Nihon Fukubu Kyukyu Igakkai Zasshi (Journal of Abdominal Emergency Medicine)
Online ISSN : 1882-4781
Print ISSN : 1340-2242
ISSN-L : 1340-2242
Volume 39 , Issue 4
Showing 1-37 articles out of 37 articles from the selected issue
  • Keiji Matsuda, Yuka Okada, Kohei Ohno, Takahiro Yagi, Mitsuo Tsukamoto ...
    2019 Volume 39 Issue 4 Pages 629-635
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    In recent years, cases of necrotizing and perforated appendicitis have drawn attention and have been referred to as complicated appendicitis (CA). This paper outlines the current status of and the factors involved with CA. Of the 196 patients treated in our department, 89 cases, 45% belonged to the CA group and 107, 55% non-CA group. In comparison with the non-CA group, the CA group had more males, older patients and BMI, higher white blood cell count and c-reactive protein (CRP) levels, more frequent emergency surgery and ileocecal resection, longer surgery time, more bleeding, longer incision, more drain placements, more postoperative complications, and longer hospital stay. The significant risk factors for the CA group were CRP levels which were 1.83 mg/dL or more, the white blood cell count which was 14,200/μL or more, and age which was 35 or more. In the guidelines, laparoscopic surgery may be performed for perforated acute appendicitis, non-surgery may be chosen for appendiceal inflammatory mass with no symptoms of peritonitis, postoperative antibiotics are recommended for CA, and percutaneous drainage is also chosen in CA. If emergency surgery is not performed for CA patients, it is important to carefully follow up the patient, taking into consideration the possibility of exacerbation.

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  • Sumiharu Yamamoto, Atsuki Taniguchi, Naoya Matsumoto, Hiroaki Asano, M ...
    2019 Volume 39 Issue 4 Pages 637-644
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    As simple appendicitis not effectively addressed with antibiotics can progress to complicated appendicitis, repeated monitoring of the effect of selected antibiotics is important to prevent treatment failure. We retrospectively examined complications after antibiotics-first treatment while focusing on two effective clinical indicators targeting disseminated peritonitis and reduction in white blood cell (WBC) counts. Receiver operating characteristic curve analysis of 50 cases established the effective cut-off value of WBC counts at 80%. Antibiotic therapy was initiated with careful management of daily WBC counts; antibiotics were changed if there was no response. Patients in whom the therapy failed were treated with surgery within 48 hours. Seventy-two patients were treated via this management strategy. Emergency surgery was performed in 26 patients. For 46 patients, antibiotics-first therapy was initiated; 8 patients required a change of antibiotics. The 46 antibiotics-first patients did not require surgery. No complications were seen in any of the patients. Based on our results, these two indicators, clinical examination and 80% cut-off for decreasing the WBC values within 24 hours, could be effective to treat simple appendicitis.

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  • Shunichi Osada, Mitsutaka Sugita
    2019 Volume 39 Issue 4 Pages 645-648
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    【Purpose】We retrospectively examined the predicting factors of necrotizing/perforated appendicitis from the preoperative findings including the imaging diagnosis of acute appendicitis surgery cases. Age, body temperature, muscle protection, white blood cell count, CRP levels, CT findings (appendicolith, appendix swelling, elevated fat tissue density around the appendix, ascites) associated with 368 cases of appendectomy from April 2005 to December 2009 were divided into two groups and predictors for necrotizing and perforated appendicitis were assessed using binomial logistic analysis. One hundred and eighty-nine cases (51.4%) of necrotizing and perforated appendicitis were identified. A univariate analysis revealed that predictors for necrotizing/perforated appendicitis were body temperature, muscle protection, CRP levels, elevated fat tissue density around the appendix of CT findings, and ascites. A multivariate analysis findings showed three factors: CRP levels, body temperature, and elevated fat tissue density around the appendix of CT. The probability of having necrotizing/perforating appendicitis was 75.5% for cases with 2 positive factors and 92.3% for 3. Based on our results, if more than one of the above factors is positive, prioritizing surgical treatment should be considered as necessary.

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  • Keisuke Hara, Takeshi Yamada, Michihiro Koizumi, Seiichi Shinji, Akihi ...
    2019 Volume 39 Issue 4 Pages 649-653
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    Interval appendectomy (IA) shows better treatment results than does emergency appendectomy (EA) for complicated appendicitis (CA). However, the deviation cases of CA that are planned for IA undergo EA instead. In this study, we evaluated the treatment results of deviated cases and examined the validity of IA for CA. The study included 165 cases of CA diagnosed from January 2011 to August 2017. The results were classified into the EA, IA success (IA-S), and IA deviation (IA failure; IA-F) groups; the surgical results and hospitalization days were compared. In this study, the EA, IA-S, and IA-F groups comprised 95, 53, and 17 cases, respectively. The postoperative complication rates in EA, IA-S, and IA-F groups were 37.9%, 7.5%, and 11.7%, respectively: complication rates in the IA-S and IA-F groups were lower than those in the EA group. With respect to the amount of bleeding and operation time, outcomes in the IA-S group were superior to those of EA, and outcomes in the IA-F and EA groups were similar. The durations of hospitalization in EA, IA-S, and IA-F groups were 10, 13, and 10 days, respectively:hospitalization days in the EA and IA-F groups were equivalent. As IA has a low postoperative complication rate and the hospitalization days in the IA-F group were comparable to those associated with EA, we suggest that IA should be the first-choice treatment for CA.

