Nihon Fukubu Kyukyu Igakkai Zasshi (Journal of Abdominal Emergency Medicine)
Online ISSN : 1882-4781
Print ISSN : 1340-2242
ISSN-L : 1340-2242
Current issue
Showing 1-39 articles out of 39 articles from the selected issue
  • Tetsuya Takahashi
    2019 Volume 39 Issue 5 Pages 807-814
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    【Aim】 To identify factors in deciding on the indications for and timing of surgery for blunt intestinal damage. 【Subjects and Methods】 The subjects were patients with blunt injury suspected of having intestinal damage based on the CT findings on arrival at our hospital, and we retrospectively attempted to identify factors in deciding on the indications for and timing of surgery. 【Results】 There were 36 patients:10 in an emergency surgery group, 6 in an elective surgery group, and 20 in a conservative treatment group. The most common site of intestinal damage was the small intestine. There was a significant difference in the number of abnormal CT findings between the emergency surgery group plus elective surgery group and conservative treatment group (3.1±1.2 vs. 2.0±0.9, P<0.01) and between the emergency surgery group and the elective surgery group (3.6±1.1 vs. 2.2±0.8, P<0.01). 【Conclusion】 The number of abnormal findings on the CT examination on arrival at the hospital appeared to be an important factor in deciding on the indications for and the timing of surgery.

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  • Yasuhisa Ando, Keiichi Okano, Tomomasa Murakami, Jun Kozai, Hirohumi S ...
    2019 Volume 39 Issue 5 Pages 815-819
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    We reviewed 8 cases of traumatic diaphragmatic rupture treated in our hospital between December 2006 and December 2017. Of the 8 patients, 6 were men and 2 were women. The average age was 63.0 years. Six patients had a history of blunt force trauma, while 2 had a history of sharp force trauma. Five and 3 patients had left-sided and right-sided diaphragmatic injury, respectively. Two of the 3 patients with right-sided diaphragmatic injury could not be diagnosed preoperatively. Four patients underwent surgical repair on the day of injury, while 4 underwent surgery 1~17 days after injury. In 4 patients, only laparotomy was performed, while in 1 patient only thoracotomy was performed. In 3 cases, both thoracotomy and laparotomy were performed. All 3 patients with right-sided diaphragmatic injury were treated with a thoracotomy approach. In conclusion, during management of a case of multiple trauma with a high severity score, it is important to consider the possibility of diaphragmatic injury while determining the treatment strategy. As preoperative diagnosis is difficult, the chest approach is useful for cases of right-sided diaphragmatic injury and for those treated several days after injury.

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  • Katsuhiro Ogawa, Shinichi Akahoshi, Katsutaka Matsumoto, Hiroshi Takam ...
    2019 Volume 39 Issue 5 Pages 821-828
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    Recombinant human soluble thrombomodulin (rhTM) was recently approved, and has been introduced for treatment of disseminated intravascular coagulation (DIC). The aim of this study was to assess the efficacy and safety of rhTM in patients with sepsis-induced DIC after abdominal emergency surgery. A retrospective cohort study of 147 patients with sepsis-induced DIC after abdominal emergency surgery was performed at our hospital between January 2009 and December 2014. Propensity score matching created 47 matched pairs between the rhTM group and the group without rhTM. The DIC, fibrin degradation product (FDP) and systemic inflammatory response (SIRS) scores on day 7 significantly improved in the rhTM group, but the DIC resolution rate and 28 days mortality showed no significant difference between two groups. We stratified patients into several strata according to disease severity, determined by the acute physiology and chronic health (APACHE) Ⅱ and sequential organ failure assessment (SOFA) scores, and rhTM administration was significantly associated with improvement of the 28 days mortality rate in the very high risk group with an APACHEⅡ score≧20 and SOFA score≧6; P=0.01. In conclusion, this study demonstrated that rhTM administration was associated with an improved DIC score among patients with sepsis-induced DIC after abdominal emergency surgery, and reduced the 28 days mortality rate in the very high risk patients.

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  • Satoshi Koizumi, Takehito Otsubo, Shinjiro Kobayashi, Masafumi Katayam ...
    2019 Volume 39 Issue 5 Pages 831-837
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    The most common treatment strategy for severe liver trauma at present is perihepatic gauze packing as damage control and complementary arterial embolization for hemostasis after surgery via a catheter. However, we sometimes encounter cases that cannot be adequately treated only with this strategy, and it is hard to say that the mortality rate of severe liver trauma is satisfactorily low. In the present article we introduce the Glissonean pedicle ligation method as the new optional surgical technique for severe liver trauma. This method has been developed to perform a hepatectomy for liver cancer more safely and easily. We have to date applied this procedure in 6 cases of type Ⅲb liver trauma (2 cases as damage control, and 4 cases definitive surgery for acute hepatic necrosis after resuscitative TAE). All the patients recovered completely and were ultimately discharged. Although there are some problems and restrictions in carrying out this procedure universally, it may be useful for patients with severe liver trauma.

