Objective: The aim of this study was to verify the validity of conservative treatment for appendiceal abscesses (AAs). Patients and Methods: Patients who underwent conservative treatment for acute appendicitis in our hospital were enrolled in this study. We divided them into two group: the AA group and the uncomplicated appendicitis (UA) group. Analysis 1: We compared the outcomes of conservative management between the two groups. Analysis 2: We also compared the outcomes of interval appendectomy after conservative treatment between the two groups. Results: There were 56 and 133 patients in the AA and US groups, respectively. C-reactive protein levels in the AA group was higher than in the UA group. In the AA group, the hospital stay was longer and the rate of intraabdominal drainage procedure in AA group was higher than in the UA group. On the other hand, there was no difference in the rate of failure of conservative treatment, the complication or recurrence rates. The outcome of interval appendectomy was also no different between the two groups. Conclusion: Based on our findings, conservative treatment for appendiceal abscesses might be valid.
Purpose: We investigated the validity of fixing the mesorectum to the sacrum with metal coil staples via a laparoscopic rectopexy (hereinafter, this is called “this procedure”). Methods: Between July 2013 and March 2018, we performed this laparoscopic rectopexy procedure for 11 patients with a full-thickness rectal prolapse at Takaoka City Hospital. The operation in this procedure was indicated for the patient who could be under full anesthesia and whose rectum had prolapsed by over 3cm. We investigated the surgical outcomes in these cases. Results: The patients were all women. The median age was 80 (range, 68-93) years, the median length of the prolapsed rectum was 3.5 (range, 3-15) cm, the median operation time was 160 (range, 116-285) minutes, the median postoperative hospital stay was 8 (range, 6-11) days. There were no postoperative complications. Postoperative dyschezia such as constipation and frequent bowel movement occurred in seven cases (64%). Recurrence of the prolapse occurred in two cases (18%). Conclusion: This procedure can be performed safely with an easy technic. The rate of postoperative dyschezia is high, however, so we are unable to recommend this procedure in its current form.
A 74-year-old woman was found to have a gastric tumor during a medical check-up. Endoscopic examination revealed a submucosal tumor with ulceration in the cardiac region of the stomach, which was diagnosed as a gastrointestinal stromal tumor (GIST) following histopathological examination. In addition, swollen lymph nodes with the maximum diameter of 8 mm were identified close to the tumor on CT scan imaging. The patient underwent proximal gastrectomy with jejunal interposition. Neither liver metastasis nor peritoneal dissemination was observed in the intraoperative findings. Intraoperative frozen resection of the lymph nodes (#1, #7) near the tumor as identified by the preoperative CT showed metastasis of a #1 lymph node, for which lymph node dissection near the tumor was also performed. The tumor was 40 × 40 × 32 mm in size, and was c-kit- and CD34-positive on immunohistochemical staining, and the diagnosis of GIST was established. Lymph node metastasis was confirmed in 2 of the 16 lymph nodes dissected. As of 3 years after surgery, adjuvant chemotherapy is being performed without recurrence. Although liver metastasis and peritoneal dissemination are frequently observed in GISTs, lymph node metastasis is rare, and herein such a case is reported on herein with a literature review.
A 65-year-old woman had undergone a laparoscopic cholecystectomy for cholecystitis eighteen years previously, and a duodenal diverticulum was detected by an upper gastrointestinal (GI) series at that time. Seven years previously, she had complained again of epigastric pain which was diagnosed as pancreatitis. Thus, we thought that the duodenal diverticulum was the cause of those symptoms, and decided to perform a diverticulectomy. As the preoperative exams, an upper GI series identified a 5 cm diameter diverticulum on the third portion of the duodenum, although there were no compressive findings of the pancreatic and bile ducts based on magnetic resonance cholangiopancreatography MRCP and disseminated intravascular coagulation (DIC)-CT findings. Firstly, we started to conduct a laparoscopic diverticulectomy, then we converted to open surgery for a duodenojejunostomy. She has had no symptoms for 18 months after surgery. Duodenal diverticulum rarely causes complications such as perforation, bleeding, diverticulitis, Lemmel syndrome, and so on. There is no definite treatment strategy. We report herein on a case of diverticulectomy on the third portion of duodenal diverticulum with a literature review.
An 89-year-old woman was admitted for right abdominal pain and vomiting. Abdominal enhanced CT showed a poorly enhanced small intestine on the back of the cecum, and the cecum was forced to the medial side by the small intestine. We diagnosed the patient as having a strangulated small bowel obstruction due to a paracecal hernia. An emergency operation was performed. We found a hernia orifice on the lateral side of the cecum and a part of the ileum was incarcerated in this orifice. Therefore, we diagnosed the patient as having a small bowel obstruction caused by a lateral type paracecal hernia. We cut the upper edge of the hernia orifice and released the ileum. The incarcerated site of the ileum was necrotic, so we performed resection and anastomosis. We added an incision to the hernia orifice and opened it to prevent recurrence of the incarcerated hernia. The postoperative course was uneventful, and the patient was discharged on hospital day 21. Paracecal hernias have rarely been reported. Preoperative diagnosis of paracecal hernia is generally difficult and they often require emergency surgery. We report on this case with a review of the literature.
