Nihon Fukubu Kyukyu Igakkai Zasshi (Journal of Abdominal Emergency Medicine)
Online ISSN : 1882-4781
Print ISSN : 1340-2242
ISSN-L : 1340-2242
Volume 38 , Issue 4
Showing 1-34 articles out of 34 articles from the selected issue
  • Hideo Kidogawa, Tomoe Moriguchi, Ryo Nonomura, Takayuki Tanoue, Toshih ...
    2018 Volume 38 Issue 4 Pages 603-607
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    We investigated the usefulness of laparoscopic surgery for a small bowel obstruction in patients with no past medical history of laparotomy. The subjects were 78 patients over the previous 16 years who had undergone laparoscopic surgery for small bowel obstruction, excluding patients with an incarcerated inguinal hernia. Eighteen patients with intestinal obstruction without previous laparotomy were designated as Group A and 60 patients with intestinal obstruction with previous laparotomy were designated as Group B. The proportions of patients with strangulation were 50.0% and 28.3% in Group A and Group B, respectively;showing a tendency to be higher in Group A. The most frequent causes of intestinal obstruction were a cord-like structure in Group A (55.6%) and adhesion to the wound in Group B (31.7%). Single-site laparoscopic surgery was performed in 61.1 and 15.0% in Groups A and B, respectively, and 11.1 and 30.0% in Groups A and B, respectively, required conversion to laparotomy;tending to be lower in Group A. The mean operation times were 85.4 and 137.5 minutes, respectively, being significantly shorter in Group A, and the postoperative hospital stays were also significantly shorter in Group A. The surgical outcomes of the patients without a previous laparotomy were favorable compared with those of the patients with a previous laparotomy, showing that intestinal obstruction without a previous laparotomy is a good indication for laparoscopic surgery.

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  • Fumihiko Nakayama, Hisashi Matsumoto, Mariko Yamamoto, Taigo Sakamoto, ...
    2018 Volume 38 Issue 4 Pages 609-615
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    It is rare for any injury to occur to the superior mesenteric artery (SMA) and/or superior mesenteric vein (SMV). Occasionally, however, such injuries cause severe hemorrhagic shock. In 6,084 trauma victims treated in our institute during the six years from 2011, there were 52 SMA/V injuries (0.85%, 50 cases due to blunt injury, 2 cases due to penetrating injury) requiring a hemostatic laparotomy. In 26 cases (24 cases due to blunt trauma), injuries were found in the more proximal zone (classification by Fullen Zone I to Ⅲ) and required a surgical approach for the vessels. All SMA injuries were ligated to control bleeding, and SMV injuries were repaired as much as possible. Subsequently, a survival rate of 76.9% could be obtained after 6 years. Although cardiac arrest is often imminent due to the massive bleeding caused by SMA/V injury, controlling hemorrhage and avoiding intestinal ischemia should be promptly and accurately performed, even in those circumstances under which is difficult to approach the injured site accompanied with a large amount of blood outflow. Accordingly, our treatment tactics is thought to be appropriate in these series.

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  • Tomonori Fujii, Eisuke Shiozawa, Masahiko Murakami, Kohei Ono, Tetsuya ...
    2018 Volume 38 Issue 4 Pages 617-626
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    Treatment of primary intestinal malignant lymphomas has not been determined because no randomized studies have been published yet. This study aimed to analyze the risk of intestinal complications and prognosis in primary intestinal lymphomas and examined treatment strategies. We retrospectively analyzed clinical data obtained from 85 patients with intestinal lymphomas who were examined at the Showa University Hospital Group between 2001 and 2015. An emergency laparotomy was performed for partial resection of the intestinal tract in 19 cases (22%) of the patients who developed a perforation. Histological examination revealed that all cases were classified as high-grade lesions and morphologically as single circular lesions. The median OS time of patients with perforation was statistically significantly shorter than that of patients without perforation (P=0.0051). Among 20 patients who underwent chemotherapy before surgery in the histologically high-grade group, 8 (40%) had severe intestinal complications, with lesions more than half the circumference of the lesion. The results of this study indicate that bowel perforation is a poor prognostic factor in primary intestinal lymphoma patients. We recommend surgical resection followed by chemotherapy as a preventive measure in cases showing histologically high-grade and single with more than half the circumference of the lesions.

