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 6
Showing 1-33 articles out of 33 articles from the selected issue
  • Hideaki Kaku, Masahiko Nakano, Satoshi Kojima, Satoshi Furukawa, Hidek ...
    2018 Volume 38 Issue 6 Pages 945-951
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    An obturator hernia is a relatively rare disease;however, in the event of onset, it is accompanied by ileus and often requires emergency surgery. Moreover, the surgical methods are also controversial. At our hospital, a total extraperitoneal (TEP) lifting procedure is usually the first choice for obturator hernia, including incarcerated cases, so the effectiveness thereof was examined. The subjects included 16 obturator hernia patients (1 male, 15 female, average age 83.3) who underwent surgery at our hospital from January 2006 to December 2017. Among the subjects, while 7 patients underwent emergency surgery immediately after visiting our hospital, in 8 patients the incarceration spontaneously abated and 1 patient was able to undergo elective surgery due to manipulative reduction using ultrasonic probes. Other than 2 patients requiring intestinal resection, 14 patients were repaired with the TEP lifting procedure using 3DMAXTM Light Mesh. The average surgical time was 68 minutes, with an average length of hospitalization following surgery of 16.4 days. As postoperative complications, 1 case of femoral abscess formation and 1 case of exacerbation of heart failure were observed;however, there was no recurrence of the obturator hernia within the observation period from 5 months to 11 years. The TEP lifting procedure is believed to be a very effective technique for the treatment of obturator hernia.

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  • Masahiro Kawasaki
    2018 Volume 38 Issue 6 Pages 953-956
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    We evaluated the relationship between C-reactive protein value (CRP) by the elapsed time and severity of acute appendicitis (AAP) in children and adolescents. Cases of AAP in 18 years old or younger who underwent appendectomies in our hospital from 2005 to 2017 were reviewed. The preoperative CRP was collected, together with the elapsed time from the onset of symptoms. The cases were classified as the simple or complicated type from their severity, based on the pathological findings and surgical record. Among the 132 cases, 112 cases were the simple type and 20 were the complex type. A strong correlation was found between CRP and elapsed time in patients under 10 years old. The accuracy of the severity determination by CRP was 0.988 (95% confidence interval:0.974 to 1.0) for the area under the curve (AUC) in the receiver operating characteristic curve. When the CRP cutoff value was 5.36mg/dL, the sensitivity was 95.0%, specificity 93.7%. CRP well reflects the severity of AAP and is useful as a parameter. The CRP can exceed the cutoff value which indicates complicated AAP in 24 hours from the onset in children.

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  • Takeshi Yamada, Yuto Aoki, Michihiro Koizumi, Seiichi Shinji, Goro Tak ...
    2018 Volume 38 Issue 6 Pages 959-963
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    【Background】The pathogenesis of small bowel strangulation (SBS) is a bowel blood─flow disorder, and non-necrotic SBS is SBS with an incomplete blood-flow disorder. Contrast enhanced CT (CECT) is promising for the diagnosis. However, it remains unclear which findings of CECT are useful for the diagnosis of non-necrotic SBS. 【Methods】Study patients included 29 patients with necrotic SBS and 48 patients with non-necrotic SBS. 【Results】We found intestinal wall thickness and mesenteric edema in over 70% of the patients with both necrotic and non-necrotic SBS. Disappearance of Kerckring’s folds, bowel hypoenhancement and hemorrhagic ascites were identified as independent risk factors indicating necrotic SBS. Hypoenhancement of the bowel wall was found in 55% of patients with necrotic SBS and 4% of non-necrotic SBS. 【Discussion】For accurate diagnosis of non-necrotic SBS, we should pay attention not so much to hypoenhancement of the bowel wall but bowel wall thickness and mesenteric edema.

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  • Takatoshi Nakamura, Masahiko Watanabe
    2018 Volume 38 Issue 6 Pages 965-970
    Published: September 30, 2018
    Released: January 29, 2020
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    Risk factors for recurrence of postoperative intestinal obstructions (PIOs) in patients who have a PIO after abdominal surgery remain unclear. Materials and Methods:The group comprised 144 patients who underwent surgery for a PIO that developed after abdominal surgery. Laparoscopic surgery was performed in 94 patients, and open surgery was done in 50. We examined the following 11 potential risk factors for PIO recurrence after surgery for a PIO. Results:A univariate analysis revealed that 2 risk factors were significantly related to the recurrence of a PIO: open surgery (P=0.0061) and the bleeding volume (P=0.0274). A multivariate analysis suggested that open surgery was an independent risk factor for the recurrence of a PIO (P=0.0263). Open surgery was identified as an independent risk factor for the recurrence of a PIO after abdominal surgery.