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  • Hironobu Suto, Keiichi Okano, Minoru Oshima, Yasuhisa Ando, Hiroyuki M ...
    2019 Volume 39 Issue 5 Pages 839-843
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    [Background] Diagnosis and selection of the optimal surgical procedure for traumatic pancreatic type Ⅲb injuries are difficult, and evaluation of short-and long-term outcomes are important. [Objective] We evaluated the treatment strategy with endoscopic retrograde cholangiopancreatography (ERCP) and the short-and long-term outcomes for traumatic pancreatic Ⅲb type injury cases. [Subjects and results] Nine patients underwent surgical treatment for traumatic pancreatic Ⅲb type injuries in our department from July 2007 to June 2018. The median age was 31 (8〜77) years. Two of the 9 cases (22%) were able to be diagnosed as having a main pancreatic duct injury from CT findings, Among 9 cases, the main pancreatic duct injury was diagnosed with CT in two cases, while it was diagnosed with ERCP in 7 cases, the injury was diagnosed in all cases. Four cases (44%) had a pancreatic fistula, and one case (11%) had bile leakage postoperatively. The median follow-up time was 57 months (5〜80 months). Four (50%) and 2 (25%) out of 8 cases performed pancreatoduodenectomy (PD) had stenosis of their choledochojejunostomy and pancreatojejunostomy anastomosis respectively and 2 (25%) underwent a reoperation for the treatment. [Conclusion] ERCP for traumatic pancreatic Ⅲb type injuries was more useful to evaluate the damage of the main pancreatic duct than CT. There were late complications in young cases, and this fact is a future issue.

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  • Nao Urushibata, Kiyoshi Murata, Yasuhiro Otomo
    2019 Volume 39 Issue 5 Pages 845-849
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    The indication for damage control surgery (DCS) in severe trauma patients is still unclear. We sought for a new criterion for DCS focusing on blunt trauma injuries. We used the data from the Japan Trauma Data Bank (JTDB) and analyzed the 1,934 blunt trauma patients who were focused assessment with sonography in trauma (FAST) positive and underwent an emergency laparotomy. We compared the 364 patients that underwent DCS to the 1,570 patients who underwent a typical laparotomy. Patients who underwent DCS had worse vital signs upon arrival, higher blood transfusion rates, and higher mortality rates. Logistic regression analysis revealed blood pressure, consciousness, and body temperature as independent risk variables for DCS. From these variables, we created a DCS prediction score comprised of blood pressure, body temperature, and GCS. This score had a positive correlation with mortality, and with a cut-off value of three points, the score had a sensitivity of 68% and specificity of 63%, and also with a mortality of 35.8%. This score could be a legitimate indicator for damage control surgery in Japan.

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  • Masaaki Hidaka, Yusuke Inoue, Takami Inokuma, Takashi Hamada, Koji Nat ...
    2019 Volume 39 Issue 5 Pages 851-854
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    Concomitantly with the decrease of traffic accident in Japan, the incidence of abdominal trauma surgery has also decreased. In this chapter we introduce the system of acute care surgery (ACS) for patients with abdominal trauma in the urban and provincial areas in Japan. Specialized staff who were sent from each department such as physician, general surgery, neurological surgery, orthopaedic surgery and plastic surgery worked in the emergency center at the general hospital in urban areas. However general surgeons or gastroenterological surgeons performed acute care surgery (ACS) and abdominal trauma surgery at general hospitals in provincial areas. Meetings about acute care surgery and trauma in provincial hospitals play an important role in the mutual understanding among medical staff in the emergency, operation room. Training systems such as Advanced Trauma Operative Management (ATOM), the Trauma Exposure Course (TEC), and the Definitive Surgical Trauma Care (DSTC) course will become more important in developing the skills of young surgeons in trauma surgery or ACS.

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  • Tomotaka shibata, Yu Takeuchi, Osamu Matsunari, Yusuke Nabeta, Masafum ...
    2019 Volume 39 Issue 5 Pages 855-858
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    In this report, I will report on the present status of critical care in Oita prefecture and the Advanced Trauma, Emergency and Critical Care Center of the Oita University Hospital, and consider the future. In Oita, 62% of secondary emergency hospital and 75% of critical care centers were dispatched the doctor from the Department of Gastroenterological and Pediatric Surgery, Oita university faculty of Medicine. However, there is not any trauma surgeon in the department. The Critical Care Center started from October 2012 and the Helicopter Emergency Medical Service started at the same time. From 2013 to 2016, 10,853 patients were treated at the Critical Care Center. Two thousand, six hundred and seventy-eight patients (25%) had an exogenous disease and a resuscitative procedure was required in 20 patients. On the other hand, 2,002 surgical procedures were performed in the Department of Gastroenterological and Pediatric Surgery and of these, an emergency operation was required in 103 cases (5.1%). Resuscitative procedures were rarely required and it is important to collect severe injury cases using the helicopter, and to educate the trauma surgeon.

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  • Naoya Matsumoto, Sumiharu Yamamoto, Hiroaki Asano, Masatoshi Kubo, Tet ...
    2019 Volume 39 Issue 5 Pages 859-862
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    Resuscitation and hemostasis are very important when treating cases of severe trauma. The popularization of Japan Advanced Trauma Evaluation and Care (JATEC) has reportedly contributed to an improved survival rate in trauma patients; however, the survival rate of patients needing surgical management has not improved. Hemostasis, such as that achieved through surgical management or embolization, following primary trauma care is very important for trauma care. For that reason, surgeons and radiologists must be involved in trauma care from the early phase. Trauma Team Activation (TTA) involves surgeons and radiologists from the early phase. One benefit of TTA is the reduced time from the arrival to the examination and surgical procedures, and definition of a command system. Thus, TTA may be useful component in a trauma care strategy.