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  • Hiroshi Maruyama, Hiroshi Yoshida
    2018 Volume 38 Issue 4 Pages 629-634
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    We performed active surveillance culturing to investigate the presence of methicillin─resistant Staphylococcus aureus (MRSA) in the nasal cavity of 170 patients hospitalized in an emergency room (ER). Regular surveillance culturing was performed upon entry to and each week after leaving the ER. Upon entry, 11 patients (6.5%) were found to be carrying MRSA. A total of 89 patients left the ER within 1 week; therefore, only 70 underwent testing upon entry into the ER. The causes underlying entry into the ER included psychiatric disorders and traffic accidents in patients without a relevant medical history, and none of these patients carried MRSA. Seventy patients were hospitalized in the ER for 1 week or longer and underwent regular surveillance culturing. Of these, MRSA was transmitted to 21 patients (30%) by the time they left the ER. We divided patients into MRSA transmission (n=21) and non─transmission (n=49) groups and investigated the risk factors for transmission. Endotracheal intubation and high blood sugar were an independent factor as a risk factor for the transmission of MRSA. Twelve patients developed MRSA infections, all of whom developed from carriers.

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  • Yu Katayose, Ichiro Ise, Hiroki Hayashi, Kei Nakagawa, Takanori Morika ...
    2018 Volume 38 Issue 4 Pages 635-641
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    PURPOSE: We aimed to analyze the risk factor of sepsis after hepatobiliary and pancreatic surgery and to investigate the prognosis. METHODS:The subjects were retrospectively studied from the database for hepatobiliary and pancreatic surgery cases, who had undergone a surgical operation at Tohoku University Hospital and Tohoku Rosai Hospital from 2011 to 2015. RESULTS:A total of 523 cases were reviewed. The sepsis rates were 6%, 16%, 10%, 33% and 56% in pancreaticoduodenectomy (PD), hepatectomy, total pancreatectomy, distal pancreatectomy combined with celiac axis resection, and hepato-pancreaticoduodenectomy, respectively. In the PD group, it was found that the low value of hemoglobin was a risk factor, and in the hepatectomy group, a prolonged activated partial thromboplastin time (APTT) was a risk factor. Regarding the long-term prognosis, when the overall survival rate was examined except for 90-day mortality with sepsis cases and benign diseases, sepsis cases showed a poor prognosis in the hepatectomy group. CONCLUSIONS: Because sepsis might have a relationship with the long-term prognosis, highly invasive surgery for hepatobiliary and pancreatic surgery requires postoperative management based on the preoperative risk factors with sepsis in mind.

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  • Yukio Tokumitsu, Satoshi Matsukuma, Kazuhiko Sakamoto, Yoshihiro Tokuh ...
    2018 Volume 38 Issue 4 Pages 643-648
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    In the current study, we compared the clinical data between 26 survival patients and 7 deceased patients before and after introduction of polymyxin B-immobilized fiber (PMX-DHP) column direct hemoperfusion therapy for septic shock. There were no differences in age, gender, site of infection, and presence or absence of source control surgery between the two groups. The vasopressor dependency index (VDI) values before introduction of PMX-DHP were significantly low in the survival group and high in the deceased group (P<0.05). There were significant improvements in metabolic acidosis in the survival group and significant worsening of metabolic acidosis in the deceased group at six hours after the start of PMX-DHP, Treatment of septic shock patients with severe cardiac dysfunction with PMX-DHP may be insufficient to ensure recovery, and early treatment and limits to adaptation should be considered.

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  • Yoshiaki Yamane, Kentaro Oi, Kenji Fukuda, Nariyuki Yamane, Shigeru Ta ...
    2018 Volume 38 Issue 4 Pages 649-655
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    Lower intestinal perforation and ischemia frequently cause sepsis and organ dysfunction with disseminated intravascular coagulation (DIC), and may subsequently result in death. We have performed direct hemoperfusion with polymyxin B-immobilized fiber and continuous hemodiafiltration with polymethyl methacrylate (PMMA) to counteract severe sepsis. In December 2014, we introduced continuous hemodiafiltration with AN69ST (AN69ST-CHDF) as a cytokine-adsorbing hemofilter. Seventy-three cases of lower intestinal perforation and ischemia since January 2010 until January 2018 were classified into 35 cases in the earlier period (before using AN69ST), 38 cases in the later period (after using AN69ST), and all cases were allocated to one of three subgroups: : group A (saved), group B (died after 28 days in hospital) and group C (died within 28 days), with estimation of the severity of sepsis using the APACHE Ⅱ and SOFA scores and the JAAM DIC diagnostic criteria. The survival rate of the earlier period was 49%, whereas the rate improved in the later period to 68%. Interestingly, in group A, the rate of DIC was 1.5-fold higher in the later period (46%) than in the earlier period. AN69ST-CHDF has been indicated in 12 cases, 9 of whom have survived. Our data suggest that the improvement of the survival rate in the later period could be associated with combination therapy against septic DIC using recombinant thrombomodulin and AN69ST-CHDF.