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  • Hideo Kidogawa, Tomoe Moriguchi, Masato Goubara, Kazuhiro Otsubo, Masu ...
    2018 Volume 38 Issue 6 Pages 971-975
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    We retrospectively examined the usefulness of laparoscopic surgery for strangulated bowel obstruction in our hospital. Twenty-six strangulated bowel obstruction patients (strangulated group) and 56 non-strangulated bowel obstruction patients (non-strangulated group) during the same time were compared and examined for the operations after 2002. The proportions of patients with a past history of laparotomy was 65.4% for the strangulated group, and 80.4% for non-strangulated group. The history of bowel obstruction was significantly lower in the strangulated group at 19.2% compared with 48.2% in the non-strangulated group. In the strangulated group, there were many cases in which the operation was carried out without reduced pressure. Intestinal resections were frequently done in the strangulated group and conversions to laparotomy were frequently done in the non-strangulated group, but there were no significant differences. The mean operating time was 89.0 minutes which was significantly shorter in the strangulated group than 144.2 minutes in the non-strangulated group, and the average hospitalization period was 9 days which was significantly shorter in the strangulated group compared with 14 days in the non-strangulation group. Laparoscopic surgery is more useful for strangulated bowel obstruction than non-strangulated bowel obstruction regarding operation time and postoperative hospitalization days.

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  • Shinichi Sekine, Shozo Hojo, Kenta Sukegawa, Katsuhisa Hirano, Makoto ...
    2018 Volume 38 Issue 6 Pages 977-982
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    Obturator hernias are a rare but significant cause of strangulated bowel obstruction. Elderly emaciated women are considered to be predisposed to this condition with many symptoms such as Howship-Romberg sign (HRS), although the relationship to intestinal resection is poorly understood. We reviewed patients with an obturator hernia. The subjects were ten patients who underwent surgery in our department. All patients were elderly women and the mean age was 85.9 years old (79~92 yr). Only four patients (40%) had HRS. All patients were diagnosed based on computed tomography (CT) imaging. Intestinal resection was performed in 6 patients (60%). We divided the subjects into 2 groups based on the presence of intestinal resection (resected group and non-resected group). There were no significant differences between the two groups in terms of the presence of SIRS, preoperative WBC and CRP values. Preoperative duration from onset (duration of illness) was significantly longer (P<0.05) in the resected group (1.3 days in the non-resected group, 8.3 days in the resected group). In the examination of the CT images, the average value of the CT slice length was significantly longer in the resected group than the non-resected group (P<0.05). Evaluating the necessity of intestinal resection before surgery is also considered to be important in selection of the surgical procedure.

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  • Minoru Tanaka, Kohei Kawagita, Yuki Segi, Yoshihiro Okuda, Michio Kono ...
    2018 Volume 38 Issue 6 Pages 983-988
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    With the aim of clarifying the preoperative factors for intestinal resection in an incarcerated groin hernia (IGH), we investigated cases of IGH in our department. 【Patients】 37 patients who underwent an emergency operation for IGH were divided into the following 2 groups by bowel resection: the resection group (n=10) and the non-resection group (n=27). 【Results】 Four items were found to be significantly different between the two groups; age, time from onset to hospital visit, serum CRP level, and the CT value of the incarcerated intestine contents. Logistic regression analysis revealed that the CT value was the only significant independent factor. The cut off value calculated using a receiver operating characteristic curve of CT values was 20 HU, with a sensitivity of 70% and a specificity of 96%. We experienced a case which caused a late-onset stricture of small intestine after a reduction of IGH. In this case, a preoperative CT image revealed a precipitation image in the back region of the incarcerated intestine. In such a case, the CT value needs to be measured in the precipitated region. 【Conclusion】 the CT value is useful to judge the reversibility of intestinal ischemia, the indication of manual reduction and the necessity for bowel resection.

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  • Toru Tonooka, Yoshihiro Nabeya, Nobuhiro Takiguchi
    2018 Volume 38 Issue 6 Pages 989-995
    Published: September 30, 2018
    Released: January 29, 2020
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    Colorectal obstruction caused by cancer, namely obstructive colorectal cancer (OCC), is frequently encountered in routine clinical practice, and often develops as an oncology emergency (OE). In OCC patients, obstruction, perforation due to tumor, abscess or peritonitis, obstructive colitis, and bacterial translocation due to disorder of the intestinal microbial flora are possible morbid conditions at the initial presentation. Therefore, it is necessary to plan decision-making of the initial treatment for the OEs (such as bowel decompression) and the subsequent cancer treatment in a short time, based on evaluation of the oncological curability. The method of bowel decompression should be selected depending on the anticipated subsequent treatment of OCC. It is essential to individually perform multidisciplinary treatment including surgery and chemotherapy, while paying attention to tumor bleeding or perforation related to the treatment. We should keep in mind that OEs may develop during the treatment process of OCC patients, and appropriate measures should be taken. In addition to recent advances in chemotherapy, application of the colonic stent placement as a bridge to surgery and expanded indication of laparoscopic surgery are expected, although long-term prognosis of the treatment has yet to be verified.