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  • Shoichi Shinohara, Masanobu Hyodo, Gaku Ota, Hirohumi Hayashi, Hirotak ...
    2019 Volume 39 Issue 5 Pages 863-866
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    An abscess of the rectus abdominis muscle is usually caused by a surgical site infection or is secondary to an intra-abdominal inflammatory process, but a primary abscess of the rectus abdominis muscle is uncommon. We present herein on a patient with a primary abscess of the rectus abdominis muscle. A 20-year old Indonesian man presented with fever (38.4℃) and left lower quadrant pain. He had no history of previous surgery, abdominal trauma or an immunocompromised state. An abscess of the left rectal abdominis muscle was found on computed tomography scan and ultrasonography imaging. He was diagnosed as having a primary abscess of the left rectus abdominis muscle. We performed emergency drainage of the abscess under local anesthesia which yielded a small amount of pus. We treated the patient with oral antibiotics as an outpatient. Two days after drainage, the abscess was found to have enlarged on a repeat computed tomography scan. We performed an additional drainage procedure under general anesthesia, which yielded about 30 mL of pus, and a drain was placed in the cavity. Staphylococcus aureus was cultured from the drainage. Five days after the second procedure, he was discharged without postoperative complications.

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  • Jumpei Ishizuka, Yoshiaki Shindo, Yuri Saito, Yuichi Tanaka
    2019 Volume 39 Issue 5 Pages 867-869
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 67-years-old man was struck on the lower left abdomen with the handlebar of his motorcycle and consulted our hospital three days later. Blood chemistry showed a slight inflammatory reaction. We recognized free air under the right diaphragm on X-ray imaging. Abdominal enhanced CT revealed free air in the mesentery of the sigmoid colon. Thus, we diagnosed sigmoid colon perforation. During the operation we discovered the perforation of the mesentery which communicated with the sigmoid colon. We therefore performed partial resection of the sigmoid colon. Delayed perforation after blunt trauma rarely occurs. We discuss the case with a review of the literature.

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  • Tomohiro Sato, Kiyoshi Hiramatsu, Takashi Seki, Hironori Fujieda, Yumi ...
    2019 Volume 39 Issue 5 Pages 871-874
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 47-year-old man under follow-up for chronic pancreatitis presented to our hospital with tarry stools and bloody vomiting. On admission, he presented in shock with severe anemia. Emergency esophagogastroduodenoscopy showed copious amounts of old blood in the stomach and duodenum, but the bleeding point could not be identified. His vital signs were improved by fluid resuscitation and blood transfusions. However, on the next morning, he once again went into shock with severe anemia. An endoscopic examination was performed again, and revealed active bleeding from a ampulla of Vater. As he had a lethal iodine allergy resulting in cardiac arrest, some diagnostic modalities using iodine, such as ERCP, enhanced CT and arterial angiography, were prohibited. Radiological intervention was also prohibited. We therefore performed abdominal US, plain CT and Gd-enhanced MRI examinations as diagnostic modalities. Finally we diagnosed hemosuccus pancreaticus due to intracystic massive hemorrhage at the pancreatic tail pseudocyst and we performed an emergency distal pancreatectomy. The patients state of shock and anemia improved rapidly after surgery. Histopathological examination revealed intracystic hemorrhage at the pancreatic tail pseudocyst.

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  • Fumitake Uchida, Hidetoshi Fukuoka, Hiroki Katayama
    2019 Volume 39 Issue 5 Pages 875-879
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    An 82-year-old man was admitted to a clinic for right sided abdominal pain. CT examination showed an intra-abdominal abscess and he was referred to our department for treatment. He had a fever with fluid collection and hypertrophy of the appendix root, both of them seen as high contrast areas. We performed CT-guided abscess drainage, and inflammation calmed down promptly. Barium enema examination showed his ascending colon was remarkably depressed to the internal side and his appendix was not enhanced. Colonoscopy showed an appendiceal papillary tumor and ascending colonic ulcer, and results of biopsies of both revealed a suspected malignant tumor. We performed a right hemicolectomy + D3 dissection. Pathological examination diagnosed pT4b (in the ascending colon, abdominal wall), pN0, pM0, and pStageⅡc. Appendiceal carcinoma with direct invasion to ascending colon and abdominal wall and intra-abdominal abscess formation at the same time as in our case has never been reported. It is very important that when we study elderly patients with severe appendicitis, we have to suspect the existence of a malignant tumor.

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  • Kaoru Kidate, Kazuhiro Toyota
    2019 Volume 39 Issue 5 Pages 881-885
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 38-year-old female presented at our hospital with lower abdominal pain. Computed tomography showed small bowel strangulation caused by the defect of an internal hernia through the right side of the broad ligament of the uterus. We performed an emergency single port laparoscopic surgery. Findings were a 2×3 cm defect of the broad ligament and ileum had herniated into the defect. We released the herniated ileum and sutured the defect of the broad ligament. After the laparoscopic procedure we pulled out the ileum from the umbilical section to observe the herniated ileum and confirmed there were no ischemic signs. Evaluation of the presence of ischemia in a herniated intestine is important in surgery for bowel strangulation. In laparoscopic surgery it is however difficult because it can only be performed by the surgeon under video-assisted laparoscopy. In single port laparoscopic surgery the surgeon can directly observe the herniated ileum from the umbilicus section. Therefore, single port laparoscopic surgery is a good adaptation for a strangulated ileus.

