Mariko Terashima

Successful treatment of a 14-year-old patient with intestinal malrotation with laparoscopic Ladd procedure: case report and literature review

Midgut malrotation is an anomaly of intestinal rotation that occurs during fetal development and usually presents in the neonatal period. We present a rare case of malrotation in a 14-year-old patient who presented with cramping, generalized right abdominal pain, and vomiting for a duration of one day. A computed tomography abdominal scan and upper gastrointestinal contrast studies showed malrotation of the small bowel without volvulus. Laparoscopy revealed typical Ladd’s bands and a distended flabby third and fourth duodenal portion extrinsically obstructing the misplaced duodeno-jejunal junction. The Ladd procedure, including widening of the mesenteric base and appendectomy, was performed. Symptoms completely resolved in a half-year follow up period. Patients with midgut malrotation may present with vague abdominal pain, intestinal obstruction, or intestinal ischemia. The laparoscopic Ladd procedure is feasible and safe, and it appears to be as effective as the standard open Ladd procedure in the diagnosis and treatment of teenage or adult patients with intestinal malrotation.

The effects of n-3 polyunsaturated fatty acid-rich total parenteral nutrition on neutrophil apoptosis in a rat endotoxemia

Although recruited neutrophils function as first-line defense to remove bacteria, delayed apoptosis is implicated in persistent inflammation leading to organ injury. Leukotrien B4, n-6 polyunsaturated fatty acids (PUFAs) product, is one of the mediators that delay neutrophil apoptosis. The mechanism of the beneficial effects of supplementation of fish oil-based long-chain n-3 PUFAs in parenteral nutrition for critically ill patients has not been fully understood. One possible mechanism is the less inflammatory n-3 PUFAs products can compete with proinflammatory n-6 PUFAs products for access to the enzymes. The aim of this study was to determine whether n-3 PUFA rich parenteral nutrition may alter the composition of fatty acids in the neutrophil membrane and restore delay of neutrophil apoptosis during endotoxin-induced systemic inflammation in rats. The animals in group 1 were treated with 20% Hicaliq NC-N in Neoparen-2 for three days. The animals in group 2 (referred to as n-6 PUFA-rich parenteral nutrition) were given parenteral nutrition solutions containing 20% soybean oil in Neoparen-2 (n-6/n-3 = 10). The animals in group 3 (referred to as n-3 PUFA-rich parenteral nutrition) were administered parenteral nutrition consisting of 10% soybean oil and 10% fish oil emulsion (n-6/n-3 = 1.3). The n-3/n-6 ratio of the neutrophil membrane was significantly increased in group 3 and was associated with restored lipopolysaccharide-delayed-apoptosis of neutrophils in bone marrow cells and increased production of leukotriene B5 from peritoneal neutrophils stimulated by lipopolysaccharide. Our preliminary results showed that n-3 PUFA-rich parenteral nutrition regulated neutrophil apoptosis and prevented synthesis of pro-inflammatory eicosanoids, explaining the protective effects seen in the clinical setting.

Supplementation of parenteral nutrition with fish oil attenuates acute lung injury in a rat model

Fish oil rich in n-3 polyunsaturated fatty acids has diverse immunomodulatory properties and attenuates acute lung injury when administered in enternal nutrition. However, enteral nutrition is not always feasible. Therefore, we investigated the ability of parenteral nutrition supplemented with fish oil to ameliorate acute lung injury. Rats were infused with parenteral nutrition solutions (without lipids, with soybean oil, or with soybean oil and fish oil) for three days. Lipopolysaccharide (15 mg/kg) was then administered intratracheally to induce acute lung injury, characterized by impaired lung function, polymorphonuclear leukocyte recruitment, parenchymal tissue damage, and upregulation of mRNAs for inflammatory mediators. Administration of parenteral nutrition supplemented with fish oil prior to lung insult improved gas exchange and inhibited neutrophil recruitment and upregulation of mRNAs for inflammatory mediators. Parenteral nutrition supplemented with fish oil also prolonged survival. To investigate the underlying mechanisms, leukotriene B4 and leukotriene B5 secretion was measured in neutrophils from the peritoneal cavity. The neutrophils from rats treated with fish oil-rich parenteral nutrition released significantly more leukotriene B5, an anti-inflammatory eicosanoid, than neutrophils isolated from rats given standard parenteral nutrition. Parenteral nutrition with fish oil significantly reduced lipopolysaccharide-induced lung injury in rats in part by promoting the synthesis of anti-inflammatory eicosanoids.