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  • Chikato Koga, Junzo Shimizu, Naoki Shinno, Haruna Furukawa, Toshinori ...
    2018 Volume 38 Issue 4 Pages 657-661
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    Blood culture is considered to be one of the useful tests for diagnosing acute abdomen, but the significance of blood culture in acute abdomen is still unclear. In 286 consecutive patients who underwent emergency surgery for acute abdomen from January 2015 to December 2016, the blood culture collection rate in each department and for each disease, and blood culture positive rate and short term outcome for each disease were examined. The blood culture collection rate was 54.2%, and in the first medical treatment department, the collection rate exceeded 60% during emergency outpatient department and internal hospital ward hospitalization. In the collection rate for each disease, the collection rate exceeded 60% in postoperative peritonitis and gastrointestinal perforation. Blood cultures were positive in 26 cases (9%) excluding 2 cases of contamination. In the digestive tract perforation, it was as high as 37%. In the case of blood culture─positive cases, the period of postoperative antibiotic drug administration and the postoperative hospital period were long, and the rate of incidence of postoperative complications was high. In patients with suspected sepsis in acute abdomen disease, blood culture would be a useful test.

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  • Toshiaki Komo, Ryutarou Sakabe
    2018 Volume 38 Issue 4 Pages 663-667
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    We report herein on a case of a ruptured right hepatic artery successfully treated with an arterio-portal shunt after an extended left lobectomy. A 65-year-old woman underwent an extended left lobectomy combining resection and reconstruction of the right hepatic artery for an intrahepatic cholangiocarcinoma. The right hepatic artery was ruptured on the fourth day after surgery. She fell into severe hemorrhagic shock and underwent an arterio-portal shunt with the right hepatic artery and right portal vein. She was discharged on the 61st day after surgery though acute respiratory distress syndrome, bile fistula, and intra-abdominal abscess had developed. Hemorrhage from the hepatic artery is a life-threatening complication. Arterio-portal shunting could be a way to avoid hepatonecrosis and treatment of a ruptured right hepatic artery and severe hemorrhagic shock.

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  • Yasushi Yamasaki, Osamu Chino, Tomoko Hanashi, Yoichi Tanaka, Hiroyasu ...
    2018 Volume 38 Issue 4 Pages 669-673
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 66-year-old man was admitted to our hospital because of anemia and passage of dark tarry stools. Upper and lower gastrointestinal (GI) endoscopy did not reveal any bleeding. Chest computed tomography (CT) showed lymph nodes enlargement extending from the anterior mediastinum to the right supraclavicular region. 18F-Fluorodeoxyglucose positron emission tomography revealed high uptake at the anterior mediastinum to the right supraclavicular lymph nodes, duodenum, and lumbar vertebra. Repeat upper GI endoscopy showed a lesion in the descending portion of the duodenum, which was subsequently diagnosed pathologically by biopsy as a poorly differentiated adenocarcinoma. The patient was discharged, but was later readmitted with abdominal pain. CT revealed a small bowel obstruction (SBO) caused by a foreign body with incarceration of the small intestine and wall thickening. He had unintentionally swallowed a dried plum stone a few days earlier. Emergency surgery was performed for refractory SBO managed conservatively with an ileus tube. Intra-operative findings showed cancerous stenosis and intramural metastasis of the small intestine. Thus, the definitive diagnosis based on histopathological findings was a small intestinal adenocarcinoma with multiple lymph node and duodenal metastasis. Small intestine carcinomas are rare. This is the rare report of a case in Japan of a small intestine carcinoma with multiple metastasis presenting as small bowel obstruction due to a dried plum stone.

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  • Keita Sato, Koji Fujii, Mitsuhiro Sakaguchi, Koji Kumamoto
    2018 Volume 38 Issue 4 Pages 675-677
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 63-year-old man, who had a diagnosis of diffuse large B-cell lymphoma following cervical lymph node biopsy, was admitted to our hospital with abdominal pain and low blood pressure. Enhanced CT showed splenic rupture and extravasation in his spleen. Urgent TAE was performed, and no further intraperitoneal bleeding was recognized. Seven days after TAE, systemic chemotherapy was started. Spontaneous rupture of spleen is a rare clinical condition. In many cases, an open splenectomy has been performed, but hemostasis with TAE can be a useful option for splenic rupture.

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  • Tomoya Takami, Masafumi Tomita
    2018 Volume 38 Issue 4 Pages 679-682
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    We present herein on a patient that was treated successfully laparoscopically.【Case 1】The patient was a 34-year-old female with a previous caesarean birth. She was admitted to our hospital due to abdominal pain. Given a diagnosis of postoperative adhesion ileus, she was put under conservative therapy, however the pain became more severe. She was operated on at the department 4 days after admission when laparoscopic operation was performed to make a definitive diagnosis and treatment. At laparotomy, we found that the small intestine was herniated into the pocket of the broad ligament of the uterus. We extricated the intestine and sutured the defect.【Case 2】The patient was a 57-year-old female with a pregnancy history. She was admitted to our hospital due to abdominal pain and vomiting from 3 day previously. Based on computed tomography findings the patient was diagnosed as having an internal hernia of the broad ligament of the uterus. She was also treated successfully laparoscopically. The postoperative course of both these cases was uneventful. Laparoscopic surgery can reduce surgical invasion and is advantageous in terms of tolerability. So, if not accompanied by intestinal necrosis, we think that it is possible to perform laparoscopic surgery.