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  • Keisuke Hara, Takeshi Yamada, Michihiro Koizumi, Seiichi Shinji, Yasuy ...
    2019 Volume 39 Issue 5 Pages 887-890
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    We report herein on a case of invagination induced twice by a long decompression tube (LT). A 20-year-old man during treatment for ulcerative colitis developed a bowel obstruction caused by acute appendicitis with an abdominal abscess. The bowel obstruction was treated with an LT, however, it relapsed after removal of the LT. An LT was reinserted; however, the bowel obstruction was not released, and the patient subsequently underwent a laparotomy. Three lesions of antegrade invagination were observed in the jejunum and we released them with Hutchinson’s maneuver. Considering the risk of ileus, we did not remove the LT. However, the bowel obstruction due to invagination relapsed. He underwent reoperation, and the antegrade invagination in the jejunum was released. The LT was removed intraoperatively. After that, recurrence of invagination was not observed. LT removal or negative pressure aspiration has been reported to induce retrograde invagination. Our case was a rare disease condition with an antegrade invagination, however, such cases require urgent attention.

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  • Toshiaki Takahashi, Toshihisa Yamano, Yasutaka Kudo, Masatoshi Kuroda, ...
    2019 Volume 39 Issue 5 Pages 891-895
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 34-year-old male was admitted to our hospital with sudden left side upper abdominal pain one hour after symptom onset. An enhanced abdominal CT scan showed regional dilation of the intestine at the left upper abdomen and a stretched inferior mesenteric vein located at the ventral edge of dilated intestinal loops. Poor enhancement of the intestinal wall was also seen. Emergency laparoscopic surgery was performed with a diagnosis of a strangulation ileus caused by a left paraduodenal hernia. Laparoscopic findings showed that the hernia orifice existed in the left side of Treitz’s ligament and about 50 cm of the proximal jejunum had intruded into the mesenteric defect. Reduction of the small intestine could be performed without necrosis or irreversible ischemia and we sutured the hernia orifice closed. The postoperative course was good and the patient was discharged from the hospital on the fourth day. In past reports, abdominal enhanced CT is useful for early diagnosis of a left paraduodenal hernia because of its characteristic findings. This disease has a lower risk of intestinal resection due to necrosis. Laparoscopic surgery is an efficient surgical treatment for this disease.

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  • Yasuhisa Fujino, Hisashi Yokofuji, Masayuki Sato, Yota Tanahashi, Hisa ...
    2019 Volume 39 Issue 5 Pages 897-900
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 40-year-old man who was diagnosed as having ileus and had been treated for hypertension was transferred to our institution. One month prior, he had experienced paresthesia in his left femoral region and left buttock. Nine days before his visit, he developed abdominal pain and fullness. His abdominal plain X-ray image showed dilatation of the colon, and abdominal CT indicated rectal stenosis. A barium enema showed no stenosis of the rectum. We diagnosed this patient as having an acute colonic pseudo-obstruction (ACPO). Spinal cord MRI showed a spinal cord hemorrhage, and the patient recovered after conservative management and medication. In this case, factor Ⅶ deficiency was thought to contribute to the spinal cord hemorrhage. For the ACPO etiology, interference with the sympathetic-parasympathetic balance has been effective;in this case, ACPO was thought to have developed due to the damage of a sympathetic nerve in the thoracolumbar region owing to the spinal cord hemorrhage. When the diagnosis of ACPO is delayed, it may be necessary to perform emergency surgery. Therefore, it is necessary to treat patients with spinal cord lesions taking ACPO development into consideration.

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  • Daisuke Takeyoshi, Takumi Miura, Shigeki Abeshima, Satoshi Hirano
    2019 Volume 39 Issue 5 Pages 901-904
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    An 80-year-old woman presented for examination in our department complaining of left lower abdominal pain that had persisted for approximately 1 month. Localized tenderness and muscular guarding of the left lower abdomen were present. Abdominal contrast-enhanced computed tomography (CT) revealed a 5-cm mass constituting a suspected abscess, together with a 4-cm-long linear hyperdensity in the greater omentum adjacent to the transverse colon. The patient had accidentally swallowed a salmon bone a few days before the lower abdominal pain appeared;therefore, peritoneal abscess due to perforation of the digestive tract with a fish bone was diagnosed, and surgery was performed. An omental mass adjacent to the transverse colon was removed by single-incision laparoscopy. The transverse colon serosa around the mass was reddened with some erosion, but no obvious perforation site was identified. Although there have been a few reported cases of peritoneal abscesses caused by fish bones in which the perforation or penetration site was unclear, the site can be roughly identified on preoperative CT. Single-incision laparoscopic surgery, which has been increasing in popularity in recent years, may therefore provide one option for treatment.

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  • Yuji Shimizu, Hirotoshi Maruo, Hajime Tsuyuki, Yukihiro Higashi, Akira ...
    2019 Volume 39 Issue 5 Pages 905-908
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 68-year-old woman visited her local clinic with refractory watery stools and weight loss, and a giant pelvic tumor was identified. Since an ovarian tumor was suspected, she was referred to our hospital. Blood biochemistry revealed marked hypoalbuminemia, and colonoscopy revealed the presence of cancer in the ascending colon. These findings led to a preoperative diagnosis of either concomitant ovarian and colon cancers or ovarian cancer with tumor infiltration into the colon, and surgery was performed. The tumor was identified in the ascending colon, and had caused a significantly tense intestinal tract. Diameters of the ovaries and fallopian tubes on both sides were almost within normal ranges. A right hemicolectomy and bilateral salpingo-oophorectomy were performed, and the histological type of the tumor was well-differentiated mucinous carcinoma. These findings suggested that the patient had colon cancer with protein-losing gastroenteropathy. Protein-losing gastroenteropathy caused by colon cancer is rare, with few reports to date. We describe our findings and discuss the literature.