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  • Yusuke Kinugasa, Toshiro Ogata, Kenichi Yasushi, Kazuhito Tamehiro, Ma ...
    2018 Volume 38 Issue 6 Pages 997-1000
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 42-year-old man suffered injuries when assaulted by an acquaintance during an argument, but returned home without any complaint immediately thereafter. Abdominal pain/vomiting presented the next day, and upon visiting a nearby clinic intra-abdominal bleeding was detected via CT scan. He was transferred to our hospital 18 hours post-accident. At the time of arrival, radial arterial blood pressure was unmeasurable. An abdominal plane CT scan showed fluid collection and a massive hematoma in the transverse mesocolon and lateral side of the duodenum. One and a half hours after arrival, emergency laparotomy was performed for intra-abdominal bleeding. Fresh bleeding was found in the peritoneal cavity, so we opened the lesser omentum and applied pressure to the abdominal aorta. A laceration 10×15 cm in the transverse mesocolon and active hemorrhaging from the middle colic artery/vein were identified, and hemostasis was performed. No injury of other intra-abdominal organs was confirmed. The final diagnosis was traumatic transverse mesocolon (type Ⅱb) and middle colic arteriovenous injury. The postoperative course was uneventful and he was discharged 12 days after surgery. Three months post-injury, the patient is fully functional with no complications. This is a report of a case of late-onset shock caused by middle colic arteriovenous injury from blunt abdominal trauma.

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  • Koichi Inukai, Hirotaka Miyai, Keisuke Nonoyama, Shinnosuke Harata, Sh ...
    2018 Volume 38 Issue 6 Pages 1001-1005
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 66-year-old male was admitted to our hospital with sudden abdominal pain. An enhanced abdominal CT scan revealed an enhanced tumor measuring 2.5cm in diameter which invaginated into the ascending colon from the ileum. Insertion of a long intestinal tube improved the ileus and reduced the intussusception. We performed laparoscopy-assisted partial resection of the small intestine under the suspicion of GIST or lymphoma. The tumor was diagnosed as a diffuse large B cell lymphoma based on the histological findings. Chemotherapy led to complete remission. Malignant lymphoma that occurs in the small intestine as its primary site has been diagnosed in some cases as intussusception. In cases of intussusception caused by a small intestinal tumor, preoperative decompression and diagnosis should be attempted to the greatest extent possible, and laparoscopy-assisted resection immediately followed by initiation of chemotherapy may result in favorable outcomes.

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  • Hiroyuki Inoue, Toshiya Ochiai, Eigo Otsuji
    2018 Volume 38 Issue 6 Pages 1007-1010
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 54-year-old man was referred to our hospital with abdominal contusion due to a traffic accident. He was diagnosed as having a duodenal injury based on computed tomography, and emergency surgery was performed. During surgery, a ruptured region of the duodenum in the ligament of Treitz and bleeding from the peripheral superior mesenteric vein was found. The pancreas was undamaged. Due to the high possibility of anastomotic leakage if we attempted end-to-end anastomosis of the ruptured duodenum, we instead closed the injured part and performed a side-to-side duodenojejunostomy, gastrojejunostomy, and Braun anastomosis. The patient was discharged uneventfully on postoperative day 24. There are many procedures for resolving a damaged duodenum, so we must select the most appropriate procedure for a given case. If a diagnosis can be made early after injury and an appropriate procedure is selected, there is a better chance of achieving a good survival outcome.

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  • Hiroyuki Maruyama, Masaru Koizumi, Kenichi Oshiro
    2018 Volume 38 Issue 6 Pages 1011-1016
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 59-year-old female with a history of a hysterectomy presented with abdominal pain. An abdominal CT scan revealed a loop of small intestine with stenosis and a caliber change in the left lower abdomen. Adhesive bowel obstruction was diagnosed and a long tube was inserted, but the patient did not improve by eight days after admission. Laparoscopic exploration was performed. An intersigmoid hernia was found intraoperatively, with the small intestine incarcerated in the intersigmoid fossa. The small intestine was mobilized by incising the hernia ring. A partial resection of the small intestine was needed because of bowel strangulation with necrotic changes. We report herein on a patient with an intersigmoid hernia, with a review of previously reported cases in Japan.