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  • Hiroaki Itakura, Masakazu Ikenaga, Katsuya Ohta, Shunji Endo, Terumasa ...
    2018 Volume 38 Issue 4 Pages 683-686
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    We report herein on two cases of bladder perforation caused by an indwelling urethral catheter. [Case 1] A 72-year-old male visited our hospital complaining of abdominal pain. He had undergone a resection of an allantoic duct abscess 12 years prior, and had received an indwelled urethral catheter 1 month prior for a vesicocutaneous fistula. Abdominal computed tomography (CT) revealed dilation of the small intestine and ascites. A physical examination revealed peritoneal irritation signs. We diagnosed acute generalized peritonitis and performed emergency surgery. Intraoperative findings revealed a paralytic ileus that was caused by bladder perforation and we performed intraperitoneal irrigation drainage and sutured the perforation site closed. [Case 2] An 86-year-old woman had received an indwelled urethral catheter 9 months prior owing to a neurogenic bladder. She complained of abdominal pain and had a fever. We diagnosed perforating peritonitis based on an abdominal enhanced CT and performed emergency surgery. Intraoperative findings revealed panperitonitis that was caused by bladder perforation and we performed intraperitoneal irrigation drainage and sutured the perforation site closed. We experienced two cases in which we suspected gastrointestinal disease, but the final diagnosis was a bladder perforation. While a bladder perforation is rare, we should remember that it can cause acute abdominal problems.

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  • Nobuhiro Takeuchi, Atsunori Nakao
    2018 Volume 38 Issue 4 Pages 687-692
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 57-year-old female patient was transferred to our institution with a high-grade fever that persisted for 4-5 days, circulatory insufficiency, and deteriorating consciousness. Laboratory analysis revealed elevated inflammatory reactions, decreased platelet count, coagulation disorders, elevated liver and biliary enzyme levels, and abnormal renal functions. Computed tomography revealed gallbladder stones and edematous gallbladder walls. Based on these findings, the patient was diagnosed as having sepsis-induced disseminated intravascular coagulation (DIC) due to acute cholangitis and was admitted to the ICU. Emergency endoscopic retrograde cholangiography was performed for biliary drainage. Hemodialysis was initiated to treat acute renal failure. The patient recovered from sepsis-induced DIC and acute kidney injury. On day 5, she presented with enormous amounts of blood in her stool and her systolic blood pressure dropped to 70 mmHg. Serum hemoglobin level dropped to 7.0 g/dL from 12.3 g/dL on arrival. Eight packs of red cell concentrate were immediately administered. After the patient’s vital signs had stabilized, upper endoscopy was performed. Massive clots were observed at the duodenal second portion and no visual fields were secured. Under endoscopy, hemostasis was impossible, and the patient was referred for angiography. Gastroduodenal artery angiography revealed extravasation at the anterior superior pancreaticoduodenal artery, which was subsequently occluded using gelatin sponges. Upper endoscopy confirmed successful hemostasis. Transcatheter artery embolization is useful and effective for patients with post-EST bleeding that is impossible to control with endoscopic treatment.

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  • Yusuke Nakamura, Tomohisa Okaya, Hirofumi Suzuki, Hirokazu Karaki, Hir ...
    2018 Volume 38 Issue 4 Pages 693-696
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 66-year-old man suffering from unresectable lung cancer was admitted to our hospital to receive systemic chemotherapy. Cisplatin, Pemetrexed and Bevacizumab were administered as first-line therapy, and the patient reported acute abdominal pain on the right side 9 days after the first administration. Because computed tomography showed intra-abdominal free air near the hepatic flexure of the colon, an emergency laparotomy was performed. We found an idiopathic perforation of the ascending colon and resected the ileocecum including the perforation. Thirteen days after the operation, the patient developed wound dehiscence due to broad wound infection. Wound irrigation and debridement was initiated to reduce necrotic tissue. From post-operative day 25 to day 53, negative pressure wound therapy was administered to the wound. Excellent wound healing was provided by this therapeutic approach and the patient was discharged. Some clinicians face difficulties in treating an infectious wound after systemic chemotherapy followed by Bevacizumab that carries a high risk of postoperative wound infection and dehiscence. Our report suggests that negative pressure wound therapy is useful in controlling wound infection and dehiscence associated with colonic perforation after administration of Bevacizumab.