Non-surgical pneumoperitoneum associated with mechanical ventilation

Dear Editor, Non-surgical pneumoperitoneum from an intrathoracic route is the most frequently reported cause in non-surgical peritoneal air collection. The true incidence of pneumoperitoneum associated with mechanical ventilation is unknown, but current estimates range from rare to 7% of intubated patients in the intensive care unit. This complication may lead to unnecessary laparotomy, however, if correctly diagnosed, it can be observed successfully without surgical intervention. We experienced a patient with subcutaneous emphysema, mediastinal emphysema, and pneumoperitoneum in whom coughing may have had a causative role, which was recognized and was managed without laparotomy. A 40-year-old female was transferred to our hospital due to loss of consciousness following a suicide attempt (hanging) and an overdose of anti-anxiety medicine. Although her vital signs were stable at admission, the patient was intubated, sedated, and ventilated in the intensive care unit, as her Glasgow Coma Scale score was 3 (E1, V1, and M1). Assisted ventilation was used with a fractional inspired oxygen concentration (FiO2) of 0.4 and a positive airway pressure of 5 cm H2O or less. On the second day of admission, she was alert with strong spontaneous breathing on the ventilator. Routine chest and abdominal X-ray revealed pneumothorax and pneumoperitoneum. Computed tomography scan of the chest and abdomen confirmed the presence of free intraperitoneal air without free fluid (Fig. 1). The patient was not symptomatic and had no fever or dyspnea. The abdomen was soft and flat without guarding or distension. Leukocytosis was present, with a white cell count of

A secure “double-check” technique of bedside post pyloric feeding tube placement using transnasal endoscopy

Enteral feeding has become an important means of providing nutritional support to seriously ill patients. Placement of the feeding tube through the pyloric ring and past the ligament of Treitz into the proximal jejunum is critical to reduce the risk of gastroesophageal regurgitation and microaspiration. We started utilizing transnasal endoscopy for intestinal feeding tube placement, placing enteral tubes for 40 patients between March 2008 and February 2009. Although we achieved a high success rate comparable to previous reports, we experienced several cases of failure, which was corrected with repeated endoscopy. Based on these experiences, we modified our method by adding a ”double-check” transnasal endoscopy through the other nasal passage. After April 2010, we have placed the feeding tube by ”double-check” method for all patients (more than 40 patients) who required transnasal endoscopic feeding tube placement. We have not experienced any misplacement in all these patients after 24 h later with 100% successful rate since the introduction of ”double-check” procedure. We describe our experience with ”double-check” transnasal endoscopic feeding tube placement, which we found to be a helpful adjunct, for patients in intensive care unit.