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  • Nobuhiro Takeuchi, Atsunori Nakao
    2018 Volume 38 Issue 6 Pages 1017-1024
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 71-year-old male visited our hospital with complaints of high grade fever and epigastric pain. The patient was diagnosed as having acute cholangitis accompanied with a deteriorating level of consciousness and sepsis. An emergency endoscopic cholangiopancreatography (ERCP) was scheduled. A guidewire could not be inserted into the common bile duct despite performing a pre-incision. Percutaneous transhepatic gallbladder drainage was then performed to relieve biliary pressure. On day 3, the patient excreted a massive melena. Contrast enhanced computed tomography (CT) revealed a thrombus at the main trunk and left branch of the portal vein. After endoscopic drainage was performed successfully, anticoagulant treatment with heparin and warfarin was initiated. A follow-up CT revealed partial reduction of the thrombus. Three months later, the patient’s gallbladder and existing hepatocellular carcinoma were removed under laparoscopy. A 67-year-old male visited our hospital with high grade fever and jaundice. Non-contrast CT revealed stones in the common bile duct and the high-density areas in the portal vein. A portal thrombus was suspected. Contrast enhanced CT confirmed a portal thrombus at the main trunk and left branch of the portal vein. An emergency ERCP was performed and a plastic biliary stent was inserted into the common bile duct. No bleeding tendency was confirmed. Anticoagulant therapy with heparin and warfarin was then initiated. Although a portal vein thrombus is a well-recognized sequela associated with liver cirrhosis, malignancies, acute pancreatitis, and intestinal infections, it is uncommon for portal vein thrombus to occur secondary to acute cholangitis and cholecystitis. In acute cholangitis accompanied with disseminated intravascular coagulation, the possibility of a portal vein thrombus should be considered, and deliberate careful and precise interpretation of CT imaging is essential.

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  • Hiroto Fujisaki, Chie Hagiwara, Yoshiyuki Suzuki, Norihiro Kishida, Ka ...
    2018 Volume 38 Issue 6 Pages 1025-1030
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 67-year-old woman was admitted to our hospital with the sudden onset of abdominal pain on exertion. Upon arrival, her blood pressure was low at 99/58 mmHg, and abdominal computed tomography revealed a giant splenic artery aneurysm measuring 8 cm in size, with concomitant hemorrhagic ascites/hematoma in the abdominal cavity and retroperitoneum. The umbilical vein showed marked enlargement. Blood tests showed thrombocytopenia and hyperbilirubinemia. Based on the above findings, she was diagnosed as having a ruptured giant splenic artery aneurysm with concomitant decompensated cirrhosis. An emergency laparotomy was planned because we concluded that the aneurysm would be difficult to treat using interventional radiology. Because the perforated splenic artery aneurysm was fixed to the pancreatic tail, we performed a distal pancreatectomy. An intraoperative liver biopsy showed no liver fibrosis. Eventually, she was diagnosed as having idiopathic portal hypertension.

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  • Masahide Fukae, Hiroe Fukae
    2018 Volume 38 Issue 6 Pages 1031-1035
    Published: September 30, 2018
    Released: January 29, 2020
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    A 53-year-old woman presented to our hospital with black stools, a 20-mm hard umbilical nodule, and body weight loss. Computed tomography revealed an intrahepatic cholangiocarcinoma with peritoneal dissemination and invasion into the portal vein, common bile duct, gallbladder, and pancreas. Endoscopic clipping for gastric varices was necessary. She died 3 months after her initial visit. One hundred seventy patients with malignant umbilical metastases, including our own case, have been reported in Japan since 1978. Forty-three patients were male ; the others were female. The mean age was 64.0±14.0 years. The primary tumors were located in the ovary, stomach, and pancreas in descending order of prevalence. Intrahepatic cholangiocarcinoma was only detected in 2 cases, including our case. The median time to death from the diagnosis of umbilical metastasis was 10.7±11.1 months. The prognosis varied according to the primary malignancy, but was basically poor. Physicians should therefore consider the prognosis when the decision is made to resect an umbilical metastasis due to such factors as exudate fluid and malodor.

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  • Hirokazu Momose, Koichiro Kojima, Tadahiko Masaki, Toshiyuki Mori, Mas ...
    2018 Volume 38 Issue 6 Pages 1037-1041
    Published: September 30, 2018
    Released: January 29, 2020
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    A 41-year-old man complained of right lower abdominal pain, vomiting and diarrhea. He was suffering chronic renal failure with Alport syndrome and had been treated with hemodialysis and sodium polystyrene sulfonate(Kayexalate, SPS) from 25 years previously. Abdominal computed tomography suggested ascending colon diverticulitis. Conservative treatment with antibiotics improved the abdominal pain and inflammatory response. However, a massive hemorrhagic stool (1,600g) was observed after hemodialysis on the 11th day. Since colonoscopic hemostasis was difficult due to massive hemorrhage in the right side colon, a right hemicolectomy was performed and an ileostomy with a transverse mucous fistula was carried out on the 15th day. Pathological examination revealed a 30mm, poorly defined ulcer in the cecum, accompanied with crystalline material, suggesting an SPS related ulcer. Although commonly used for improving hyperkalemia in patients with chronic renal failure, SPS may sometimes induce severe intestinal injury.

