with no sign of recurrence of the aneurysm.
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  • Yuki Yamasaki, Seiichi Yamamoto, Kentaro Sakurai, Ayako Kanamoto, Akir ...
    2013 Volume 33 Issue 7 Pages 1173-1176
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    We report herein on a case of gallstone ileus which recurred during the early postoperative period. The patient was a 51-year-old woman. who had been referred to our hospital due to nausea and vomiting. Gallstone ileus was suspected from the CT scan findings and an emergency operation was undertaken with an enterotomy and lithotomy revealing and extracting two gallstones 4 cm at their smallest diameter. Because of severe inflammation of the gallbladder, a cholecystectomy was not performed. Although the patient was discharged on postoperative day 9, abdominal pain and vomiting appeared again on postsurgical day 30. Under the diagnosis of recurrent gallstone ileus, we removed a gallstone from the ileum, and sequentially performed cholecystectomy and closure of the fistula. It is controversial whether a one or a two-stage procedure is the optimal surgical treatment of gallstone ileus. This case of gallstone ileus recurred during the early postoperative period because we had not closed the fistula.
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  • Ryo Oono, Toshiyuki Ishiba, Yu Hiraoka, Shinya Ishimaru, Megumu Enjyoj ...
    2013 Volume 33 Issue 7 Pages 1177-1179
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    We report herein on a patient with an esophageal hiatus hernia after an open total gastrectomy. The patient was a 73-year-old male who underwent open total gastrectomy and Roux-en-Y reconstruction for cardiac gastric cancer. Six months postoperatively he visited our hospital with dysphagia, which became progressively worse. A computed tomography scan showed that the dilated intestine was located in the left thoracic space, leading us to make a diagnosis of esophageal hiatus hernia after total gastrectomy. The repair of the esophageal hiatus hernia was performed. The operative findings showed that the small intestine was incarcerated in the thoracic cavity through the esophageal hiatus. The protrusion of the intestines was reduced into the abdominal cavity, and the hernia orifice was occluded by suturing the diaphragm crus. The postoperative course was uneventful.
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  • Junichi Hamada, Kenichirou Takashina
    2013 Volume 33 Issue 7 Pages 1181-1184
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    We report herein on successful POBA (plain old balloon angioplasty) in a patient with an ischemic ileum caused by the dissection of the superior mesenteric artery (SMA). A 73-year-old man complained of abdominal pain and bloody bowel discharge. CT revealed a flap in the SMA, no blood flow in the distal side of the SMA and an ischemic ileum. On emergency angiography, the SMA distal blood flow and ileum blood flow were almost not visible because of high pressure from the false lumen, so we decided to perform a POBA in the true lumen. The POBA enabled the true lumen to be opened and maintain blood flow, and blood flow to the ileum became measurable. On the next day, the blood flow was maintained in both the true and false lumens and the jejunal wall had good contrast on CT. Sometimes, SMA dissections make a long section of small intestine ischemic and we have to perform a resection because of the potentially life-threatening situation. POBA may avoid such a miserable outcome in cases of SMA dissection with an ischemic intestine.
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  • Kensuke Umakoshi, Takashi Nishiyama, Satoshi Kikuchi, Mayuki Aibiki
    2013 Volume 33 Issue 7 Pages 1185-1187
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    A 75-year-old man was admitted because of pain in the left leg and bloody bowel discharge. Purpuric lesions were found on the tips of his fingers and toes. A blood test showed anemia and disseminated intravascular coagulation (DIC). The purpura progressed to gangrene in parallel with a gradual deterioration of his general condition, and the patient finally died on the 50th hospitalization day. The autopsy findings revealed that the symmetric peripheral DIC-related gangrenous lesions were due a gastric carcinoma. We should follow a multidirectional approach when we encounter a patient having the clinical manifestations demonstrated in this report.
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  • Tatsuya Tazaki, Hiroaki Tsumura, Hiroaki Yamaoka, Hiroshi Hino, Tetsuy ...
    2013 Volume 33 Issue 7 Pages 1189-1193
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    An 8-year-old girl presented to our hospital for abdominal pain, vomiting, and fever. She exhibited guarding in the midline of the lower abdomen. Laboratory examination revealed an increased white blood cell count and C-reactive protein level. A conclusive diagnosis could not be reached with abdominal ultrasonography. Enhanced multidetector-row computed tomography (MDCT) showed that the colon was localized to the left side of the abdomen and that the small intestine had shifted to the right. The superior mesenteric artery was running along the right side of the superior mesenteric vein, opposite to its expected position. A swollen vermiform appendix was detected in the mid-lower abdomen. Emergency laparotomy was performed under the diagnosis of acute appendicitis with intestinal malrotation. The intraoperative findings were consistent with gangrenous perforated appendicitis and the cecum was observed to be in the midline of the abdomen. We performed drainage and an appendectomy. The preoperative diagnosis of acute appendicitis with intestinal malrotation is often difficult because abdominal pain presents at atypical sites. MDCT enabled us to determine the correct diagnosis and the proper skin-incision site in this patient.