Unusual rectal foreign bodies: a case report and review of published works

Dear Editor, The various reasons for insertion of a rectal foreign body are well documented, including criminal assault, self-treatment, sexual gratification, and even the occasional accident. Rectal foreign bodies are mostly associated with increased numbers of incidents related to homosexual practices and anal auto-eroticism and are increasingly the cause of mortality and morbidity. We experienced a case of an adult male who presented in the emergency department with a lodged rectal foreign body. Although rectal foreign bodies are quite common—most general surgeons or emergency room physicians will encounter such a patient at some point in their career—we found interesting data based on a review of published reports. A 33-year-old male presented to the emer gency department with complaints of abdominal pain, anal pain, constipation, and abdominal distention with minimal passage of flatulence for 3 days. Digital rectal examination showed a hard edge of a metallic coffee can with blood-stained mucus located just beyond the anal sphincter. A blood test, including blood cell count, revealed leukocytosis associated with a remarkable increase in C-reactive protein. A plain abdominal radiograph and abdominal computed tomography scan showed dilated bowel loops and located the foreign body in the rectum. Based on the diagnosis of rectal foreign body, manual extraction was carried out under sedation. The patient recovered fully with complete recovery of the rectal ulcer on day 7. The keys to adequate care for patients with a colorectal foreign body are: respect for their privacy; evaluation of the type and location of the foreign body; determination if extraction can be carried out in the emergency room or if surgery is needed; and use of appropriate techniques for removal. Patients should be asked if the foreign body is the result of assault, as this is more likely to result in a serious injury and legal authorities need to be notified. In these circumstances, psychological support is also needed, as such patients usually require extended counseling to enable them to lead normal social and sexual lives. We reviewed reports published between 1980 and 2012 with available data using the PubMed website and the keywords “rectal foreign body”. A total of 589 cases were found, consisting of 556 male and 33 female patients with a mean age of 41 years. Interestingly, 94.4% of the patients were male, as was the patient in our case. A wide variety of objects were noted in the reports, including bottles, vibrators, fruits, vegetables, tools, and miscellaneous items such as light bulbs, candles, balls, and flashlights. Management of these cases varied from simple manual retrieval with or without general anesthetics, or use of a sigmoidoscope. Eighty patients (13.6%) required surgery, although manual retrieval was possible in the rest of the patients. Among the patients who underwent surgery, stomas were created in 53 patients (66.2%).The laparoscopic approach to assist in rectal foreign body removal is a good treatment choice for difficult cases. It allows for easy removal, detection of rectal injury, and early discharge. In general, laboratory evaluation may not be very helpful for patients with rectal foreign bodies.

Duodenal perforation due to infection caused by pledget 29 months after blunt liver injury suture

Dear Editor, In liver trauma care, operative management is still necessary for hemodynamically unstable patients. Although liver suture using pledgets is considered a standard procedure, complications related to pledgets have not yet been described. Here, we present a case in which pledgets used for an operation in blunt liver injury caused delayed perihepatic abscess infection, leading to gastrointestinal perforation. A 34-year-old woman was referred to our emergency department after falling from the fifth floor of a building. As the patient’s hemodynamics were unstable, we decided to perform surgery and transferred her to the operating room. A median laparotomy revealed a laceration of segments V, VII, and VIII, and the falciform ligament of the liver. We performed gauze packing as a damage control surgery, and open abdominal management was selected. The second generation cephalosporin antibiotic cefmetazole (Daiichi Sankyo, Tokyo, Japan) was given prophylactically. A second operation was carried out 48 h after the first, which involved removal of packing gauze and additional sutures with a pledget on the oozing point of the liver. We confirmed complete hemostasis and washed the abdominal cavity, and then closed the wall. The patient was discharged on day 74 with a remaining fistula and abscess and she received follow-up care as an outpatient. During follow-up, food residue outflow from the fistula was seen 27 months after initial surgery. Abdominal computed tomography showed a perihepatic abscess containing foreign matter, which was most likely a floating pledget that was used for liver suture (Fig. 1). Fistulography showed traffic with a fistula and the duodenum. The diagnosis was perihepatic abscess and duodenal perforation secondary to infection caused by a felt pledget. The patient had surgery to remove the pledget 29 months after the injury, for abscess infection control. The fistula was closed and the patient shortly resumed her normal life. It is important to choose a surgical strategy that does not involve using the device or removing the device early. However, in trauma surgery, the best strategy should be followed, depending on the situation. The surgeon can use one or more of the following hemostatic maneuvers for severe parenchymal injury: packing, direct suture, finger fracture, omental packing, fibrin sealants, hemostatic devices, and resection. Application of double sutures or wall reinforcement with felt strips are widely used methods to prevent laceration of the liver parenchyma by suture. Procedures using absorbable, minimal foreign sheets instead of pledgets may be possible, but cases in which bleeding is stanched solely with such sheets have been reported only in animal experiments. Although liver suture with felt pledgets is an effective approach for liver trauma, trauma surgeons should keep in mind the possibility of secondary infection to foreign body, even over a long-term period. At this stage, there are no alternatives to pledgets. It is important to find replacements that could avoid complications such as those described here. Our case may be helpful to describe to trauma surgeons the surgical technique and the pledget material, as well as indications for pledget utilization.