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  • Kenta Doden, Noriyuki Inaki, Daisuke Yamamoto, Hirotaka Kitamura, Shin ...
    2019 Volume 39 Issue 4 Pages 655-661
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    The value of open interval appendectomy for appendicular abscesses has long been debated. Laparoscopic interval appendectomy (LIA) for appendicular abscesses was first reported in the early 2000s and has been widely performed recently. However, only a few small retrospective studies have focused on the clinical results of LIA compared to laparoscopic emergency appendectomy (LEA). In the present study, we compared the results of LIA following conservative treatment versus LEA. We retrospectively reviewed the medical records of 68 patients with an appendicular abscess who underwent LIA or LEA from January 2007 to December 2016 at the Department of Gastroenterological Surgery at Ishikawa Prefectural Central Hospital. We performed 1 : 1 propensity score matching (PSM) between the LIA and LEA groups. In total, 62 patients were included the analysis. After PSM, demographic, clinical and abscess characteristics were similar and not statistically different between the 31 LIA and the 31 LEA patients. The operative time and amount of intraoperative bleeding were similar between the groups. The rate of conversion to open surgery or ileocecal resection was relatively lower among LIA patients (3.2% vs. 22.6%; P=0.08). Patients undergoing LIA experienced fewer postoperative complications (0% vs 25.8%; P=0.01) and a shorter postoperative hospital stay (4 [3–5]days vs. 7 [5–8] days; P=0.007) compared to LEA patients. The total hospital stay that included a conservative treatment period was significantly longer in LIA patients (16 [12–18] days vs. 8 [6–10] days, P=0.00009). The results of the present study demonstrated that LIA had fewer postoperative complications and a shorter postoperative hospital stay than LEA.

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  • Kenichi Ogata, Taishi Yamane, Hideaki Takeyama, Katsuhiro Ogawa, Hirom ...
    2019 Volume 39 Issue 4 Pages 663-667
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    Interval appendectomy after antibiotic administration and/or drainage has increased in patients with perforated appendicitis with abscess formation. On the other hand, in cases of appendicitis with a perforated appendix without abscess perforation, it is unknown whether emergency laparoscopic surgery is useful. From 2011 to 2017, 68 patients underwent an urgent appendectomy under the diagnosis of perforated appendicitis. Surgical factors and postoperative early outcome were evaluated between laparoscopic surgery (n=53) and open surgery, including conversion cases (n=15). No significant difference was observed in the operation time between the two groups, but the amount of bleeding was significantly less in the laparoscopic group (15.1g vs. 82.7g, P<0.001). There was no significant difference between postoperative complications, including surgical site infection in both groups, but the postoperative hospital stay was significantly shorter in the laparoscopic group (8days vs. 14days, P<0.001). Laparoscopic appendectomy in patients with perforated appendicitis without abscess formation could shorten hospital stay without increasing complications.

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  • Yusuke Okamura, Kazuki Kishi, Toshihiro Okada, Masayuki Nakau, Fusao I ...
    2019 Volume 39 Issue 4 Pages 669-673
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    Laparoscopic appendectomy (LA) has been recognized as the standard treatment for appendicitis. We need to manage complicated cases including perforated appendicitis with a laparoscopic approach. We investigated the outcome of LA for perforated appendicitis in our institution. Between January 2014 and October 2018, 274 patients underwent appendectomy. Among the 122 patients who underwent emergency LA, 36 patients had a perforated appendix. An appendectomy for a perforated appendix has been associated with an extended operative time, an increase in postoperative complications and a prolonged postoperative hospital stay compared with simple appendicitis. There was no significant differences in the postoperative complications and the length of hospital stay between laparoscopic (n=36) and open (n=14) appendectomies for perforated appendicitis. Drain placement was significantly less in the laparoscopic approach. In comparison of localized (n=22) and extensive (n=14) contamination involved with appendectomies for perforated appendicitis, the extent of the abdominal contamination was not associated with the postoperative complications and the length of hospital stay after LA. The laparoscopic approach for treatment of perforated appendicitis can become the standard procedure, although it has been associated with a higher rate of postoperative complications compared with LA for simple appendicitis.

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  • Shohei Miyanaga, Kazuya Mori, Eisuke Ojima, Yoshio Michiwa, Tatsuo Nak ...
    2019 Volume 39 Issue 4 Pages 675-678
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 38-year-old woman consulted to our hospital with abdominal pain and vomiting. Abdominal ultrasound and abdominal CT findings showed Meckel’s diverticulitis with an enterolith. The Meckel’s diverticulum was treated with Single Incision Laparoscopy Surgery (SILS). Because many cases of Meckel’s diverticulum have been shown to be benign and it occurs in relatively young people, minimally invasive diagnosis and treatment are preferable.