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  • Hirokatsu Hayashi, Yoshito Kuroki
    2018 Volume 38 Issue 4 Pages 697-700
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    An 83-year-old woman presented to the emergency department complaining of epigastric pain. A CT scan indicated the transverse colon had incarcerated the Morgagni foramen. She has a past medical history of abdominal pain twice in one year, however her symptom was improved spontaneously. On this occasion her symptom did not improve, and an emergency operation was performed. In operative findings, the transverse colon and greater omentum were incarcerated into the Morgagni foramen, which could be manually returned into the abdominal cavity. There was no perforation and necrosis in the hernia contents and the hernia orifice was around 3 cm×3 cm in diameter, which was closed with a direct suture. The postoperative course was uneventful. No recurrence has been seen since the surgery. A recurrent Morgagni hernia should be treated with surgical repair.

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  • Yasunobu Terasaki, Takahiro Ohshima, Koji Okuda, Takahiro Uesaka, Mich ...
    2018 Volume 38 Issue 4 Pages 701-705
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    An iatrogenic diaphragmatic hernia after anterior spinal surgery is very rare. A 66-years-old man underwent posterior spinal fusion for a spinal burst fracture 39 months earlier. However, 10 months after the surgery, he underwent posterior spinal fusion via the left thoracoabdominal approach due to bone union failure. Following the surgery, he was diagnosed as having a left diaphragmatic hernia. However, as he was asymptomatic, he was followed conservatively. At this time, he was admitted to our hospital with nausea, epigastric pain, and the emergence of lower bleeding. A CT scan showed that his stomach, colon, and spleen were incarcerated into the left thoracic cavity, and there was very poor enhancement of the colonic wall. An emergency laparotomy was performed. Intraoperatively, the strangulated colon and stomach revealed no ischemic signs and were reduced back into the abdominal cavity. Thereafter, the defect was repaired with a non-absorbable interrupted suture. We understood that an acute presentation with high index of suspicion for strangulated intestines may represent a diagnostic dilemma and require an emergency operation, even if a diaphragmatic hernia has been conservatively followed in an asymptomatic patient. Therefore, we recommend that even asymptomatic diaphragmatic hernias should be strictly and carefully observed or operated on, if the need arises.

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  • Yuichiro Kawano, Takuya Noguchi
    2018 Volume 38 Issue 4 Pages 707-710
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 36-year-old woman was diagnosed as having acute myelogenous leukemia and started anti-leukemic treatment. The patient complained of right lower quadrant pain and a high fever on the 14th day after initiation of the regimen. Abdominal computed tomography (CT) revealed a swollen appendix and the patient was diagnosed as having acute appendicitis, however the laboratory data showed pancytopenia. Therefore, we preferred conservative therapy to surgery. Starting on the 14th days after conservative therapy, the pancytopenia improved, so we performed a laparoscopic appendectomy. The patient was discharged on the 7th day after the surgery without complication. We report our experience with a review of the pertinent literature.

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  • Toshiya Sugishita, Mamoru Sakai
    2018 Volume 38 Issue 4 Pages 711-715
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 67-year-old man was referred to our hospital for a feeling of fullness. CT scan revealed multiple liver metastases and thickening of the rectal wall. CT scan also revealed a large quantity of pooling stool, so we diagnosed ileus due to colorectal cancer. Therefore a colonic stent (WallFlex metallic stent 22mm×90mm) was inserted on the day of the operation. Fourteen days later, the patient developed acute abdominal pain. CT scan revealed free air suggesting gastrointestinal perforation. Therefore emergency surgery was performed. At the surgery it was noticed that the intestinal wall at the proximal end of the stent was perforated, so we employed a Hartmann operation by preforming the associated resection of the colonic stent and the intestine. A colonic stent is effective for ileus due to colorectal cancer, but colonic perforation due to the colonic stent can lead to a fatal situation. We should use such a stent thinking of the risk of perforation at all times.

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  • Nobuhiro Kobayashi, Daisuke Kuraya, Takayuki Hanamoto
    2018 Volume 38 Issue 4 Pages 717-722
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    An 84-year-old woman experienced abdominal pain and vomiting. She was previously diagnosed as having small bowel obstruction and was transferred to our hospital for intensive examination and treatment. The CT showed a mass in the small intestine, which on an ultrasonogram showed high echoes;we thought that was caused by a foreign body. The small intestine on the proximal side of the foreign body was expanded, we diagnosed her as having small bowel obstruction caused by a foreign body in the intestinal tract. The symptoms did not improve by ileus tube placement, and the foreign body could not be removed by an enteroscope;thus, an operation was performed. The small intestine containing a foreign body was identified by a laparoscope, and a lithotomy was performed via a minilaparotomy through the umbilicus. The xanthochromic foreign body measured 3.5×3.0×2.5cm. Infrared spectrometry revealed the calculus to be a bile acid concretion, which we thought was an enterolith. The enterolith was visible in the duodenal diverticulum on a CT scan 6 months previously, but had disappeared when the small bowel obstruction occurred. The diagnosis was small bowel obstruction by an enterolith that fell from the duodenum into the small intestine.