The patient was a 71-year-old female who was examined at a local clinic because of occasional bleeding when she defecated during the previous several months, and she was referred to our hospital for a thorough gastrointestinal (GI) examination. When advanced rectal cancer was detected during an endoscopic examination of the lower GI tract and abdominal CT revealed a mass in the ileocecal area in addition, a proctectomy and simultaneous ileocecal resection were performed. The ileocecal mass was observed to be in the form of a semipedunculated polyp on the cecum, and although routine pathological examination by hematoxylin and eosin (H.E.) staining showed pTis depth of invasion, a diagnosis of local lymph node metastasis was made. The results of a repeat examination by D2-40 immunostaining and additional excision revealed that the deepest part of the mass was limited to within the mucosa, but vascular invasion was observed in the proper mucosal layer and submucosal layer, and the final histopathological diagnosis was pT1a(Ly)-M, ly1. It was concluded that even when based on a routine pathological examination the diagnosis is Tis cancer, T1 cancer is also possible, and in some cases a detailed assessment by D2-40 immunostaining and preparation of a large number of sections is necessary despite appearing to be Tis cancer based on endoscopic excision.
A 61-year-old man was admitted to our hospital complaining of right lower abdominal pain and fever. A mass was palpated with localized tenderness in the right lower quadrant. Blood chemistry showed an increased inflammatory response. Computed tomography (CT) revealed a low-density mass in the ileocecal area and the appendix was not identifiable. We diagnosed abscess forming appendicitis with localized peritonitis, and selected conservative therapy with antibiotics prior to surgery. After hospitalization, symptoms and inflammatory response improved following antibiotic administration, and CT revealed the size of the mass had decreased. The patient was discharged from the hospital. Follow-up CT performed 2 months after discharge revealed the mass remained and colonoscopy showed the submucosal elevated lesion surrounding the appendiceal orifice. We suspected an appendiceal tumor and performed laparoscopic ileocecal resection because the tumor had adhered to the ileum and the cecum. Pathological findings were perforation of an appendiceal mucocele due to a mucinous cystadenoma. Because perforation of an appendiceal mucocele is difficult to discriminate from abscess forming appendicitis, surgery should be done if an ileocecal mass remains after conservative therapy. We report herein on a case of a perforated appendiceal mucocele with a review of literature.
A woman in her 80s with Parkinson’s disease presented with abdominal pain of acute onset. The patient had chills. The abdomen was flat and soft, but there was tenderness in the epigastric region. Blood examination showed an increase in the levels of inflammatory markers. Abdominal contrast-enhanced CT showed intraperitoneal free air and mesenteric air around the ascending colon. We made the diagnosis of ascending colon perforation and performed emergency surgery. No obvious perforation, purulent ascites or intestinal ischemic changes were observed, but subserosal emphysema was observed from the cecum to the ascending colon. We performed resection of the segments of the ileocecal region and ascending colon with emphysema and ileocolic anastomosis. Histopathology revealed emphysema in the intrinsic muscle layer of the ascending colon, and the patient was diagnosed as having pneumatosis cystoides intestinalis (PCI). In this case, we could not rule out colonic perforation, and performed intestinal resection. PCI may manifest as intraperitoneal free air in addition to intestinal emphysema, even in the absence of gastrointestinal perforation. We could not identify the PCI during the operation. We report this case with a consideration of the literature.
Nine years previously, an 85-year-old male underwent endovascular aortic repair (EVAR) for an abdominal aortic aneurysm (AAA) that was increasing in size. Contrast enhanced CT revealed the presence of ascending colon cancer invagination and an AAA with a Type Ⅱ endoleak. We treated the ascending colon cancer previous to the treatment of the Type Ⅱ endoleak, because of the risk of ascending colon cancer blockage and cancer progression. Single-port laparoscopy-assisted surgery (SPS) was selected to treat the ascending colon cancer owing to the risk of aneurysm oppression. The loss of intracorporeal view and limitation of movement of the forceps were avoided with SPS. SPS was a less invasive and safer approach for the treatment of advanced colon cancer combined with AAA.
