Masayasu Kawasaki

Laparoscopic colorectal surgery in patients with prior abdominal surgery.

Purpose: We retrospectively investigated the impact of prior abdominal surgery on the outcome of laparoscopic colorectal surgery. Patients: Among 607 colorectal cancer patients who underwent laparoscopic surgery, 192 patients had previously undergone abdominal surgery (S group) and 415 had not (non-S group). Results: The percentage of female patients was higher in the S group than in the non-S group. The incidence of conversion to open surgery was higher in the S group (5.2%, 10/192) than in the non-S group (2.6%, 11/415), but the difference was not significant (p = 0.108). Although the mean operating time and estimated blood loss were similar in the two groups, right and transverse colectomy after prior gastrectomy and ipsilateral colectomy after prior colectomy took longer and were associated with greater blood loss. The morbidity rates of the two groups were similar (S group: 15.6%, 30/192; non-S group: 14.5%, 60/415). There were 5 intraoperative small-bowel injuries or postoperative small-bowel perforations in the S group, especially in the patients with prior gastrointestinal-tract surgery. Conclusion: Our findings suggest that there is no reason to avoid laparoscopic procedures in most patients with prior abdominal surgery despite a higher conversion rate, but caution is warranted in patients who have undergone major gastrointestinal-tract surgery.

Non‐traumatic bladder rupture showing less than 10 Hounsfield units of ascites

Bladder ruptures are commonly misdiagnosed as gastrointestinal perforations or intestinal ischemia. If a diagnosis is made preoperatively, conservative treatment is a safe and effective option. We evaluated the validity of using the attenuation value of ascites, measured by non‐contrast computed tomography (CT), to identify patients with bladder ruptures.

Use of dynamic CT attenuation value for diagnosis of acute gangrenous cholecystitis.

OBJECTIVE To determine if the increase in transient focal enhancement of the liver adjacent to the gallbladder seen on dynamic computed tomography (CT) is greater in gangrenous cholecystitis than in nongangrenous cholecystitis by determining the CT attenuation value. METHODS We retrospectively reviewed the medical records of 57 patients who underwent emergency cholecystectomy for acute cholecystitis and preoperative dynamic CT scans between March 2011 and April 2016. Based on the pathology findings, patients were assigned to a gangrenous group or a nongangrenous group. The CT attenuation ratio (AR) was defined as the ratio of the maximum CT attenuation value in the region of interest in segment 5 (liver parenchyma adjacent to the gallbladder) and that in the control region of interest in segment 8. The patient characteristics and CT findings were compared between the groups. The appropriate AR of the arterial phase (ARAP) cutoff value for a diagnosis of gangrenous cholecystitis was determined using receiver operating characteristic curve analysis. RESULTS The ARAP was significantly higher in the gangrenous group than in the nongangrenous group (P < .001); the area under the receiver operating characteristic curve was 0.849. The ARAP cutoff value of 1.46 had a sensitivity and specificity of 84.6% and 83.9%, respectively (odds ratio, 21.17; 95% confidence interval, 4.90-118.91), and ARAP ≥1.46 was significantly correlated with a diagnosis of gangrenous cholecystitis (P < .001). CONCLUSIONS The increase in transient focal enhancement of the liver adjacent to the gallbladder during the arterial phase of dynamic CT was greater in gangrenous cholecystitis than in nongangrenous cholecystitis.

Cytomegalovirus-induced small-bowel hemorrhage in a patient with nonsystemic vasculitic neuropathy

A 73-year-old man who was being treated with corticosteroids for nonsystemic vasculitic neuropathy developed small-bowel hemorrhage after ileostomy for ileus. Immunohistochemical staining for cytomegalovirus (CMV) antigen in the ulcer in the resected ileum was positive; thus, cytomegalovirus infection of the small intestine caused his gastrointestinal manifestations. Cytomegalovirus infection should be considered in the differential diagnosis of gastrointestinal diseases in patients with collagen vascular diseases receiving immunosuppressive agents.

Ascitic fluid with ammonia odor as a symptom of bladder rupture

An 88‐year‐old woman presented with abdominal pain, massive ascites, and acute kidney injury. She was clinically hypervolemic and the computed tomography attenuation value of the ascites was near that of water. Subsequent abdominocentesis revealed ammonia‐smelling ascites fluid, leading to a suspicion of urinary tract injury, and a conclusive diagnosis of spontaneous bladder rupture was achieved using cystography.

Continuous Administration of Vancomycin through a Long Intestinal Tube for Clostridium difficile Infection.