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  • Miho Watanabe, Shigeru Fujisaki, Motoi Takashina, Ryoichi Tomita, Keni ...
    2019 Volume 39 Issue 4 Pages 679-682
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    We report herein on a case of gallbladder perforation that was accompanied with bile retention in the retroperitoneal space. A 74-year-old woman presented with abdominal pain from the day before admission. She was transferred to our hospital. A physical examination revealed tenderness of the right upper abdomen. A blood examination revealed a white blood cell count of 17,000/μL and a C-reactive protein level of 9.52 mg/dL. An abdominal contrast CT scan revealed a higher CT density of the fat tissue around the third portion of the duodenum and fluid retention in the retroperitoneal space. The patient was diagnosed as having perforation of the duodenum, and emergency surgery was performed. Although an intraoperative examination revealed bile ascites in the peritoneal cavity, we could not detect the perforated site of the duodenum. Bile retention was also observed in the retroperitoneal space around the right kidney and the second portion of the duodenum. The serosa of the gallbladder had partially collapsed. It was thought that the bile had broken out from the gallbladder wall and into the retroperitoneal cavity. A cholecystectomy and peritoneal drainage were performed. The patient was discharged on Day 11 with a good postoperative course.

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  • Kenshiro Tanaka, Hiroyuki Yokoyama
    2019 Volume 39 Issue 4 Pages 683-686
    Published: May 31, 2019
    Released: May 27, 2020
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    Hypermagnesemia is often caused by the excessive administration of preparations containing magnesium (Mg) in patients with renal dysfunction. We report a case of a patient who developed hypermagnesemia and large bowel obstruction following administration of Mg citrate (Magcorol P®). The patient was a 66-year-old woman, scheduled to undergo a barium enema examination to determine the cause of anal pain and constipation. Upon oral administration of Mg citrate as pretreatment, the patient started vomiting and exhibited altered consciousness, and was transferred to the emergency outpatient department of our hospital. Close examination revealed hypermagnesemia and fecal large bowel obstruction, so emergency hemodialysis was performed. The following day, re-elevation of the Mg levels and worsening of the large bowel obstruction were observed. An emergency sigmoid colostomy was therefore performed. After surgery, serum Mg concentration normalized rapidly. Reports have appeared on patients who have developed severe hypermagnesemia upon administration of Mg citrate preparations in the absence of renal dysfunction. Because severe hypermagnesemia can be fatal, due care and guidance should be provided to patients during Mg citrate administration, and prompt treatment is important if hypermagnesemia develops.

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  • Toshiya Akai, Yukihiro Higashi, Hirotoshi Maruo
    2019 Volume 39 Issue 4 Pages 687-690
    Published: May 31, 2019
    Released: May 27, 2020
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    A man in his 70s had an esophagectomy for esophageal cancer with reconstruction using a gastric tube by the posterior mediastinal route. At the same time, he received a jejunostomy for enteral alimentation. Although there was no recurrence of the esophageal cancer, he had repeated intestinal obstruction that was relieved with conservative treatment. Six years after the esophageal cancer surgery, he complained of abdominal pain and vomiting. he was admitted under a diagnosis of intestinal obstruction. His abdomen was slightly bulging and tenderness was noted, but there was no apparent peritoneal irritation symptom. On abdominal contrast CT imaging, a spiral-like finding was found in the mesentery of the small intestine, and the superior mesenteric artery (SMA) was deviated to the left. An emergency operation was performed on suspicion of intestinal obstruction caused by the jejunostomy. Upon laparotomy, the small intestine was incarcerated into the gap between the jejunostomy site and the abdominal wall, and rotated counterclockwise. Intestinal resection was not performed because no necrosis was observed. The jejunum of the intestinal fistula formation site was peeled from the abdominal wall. Intestinal obstruction involving the jejunostomy site after esophageal surgery is one of the conditions encountered in clinical practice although it rarely occurs. We report on this condition with a review of the relevant literature.

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  • Asayo Saito, Kiyoshi Hiramatsu, Takashi Seki, Hironori Fujieda, Yumi S ...
    2019 Volume 39 Issue 4 Pages 691-694
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 76-year-old man, who had undergone a right colectomy for ascending colon cancer at the age of 57, was admitted to our hospital with vomiting. Abdominal computed tomography (CT) showed a small bowel obstruction with caliber change, gastric pneumatosis, and portal venous gas (PVG), and we performed an emergency operation. Intraoperative findings revealed that a cord-like structure between the mesentery of the small intestine caused the obstruction, and we performed an adhesiotomy without any intestinal resection. To reduce the intragastric pressure, we inserted a gastric tube from the time of the operation. His postoperative course was good. CT performed at 10 days after the operation showed that both the gastric pneumatosis and PVG had disappeared, and he was discharged on the same day.

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  • Akitoshi Inoue, Michio Yamasaki, Kunio Hamanaka, Kentaro Itabashi, Kat ...
    2019 Volume 39 Issue 4 Pages 695-698
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 40-year-old man presented with sudden epigastralgia. Contrast enhanced CT examination revealed an exophytic large mass (11×10×8cm) with a fill-in pattern in the hepatic left lobe and a subcapsular hematoma with bloody ascites. We diagnosed a ruptured hepatic hemangioma and performed transcatheter arterial embolization(TAE) immediately. Angiography via the left hepatic artery demonstrated the patchy steins in the tumor to be compatible with hepatic hemangioma and A2 and A3 were embolized with gelatin sponge particles. A left hepatic lobectomy was performed on the eleventh day after TAE and a histopathological examination led to the diagnosis of a hepatic cavernous hemangioma. TAE is effective in the hemostasis for spontaneous rupture of hepatic hemangiomas and hepatectomy should be performed to obtain radical treatment and a histopathological diagnosis.