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  • Chikara Maeda, Tadahiro Kamiya, Takehito Katoh, Kazuhiro Hiramatsu, Yo ...
    2018 Volume 38 Issue 6 Pages 1043-1046
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 84-year-old man was diagnosed as having sigmoid colon cancer after a colonoscopy performed a few days previously by a local doctor. He presented at our hospital emergency outpatient clinic with abdominal pain and vomiting. Tenderness and muscular defense were observed throughout his abdomen. His blood test results showed WBC 16,690/μL, and CRP 1.12mg/dL. Abdominal computed tomography showed osmotic wall fertilization and intestinal dilation in the oral side of the sigmoid colon. In addition, an irregular high absorption region extending from the tumor to the central side along the sigmoid colon artery was recognized, and it was considered to be local development of the tumor. Emergency laparotomy surgery was performed under the diagnosis of obstructive sigmoid colon cancer. We palpated the tumor in the sigmoid colon and continuous necrosis for 30 cm was present in the oral side of the intestinal tract. We resected the sigmoid colon containing the necrotic intestine and constructed a single-hole colostomy. In the excised specimen, a black color change in the oral side of the colon mucosa was observed with the tumor center as the boundary. There have been no reports of obstructive colon cancer in which local proliferation of the primary tumor was thought to contribute to intestinal necrosis. This is considered a valuable case and is reported herein with a discussion of the relevant literature.

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  • Koji Osumi, Takashi Oishi, Yuichi Nishihara, Yo Isobe
    2018 Volume 38 Issue 6 Pages 1047-1050
    Published: September 30, 2018
    Released: January 29, 2020
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    A 20-year-old male visited our hospital with sudden right abdominal pain. Computed tomography and abdominal ultrasonography revealed a multiple concentric ring sign in the ascending colon, so he was diagnosed as having intussusception. The intussusception was relieved with a high pressure enema using amidotrizoic acid. Colonoscopy showed multiple elevated lesions with a smooth surface in the ascending colon and cecum. On the sixth day after admission, a laparoscopic right hemicolectomy was performed. Histopathological findings of the resected specimen showed pneumatosis cystoides intestinalis (PCI). PCI cases with intussusception are relatively rare. PCI has been reported to be cured with oxygen treatment, therefore the appropriateness of surgery needs to be judged carefully.

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  • Takahiro Manabe, Natsuki Kato, Tetsuji Yamaguchi, Koki Kamiyama, Shige ...
    2018 Volume 38 Issue 6 Pages 1051-1054
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 41-year-old woman was admitted to our hospital with upper abdominal pain and repeated high fever. The examination showed a transverse colon tumor measuring 10 cm, and a marked inflammatory response. We suspected that this tumor was a gastrointestinal mesenchymal tumor with abscess formation. We performed a transverse colon resection with D3 dissection and a partial gastrectomy. The marked inflammatory response improved quickly after the operation, and the patient was discharged without postoperative complications. The histopathological examination revealed spindle-shaped tumor cells within the colon wall and an immunohistochemical examination revealed αSMA (+), desmin (+), C-kit (−), CD34 (−), DOG-1 (−). A leiomyosarcoma of the transverse colon was diagnosed based on the results of the immunohistochemical examination. The patient was followed for 18 months postoperatively without any recurrence.

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  • Hironori Kuroda, Sho Yamada, Kengo Hayashi, Masahiro Hada, Takuo Hara
    2018 Volume 38 Issue 6 Pages 1055-1058
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    An 81-year-old woman was admitted for fever and a left lower abdominal 10 cm red mass, with pain and tenderness. Computed tomography showed a locally advanced sigmoid colon tumor with an abdominal wall abscess. Following abdominal wall drainage and drug treatment with MEPM, a colonoscopy and a barium enema examination confirmed double cancers of the sigmoid colon penetrating the abdominal wall and rectal S-shaped portion. On hospital day 16, a laparoscopic Hartmann operation was performed with en-bloc excision of the abdominal wall and a D3 lymph node dissection. The patient left the hospital 27 days after surgery. Though laparoscopic surgery for this advanced case is very beneficial with minimal invasion, there is an associated risk of failing pneumoperitoneum. Careful follow-up examinations will be needed for this patient with a high risk of local recurrence.