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  • Shigeyoshi Shimaoka, Isao Sato, Yoshihide Chino, Tomotatake Tabata, To ...
    2018 Volume 38 Issue 4 Pages 723-726
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    Delayed perforation after gastric endoscopic submucosal dissection (ESD) has been reported to have large pore size when it has occurred, is difficult to close directly. And also, it is reported that emergency surgery is often required. We experienced three cases of emergency laparoscopic surgery for delayed perforation after gastric ESD. It is believed that the cause of the delayed perforation may be necrosis of the muscular layer due to excessive current applied to the muscular layer during hemostasis. Since the tissue around the perforated area becomes weak due to necrosis, gastric resection is often required.

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  • Yuki Kano, Satoshi Asai, Kenzi Matsuo, Kotaro Takeshita, Takumi Ichino ...
    2018 Volume 38 Issue 4 Pages 727-731
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 92-year-old woman swallowed press through packages (PTP), and was brought to our hospital by ambulance with dyspnea and chest pain. Detailed evaluation using abdominal CT images showed seven PTPs in the esophagus and stomach, and we removed them via upper gastrointestinal endoscopy. In fact, we discovered four PTPs each in the esophagus and stomach. On the following day, we checked that there no PTP in the digestive tract on abdominal CT images and upper gastrointestinal endoscopy. Swallowing a PTP puts the patient at risk of gastrointestinal perforation, and we should remove it quickly with upper gastrointestinal endoscopy. We experienced a rare case of swallowing eight PTPs. We removed more PTPs than were actually seen on the abdominal CT images. We should examine the patient carefully in consideration of more PTPs than seen on the abdominal CT images.

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  • Tomoki Konishi
    2018 Volume 38 Issue 4 Pages 733-737
    Published: May 31, 2018
    Released: December 07, 2019
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    A-39-year-old man was admitted to our emergency center because his lower abdomen was trapped under some iron plates at a construction site. He had severe abdominal pain and could only lie on his left lateral decubitus position rather than in a supine position. During the immediate medical attention he had been diagnosed as having lumbar transverse process fractures, iliac bone fracture and hemoperitoneum and needed primary care. Based on the clinical diagnosis of intraperitoneal bleeding, an emergency laparotomy was carried out. Intraoperative findings revealed a mesenteric perforation of about 15cm with bleeding from the mesenteric vein. Hemostasis was completed and there was no other injury noted. The patient’s postoperative vital signs were stable, but abdominal X-ray photography the day after the operation showed that enlargement of the pubic symphysis was diagnosed as an open book type pelvic fracture. It was difficult to identify the pelvic fracture as the left lateral decubitus position differed from the supine position. In high-impact trauma, it is important to deal it with carefully and repeatedly.

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  • Takahito Taniura, Shinji Hattori, Nobuhiko Toyota
    2018 Volume 38 Issue 4 Pages 739-743
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A pyometra rarely causes uterine perforation. An 83-year-old woman was admitted to our hospital with abdominal pain and fever. There was defense in her right hypochondrium. Abdominal contrast CT confirmed ascites around the liver and along the right paracolic gutter, and an enlarged gallbladder was noted with a partially non-enhancing gallbladder wall. Although acute cholecystitis was suspected, at the same time, the swelling of the uterus, the thickening of the wall and intraluminal fluid accumulation were recognized. With the possibility of perforation of the uterus also in mind, we performed a laparoscopic examination. At laparoscopy, the gallbladder was intact without any inflammation. The uterus was enlarged, and was found to have a small perforation, 5mm in diameter, in the uterine fundus, with identification of purulent material exuding from the uterine cavity, which was compatible with the diagnosis of a perforated pyometra. We performed laparoscopic hysterorrhaphy, peritoneal irrigation, and drainage. Although the patient developed septic shock postoperatively, she recovered well after intensive care and was discharged on the 24th postoperative day. We were able to treat her without a great deal of stress thanks to the use of the examination laparoscope. Laparoscopic surgery was useful in both the diagnosis and treatment of this perforated pyometra.

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  • Takamitsu Inokuma, Hiroo Izumino, Syuhei Yamano, Kensuke Takahashi, Go ...
    2018 Volume 38 Issue 4 Pages 745-748
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 16-year-old boy who had been beaten many times was admitted to our hospital. Contrast-enhanced computed tomography showed splenic injury (type 3b), splenomegaly, and left pneumothorax. The patient was treated with non-operative management. After admission, the patient developed a fever, pharyngitis, and swollen cervical lymph nodes, and atypical lymphocytes were seen in his blood. Antibody tests showed EBV VCA-IgM to be positive and EBNA antibody to be negative. Infectious mononucleosis due to EBV infection was diagnosed. The infectious mononucleosis was thought to be the cause of the splenomegaly on admission. After admission, the patient showed no progression of anemia or formation of splenic artery pseudoaneurysm, and he was discharged on the 20th day. In conclusion, we suspect that the patient’s spleen injury was cause by external force applied to a spleen already fragile due to infectious mononucleosis.