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  • Kanji Kawai, Hiroko Okamura, Kazuhiro Yoshii
    2019 Volume 39 Issue 4 Pages 699-702
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    An 86-year-old woman came to our hospital with right lower quadrant abdominal pain and was examined for suspected acute appendicitis. Abdominal CT scan revealed dilatation of the cecum, however, neither swelling of the appendix nor abdominal free air was detected. Thus the initial diagnosis was made as fecal ileus, but contradictory to acute appendicitis, and a conservative treatment was conducted. Two days after admission, an abdominal CT scan was performed again because of persistent abdominal pain, and swelling of the appendix was then detected. An appendectomy was performed under the diagnosis of acute suppurative appendicitis, although perforation of the appendix was observed intraoperatively. Histology of the surgical specimen revealed perforation of the appendiceal diverticulum as well as acute phlegmonous appendicitis. We report herein on a case of perforated appendiceal diverticulum in which difficulty was encountered in the diagnostic process.

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  • Yosuke Morimoto, Koji Fujita, Hiroyuki Kikunaga, Hiroshi Miura, Shojir ...
    2019 Volume 39 Issue 4 Pages 703-706
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 87-year-old woman visited our hospital complaining of abdominal pain with onset a week previously. She had rebound tenderness and defense in the right upper quadrant of the abdomen. Laboratory data showed elevation of inflammation markers. Abdominal CT showed air bubbles in a swollen gallbladder, intraabdominal free air, pneumobilia and gallstones. She was admitted with a diagnosis of perforated emphysematous cholecystitis and generalized peritonitis,and underwent an emergency operation. During the operation, gallbladder perforation, bile leakage and gallstones in the abdominal cavity were found. We performed a subtotal cholecystectomy. Bilious ascites culture showed the inflammation had been caused by Escherichia coli. Pathological examination of the gallbladder revealed gangrenous cholecystitis. Surgical site infection occurred in day 6 which was treated with antibiotics, otherwise the postoperative course was uneventful. There have been 13 cases of cholecystitis with intraabdominal free air reported in Japan.

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  • Yuki Tateno, Kuniaki Kanada, Takahiro Hayashi, Toru Tezuka
    2019 Volume 39 Issue 4 Pages 707-710
    Published: May 31, 2019
    Released: May 27, 2020
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    A 51-year-old male presented with intense epigastric pain immediately after a bogie had struck his epigastrium 2 hours post lunch. On examination, his vital signs were stable, but he reported intense abdominal pain accompanied by symptoms of peritoneal irritation. Routine hematological studies revealed elevated white blood cell counts. Enhanced computed tomography revealed free air around the liver. On the basis of these findings, we diagnosed the patient as having traumatic digestive tract perforation. Laparoscopic examination performed 8 hours following the injury revealed contaminated ascites throughout the peritoneal cavity and a round perforation of the duodenal bulb without intramural contusion around the hole, similar to a perforated peptic duodenal ulcer. Accordingly, we performed laparoscopic simple closure, omental covering and drainage, the same procedure as is usually done for a perforated peptic duodenal ulcer. Notably, his postoperative course was unremarkable, and the patient was discharged on the 9th postoperative day. Herein, we report on a rare case of a duodenal perforation without contusion immediately after epigastric trauma, which was easily detected and treated using laparoscopic surgery, in a similar manner to the treatment of perforated peptic duodenal ulcers.

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  • Yuji Takeuchi, Mari Nakagawa, Mizuki Takeuchi, Gen Ebara, Mayu Shimagu ...
    2019 Volume 39 Issue 4 Pages 711-714
    Published: May 31, 2019
    Released: May 27, 2020
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    A 27-year-old female had impulsively stabbed herself in the abdomen with a knife, and came to our hospital the following morning. A definite peritoneal sign was unclear, and a CT scan revealed damage to the left abdominal rectus muscle. We decided to perform exploratory laparoscopy. The exploratory laparoscopy was, however, not adequate to scrutinize the stabbing route of the knife and show the precise damage to the abdominal organs, so we decided to convert to laparotomy. The knife had perforated all stomach walls, the mesentery of the transverse colon and the upper portion of the jejunum. We sutured both the anterior and posterior stomach walls, and the jejunal and colonic mesentery. We report hereon on this case of a stab injury to the abdomen successfully treated with conversion from an exploratory laparoscopy to a laparotomy.

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  • Yoshitsugu Tsukamoto, Hiroyuki Negishi, Takehito Otsubo, Yuta Ogura, A ...
    2019 Volume 39 Issue 4 Pages 715-718
    Published: May 31, 2019
    Released: May 27, 2020
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    Early diagnosis and treatment of superior mesenteric artery occlusive disease offer a good prognosis. However, patients with early-stage acute superior mesenteric artery occlusion, which can lead to death if treatment is delayed, sometimes visit a physician complaining only of mild abdominal pain, making early diagnosis difficult. A 70-year-old man visited a previous physician complaining of bloody stools and abdominal pain and was acutely diagnosed as having mesenteric artery occlusion and suspected small intestinal necrosis. He was later transferred to our hospital. Because he was diagnosed within 24 hours of onset and a computed tomography image did not reveal intestinal necrosis, a thrombus was removed with interventional radiology techniques. Subsequently, we began thrombolytic therapy with continuously administered urokinase. We performed superior mesenteric artery angiography daily and confirmed no thrombus by the 3rd day. Oral ingestion started on hospital day 5. He was discharged on hospital day 17 and is currently receiving outpatient anticoagulant therapy. Early diagnosis and an interventional radiology procedure rescued this patient. We successfully treated a patient with superior mesenteric artery occlusion with an early diagnosis followed by interventional radiology without surgery. Early diagnosis and interventional radiological treatment are important for patients with acute superior mesenteric artery occlusion.