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  • Koji Asai, Manabu Watanabe, Hiroshi Matsukiyo, Tomoaki Saito, Manabu K ...
    2018 Volume 38 Issue 6 Pages 1059-1064
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 70-year-old man underwent a pancreaticoduodenectomy for distal bile duct cancer. At 23 months postoperatively, local recurrence was suspected around the pancreatojejunostomy site, and chemoradiation therapy was started. At 27 months postoperatively, he was admitted to the hospital with intestinal bleeding. After a detailed examination, hemorrhagic varices at the hepaticojejunostomy site associated with hepatopetal collateral vessels and portal vein stenosis were diagnosed. Although endoscopic hemostasis was repeatedly performed, intestinal bleeding from the varices could not be controlled. Therefore, the patient was repeatedly admitted. Percutaneous transhepatic portal vein stent insertion was considered for the portal vein stenosis. After embolizing the varices, including those associated with the hepatopetal collateral vessels, a portal vein stent was inserted. At 42 months after portal stent insertion, the stent was patent, and the patient was doing well without recurrence. Portal vein stent insertion can be considered to be an effective therapeutic strategy for malignant as well as benign portal vein stenosis with severe collateral symptoms.

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  • Keisuke Toguchi, Kazutaka Toyama, Takuya Yamaguchi
    2018 Volume 38 Issue 6 Pages 1065-1070
    Published: September 30, 2018
    Released: January 29, 2020
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    A 52-year-old man visited our hospital with lower abdominal pain, urination pain, and dysuria. Abdominal computed tomography showed many diverticula in the sigmoid colon and adherence between the sigmoid colon and bladder was confirmed. Since we found air in the bladder, our diagnosis was a colonic bladder fistula due to sigmoid colon diverticulitis. Fasting intravenous drip therapy with antibiotics was performed. After relief of the inflammation, laparoscopic surgery was performed, using magnification via the laparoscope of the layer on the colon side, and the fistula was closed with the Vessel Sealing System. The sigmoid colon was excised and anastomosis of the sigmoid colon and the rectum was performed without diversion. About 200mL of physiological saline was injected into the bladder, it was confirmed that there was no outflow from the fistula, and surgery was terminated without any additional procedure for the bladder. We placed a urethral balloon for decompression of the bladder, but it was withdrawn on the 6th postoperative day. The patient was discharged without complications on the 18th postoperative day. A colonic bladder fistula due to sigmoid colon diverticulitis was treated laparoscopically after relief of the inflammation, making it possible to treat less invasively with few complications.

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  • Kyota Tatsuta, Shinichiro Miyazaki, Yoshiro Nishiwaki
    2018 Volume 38 Issue 6 Pages 1071-1074
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    An 85-year-old man who had formerly received antibiotic therapy for appendicitis and undergone no laparotomy was referred to our hospital with the diagnosis of strangulated obstruction seen on computed tomography. A laparotomy revealed that the tip of the appendix had adhered to the small intestinal mesentery, an adjacent loop of the small intestine was incarcerated through the hole made by that adhesion, and the incarcerated intestine exhibited ischemic change. However, the color and peristalsis of the ischemic intestine improved after release of the fibrous adhesion between the appendix and the mesentery. Therefore, resection of the affected intestine could be avoided and an appendectomy was performed on its own. Although appendicitis can cause paralytic ileus or adhesive intestinal obstruction after appendectomy, strangulated obstruction caused by appendicitis has been rarely described. We herein report on a case of strangulated obstruction after antibiotic therapy for appendicitis with a review of the relevant literature.

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  • Kenji Matsumoto, Yoshimitsu Izawa, Toshiaki Terauchi, Kenji Kobayashi, ...
    2018 Volume 38 Issue 6 Pages 1075-1079
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 44-year-old man was brought to the emergency room with epigastric pain and dyspnea. His hemodynamic state was unstable, and an enhanced computed tomography scan showed a ruptured inferior pancreaticoduodenal artery with multiple aneurysms. A resuscitative endovascular balloon was inserted into the aorta, and angioembolization was performed. The patient became hemodynamically stable. However, the patient again became unstable after embolization, with massive abdominal distension. The patient was diagnosed as having abdominal compartment syndrome and underwent an emergency decompressive laparotomy. Non-operative management using interventional radiology techniques for hemorrhagic shock are often reported. Abdominal compartment syndrome can occur after non-operative management, which requires immediate surgical decompression.

