Motoaki Shirakawa

Obturator hernia: The usefulness of computed tomography in diagnosis

BACKGROUND Delay in diagnosis and treatment of the rare obturator hernia often leads to high resection and mortality rates. Reviews of the clinical courses and the reliability of computed tomography (CT) in early diagnosis are reported. METHODS Seventeen patients with obturator hernias were treated between April 1983 and December 1994. Except for one man, all were emaciated women who had undergone an average of 4.7 live deliveries. The mean age was 79.9 years. RESULTS All patients had small bowel obstruction symptoms. Howship-Romberg sign was present in 11 patients. Twelve cases were correctly diagnosed before operation. After the introduction of CT in the diagnosis of suspected hernia cases, preoperative diagnosis was made on 9 of the 10 patients (90%) and CT was performed on 8 patients with 100% accuracy. CONCLUSIONS Definite and early diagnosis is possible with the awareness of the clinical courses of this hernia and by performing CT on suspected cases.

Laparoscopic resection of adult colon duplication causing intussusception

Gastrointestinal duplications are uncommon congenital malformations that can occur anywhere along the gastrointestinal tract. Most cases are recognized before the age of 2 years, and those encountered in adults are rare. We describe here a case of ascending colon duplication in a 20-year-old male that caused intussusception and was treated laparoscopically. Although computed tomography revealed a cystic mass filled with stool-like material, the preoperative diagnosis was a submucosal tumor of the ascending colon. We performed a laparoscopic right colectomy, and the postoperative pathological diagnosis was duplication of the ascending colon, both cystic and tubular components. We conclude that gastrointestinal duplications, although rare, should be considered in the differential diagnosis of all abdominal and submucosal cystic lesions and that laparoscopy is a preferred approach for the surgical treatment of gastrointestinal duplications.

Simultaneous Left Ventricular and Deep Vein Thrombi Caused by Protein C Deficiency

Protein C deficiency is a risk of venous thrombosis because of poor fibrinolytic activity. It remains controversial whether protein C deficiency causes arterial thrombosis. A 21-year-old woman was referred with a chief complaint of right leg pain and numbness. Contrast-enhanced computed tomography revealed a low-density mass in the left ventricle (LV), splenic infarction, and peripheral arterial obstructions in her right leg. Thrombosis extending from the renal vein to the inferior vena cava was also detected. Electrocardiography revealed ST depression in leads II, III, and aVF. Transthoracic echocardiography revealed hypokinesis of the apex and interventricular septum and a hypoechoic mass in the LV (26 × 20 mm). She was diagnosed with acute arterial obstruction caused by the LV thrombus, which might have resulted from previous myocardial infarction. Protein C activation turned out to be low (41%) 5 days after admission. The anticoagulant therapy was switched from heparin to rivaroxaban 16 days after admission. The LV thrombus disappeared 24 days after initial treatment, and she has had no thrombotic episodes for 2.8 years under rivaroxaban therapy. Thrombophilia should be investigated for cases of simultaneous left ventricular and deep venous thrombi. Rivaroxaban can be effective in prevention of further thrombotic events.

Transabdominal approach assisted by thoracoscopic drainage for lower esophageal perforation

The effectiveness of use of thoracoscopy for esophageal perforation has not been fully evaluated. We herein report a case of esophageal perforation for which a transabdominal approach assisted by thoracoscopic drainage was performed.