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  • Sayaka Arisaka, Tsutomu Hayashi, Kenki Segami, Ryo Takagawa, Hitoshi M ...
    2019 Volume 39 Issue 4 Pages 719-721
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 74-year-old man who had swallowed his denture was referred to our hospital. The presence of the denture had been confirmed in the lower thoracic esophagus with upper gastrointestinal endoscopy. However endoscopic extraction was considered to present a high risk of esophageal perforation. The denture was moved into the stomach, and removed with cooperative laparoscopy and endoscopy surgery. The denture was gripped with endoscopic forceps, and removed laparoscopically via a small incision in the anterior wall of the stomach. No postoperative complications occurred. The patient was discharged 15 days after the operation. A combination of endoscopic technique and LECS made it possible to avoid a thoracotomy and laparotomy, and this combination is therefore considered to be a minimally invasive and useful treatment.

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  • Daisuke Muroya, Masayuki Okabe, Yukiya Kishimoto
    2019 Volume 39 Issue 4 Pages 723-726
    Published: May 31, 2019
    Released: May 27, 2020
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    A 68-year-old man presented to the emergency department with pain and a mass in the abdominal wall. He had undergone an appendectomy 44 years previously. Physical examination revealed a mass under the appendectomy scar. Abdominal computed tomography scan revealed a large right abdominal wall abscess that contained a hypodense mass measuring 10 cm in diameter with extension into the ileocecal area. The patient underwent subsequent percutaneous abscess drainage under image guidance and antibiotic therapy. There were no significant abnormal findings in the endoscopic examination of the bowel. In this case, Streptococcus constellatus infection was confirmed by the culture of abscess samples. The patient was discharged 13 days after admission. At follow-up 1 year later, no recurrence of the abscess was observed.

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  • Yosuke Igarashi, Eriko Taguchi, Takanori Kurogochi, Hideyuki Suzuki, M ...
    2019 Volume 39 Issue 4 Pages 727-731
    Published: May 31, 2019
    Released: May 27, 2020
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    A 75-year-old man, with no past surgical history, presented with abdominal distention. He was admitted to our hospital with a diagnosis of small bowel obstruction (SBO). In the abdominal CT, an oval foreign body that caused the SBO was found in the ileum. His symptoms improved conservatively and he was discharged on the seventh hospital day. However, five months after the discharge, his SBO symptoms relapsed and he was hospitalized again. CT findings revealed a foreign body in the ileum similar to that at the time of the previous hospitalization. We performed laparoscopic surgery on the fifth hospital day because there was no improvement with conservative treatment. A pickled plum stone found in the partially resected intestinal tract with inflammatory hypertrophy and ulceration. He was discharged on the seventh day after surgery with good progress and has been followed up to present without any bowel obstruction symptoms. It was conceivable that the stone had remained in the ileum for at least 5 months and it could have caused intestinal perforation if it had been left in the intestine. We concluded that, for SBO cases in which excretion of the causative stone cannot be confirmed, an operation should be performed.

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  • Katsutaka Mitachi, Kyohei Ariake, Fumiyoshi Fujishima, Fuyuhiko Motoi, ...
    2019 Volume 39 Issue 4 Pages 733-737
    Published: May 31, 2019
    Released: May 27, 2020
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    A 54-year-old man diagnosed with esophageal cancer with multiple metastasis was referred to our hospital. While receiving chemoradiotherapy, severe hematochezia and anemia were detected. Computed tomography revealed intestinal hemorrhage, and emergency surgery was performed. Nodules were detected in the small intestinal wall, which were the source of the hemorrhage. Partial resection of the small intestine was subsequently performed. Pathological examination of the resected intestinal wall showed lesions with vascular invasion present across the mucosal to subserosal layers. They were diagnosed as metastases from the esophageal cancer. The patient recovered uneventfully but he died on postoperative day 56 due to disease progression. Metastasis of esophageal cancer to small intestine is rare, mostly occurring as part of systemic multiple metastases. Such metastases can cause intestinal obstruction or perforation, however the necessity of surgical intervention as an oncological emergency due to persistent hemorrhage has been rarely reported. Careful clinical evaluation is essential for surgery, considering the extremely short survival rate.

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  • Masataka Hayashi, Naoki Yamanaka
    2019 Volume 39 Issue 4 Pages 739-742
    Published: May 31, 2019
    Released: May 27, 2020
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    A 76-year-old woman was admitted to our hospital with melena. She had an autoimmune disease and had been prescribed steroids and immunosuppressive drugs for a long time. Colonoscopy revealed massive bleeding from the diverticulum of the descending colon, and endoscopic hemostasis was successful. Five days later, bleeding developed from the same diverticulum again, which required endoscopic hemostasis. On the day following the second colonoscopy, high fever developed without abdominal symptoms. The laboratory data showed a significant inflammation reaction. A computed tomography scan showed massive pneumoretroperitoneal, pneumomediastinal, subcutaneous emphysema without pneumoperitoneum. A contrast enema study showed the absence of perforation. We chose conservative treatment, and the clinical course was uneventful. She was discharged 18 days after initial observation. Retroperitoneal emphysema after colonoscopy is a rare complication. It is suggested that more cases with retroperitoneal emphysema after colonoscopy can potentially be treated without operation.