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  • Kazuma Rifu, Daishi Naoi, Yuichi Aoki, Chuji Sekiguchi
    2018 Volume 38 Issue 6 Pages 1081-1084
    Published: September 30, 2018
    Released: January 29, 2020
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    A 67-year-old female presented with right upper quadrant abdominal pain. Physical examination showed a temperature of 38.2℃ and tenderness on palpation in the right upper quadrant. WBC count, C-reactive protein, AST, ALT, and total bilirubin were elevated. An abdominal CT scan was consistent with acute cholecystitis. Incidentally, a 70-mm submucosal tumor was seen in the gastric wall. The acute cholecystitis was treated with percutaneous transhepatic gallbladder drainage. Esophagogastroduodenoscopy (EGD) showed a submucosal tumor with an ulcer in the gastric body. Biopsy of the ulcer bed showed tangled spindle tumor cells, and immunohistochemical staining revealed S100+, desmin-, CD34-, c-kit-. And an MIB-1 index of 5~10%. The lesion was diagnosed as a gastric schwannoma. We performed partial gastrectomy, and open cholecystectomy. The patient’s post-operative course was uneventful.

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  • Hiroaki Suzuki, Keiki Shimizu, Jun Hamaguchi, Takeshi Koshiishi, Taku ...
    2018 Volume 38 Issue 6 Pages 1085-1089
    Published: September 30, 2018
    Released: January 29, 2020
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    A 75-year-old male was transported to our hospital because of hematemesis. Computed tomography (CT) showed an aneurysm in the distal splenic artery perforating into the stomach. We performed transcatheter arterial embolization of the splenic artery aneurysm and hemostasis was obtained. We performed an abdominal paracentesis on the next day and found high levels of alkaline phosphatase and amylase in the fluid collection suggesting a stomach rupture. The subsequent CT examination on ICU day 3 showed the rupture of the stomach, and we performed an emergency laparotomy. We found an approximately 10cm laceration in the anterior wall of the gastric body on the side of the lesser curvature presumably caused by the perforation of the splenic artery aneurysm. We made a primary closure of the laceration with an Albert-Lembert suture. The patient, who was under respirator management, was extubated on ICU day 5 and his oral ingestion began on ICU day 11. He was discharged on hospitalization day 60 with a good postoperative course. Perforation with a splenic artery aneurysm and rupture of the stomach are both critical injuries requiring prompt initial management for bleeding and less invasive surgical intervention to get a good outcome.

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  • Yasuyo Nishikawa, Ryo Kudo, Hideo Ann, Shinya Hamasu
    2018 Volume 38 Issue 6 Pages 1091-1094
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    An 89-year-old woman came to our hospital with frequent abdominal pain and anorexia. The physical examination revealed rebound tenderness and muscle guarding on the epigastric and left hypochondrial regions. An abdominal computed tomography (CT) scan showed free air and a cystic lesion with an air-fluid content adjacent to the stomach. Upper gastrointestinal endoscopy revealed a perforated gastric ulcer at the lesser curvature of the gastric angle. The patient was diagnosed as having perforation of a gastric ulcer with an abdominal abscess and underwent emergency laparoscopic surgery. We found a collapsed liver cyst in the left hepatic lobe, and the perforation of the gastric ulcer into the liver cyst was revealed. The perforation of the gastric ulcer was covered with the greater omentum. We cut and excised the cyst wall under laparoscopy. The patient was discharged on the 25 postoperative day, without any deterioration in her activities of daily living (ADL). We report herein on a case of laparoscopic surgery in a very elderly patient with peritonitis due to a ruptured infectious liver cyst penetrated by a gastric ulcer.

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  • Yukino Yoshimura, Yako Hasegawa, Junichi Suzuki, Tomonori Kawase, Tets ...
    2018 Volume 38 Issue 6 Pages 1095-1099
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 64-year-old man with chronic renal failure underwent renal transplantation. On the 9th post operative day, he complained of abdominal pain, and based on abdominal CT findings, our diagnosis was a perforation of the digestive tract. The patient was unresponsive to conservative management, and an emergency operation was performed. On laparotomy, multiple diverticula of the jejunum and some diverticular perforations were recognized. We performed partial resection of the jejunum. After surgery, under maintained antirejection therapy, he recovered without complications having occurred.

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  • Arisa Kurihara, Yasuhiro Ishiyama, Junichi Seki, Yojiro Takano, Shoji ...
    2018 Volume 38 Issue 6 Pages 1101-1104
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 59-years-old man was brought to our hospital with right lower abdominal pain and fever. He underwent partial resection of the duodenum and small intestine and was treated with chemotherapy for duodenal cancer. An enhanced abdominal CT examination revealed a swollen appendix with a thick wall and the dirty fat sign around the appendix. The previous PET-CT revealed the appendix with abnormal uptake on FDG-PET. We diagnosed acute appendicitis due to peritoneal dissemination and performed a laparoscopic appendectomy for the appendicitis. Part of the appendix was perforated. Following resection of the appendix, the ascending colon was closed with an automatic suturing device. Intraoperative findings revealed numerous peritoneal nodules at the right diaphragm and around the appendix. The histopathological diagnosis was appendiceal metastasis from duodenal cancer. The patient was discharged from hospital on the 11th postoperative day, but died of cancer-related pleurisy 6 months after surgery.

