Ken Mizokami

Emphysematous cholecystitis successfully treated by laparoscopic surgery

Emphysematous cholecystitis (EC) is an uncommon variant of acute cholecystitis, which is caused by secondary infection of the gallbladder wall with gas-forming organisms. The mortality rate of EC is still as high as 25%. Emergency surgical intervention is indicated. Open cholecystectomy has been traditionally accepted as a standard treatment for EC. We present a case of EC successfully treated by laparoscopic surgery. Laparoscopic cholecystectomy for EC is considered to be safe and effective when indicated.

Idiopathic omental hemorrhage: A case report and review of the literature.

Highlights • Idiopathic omental hemorrhage is a rare cause of an acute abdomen, which is potentially life-threatening.• Idiopathic omental hemorrhage may develop after eating.• Omentectomy is preferred to ligation or transcatheter arterial embolization to rule out an underlying malignancy or aneurysm.

Barium appendicitis: A single institution review in Japan.

AIM To review clinical experience with barium appendicitis at a single institution. METHODS A retrospective review of patients admitted with a diagnosis of acute appendicitis, from January 1, 2013 to December 31, 2015 was performed. Age, gender, computed tomography (CT) scan findings if available, past history of barium studies, pathology, and the presence of perforation or the development of complications were reviewed. If the CT scan revealed high density material in the appendix, the maximum CT scan radiodensity of the material is measured in Hounsfield units (HU). Barium appendicitis is defined as: (1) patients diagnosed with acute appendicitis; (2) the patient has a history of a prior barium study; and (3) the CT scan shows high density material in the appendix. Patients who meet all three criteria are considered to have barium appendicitis. RESULTS In total, 396 patients were admitted with the diagnosis of acute appendicitis in the study period. Of these, 12 patients (3.0%) met the definition of barium appendicitis. Of these 12 patients, the median CT scan radiodensity of material in the appendix was 10000.8 HU, ranging from 3066 to 23423 HU (± 6288.2). In contrast, the median CT scan radiodensity of fecaliths in the appendix, excluding patients with barium appendicitis, was 393.1 HU, ranging from 98 to 2151 HU (± 382.0). The CT scan radiodensity of material in the appendices of patients with barium appendicitis was significantly higher than in patients with nonbarium fecaliths (P < 0.01). CONCLUSION Barium appendicitis is not rare in Japan. Measurement of the CT scan radiodensity of material in the appendix may differentiate barium appendicitis from routine appendicitis.

Giant gastrointestinal stromal tumor arising from the fourth portion of the duodenum

A 57-YEAR-OLD WOMAN was referred with fever and a left upper quadrant mass. Two months before admission, she noticed a left upper quadrant mass but did not seek medical attention at that time. Three days before admission, she had a fever of 408C and chills. On the day of admission, her symptoms had improved and she visited her physician. She was found to have abnormally elevated liver function tests, and was referred for further investigation. The patient had a past history of diabetes mellitus, 2 Cesarean sections, and an infectious disease on her back when she was a neonate (details are unknown). On admission, her temperature was normal. On physical examination, a hard mass was palpable in the left upper quadrant toward the left flank with mild tenderness. Abdominal computed tomography revealed a lobulated mass with central necrosis and calcifications in the left upper quadrant (Fig 1, A and B) with a maximum diameter of 25 cm. There was no obvious invasion to adjacent organs. The origin of this lesion was uncertain based on its appearance on imaging. We performed esophagogastroduodenoscopy and colonoscopy, but there was no obvious site of origin of the lesion. Computed tomography of the chest showed no metastases or intrathoracic tumor. Exploratory laparotomy was performed for diagnosis and treatment of the mass. On exploration of

Afferent Loop Syndrome after Roux-en-Y Total Gastrectomy Caused by Volvulus of the Roux-Limb

Afferent loop syndrome is a rare complication of gastric surgery. An obstruction of the afferent limb can present in various ways. A 73-year-old man presented with one day of persistent abdominal pain, gradually radiating to the back. He had a history of total gastrectomy with a Roux-en-Y reconstruction. Abdominal computed tomography scan revealed dilation of the duodenum and small intestine in the left upper quadrant. Exploratory laparotomy showed volvulus of the biliopancreatic limb that caused afferent loop syndrome. In this patient, the 50 cm long limb was the cause of volvulus. It is important to fashion a Roux-limb of appropriate length to prevent this complication.