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  • Yusuke Endo, Hideto Ochiai, Keisuke Inaba, Osamu Jindo, Shohachi Suzuk ...
    2019 Volume 39 Issue 4 Pages 743-746
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    An 80-year-old man was referred to our hospital for a right inguinal mass and anorexia. Ultrasonography revealed a tubular structure from the abdominal cavity through the right inguinal canal. Abdominal enhanced computed tomography demonstrated the inflamed tubular structure trapped within a right indirect inguinal hernia. The tubular structure connected with the cecum and ended in the hernia sac. We diagnosed the condition as an incarcerated Amyand’s hernia with appendicitis, based on the clinical imaging. We started the operation with a right inguinal incision, and identified the hernia sac protruding through the inner inguinal ring. We further defined the incarcerated vermiform appendix with localized abscess formation in the hernia sac. Upon exploration of the peritoneal cavity, no existence of inflammation or infection was confirmed. Thus an appendectomy and primary hernioplasty with McVay repair were performed. The postoperative course was uneventful and the patient was discharged on the fourth day after surgery. Amyand’s hernia is a rare type of inguinal hernia containing the vermiform appendix. We report herein a case of Amyand’s hernia with a literature review of previous cases in Japan.

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  • Kodai Nishimura, Eiji Sakamoto, Shinji Norimizu, Hidehiko Otsuji, Yosh ...
    2019 Volume 39 Issue 4 Pages 747-749
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 69-year-old man had undergone laparoscopic distal gastrectomy with a retrocolic Roux–en–Y reconstruction for early gastric cancer in our hospital. He visited our hospital with abdominal pain 2 years after the surgery. CT revealed dilation of the Roux limb and afferent loop. We suspected an internal hernia without ischemia, and performed decompression with an ileus tube. Although the clinical symptoms were relieved by conservative treatment, a follow-up CT showed the internal hernia persisted. An operation was performed and revealed that almost the entire small intestine including the afferent loop had been affected due to a widely dilated defect at the transverse mesocolon. In addition, a part of the small intestine was impacted in the mesenteric defect at the dorsal aspect of the Y-anastomosis. Since no ischemic changes were observed, the intestine was preserved. The internal hernia was therefore reduced and these defects were repaired with suture closure. There has been no recurrence of the internal hernia after the surgery.

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  • Jun Ichikawa, Ippei Yamana, Nobuhiko Koreeda, Yuki Shin, Hiroto Sannom ...
    2019 Volume 39 Issue 4 Pages 751-754
    Published: May 31, 2019
    Released: May 27, 2020
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    An eight-year-old girl was running down the street and fell forward. Her abdomen was injured in the fall by the water bottle she had been wearing around her neck at the time. After the fall, she complained of abdominal pain. Because she was vomiting frequently, she was taken to our hospital by ambulance. Contrast-enhanced abdominal computed tomography suggested free air around the duodenum, so she was referred with traumatic gastrointestinal perforation and an emergency laparotomy was performed. The intraoperative findings revealed a rupture 3 cm in diameter at the descending part of the duodenum that was diagnosed as traumatic duodenal injury typeⅡa (Japanese Association for the Surgery of Trauma, Digestive Tract Damage Classification). No injuries to any other organs were recognized. The perforated portion was closed by simple closure. The postoperative course was good, and the patient was discharged from our hospital on the 26th postoperative. Duodenal injury in children caused by a fall while wearing a water bottle around their neck is not an unthinkable occurrence, so we should be alert for such cases.

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  • Atsushi Sugimoto, Tatsunari Fukuoka, Kiyoshi Maeda, Hisashi Nagahara, ...
    2019 Volume 39 Issue 4 Pages 755-758
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 68-year-old man, who had uncontrollable ascites and had been treated with diuretics for 6 months, presented with an umbilical bulge and was referred to our hospital for further examination and treatment. Abdominal contrast enhanced computed tomography (CT) revealed a large amount of ascites and a strangulated umbilical hernia involving the small intestine. We performed an emergency operation comprising partial resection of approximately 10 cm of the small intestine and repair of a 3×2 cm hernia orifice with primary closure. There was no peritoneal nodule and ascitic smear, and culture and polymerase chain reaction (PCR) were negative. The levels of adenosine deaminase (ADA) in the ascites was high and the QuantiFERON–TB (QFT) test was positive. We diagnosed the condition as an umbilical hernia due to tuberculous peritonitis. The patient was treated with anti-tuberculous drugs and the ascites disappeared. Tuberculous peritonitis is so rare that it often needs a prolonged examination before diagnosis can be made. Therefore, it may cause secondary acute abdomen require an emergency operation such as in our case. In acute abdomen with refractory ascites, it is important to exam intraoperatively the ascites and peritoneal nodules to arrive at the diagnosis of tuberculous peritonitis.