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  • Hiroaki Sugita, Kaname Ishiguro
    2019 Volume 39 Issue 5 Pages 909-911
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 71-year-old man underwent thoracoscopic and laparoscopic subtotal esophagectomy with reconstruction using a gastric tube through the retro-mediastinal route for esophageal cancer which was performed elsewhere one year and a half previously. He was admitted to our hospital with continuous nausea and abdominal pain from two days previously. Computed tomography (CT) revealed prolapse of the transverse colon into the left thoracic cavity through the esophageal hiatus on the left side of the gastric tube. He was diagnosed as having an incarcerated diaphragmatic hernia and an emergency operation performed. The prolapsed transverse colon was reduced to the abdominal cavity and the diaphragmatic defect was directly sutured laparoscopically. A diaphragmatic hernia after surgery for esophageal cancer is a rare but life-threatening complication. Immediate diagnosis and treatment are therefore important.

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  • Kota Okuno, Masakazu Wakabayashi, Satoru Kono
    2019 Volume 39 Issue 5 Pages 913-916
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    We report herein on a case of an afferent loop obstruction due to an internal hernia. A 66-year-old woman had undergone a distal gastrectomy and Roux-en-Y reconstruction for gastric cancer. The patient visited our hospital with acute abdominal pain 3 years after the surgery. The patient was admitted to the hospital for observation under the diagnosis of ileus, but she began to get worse on the following day, and her levels of liver, biliary and pancreas enzymes rose. Computed tomography revealed increased ascites and expansion of the afferent loop, therefore an emergency laparotomy was performed. There was no adhesion in the abdominal cavity, but the whole small intestine had turned to a dark red color with ischemia, following incarceration in the mesentery gap of the jejuno-jejunostomy from the right side to the left side, and afferent loop obstruction had occurred. We pulled out the small intestine from the hernia orifice. The resection of small intestine was not necessary. We closed the hernia orifice with an interrupted suture and finished the operation. The postoperative course was uneventful and the patient was discharged on the 11th postoperative day. It was considered that the mesentery gap of the jejuno-jejunostomy had to be closed when performing a Roux-en-Y reconstruction.

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  • Jo Tokuyama, Yuichi Nishihara, Hidejiro Urakami, Shiko Seki, Takashi O ...
    2019 Volume 39 Issue 5 Pages 917-920
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    Although inguinal hernioplasty with synthetic mesh is fairly common in recent years, very few reports have been made on a hernioplasty with a sheet of an autologous fascia lata free grafts from the thigh. A 74 year–old male patient with a past surgical history of left hip disarticulation due to a liposarcoma in his left proximal femur was diagnosed as having an incarcerated left femoral hernia with perforative peritonitis of the sigmoid colon. He underwent an emergency laparotomy, and elective surgery for femoral hernia repair three month thereafter resulted in recurrence of the femoral hernia in two weeks. Laparotomy for the recurrent femoral hernia was performed successfully with a concurrently harvested sheet of the fascia lata graft from his unaffected limb to cover the femoral ring intraperitoneally. A sheet of fascia lata free graft is one of the safe and simple biologic materials to repair a recurrent hernia in the infection–prone peritoneal cavity in patients with a single lower extremity.

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  • Atsushi Tanikawa
    2019 Volume 39 Issue 5 Pages 921-923
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 73–year–old man was admitted to our ER with sharp abdominal pain. Physical examination revealed abdominal tenderness in the left lower abdomen. Abdominal contrast–enhanced computed tomography showed a giant (14 cm) outgrowing jejunal tumor, not yet ruptured. However, the inflammatory response in the laboratory data was high which was associated with limited peritonitis. The patient was therefore diagnosed as having a jejunal tumor, suspected as being a gastrointestinal stromal tumor (GIST) with inflammation, judged to be at risk of rupture. GIST is a disease related to the prognosis unless complete resection is possible. Emergency surgery was performed because of the oncological emergency. The large tumor was squeezing the pancreas. The jejunum was resected together with the large tumor and a distal pancreatectomy was performed. The immunohistological examination led to the diagnosis of a jejunal GIST, not yet ruptured. The patient was prescibed imatinib 400 mg per day and had to be followed up carefully.

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  • Shunji Endo, Terumasa Yamada, Hiroaki Itakura, Katsuya Ohta, Masami Ue ...
    2019 Volume 39 Issue 5 Pages 925-928
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    The strategy for perforated gastric cancer is still controversial. In our institution, we primarily perform laparoscopic omental plugging or patching and drainage for the perforation, and secondly perform a gastrectomy. Between 2013 and 2017, we experienced four cases of perforated gastric cancer treated with primary laparoscopic closure followed by a gastrectomy. They included two males and two females. The age ranged from 69~76 (median 74) years. Preoperative diagnosis was gastric carcinoma (confirmed by pathological findings) in two, and suspected gastric carcinoma based on CT findings in two. All patients were treated laparoscopically at first (omental plugging for two, and omental patching for two). Then, the second operation was performed with a laparotomy (distal gastrectomy for three, total gastrectomy for one). No major procedure–complication was encountered. Two patients died of gastric cancer after 13 and 11 months after the first operation and two patients were alive for 39 and 16 months. The strategy for perforated gastric cancer consisting of primary laparoscopic closure followed by the second gastrectomy was thought to be feasible.

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  • Junichi Aburaki, Hitoshi Hasegawa, Tatsuyoshi Saiga, Kazuya Matsuda
    2019 Volume 39 Issue 5 Pages 929-933
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 51–year–old man presented with acute pain from the right lower abdomen. A CT scan showed the entire appendix was swollen and perforated, so we diagnosed an acute perforated appendicitis and performed an emergency operation. We removed a portion of the intestine looked like an appendix, which was penetrated and perforated. We identified it as the colon by pathological examination. The true appendix, which was atrophied, existed in the mesenterium mesentery. So we diagnosed it as duplication of the colon. There are few cases of duplication of the colon. We experienced a case which demonstrated both penetration and perforation. We have to be careful when operating for appendicitis.