A 76-year-old previously healthy Japanese man experienced severe diarrhea (8,000 mL per day) after undergoing laparotomy for small bowel obstruction and was diagnosed with Clostridium difficile infection. Although he developed a maculopapular rash secondary to the systemic absorption of enteral vancomycin (VCM), the patient was successfully treated with the continuous administration of VCM through a long intestinal tube placed in the terminal ileum. This method ensured the reliable delivery of VCM to the colon, while the continuous administration maintained high fecal levels of the drug. This treatment approach is an effective minimally invasive option for patients with severe diarrhea.

Spontaneous external biliary fistula arising from an intrahepatic duct

A spontaneous external biliary fistula is most commonly a cholecystocutaneous fistula secondary to acute cholecystitis. A fistula arising from an intrahepatic duct is extremely rare. An 87-year-old man presented with swelling of the epigastric region and right upper quadrant abdomen. He had a history of cholecystectomy and endoscopic sphincterotomy. After antibiotic treatment and surgical opening of both lesions, abdominal computed tomography demonstrated a soft tissue mass cephalad to the umbilicus. We excised the mass, and found it to be associated with a fistula through the linea alba. Fistulography showed an abscess cavity communicating with the intrahepatic duct in segment III. Histopathological examination of the mass showed an abscess without malignancy. The fistula closed spontaneously without laparotomy. In this case, the underlying pathology was considered to be associated with a subcapsular hepatic cyst in segment III.

Short-term outcomes of laparoscopic colorectal resection in psychiatric patients

Aim: To investigate the short-term outcomes of laparoscopic colorectal resection compared with open surgery in psychiatric patients with colorectal cancer. Methods: The authors retrospectively reviewed the medical records of 31 consecutive patients who underwent open surgery (OS) or laparoscopic surgery (LS) for colorectal cancer between April 2013 and September 2015. All patients were involuntarily admitted to the hospital, because of anosodiaphoria. The clinicopathological characteristics, intraoperative outcomes, and postoperative data of the two groups were analyzed. Categorical data were compared using the χ2 test or Fisher exact test, as appropriate. Continuous variables were compared using the Student t test or Mann-Whitney U test, as appropriate. Statistical analyses were performed using the statistical software program, SPSS, version 22 (SPSS Japan, Tokyo). P-values < 0.05 were considered statistically significant. Results: Sixteenpatients underwent LS, and 15 underwent OS. Blood loss was lower in the LS group than in the OS group (P = 0.001). LS was associated with the earlier resumption of psychiatric drug treatment (P < 0.001) and a shorter hospital stay (P = 0.021) compared with OS. Conclusion: Laparoscopic colorectal surgery is safe for psychiatric patients. The main advantages of LS include a shorter washout period and reduced hospital stay.

Brief Aripiprazole-induced Neuroleptic Malignant Syndrome with Symptoms that Only Lasted a Few Hours

Neuroleptic malignant syndrome (NMS) with characteristic symptoms is a potentially lethal reaction to antipsychotic drugs. Atypical NMS usually lacks major symptoms and frequently occurs after treatment using atypical antipsychotics, such as aripiprazole. A 64-year-old man developed aripiprazole-induced NMS after surgery, and our early recognition of the NMS was based on high creatine kinase levels and low serum iron levels. His characteristic symptoms (a fever, rigidity, and altered mental status) were only present for a few hours and were resolved by aripiprazole discontinuation and supportive care. Aripiprazole-induced NMS can present with brief but major symptoms, and clinicians may overlook this “brief” appearance of NMS.

Sigmoid colon cancer with an incidental diagnosis of Leriche syndrome successfully treated without inferior epigastric artery injury

Leriche syndrome involves atherosclerotic occlusion of the infrarenal aorta and bilateral common iliac arteries, and the inferior epigastric artery is an important route for lower-extremity perfusion. A 65-year-old Japanese man with sigmoid colon cancer was scheduled to undergo laparoscopic colectomy, and three-dimensional computed tomography angiography was performed to detect the feeding artery of the tumor. The angiography incidentally showed occlusion of the infrarenal aorta and common iliac arteries with the following collateral pathways: the internal thoracic artery supplied the external iliac artery via the inferior epigastric artery and the intercostal arteries supplied the external iliac artery via the superficial circumflex iliac artery. Therefore, he was diagnosed with Leriche syndrome. We performed open colectomy with midline incision and colostomy at the midline, without drain placement to prevent inferior epigastric artery injury. In patients with Leriche syndrome, this approach might be a safe option to avoid lower extremity ischemia. Abbreviations: ITA: internal thoracic artery; IEA: inferior epigastric artery; CT: computed tomography; 3D: three-dimensional