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  • Chikara Maeda, Tadahiro Kamiya, Takehito Kato, Kazuhiro Hiramatsu, Yos ...
    2019 Volume 39 Issue 4 Pages 759-763
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 70-year-old woman who had undergone mesh plug repair for a right inguinal hernia in 1996, visited our hospital because of right inguinal swelling and pain. Right inguinal swelling and redness were observed, and a right inguinal abscess was shown on abdominal enhanced computed tomography (CT). Continuity of this abscess with the ileocecal intestinal tract was suspected. Based on the suspicion of a fistula between the plug and ileocecal intestine, we performed an emergency operation. In the inside of the abdominal cavity, the mesh plug and the ileum had adhered to form a fistula, and an abdominal wall abscess spreading from the subcutaneous to the peritoneal frontal space was observed continuously at the same site. Fistula resection, mesh plug removal and repair of abdominal wall abscess drainage were performed. The postoperative course was not eventful and the patient left the hospital on the seventh postoperative day. At 11 months after surgery, there had been no recurrence of infection or hernia.

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  • Yusuke Tsunetoshi, Nobuaki Kurauchi, Takuji Kagiya, Takeyuki Sawano, H ...
    2019 Volume 39 Issue 4 Pages 765-768
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 13-year-old girl sustained a handlebar injury to her upper abdomen after falling while riding a bicycle. She was admitted to a hospital with abdominal pain but was transferred to our hospital the following day because pancreatic injury was suspected. CT showed laceration of the pancreatic superior mesenteric vein (SMV). To assess the damage to the main pancreatic duct, we attempted endoscopic retrograde cholangiopancreatography (ERCP). However, we could not reach the Vater’s papilla owing to inflammation of the duodenum. We determined that her pancreatic injury was either Type Ⅲa or Ⅲb. We selected a non-operative management (NOM) because the patient was hemodynamically stable. The treatment was successful. She resumed oral intake on Day 8. Repeat CT showed no worsening of the pancreatic injury. She was discharged on Day 23. For managing blunt pancreatic trauma in children, NOM is a feasible option depending on the general condition of the patient and findings of imaging modalities.

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  • Ryutaro Kobayashi, Tadahiro Kamiya, Takehito Kato, Kazuhiro Hiramatsu, ...
    2019 Volume 39 Issue 4 Pages 769-772
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 20-year-old man was transported to our hospital following a traffic accident. A seatbelt mark was found on his abdomen and tenderness was recognized at the same site. Because there were no abnormal findings in a blood test and contrast CT findings, it was decided to follow him up without admission. Stomachache appeared on day eight after the injury. Contrast CT revealed two small intestinal stenosis under the navel and the small intestine more oral than the stenosis site was swollen. We diagnosed this situation as posttraumatic delayed small bowel stenosis and operated with single incision laparoscopic surgery. The thickening and shortening of the small mesentery was confirmed in the peritoneal cavity. The stenotic site was removed from the navel and the small intestine was resected. The patient was discharged on the 8th day after surgery. In posttraumatic delayed small bowel stenosis, it is difficult to expose the small intestine of the lesion to the outside due to thickening or shortening of the mesentery. However, by confirming the stenotic site and grasping the situation based on CT imaging, laparoscopic surgery (Single incision laparoscopic surgery: SILS) could be considered as one of the useful options.

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  • Noriyuki Ohno, Makoto Ishida, Masaaki Deguchi
    2019 Volume 39 Issue 4 Pages 773-776
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    Broad ligament hernias are a very rare condition, reported in less than 5% of internal abdominal hernias, and are difficult to diagnose preoperatively. We report herein on a case of a broad ligament hernia with small bowel obstruction diagnosed preoperatively and treated with reduced port surgery (RPS). A 46-year-old woman presented with abdominal pain and vomiting. A CT scan of the abdomen confirmed closed loop obstruction of the small bowel on the left side of the uterus. We strongly suspected a broad ligament hernia and performed an emergency laparoscopic RPS. The ileum was incarcerated in a defect of the left broad ligament but had no sign of necrosis. We successfully repaired the broad ligament defect with suturing. Under an accurate preoperative diagnosis of broad ligament hernia, RPS is practical without decompression of the small bowel, and has a cosmetic advantage especially in female patients with this condition.

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  • Naotake Funamizu, Katsushi Dairaku, Yukio Nakabayashi, Katsuhiko Yanag ...
    2019 Volume 39 Issue 4 Pages 777-780
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    An 84-year-old man was admitted to Kawaguchi Municipal Medical Center with a high fever and epigastric pain. The patient was suspected of having an infected liver cyst (ILC) based on the findings of abdominal computed tomography (CT) and a hematological examination. The CT findings demonstrated a 70-mm cyst containing fluid with a thick wall in the lateral segment of the liver. Percutaneous transhepatic abscess drainage (PTAD) was performed. The patient was discharged in 10 days. Five month later, the patient was re-admitted due to recurrent ILC, for which PTAD was carried out again. Moreover, the patient underwent minocycline injection therapy four times. However, in a further 2 months he developed the third ILC, for which ethanol injection was performed. Finally, a total of three injections were performed every two days after cystography revealed no communication between the cyst and the biliary tract. Ethanol injections successfully reduced the fluid production of the cyst without recurrence for the last nine months. For refractory ILC, ethanol injections may be a good treatment modality.