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  • Manabu Nakamura, Katsuhiko Ishizaka, Jun Nakayama
    2019 Volume 39 Issue 5 Pages 935-938
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    An 80–year–old man who had undergone surgery for gastric cancer about 20 years previously had metastasis of poorly differentiated adenocarcinoma in the left supraclavicular lymph nodes. CT showed multiple lymph node metastases in the right upper abdomen and hepatocellular carcinoma, but showed no other lesions suspected of malignancy. Findings of histopathology with immunohistochemical staining of the metastatic lymph node biopsy and CT revealed recurrence of gastric cancer. Chemotherapy for gastric cancer markedly reduced the metastatic lymph nodes. Approximately 8 months after the treatment initiation, partial resection of the colon was performed for the transverse colon perforation. Because a perforated poorly differentiated adenocarcinoma which invaded the subserosa was detected in the resected specimen, we reexamined to identify the primary site of metastasis to the lymph nodes with immunohistochemical staining. Based on the findings, the patient was finally diagnosed as having lymph node metastasis from a medullary–type colonic adenocarcinoma with the expression of CK7+/CK20-/CDX2− and a mismatch repair deficiency.

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  • Yuya Iwase, Osamu Jindou, Nozomu Ishikawa, Ryuta Muraki, Akihiro Uno, ...
    2019 Volume 39 Issue 5 Pages 939-943
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    A 45–year–old man was taken to the ER because his car had collided head–on with a guardrail. On examination, we observed upper abdominal tenderness, slight anemia, and increased hepatobiliary enzyme levels. Abdominal US showed an echo–free space under the liver. Contrast enhanced abdominal CT showed extravasation on the gallbladder bed. From these findings, we made the diagnosis of traumatic liver injury along the Cantlie’s line with hemorrhagic shock and performed an emergency laparotomy. We blocked the blood supply to the liver by the Pringle maneuver and found an enlarged gallbladder, which was avulsed from the gallbladder bed. It was linked to the hepatoduodenal ligament only via the cystic duct and cystic artery. We could stop the bleeding by performing a cholecystectomy. Gallbladder avulsion caused by blunt abdominal trauma can be an important morphology of injury because it should be distinguished from liver injury when deciding on the therapeutic strategy.

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  • Kosuke Yoshimura, Ryutaro Sakabe, Aki Kuwada
    2019 Volume 39 Issue 5 Pages 945-948
    Published: July 31, 2019
    Released: June 25, 2020
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    We report herein on a salvage case, without performing an operation, of a superior mesenteric artery (SMA) occlusion complicated by Leriche syndrome. An 81–years–old man came to our hospital with sudden abdominal pain. Laboratory data showed acute kidney injury (AKI) due to severe dehydration, and severe inflammation. Plain computed tomography (CT) showed an ileus with non–occlusion. After 72 hours, following recovery from the AKI, contrast CT showed SMA occlusion and infrarenal aortic occlusion with inferior mesenteric artery occlusion, termed the Leriche syndrome. Immediately, we started antithrombotic therapy (Heparin Sodium) and peripheral vasodilation therapy(Prostaglandin E1). Following improvement of the intestinal ischemia, he was discharged with oral nutrition and oral antithrombotic medicine.

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  • Noriaki Koizumi, Yosuke Ariyoshi
    2019 Volume 39 Issue 5 Pages 949-952
    Published: July 31, 2019
    Released: June 25, 2020
    JOURNALS FREE ACCESS

    While drainage is essential in the treatment of perforated diverticulitis accompanied by an abscess, a therapeutic strategy including surgical drainage is needed when percutaneous drainage is difficult. We report herein on a case of sigmoid colon diverticulitis accompanied by an intramesenteric abscess treated less invasively with a planned two–step laparoscopic surgery. A 36–year–old man was referred to our hospital with a diagnosis of sigmoid colon diverticulitis accompanied by an intramesenteric abscess. At the first surgery, a small laparotomy was made at the right lower quadrant and laparoscopic drainage was performed using an access device inserted at the laparotomy site. A temporary ileostomy was subsequently made at the site of the laparotomy. Three months after the first surgery, the second surgery was performed. The ileostomy was closed at first, and an access device was again inserted at the same site. A laparoscopic sigmoidectomy was performed in the usual manner. The patient was discharged 7 days after surgery. A radical laparoscopic surgery with primary anastomosis was safely accomplished owing to adequate control of local inflammation, resulting in avoidance of a permanent colostomy. Effective utilization of an access device enabled the sequence of surgical procedures with only one small laparotomy incision. This sequential procedure seems to be useful when percutaneous drainage is difficult.