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  • Koichi Kato, Yasuyuki Asai, Yoshiyasu Kato, Keisuke Kurimoto, Nobutake ...
    2013 Volume 33 Issue 7 Pages 1195-1199
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    We report herein on a rare case of penetration of a Composix Kugel Patch® (CKP) into the small bowel after repair of an incisional hernia. A 74-year-old man, who had undergone abdominal incisional hernia repair with a CKP 31 months previously, was admitted to our hospital suffering from high fever and chills. He had redness and swelling around the scar in the lower abdominal midline. Abdominal CT showed fluid and free air inside the abdominal wall including the CKP. While attempting incision and drainage, puncture of the CKP revealed retention of intestinal fluid. Under a diagnosis of small bowel penetration by the CKP, the patient underwent removal of the CKP and wedge resection of penetrated small bowel. Neither recurrence of the incisional hernia nor abscess formation has been observed in the three years after the surgery.
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  • Tomohiro Murakami, Keigo Matsumoto, Osamu Jindou, Akihiro Uno, Atsuko ...
    2013 Volume 33 Issue 7 Pages 1201-1205
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    An 84-year-old woman was brought to our emergency outpatient clinic with fever, epigastralgia, and back pain. On blood analysis, mild anemia and leukocytosis were noted. Abdominal CT showed a diverticulum in the fourth portion of the duodenum and pneumoretroperitoneum around this site. We conducted an emergency operation with the diagnosis of a perforated duodenal diverticulum. On laparotomy, the Treitz ligament showed inflammatory thickening, incision of the ligament allowed the efflux of the pus from the retroperitoneal space, and a perforated diverticulum was observed in the 4th portion of the duodenum. The diverticulum was resected, the wall was closed by suturing, and the abscess was drained. Histologically, the diverticulum was found to be a psuedodiverticulum lacking the muscularis propria, and the tissue around the thinned perforation site was necrotized. The patient’s postoperative course was uneventful, and she was discharged on the 24th hospital day. Perforation in the diverticulum in the 4th portion of the duodenum is a rare but serious disorder, and early surgical treatment with a prompt and accurate diagnosis is important.
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  • Takuya Yoichi, Hiroyuki Yoshidome, Hiroaki Shimizu, Masayuki Ohtsuka, ...
    2013 Volume 33 Issue 7 Pages 1207-1211
    Published: November 30, 2013
    Released: February 05, 2014
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    A 74-year-old man had recurrence of colorectal liver metastasis and synchronous lung metastasis. He underwent S1 resection of the remnant liver combined with the inferior vena cava resection under total hepatic vascular exclusion, and simultaneously underwent a partial lung resection. During the postoperative course, he suffered from septic shock due to severe pneumonia. Despite of intensive treatment such as continuous hemodiafiltration (CHDF), recovery was unable to be easily achieved. The relatively low serum cortisol levels and little response to the rapid ACTH test were observed. He was diagnosed as having adrenal insufficiency associated with critical illness and liver failure. The septic shock with little response to the catecholamine administration was treated with intravenous hydrocortisone administration and could be controlled. Thereafter, the patient recovered without a subsequent severe complication. If septic shock after major liver surgery is difficult to regulate despite catecholamine administration, adrenal insufficiency should be recognized as a differential diagnosis.
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  • Koji Asai, Manabu Watanabe, Hiroshi Matsukiyo, Tomoaki Saito, Hajime K ...
    2013 Volume 33 Issue 7 Pages 1213-1217
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    A 70-year-old man underwent tumorectomy, partial resection of the small intestine, gastrostomy and enterostomy for a mesenchymal liposarcoma. Although hepatic portal venous gas (HPVG) and pneumatosis intestinalis (PI) were identified on postoperative day (POD) 6, conservative management was selected because the general condition of the patient was stable. However, HPVG and PI with massive ascites developed again with septic shock. An exploratory laparotomy was performed under the suspicion of intestinal necrosis, but no definitive necrosis was revealed. PI again occurred on POD 34, and HPVG and acute cholecystitis were identified on POD 80, with conservative managements proving effective for both episodes. The patient was discharged on POD 117. HPVG and PI have been considered to warrant an emergency operation, but if the general condition of the patient is stable, conservative management is possible.