An 86-year-old woman presented to a hospital with lower abdominal fullness. Based on abdominal radiography, she was diagnosed as having sigmoid volvulus, and endoscopic detorsion was planned. However, her symptoms resolved following the administration of an enema for preoperative bowel preparation, and subsequent colonoscopy revealed detorsion. Unfortunately, symptoms relapsed the following day. Owing to persistence of the symptoms, the patient visited another hospital and was eventually referred to our hospital for treatment of right colonic volvulus diagnosed by contrast-enhanced abdominal computed tomography. We performed an emergency operation and observed that the right colon was not fixed to the retroperitoneum and was rotated 270 degrees in a clockwise direction around the ileocecal mesentery. After detorsion, we identified several serosal defects and therefore performed a right hemicolectomy. Her postoperative course was uneventful, and she was discharged on the 21st postoperative day.
An 83-year-old male patient underwent colonoscopy following bloody bowel discharge. Sigmoid colon tumor invading the surrounding diverticula was suspected, and the diagnosis of adenoma was confirmed by a biopsy sample. However, there was a possibility that the adenoma was an adenocarcinoma. Abdominal contrast-enhanced computed tomography evidenced a thickening of the sigmoid colon wall. No lymph node metastasis or distant metastasis was found. Barium enema examination revealed diverticulosis around the sigmoid colon tumor; however, there was no evidence of transformation of the wall. Since the sigmoid colon tumor invaded the diverticula, we considered the patient to be at a high-risk of the perforation by endoscopic submucosal dissection. Therefore, laparoscopic sigmoidectomy was performed. Pathological findings indicated the presence of cancer in a mucosa. Locally, the cancer was revealed to be present in the subserosa and the tissue continued from a normal membrane to a pseudodiverticulum. The final diagnosis was of an advanced colon cancer. The muscular layer is absent in a diverticulum perforation due to an advanced cancer occurs more readily in a diverticulum compared with cancers occurring in a normal colon mucosa membrane. Considering the case was of a mucosal carcinoma or high-grade atypical polyp, surgery was recommended.
A 76-year-old woman visited our hospital with abdominal pain, diarrhea and abdominal distension, and was subsequently diagnosed as having a large type 2 tumor of the rectum (RSRa). A second-look operation was scheduled after chemotherapy to ascertain expected tumor shrinkage because the huge tumor was occupying whole pelvis. After transverse colostomy, six courses of mFOLFOX6 plus bevacizumab therapy were administered. Since subsequent examinations revealed a significant decrease in the size of the primary lesion and disappearance of swollen lymph nodes, high anterior resection was performed curatively. The pathological examination revealed that there were no residual cancer cells, neither at the primary lesion nor the lymph nodes, and thus pathological CR was achieved.
A 69-year-old woman visited our hospital with a several days’ history of persistent left-sided abdominal pain. An ultrasound examination of the abdomen performed as part of the medical workup revealed a tumorous lesion in the right lower quadrant of the abdomen, and abdominal CT also revealed a hypervascular tumor in the right lower quadrant of the abdomen. Laparoscopic resection of the tumor, which was found to arise from the greater omentum, was performed. Based on the histopathology and the results of immunohistochemistry, which revealed the following, the tumor was diagnosed as a solitary fibrous tumor (SFT): CD34(+), STAT6(+), S100(-), SMA(-), Desmin(-), MDM2(-), CDK4(-), c-kit(-), EMA(+/-). Herein, we present a report on this rare case of SFT arising from the greater omentum, along with a review of the literature.
Acute traumatic abdominal wall hernia is a rare complication. A 55-year-old man fell onto some rebar from a 2-meter height while at work and injured his abdomen. Abdominal computed tomography(CT) showed a defect in the peritoneum and muscle of the left lateral abdominal wall along with a herniated small intestine and free air. We diagnosed a traumatic abdominal hernia with bowel injury and performed an operation. There was small intestinal and mesenteric injury. Since the hernial orifice was small and strong, it only required suturing. The patient had an uneventful postoperative recovery and was discharged from our hospital on postoperative day 26 without any complications. We report a case of trauma from the thigh to the abdomen with the mechanism of abdominal wall hernia.
A 76-year-old woman visited another hospital complaining of epigastralgia and vomiting; a plain x-ray of the abdomen led to the suspicion of intestinal obstruction and the patient was referred to our hospital. Abdominal computed tomography revealed herniation of the stomach and transverse colon into the right thoracic cavity, and Morgagni hernia was diagnosed. We reduced the hernia and performed laparoscopic repair of the diaphragmatic defect with a Symbotex™ composite mesh. Postoperatively, a fluid collection was found in the residual hernia sac, and the patient developed respiratory symptoms and inflammation. Therefore, we performed percutaneous transhepatic drainage via the diaphragm, which led to prompt resolution of both the inflammation and respiratory symptoms. Although laparoscopic repair of a Morgagni hernia is an easy, minimally invasive and effective treatment, postoperative fluid collection could cause cardiorespiratory symptoms and necessitate postoperative drainage or other measures, depending on the need of individual cases.