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  • Kaori Watanabe, Hidehiko Kitagami, Eri Tsuji, Keisuke Nonoyama, Shunsu ...
    2019 Volume 39 Issue 5 Pages 953-957
    Published: July 31, 2019
    Released: June 25, 2020
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    Ulcerative colitis (UC) is known to be associated with a high probability of having colorectal adenocarcinoma, but complication with a malignant lymphoma is rare. We report herein on a case of intestinal obstruction due to a malignant lymphoma of the rectum in a patient with a long–term history of untreated UC. A 66–year–old man had been diagnosed as having UC about 30 years before, but he had never been treated for it. He was admitted to our hospital with melena and right lower abdominal pain. Abdominal CT showed a mass with wall thickening of the rectum, and colonoscopy revealed a type 3 tumor of the rectum and loss of the typical mucosal vascular pattern starting at the anal verge. We performed a Hartmann operation for a suspected rectal cancer with UC. The tumor was adherent to the peritoneum, right vas deferens, and right ureter, and infiltration was suspected. On histopathological examination, the tumor was diagnosed as being a diffuse large B–cell lymphoma. Chronic inflammation and immunosuppressive drugs have been reported to increase the incidence of malignant lymphoma in patients with UC. A malignant lymphoma can also be considered when intestinal obstruction has developed in patients with UC although diagnosis is difficult.

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  • Yoshinori Shimizu, Wataru Shoji, Takeo Ogino, Juro Yanagida, Masatoshi ...
    2019 Volume 39 Issue 5 Pages 959-962
    Published: July 31, 2019
    Released: June 25, 2020
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    We experienced a cured case of a ruptured pseudoaneurysm of the right hepatic artery after surgery of the biliary tract. A 73–year–old man was admitted to our hospital due to sense of chest oppression and was diagnosed as having a choledochal cyst (Todani Ia type) with gallbladder cancer based on several radiological examinations. He underwent an extended cholecystectomy, bile duct resection and choledochojejunostomy and was discharged from our hospital on postoperative day (POD) 10 with no complications. However, he was readmitted to our hospital with hematemesis on POD 24. Emergency enhanced abdominal CT was carried out on him for shock–related vital signs and revealed a pseudoaneurysm of the ligated gallbladder artery in the right hepatic artery with extravasation of contrast medium at the site of the choledochojejunostomy. An emergency angiography was performed for transcatheter artery embolization (TAE) with microcoils and showed the pseudoaneurysm. TAE was completed and the pseudoaneurysm was not detected by arteriography after the TAE. Angio CT could not identify the pseudoaneurysm or any extravasation of contrast medium on nine days after the TAE (POD 33). Eventually, he was healthily discharged from our hospital 12 days after the TAE (POD 36).

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  • Masaaki Minagawa, Akinori Miyata, Takashi Ishida, Yukihiro Nomura
    2019 Volume 39 Issue 5 Pages 963-966
    Published: July 31, 2019
    Released: June 25, 2020
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    We report herein on a case of an emergency laparotomy for spontaneous biliary peritonitis due to transudation of bile from the gallbladder caused by a venous thrombosis. An 87–year–old woman was admitted to our hospital with severe right quadrant abdominal pain, which had occurred before she was admitted. Abdominal Ultra Sonography and CT showed the presence of ascites around the liver. Biliary ascites was found around the liver before the operation. The histological examination revealed venous thrombosis at the site without any perforation and the condition was diagnosed as spontaneous biliary peritonitis. An operation was performed. There were no intestinal or gallbladder perforations, but a part of the gallbladder wall was quite thin and bile had leaked at that point. A cholecystectomy and peritoneal drainage were performed. Transudation of bile from the gallbladder due to a venous thrombosis is quite rare and therefore warrants a case report.

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  • Tasuku Miyake, Atsuo Murata, Toshikazu Kurogi, Jyunko Matsuyama, Miyak ...
    2019 Volume 39 Issue 5 Pages 967-970
    Published: July 31, 2019
    Released: June 25, 2020
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    We report herein on a case of a pancreatic duct injury of type Ⅲb (pancreatic body transection, AAST grade Ⅲ). The patient was a teenage boy who presented at our hospital with abdominal pain 4 hours after the bicycle accident. Based on enhanced CT findings, we suspected pancreatic and intestinal injury. An emergency exploratory laparoscopy was performed to confirm no presence of intestinal injury, and then an open laparotomy was performed for evaluation and to treat the pancreatic injury. We identified the pancreatic duct injury and treated it with a spleen−preserving distal pancreatectomy with conservation of the splenic artery and vein. His postoperative course was satisfactory with a minor pancreatic fistula and he was discharged on the 26th post-operative day. Pancreatic trauma with a main pancreatic duct injury in children is rare and its management has been controversial, especially in case of duct injury of the pancreatic body. We expect an established management from the national clinical database in addition to more case reports.

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  • Akihiro Murata, Sadatoshi Shimizu, Yoichi Koda, Shintaro Kodai, Yutaka ...
    2019 Volume 39 Issue 5 Pages 971-974
    Published: July 31, 2019
    Released: June 25, 2020
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    A 50–year–old male was transferred to our hospital following blunt abdominal trauma. An abdominal computed tomography scan showed a perforation at the third portion of the duodenum, with contrast extravasation in a hematoma around the duodenum. Because the patient’s vital signs were improved after volume resuscitation, interventional radiology (IVR) prior to a laparotomy was performed. Angiography revealed extravasation from the inferior pancreaticoduodenal artery and transcatheter arterial embolization (TAE) was performed for the artery successfully. During laparotomy, arterial bleeding around the pancreas head was almost controlled and the third portion of the duodenum was injured diffusely with perforation. The injured part of the duodenum was resected, and a side–to–side duodenojejunostomy was performed. The patient was discharged from the hospital without serious complications. TAE prior to laparotomy is thought to be a useful treatment strategy for traumatic duodenal injury with intra–abdominal hemorrhage.