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  • Taku Watanabe, Yasuhiro Sumi, Yuta Ishigami, Ryota Nakano, Yoshihiko K ...
    2018 Volume 38 Issue 4 Pages 749-752
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    An unconscious 75-year-old female was admitted to our hospital. She went into cardiopulmonary arrest in the emergency room, but was resuscitated successfully. Abdominal computed tomography revealed a massive hematoma in the stomach. Gastrointestinal endoscopy was performed, but the source of the bleeding could not be identified. An emergency laparotomy was performed under a diagnosis of a hemorrhagic gastric ulcer. Laparotomy revealed ulcerative lesions in the posterior wall of the upper body of the stomach. A total gastrectomy was performed and the patient was rescued. On postoperative day 35, Roux-Y reconstruction was performed. We report herein on a case of cardiopulmonary arrest due to a hemorrhagic gastric ulcer successfully treated with a two staged operation and discuss the clinical implications based on a review of the literature.

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  • Kazuaki Seita, Hidehiko Otsuji, Keiji Hasebe, Kiyomitsu Kuwahara, Yasu ...
    2018 Volume 38 Issue 4 Pages 753-756
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 51-years-old man who was on medication presented at our hospital because of stomachache. Enhanced computed tomography revealed blood extravasation at the ventral part of the third portion of the duodenum, a giant hematoma at the retroperitoneal area and a hooked appearance of the celiac artery. Angiography revealed an aneurysm of the inferior pancreaticoduodenal artery. We were however unable to cannulate because complication with collateral circulation had developed. The patient was diagnosed as having a ruptured aneurysm of the inferior pancreaticoduodenal artery caused by median arcuate ligament compression syndrome and emergency surgery was performed. We found an aneurysm at the ventral portion of pancreas head and resected it. Arterial pulse obviously strengthened after we incised the median arcuate ligament. Postoperatively, the patient needed drainage treatment because of residual hematoma infection. The patient was discharged without any critical complication. We report herein on a case of a ruptured aneurysm of the inferior pancreaticoduodenal artery caused by median arcuate ligament compression syndrome.

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  • Shuhei Yamada, Hirofumi Sugawara, Takehiro Takahashi
    2018 Volume 38 Issue 4 Pages 757-761
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 58-year-old man was admitted for left hypochondrium pain:enhanced computed tomography (CT) revealed a cystic lesion of the intra-abdominal space. He was referred as a case of intra-abdominal hemorrhage and we aspirated the cyst for diagnosis. Since the aspirated cyst showed just stromal and blood component, we performed diagnostic laparoscopic surgery and excised the mass including the omentum. The pathology report showed the mass was a hematoma, but the outermost layer was uniformly surrounded by c-kit positive cells. The diagnosis was a primary gastrointestinal stromal tumor (GIST) of the omentum. Primary omental GISTs and cystic GIST lesions are rare. We report herein on a case of omental GIST which was difficult to diagnose. We have also included a short discussion of the relevant medical literature in our report.

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  • Shiro Fujihata, Yasuhiro Kondo, Koichi Inukai, Sinnosuke Harata, Keisu ...
    2018 Volume 38 Issue 4 Pages 763-766
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    An 85-year-old man underwent laparoscopic cholecystectomy for cholecystitis while being treated with percutaneous transhepatic gallbladder drainage (PTGBD) at a local hospital. On postoperative day 11, he was discharged from the hospital. However, in the afternoon of the same day, he developed disturbance of consciousness and was taken to the same hospital by ambulance. Hemorrhage from the cystic artery was suspected. His systolic blood pressure was under 70 mmHg, showing a state of hemorrhagic shock. However, systolic blood pressure rapidly increased to over 90 mmHg by initial transfusion, and the patient was then transferred to our hospital. During preparations for emergency surgery, transcatheter arterial embolization (TAE) was performed. Hemorrhage from the hepatic artery (A8) was identified and thereby stopped with embolization with coils. Delayed hemorrhage after laparoscopic cholecystectomy is rarely encountered, but, in this patient, delayed hemorrhage occurred without an aneurysm. No similar cases have been reported. Minimally invasive hemostasis employing TAE was shown to be effective in this elderly patient.