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  • Ichiro Ohmori, Shinji Kusunoki, Takao Yamanoue
    2013 Volume 33 Issue 7 Pages 1219-1222
    Published: November 30, 2013
    Released: February 05, 2014
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    We report herein on a case of IIIb type liver injury concomitant with IIIb type pancreatic injury. A 56-year-old woman was injured after falling down from a building and was admitted to our critical care center. As a CT scan revealed that the median section of the liver was deeply ruptured and the pancreas was completely divided into the head and tail portions, an emergency operation was performed. Distal pancreatectomy and hepatorrhaphy were performed but we could not achieve complete hepatic hemostasis, so that hepatotomy was performed with the finger fracture technique. We have reported this case as recue was accomplished in a case of IIIb type liver injury concomitant with IIIb type pancreatic injury.
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  • Kanji Ishihara, Shogo Tanaka, Ryoya Hashiba, Kazunori Ohhata, Takahiro ...
    2013 Volume 33 Issue 7 Pages 1223-1226
    Published: November 30, 2013
    Released: February 05, 2014
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    Three days before admission in a thirty-year-old man the left lower abdomen at the upper region of the inguinal ligament had been compressed by a fork-lift truck. He visited a doctor's office, there were no abnormal findings and nothing abnormal showed up on the X-ray at this time. He returned home and rested for 3 days. He visited our hospital with increasing abdominal pain and a high grade fever. His vital signs were stable and the left lower abdominal wound was mild, but bowel sounds were weak and the whole abdominal wall was hard. An abdominal X-ray and plain CT showed free air under the bilateral diaphragm and intra-mesenteric gas. A lower intestinal rupture was suspected and an emergency operation was performed. An approximately 1-cm long perforation of the mid-sigmoid colon was found at the mesenteric side surrounded by blunt mesenteric injury. Contaminations with feces was very mild and partial resection of sigmoidal colon and primary end-to-end anastomosis were carried out. Half of the diameter of the sigmoidal colon was ruptured at the mesenteric side of the resected specimen. A timely check-up is important in cases of mild abdominal blunt injury with no significant abdominal findings at onset.
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  • Masatoshi Matsunami, Hiroshi Kusanagi, Ken Hayashi, Akira Tsunoda, Nob ...
    2013 Volume 33 Issue 7 Pages 1227-1230
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    We report herein on a case of bowel necrosis resulting from the administration of leuprolide acetate depot (LH-RH analog). The patient was an 82-year-old man who had undergone a prostatectomy for prostate cancer and had been taking a course of leuprolide acetate depot for ten years. The patient was admitted with sudden abdominal pain and vomiting. Small bowel necrosis was noted on contrast enhanced CT scan. The patient underwent an emergency laparotomy. Small bowel necrosis caused by mesenteric venous thrombosis was found. The necrotized intestine was resected, followed by end-to-end anastomosis. After the operation, we started anticoagulation therapy. The patient recovered well and was discharged on POD 28. Histopathological examination showed multiple thromboses in the mesenteric blood vessels. Coagulation studies showed no abnormality, so we considered that the euprolide acetate depot had induced this condition. There are some reports that this medicine has some influences on coagulatory and fibrinolytic activities. We should therefore always be on the alert for mesenteric venous thrombosis in patients on this medicine.
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  • Motohiro Ito, Takayasu Nagata
    2013 Volume 33 Issue 7 Pages 1231-1234
    Published: November 30, 2013
    Released: February 05, 2014
    JOURNALS FREE ACCESS
    A 74-year-old male patient, who had been given an enema 4 days previously due to the absence of bowel movements for 1 week and who had been experiencing lower abdominal pain for 3 days previously, was admitted to our hospital. The patient showed tenderness and rebound tenderness in his left lower abdominal region, and a blood test showed increased inflammatory reaction. Abdominal CT showed abnormal gas distribution into the sigmoid mesocolon and bilateral posterior pararenal spaces via the sigmoid diverticulitis. Based on these data, the patient was diagnosed as having sigmoid diverticulitis that had penetrated the mesentery, and 3 days after onset, he underwent emergency surgery. During the surgery, the presence of mild ascites in the abdominal cavity was confirmed, and the sigmoid diverticulum had penetrated the mesentery. During the surgery, resection of the sigmoid colon, functional end-to-end anastomosis, and abdominal cavity drainage were performed. In the examination of the resected specimen, 2-mm penetration into the mesentery was confirmed on the mucosa. The patient was discharged on post-operative day 23, and the postoperative course was uneventful. It is difficult to confirm the symptoms of peritonitis in patients with penetration of the diverticulum into the mesentery, because the contents of the intestinal tract are covered by the mesenteriolum. Therefore, it is important to make an early diagnosis using abdominal CT and perform surgery when appropriate.
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