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  • Yu Asakura, Takuro Yoshikawa
    2018 Volume 38 Issue 6 Pages 1105-1109
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    We report herein on two cases of intraabdominal foreign body identified as pieces of metal. Case 1: A 97-year-old woman was admitted to our hospital because of right lower abdominal pain. Abdominal CT scan revealed a high-density substance in the free abdominal cavity. Under a diagnosis of an intraabdominal foreign body, open surgery was urgently performed. A 2.0-cm long needle-shaped metal foreign body in the greater omentum near the right transverse colon was confirmed and removed. Case 2: A 33-year-old man visited our hospital for an appendicitis operation. A CT scan incidentally revealed a high-density substance in the pelvic area. We performed laparoscopic surgery, in which we combined the appendectomy with removal of a 5.0-cm long needle-shaped metal foreign body in the pelvic region near the bladder.

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  • Atsuro Fujinaga, Takuya Noguchi, Yuichiro Kawano, Kohei Shibata
    2018 Volume 38 Issue 6 Pages 1111-1116
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    Tuberculous peritonitis is a type of extrapulmonary tuberculosis that is fatal when in the advanced stages. Early diagnosis and treatment of tuberculous peritonitis are important for treatment success. We report herein on two cases of tuberculous peritonitis diagnosed with a laparoscopic biopsy. The first patient was a 70-year-old female who presented to our hospital with abdominal pain and vomiting. Computed tomography (CT) revealed the thickening of the small intestinal wall, which was diagnosed as ileus. Surgery was performed following conservative therapy. The second patient was an 80-year-old female who presented to our hospital with abdominal distension. CT revealed ascites and mesenteric fat stranding. In the ascites, an increase in adenosine deaminase levels was confirmed without any atypical cells. Tuberculous peritonitis was suspected, and surgery was performed for a definitive diagnosis. In both cases, numerous white millet seed-sized nodules were observed in the abdominal cavity, and tuberculous peritonitis was pathologically diagnosed by confirming epithelioid cell granuloma with peritoneal biopsies. The diagnosis of tuberculous peritonitis can be difficult due to its varied symptoms. A laparoscopic biopsy is minimally invasive and can be effective for the early diagnosis and treatment of tuberculous peritonitis, leading to favorable outcomes.

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  • Shigeki Kinoshita, Hiromitsu Suzuki, Nobuhiro Kawasaki, Kazuo Okano
    2018 Volume 38 Issue 6 Pages 1117-1120
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 101-year-old female with abdominal pain and nausea was taken to our hospital by ambulance. Computed tomography (CT) revealed a lot of gas in the portal and superior mesenteric veins. Abdominal pain improved along with the recovery from hypovolemia. However, the patient developed abdominal pain again with high fever, vomiting and anal bleeding 8 hours later. CT revealed ascites, thickening of the ileum wall and elevation of the mesenteric density. Mesenteric ischemia was suspected and an emergency laparotomy was performed. 40 cm of the ileum demonstrated an ischemic change, and approximately 60 cm of the ileum was resected. The operation was performed smoothly and was uneventful. Histopathological analysis showed an acute ischemic changes without thrombus, suggesting non-occlusive mesenteric ischemia. The patient was discharged on the 36th day after the operation.

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  • Atsushi Hirata, Koichi Shinoto, Yasushi Okazaki, Masahiko Ozaki, Hisah ...
    2018 Volume 38 Issue 6 Pages 1121-1125
    Published: September 30, 2018
    Released: January 29, 2020
    JOURNALS FREE ACCESS

    A 71-year-old man had undergone total gastrectomy with Roux-en-Y reconstruction for scirrhous gastric carcinoma. On postoperative day 4, enteral nutrition was started via a trans-nasal jejunal feeding tube, because anastomotic leakage at the esophagojejunostomy was revealed. On postoperative day 7, the antibiotic was changed and it caused anaphylactic shock, which was soon relieved with intravenous administration of adrenaline 0.3mg, and enteral nutrition resumed after a few hours. He complained of a strong abdominal pain and abdominal CT revealed pneumatosis intestinalis and hepatic portal venous gas. An emergency exploratory laparotomy showed segmental and discontinuous ischemia at the beginning at the feeding tube site, but there was no evidence of bowel necrosis. The next day, a second look operation showed that the bowel ischemia had improved, and the patient recovered with conservative treatment. Early postoperative enteral nutrition is well known to contribute to the reduction of length of stay and the incidence of postoperative complications. Non-occlusive mesenteric ischemia or bowel necrosis is now recognized as a rare and fatal complication of enteral tube feeding, but is almost unknown in Japan. We report herein on a case of non-occlusive mesenteric ischemia during postoperative early enteral nutrition with reference to previous related papers.

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