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  • Yoshinori Kajiwara, Katsuyuki Aoyama, Takayoshi Miyake
    2018 Volume 38 Issue 4 Pages 767-770
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 95-year-old man visited a local doctor with right hypochondrium pain and was referred to our hospital with a suspected strangulated small bowel obstruction. Contrast-enhanced abdominal CT revealed a massively distended gallbladder and loss of enhancement of the gallbladder wall. Abdominal MRI revealed beak-like stenosis of the cystic duct. We diagnosed gallbladder torsion and performed emergency single incision laparoscopic cholecystectomy. The gallbladder was in a gangrenous state and was twisted clockwise by 270°. The patient was discharged on the 2nd postoperative day without any complications. In most cases, inflammation associated with gallbladder torsion is milder than typical cholecystitis and we can thus often perform an operation easily. If we can diagnose gallbladder torsion preoperatively, we can safely perform single incision laparoscopic cholecystectomy.

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  • Akira Nakayama, Nariatsu Sato, Yuki Takai, Toru Kamata, Masahiro Kanno
    2018 Volume 38 Issue 4 Pages 771-776
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    We report herein on a case of peritonitis associated with Streptococcal Toxic Shock Syndrome (STSS). An 80-year-old man presented with anemia and underwent a laparoscopic-assisted right hemicolectomy under the diagnosis of advanced ascending colon cancer. On postoperative day 5, chylous ascites began to develop after commencement of oral intake. The next day, abdominal pain with muscular defense occurred, but no sign of digestive tract perforation was found on CT. He went into shock after 7 hours, and emergency laparoscopic surgery for drainage was performed. Intraoperatively, we discovered filthy ascites with swelling and redness of the lower part of the ileum, but no sign of anastomotic leakage. After the operation, he developed disseminated intravascular coagulation (DIC) and acute renal failure, so that continuous hemodiafiltration (CHDF) and polimyxin-B direct hemoperfusion (PMX-DHP) were started that achieved stable circulatory kinetics. The patient showed favorable progress, resulting in discharge from hospital. Bacterial culture of the ascites taken just before surgery yielded fulminant type Streptococcus pyogenes.

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  • Kei Ohyama, Shinya Mikami, Tsunehisa Matsushita, Taichi Mafune, Osamu ...
    2018 Volume 38 Issue 4 Pages 777-781
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 16-year-old boy was transferred to our hospital for epigastric and right hypogastric pain that had persisted for approximately 2 weeks. Abdominal CT was performed, and an ileocecal intussusception was detected. Ascites depicted on the CT scan prompted us to perform emergency surgery. Laparoscopically assisted segmental resection of the lower ileum was performed. The intussusception derived from a mass lesion in the terminal ileum. Histopathologically, the tissue had a “starry sky” appearance, and Burkitt’s lymphoma was diagnosed. We consulted with physicians from the departments of pediatrics and internal medicine and selected an appropriate postoperative chemotherapy regimen. Remission was achieved. We report on a case of surgical treatment of a case of juvenile-onset of small intestine Burkitt’s lymphoma which resulted in an intussusception.

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  • Naoto Mizumura, Satoshi Okumura, Sho Toyoda, Masao Ogawa, Masayasu Kaw ...
    2018 Volume 38 Issue 4 Pages 783-785
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    Patients who present with transanal foreign body insertion often do not provide precise information. A male in his fifties with a history of duodenal ulcer was brought to our hospital by ambulance for epigastric pain after meals. Abdominal computed tomography (CT) showed free air around the duodenum and massive ascites. We initially considered that the patient was presenting with a perforated duodenal ulcer. However, fresh blood on the rectal examination and high CT attenuation values of the ascites led us to suspect traumatic lower gastrointestinal perforation. Finally, privacy-conscious history taking revealed a hidden mechanism of injury caused by the patient’s male partner having inserted his hand and arm into the patient’s rectum. A Hartmann’s procedure was performed and revealed a rectosigmoid perforation with a seromuscular laceration of the lower sigmoid colon. This case mimicked a perforated duodenal ulcer. A hidden mechanism of injury is important for the preoperative diagnosis of a perforation site.

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  • Takeshi Oshima, Shinsuke Sato, Erina Nagai, Kou Ohata, Noriyuki Oba, M ...
    2018 Volume 38 Issue 4 Pages 787-791
    Published: May 31, 2018
    Released: December 07, 2019
    JOURNALS FREE ACCESS

    A 42-year-old woman with complaints of abdominal pain and vomiting had visited a hospital previous to our seeing her. Conservative treatment was performed under the diagnosis of mesenteric fat inflammation and intestinal obstruction. However, she showed no improvement and thus was transferred to our hospital. We decided to perform surgery under the diagnosis of intestinal obstruction due to poor fixation and torsion of the intestinal tract, based on the findings from the abdominal computed tomography after hospitalization. We found the intestinal tract from the origin of the jejunum to the sigmoid colon was engaged with a transomental hernia in the background, without total mesenteric fixation to the retroperitoneum from the cecum to the descending colon. The obstruction was released, and the omentum associated with the hernia was resected. As this is the first case report of a mesenterium commune concomitant with intestinal obstruction due to a transomental hernia, we report on the case with a review of the pertinent literature.

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