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  • Takuji Ota, Kazuhiro Mino, Shunsuke Shichi, Kazuhito Uemura
    2019 Volume 39 Issue 4 Pages 781-785
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    Non-occlusive mesenteric ischemia (NOMI) is an acute mesenteric circulatory disease that occurs in the absence of an organic obstruction. The disorder comprises large segmental ischemic lesions in the intestines and recurs in some cases. Management of water and sodium deficiency is often required after surgical intervention. We report herein on a case of NOMI that was treated with resection of the small intestines followed by a reoperation for recurrence. A 72-year-old man presented with abdominal pain and vomiting. After examining him, we strongly suspected intestinal bowel necrosis and performed an emergency laparotomy. The intraoperative findings showed massive necrosis of most of the small intestine. Resection of the necrotic small bowel, jejunostomy and an ileal mucous fistulostomy were performed. On postoperative day 26, the mucous fistula became necrotic. We therefore performed resection of the right colon and a jejunocolic anastomosis. The patient was successfully put on an oral diet with intravenous nutrition. On postoperative day 137, he was transferred to the internal medicine department for management of his nutritional status.

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  • Shin Emoto, Keigo Chida, Michio Tani, Tomoaki Kawai, Seiji Kobayashi, ...
    2019 Volume 39 Issue 4 Pages 787-791
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    An 84-year-old woman consulted a hospital for left inguinal pain. At the hospital she was diagnosed as having an incarcerated inguinal hernia and was referred to our hospital. A CT exam revealed fluid collection with air bubbles in the inguinal canal. We diagnosed the condition as a strangulated hernia of small intestine with an inguinal canal abscess and performed an exploratory laparotomy. Intraoperatively, a uterine fibroid was observed incarcerated into the deep inguinal ring. During dissection of the adhesion of the uterine fibroid into the deep inguinal ring, pus was observed in the inguinal canal. The tissue of the inguinal canal had been destroyed by the inflammation. We opened the abscess and closed the deep inguinal ring. We report in this paper on a very rare case of an inguinal abscess due to an uterine fibroid incarcerated in an inguinal hernia .

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  • Miki Hosaka, Atsuko Tsutsui, Ryo Nakanishi, Kenji Omura, Go Wakabayash ...
    2019 Volume 39 Issue 4 Pages 793-796
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 62-year-old man was admitted with sudden onset abdominal pain. A CT scan demonstrated incarcerated bowel loops lateral to and behind the descending colon. Strangulated bowel obstruction due to internal hernia was suspected based on the CT scan findings, and he underwent emergency laparoscopic surgery. Extensive adhesions were found between the descending colon and the left abdominal wall, and the small intestine had invaginated into the gap between the adhesive membrane and the paracolic region of the descending colon. A diagnosis of an internal hernia in the paracolic gutter of the descending colon was made. We opened the hernia orifice, and removed the strangulated intestine. We report herein on a very rare case of an internal hernia in the paracolic gutter of the descending colon.

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  • Tadashi Tsukamoto, Takaaki Hori, Ryoji Kaizaki, Eijiro Edagawa, Shingo ...
    2019 Volume 39 Issue 4 Pages 797-800
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    A 69-year-old man was transferred to our hospital for the treatment of pulmonary tuberculosis. At admission, abdominal computed tomography showed right renal cancer and chronic pancreatitis with a pancreatic pseudocyst and pancreatolithiasis. After 4 months of therapy for the pulmonary tuberculosis, a right nephrectomy was performed for the renal cancer. Two months postoperatively, the patient complained of increasing intermittent abdominal pain that had lasted for a month. Abdominal CT revealed acute on chronic pancreatitis and a hemorrhagic pancreatic pseudocyst. Gastroduodenoscopy showed hemosuccus pancreaticus, which is bleeding from the ampulla of Vater via the pancreatic duct. Abdominal angiography demonstrated extravasation into the pancreatic pseudocyst from the arterial branches to the gastric lesser curvature from the left and right gastric arteries, and those branches were embolized. Ten months after the arterial embolization, the intracystic bleeding relapsed. The bleeding subsequently ceased and an elective distal pancreatectomy was performed for the pseudocyst. The patient was discharged 19 days after surgery and has been alive for 30 months since the distal pancreatectomy, without recurrence of the pancreatitis or pancreatic pseudocyst.

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  • Masaru Komatsu, Taku Ohashi, Yoshiyuki Ikeda, Norio Tanaka
    2019 Volume 39 Issue 4 Pages 801-804
    Published: May 31, 2019
    Released: May 27, 2020
    JOURNALS FREE ACCESS

    Rupture of a splenic artery aneurysm, one of the most common visceral aneurysms, is relatively rare and potentially fatal. To date, endovascular treatment of ruptured visceral artery aneurysms is being increasingly performed. Abdominal compartment syndrome (ACS) is a known complication of abdominal aortic aneurysms and can occur with endovascular treatment. We herein report on a case of decompressive laparotomy for ACS following endovascular treatment of a ruptured splenic artery aneurysm. A 49-year-old man presented to our hospital with abdominal distension and subsequent hemorrhagic shock. CT showed a ruptured splenic artery aneurysm with intra-abdominal hemorrhage. We performed transcatheter arterial embolization (TAE) of the splenic artery with a massive blood transfusion and his hemodynamics stabilized. However, he complained of dyspnea and abdominal distension 12 hours after the TAE and intra-abdominal pressure measured by the trans-bladder technique was 35 mmHg. We then diagnosed him as having ACS. The patient underwent an emergency decompressive laparotomy which revealed 3,700 g of hematoma in the peritoneal cavity without the prophylactic use of open abdominal management. His postoperative course was uneventful. Immediate decompressive laparotomy should be performed in cases of overt ACS following endovascular treatment for ruptured visceral artery aneurysms.

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