Metastatic colon cancer derived from a diverticulum incidentally found at herniorrhaphy: a case report

BackgroundThere are few reports of metastases from colon cancer to an inguinal hernia sac, and few reports of colon cancer originating in diverticula. We report a patient with carcinoma of the sigmoid colon arising in two diverticula, who presented with peritoneal seeding to an inguinal hernia sac, and a review of the literature.Case presentationA 55-year-old male underwent open herniorrhaphy for a left inguinal hernia. At operation, a nodule in the inguinal hernia sac was resected and histologic examination revealed adenocarcinoma, which was suspected to be a metastasis from a distant primary lesion. Postoperative evaluation included colonoscopy and positron emission tomography which showed two suspected lesions in sigmoid diverticula. Laparoscopic subtotal colectomy was performed, and pathology revealed adenocarcinoma in two sigmoid diverticula.ConclusionsIf a nodule is found in an inguinal hernia sac, especially in older patients, peritoneal metastases should be considered. Resection of the nodule with histopathologic evaluation is essential. Colon cancer arising in a diverticulum should be considered as a possible site of the primary lesion.

Ductal Carcinoma in situ of the breast in sclerosing adenosis encapsulated by a hamartoma: A case report

Highlights • Ductal Carcinoma in situ in sclerosing adenosis encapsulated by a hamartoma is rare.• The diagnosis is difficult due to the appearance of these combined lesions.• Atypical appearance of a hamartoma may suggest a co-existing malignancy.

Treatment of Complete Anal Stricture after Diverting Colostomy for Fournier’s Gangrene

Background. Anal stenosis is a rare but serious complication of anorectal surgery. Severe anal stenosis is a challenging condition. Case Presentation. A 70-year-old Japanese man presented with a ten-hour history of continuous anal pain due to incarcerated hemorrhoids. He had a history of reducible internal hemorrhoids and was followed for 10 years. He had a fever and nonreducible internal hemorrhoids surrounding necrotic soft tissues. He was diagnosed as Fourniers gangrene and treated with debridement and diverting colostomy. He needed temporary continuous renal replacement therapy and was discharged on postoperative day 39. After four months, severe anal stenosis was found on physical examination, and total colonoscopy showed a complete anal stricture. The patient was brought to the operating room and underwent colostomy closure and anoplasty. He recovered without any complications. Conclusion. We present a first patient with a complete anal stricture after diverting colostomy treated with anoplasty and stoma closure. This case reminds us of the assessment of distal bowel conduit and might suggest that anoplasty might be considered in the success of the colostomy closure.

Blunt pharyngeal trauma detected by ultrasound sonography: A case report

Pharyngeal perforation related to blunt neck trauma is a rare clinical entity. Here in, we report a case of pharyngeal perforation secondary to minor blunt neck trauma. A 46 year old female was brought to our emergency room with neck pain. She fell down and hit her neck directly to the edge of a bed. There was no crepitation in physical examination. Neck ultrasound showed a small amount of air in her deep neck space. Followed CT and nasopharyngeal scope supported the presence of pharyngeal perforation. So emergency exploration was done. We found a laceration of hypopharynx and it was repaired. She could discharged without any complication on day 7. The indirect finding of pharyngeal perforation is subcutaneous emphysema. However if the air is localized only in deep cervical space, physical assessment is difficult. Although CT scan is potent modality to find air in the deep organs, ultrasound may be alternatives. Emphasis is based on the suspicion that minor blunt neck trauma may cause pharyngeal perforation.

Massive hematoma after fine-needle aspiration of the thyroid.

A 47-YEAR-OLD WOMAN was referred with a 6-week history of an anterior cervical mass. There were no symptoms which suggested hyperthyroidism or hypothyroidism. Two weeks before admission, she developed a viral infection and visited her family physician who identified a thyroid nodule and referred her for further investigation. The patient had a past medical history that included hypertension. She stopped taking her antihypertensive medication about 1 year before presentation. On physical examination, there was a round, elastic hard mass in the left lobe of the thyroid gland. There were no palpable cervical lymph nodes. Laboratory data was consistent with a euthyroid state. There was no history or laboratory data consistent with coagulopathy. Ultrasonography showed a cystic lesion in the left lobe of the thyroid gland, which measured 26 3 29 3 24 mm. An ultrasound-guided fine-needle aspiration (FNA) of the nodule was performed with a 22-G needle in the routine fashion. Under ultrasound guidance, we passed the needle 2 times, and no bloody material was aspirated. The procedure was completed with no obvious complications. The patient returned home with no complaints soon after the procedure. Approximately 3 hours later, she returned to the hospital complaining of cervical swelling with pain, and an uncomfortable sensation when breathing. She was able to talk without difficulty, and seemed to have a stable airway. Her anterior neck was swollen and tender. Although she seemed to have a stable airway, the rapidly growing hematoma suggested the need