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  • Kohei Nishio, Katsunobu Sakurai, Akihiro Murata, Takafumi Nishii, Akik ...
    2019 Volume 39 Issue 5 Pages 975-978
    Published: July 31, 2019
    Released: June 25, 2020
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    A 36–year–old female with a one–day history of pain and swelling in the right inguinal region was admitted to our hospital. Physical examination revealed a small mass in the right side of the femoral region, which was nonreducible. Abdominal contrast–enhanced computed tomography showed a 10mm mass in the right femoral region and no findings of ileus. Transvaginal sonography showed bilateral normal ovaries in the pelvic cavity. She was diagnosed as having a right incarcerated femoral hernia with the contents unknown, and underwent an emergency operation. Laparoscopy revealed a right incarcerated femoral hernia containing the right fallopian tube. No signs of ischemic change was detected and the content was reduced back into the pelvic cavity. The femoral hernia was repaired with mesh, covering the myopectineal orifice. Her postoperative course was uneventful and she was discharged on the third day after the operation. There is a possibility that the contents of a femoral hernia without any findings of ileus in females could be uterine appendages. Laparoscopic surgery for a femoral hernia containing an unknown visceral organ is very useful for differential diagnosis and treatment.

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  • Ryohei Shoji, Katsuyuki Aoyama, Yu Mikane, Tsuyoshi Okada, Megumi Wata ...
    2019 Volume 39 Issue 5 Pages 979-982
    Published: July 31, 2019
    Released: June 25, 2020
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    Although lower gastrointestinal (GI) perforation and barium peritonitis rarely occur after upper GI examinations with barium contrast, they are difficult to treat and often follow a severe clinical course. At our hospital, we experienced eight cases of lower GI perforation after upper GI examinations with barium contrast between 2001 and 2017. We report herein on our findings. These eight cases included three men and five women with a mean age of 73.4 years. The mean duration between the upper GI examination with barium contrast and onset was 5.5 days, the mean duration between onset and hospital visit was 15.8 hours, and the mean duration between visit and surgery was 6.3 hours. The perforation site was the sigmoid colon in five patients and the rectum in three patients. Hartmann’s operation was performed in all patients. Comorbidities included cancer in two patients and diverticulitis in three patients. All patients required intensive care postoperatively and were admitted to the intensive care unit. The mean duration of the hospital stay was 23.8 days. There was one hospital death. Among the surviving patients, four patients underwent colostomy closure at a later time.

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  • Mamoru Sato, Junichiro Yamauchi, Tomoya Ikeda, Shota Fujita
    2019 Volume 39 Issue 5 Pages 983-987
    Published: July 31, 2019
    Released: June 25, 2020
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    Although percutaneous or trans–gastric drainage is often adopted for the treatment of an intraabdominal abscess derived from pancreatic fistula after pancreatectomy, it is sometimes difficult to perform. A case of effective trans–papillary drainage for intraabdominal abscess is presented herein, and we discuss the effectiveness of the trans–papillary drainage. The patient was a 77–year–old male who underwent a central pancreatectomy for a solitary metastatic pancreatic tumor from renal cell carcinoma. He was discharged on the 8th postoperative day. However, he was re–admitted to our hospital on the 14th postoperative day for appetite loss, and the CT findings showed an intraabdominal abscess derived from a pancreatic fistula around the pancreatic head stump. Percutaneous or trans–gastric drainage was difficult to perform because the abscess was not adjacent to the abdominal wall or stomach. Therefore, endoscopic retrograde pancreatography was performed and an external drainage tube was inserted into the abscess through the main pancreatic duct via the duodenal papilla. The drainage tube was obstructed by a viscous discharge several times, but it was resolved by inserting an internal drainage tube in combination with the external one. The patient was discharged home on the 85th postoperative day.

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  • Toshihiko Goto, Toru Murata
    2019 Volume 39 Issue 5 Pages 989-991
    Published: July 31, 2019
    Released: June 25, 2020
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    A 75–year–old man visited our hospital with enlargement of an inguinal mass. Abdominal computed tomography and ultrasonography showed a tubular structure running from the cecum through the femoral ring into the hernial sac. A femoral hernia with a strangulated appendix in its sac was highly suspected and an emergency operation was performed. The appendix was strangulated, and its tip has become dark red. Neither perforation nor abscess formation was detected, and appendectomy and mesh repair were performed. Inflammatory cells were hardly detected and congestive change was the main finding in the pathological examination. Ileus is rarely detected in cases of De Garengeot hernia, and imaging inspections are useful for diagnosis. Mesh repair is possible in cases with little pollution.

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  • Akira Matsumoto, Shunro Matsumoto, Katsuki Ohji, Maki Kiyonaga, Kazuhi ...
    2019 Volume 39 Issue 5 Pages 993-996
    Published: July 31, 2019
    Released: June 25, 2020
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    A 56–year–old man was transferred to our emergency department with acute lower abdominal pain following recurrent vomiting. Contrast–enhanced CT showed findings of cholecystitis and cholangitis with a small biliary stone located around the papilla of Vater. In addition, a superior mesenteric arterial dissection with entry at 2.5cm from its origin was identified. There was no acute intestinal ischemia or aneurysmal dilatation of the superior mesenteric artery and thus, conservative therapy was chosen. Retrieve of common bile duct stones and placement of a bile duct tube under endoscopic retrograde cholangiopancreatography was performed for the next day, and two weeks later, a laparoscopic cholecystectomy was executed. Follow–up CT findings obtained 2 months and 7 months after the initial event showed an improvement of narrowing of the true lumen and thus, the patient is being followed up with contrast–enhanced CT on an annual basis. In this case, we suggest that cholecystitis and cholangitis served as the initial trigger for the isolated superior mesenteric arterial dissection.

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