Toru Fukunaga

Appendicitis Caused by an Endoluminal Clip

Management of gastric ascariasis is based on two simple principles: (1) extraction of the off ending worms and (2) institution of eff ective anthelmintic therapy so that worms downstream in the jejunum do not travel upstream. All our patients had eff ective relief of symptoms and pointed to the parasite as the cause of symptoms. Dyspepsia is a common symptom in the community. As a signifi cant percentage of dyspeptic patients had gastric ascariasis, this entity should be considered as a diff erential diagnosis of dyspepsia in endemic regions.

Clinical Significance of Fibrinogen Degradation Product Among Traumatized Patients

OBJECTIVE We retrospectively analyzed trauma patients who were transported by a physician-staffed helicopter (doctor helicopter) to investigate the clinical significance of the fibrinogen degradation product (FDP) level on arrival. METHODS From February 2011 to July 2016, a medical chart review was retrospectively performed for all patients with trauma who were transported by the doctor helicopter. The subjects were divided into 2 groups: a survival group and a fatal group. RESULTS There were 135 patients in the survival group and 16 in the fatal group. The ratio of head injury, value of Injury Severity Score (ISS), and level of FDP in the fatal group were significantly greater than in the survival group. The average Glasgow Coma Scale and systolic blood pressure in the fatal group were significantly smaller than in the survival group. The FDP level at arrival was positively associated with the ISS (R = 0.74, P < .0001). After excluding subjects with shock, unconsciousness, and head injury, the FDP level was still positively associated with the ISS (R = 0.60, P < .0001). CONCLUSION Therefore, the FDP level may be a useful biochemical parameter for the initial evaluation of the severity of trauma, even in blunt trauma patients without head injury or with stable vital signs.

Horse kick injury mimicking a handle bar injury or a hidden speared injury

A 16‐year‐old male was transported to our emergency department after he was kicked in the abdomen by a horse. He was diagnosed with injury of the liver and abdominal rectus muscle, and was cured by observational treatment. An Ichushi search was undertaken to identify articles published from 1983 to 2013 using the key words “horse” and “trauma”. We found 13 cases that described horse‐related injuries and summarized these cases, including our case. There were 10 males, three females and one patient of an undescribed sex. The patients ranged in age from 16 to 58 years old, with an average age of 33 years. The injured sites were predominantly the face (mandible) and upper abdomen, indicating that a projecting part of the body may be more likely to be injured. Cardiac rupture, aortic head injury, or lethality induced by a horse kick have not been reported in Japan, but such injuries have been reported in other countries. Ten of 15 cases (67%) required surgical treatment for severe injuries. Horse kick injuries tend to be severe, because the transfer of energy from the end of the hoof, with a small cross‐sectional area, to a small field, leads to internal organic injuries that are more severe than predicted, similar to a handlebar injury. Accordingly, we advocate the close observation of patients with horse kick injuries, which may be regarded as being similar to blunt stab wounds or hidden speared injuries.

Esophageal intramural pseudodiverticulosis of the residual esophagus after esophagectomy for esophageal cancer

A 91-year-old man was referred to our hospital with intermittent dysphagia. He had undergone esophagectomy for esophageal cancer (T3N2M0 Stage III) 11 years earlier. Endoscopic examination revealed an anastomotic stricture; signs of inflammation, including redness, erosion, edema, bleeding, friability, and exudate with white plaques; and multiple depressions in the residual esophagus. Radiographical examination revealed numerous fine, gastrografin-filled projections and an anastomotic stricture. Biopsy specimens from the area of the anastomotic stricture revealed inflammatory changes without signs of malignancy. Candida glabrata was detected with a culture test of the biopsy specimens. The stricture was diagnosed as a benign stricture that was caused by esophageal intramural pseudodiverticulosis. Accordingly, endoscopic balloon dilatation was performed and anti-fungal therapy was started in the hospital. Seven weeks later, endoscopic examination revealed improvement in the mucosal inflammation; only the pseudodiverticulosis remained. Consequently, the patient was discharged. At the latest follow-up, the patient was symptom-free and the pseudodiverticulosis remained in the residual esophagus without any signs of stricture or inflammation.

Successful resection of metachronous para-aortic, Virchow lymph node and liver metastatic recurrence of rectal cancer

A 66-year-old female presented with the main complaint of defecation trouble and abdominal distention. With diagnosis of rectal cancer, cSS, cN0, cH0, cP0, cM0 cStage II, Hartmanns operation with D3 lymph node dissection was performed and a para-aortic lymph node and a disseminated node near the primary tumor were resected. Histological examination showed moderately differentiated adenocarcinoma, pSS, pN3, pH0, pP1, pM1 (para-aortic lymph node, dissemination) fStage IV. After the operation, the patient received chemotherapy with FOLFIRI regimen. After 12 cycles of FOLFIRI regimen, computed tomography (CT) detected an 11 mm of liver metastasis in the postero-inferior segment of right hepatic lobe. With diagnosis of liver metastatic recurrence, we performed partial hepatectomy. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer with cut end microscopically positive. After the second operation, the patient received chemotherapy with TS1 alone for 2 years. Ten months after the break, CT detected a 20 mm of para-aortic lymph node metastasis and a 10 mm of lymph node metastasis at the hepato-duodenal ligament. With diagnosis of lymph node metastatic recurrences, we performed lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as metastatic rectal cancer in para-aortic and hepato-duodenal ligament areas. After the third operation, we started chemotherapy with modified FOLFOX6 regimen. After 2 cycles of modified FOLFOX6 regimen, due to the onset of neutropenia and liver dysfunction, we switched to capecitabine alone and continued it for 6 mo and then stopped. Eleven months after the break, CT detected two swelling 12 mm of lymph nodes at the left supraclavicular region. With diagnosis of Virchow lymph node metastatic recurrence, we started chemotherapy with capecitabine plus bevacizumab regimen. Due to the onset of neutropenia and hand foot syndrome (Grade 3), we managed to continue capecitabine administration with extension of interval period and dose reduction. After 2 years and 2 mo from starting capecitabine plus bevacizumab regimen, Virchow lymph nodes had slowly grown up to 17 mm. Because no recurrence had been detected besides Virchow lymph nodes for this follow up period, considering the side effects and quality of life, surgical resection was selected. We performed left supraclavicular lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer. After the fourth operation, the patient selected follow up without chemotherapy. Now we follow up her without recurrence and keep her quality of life high.

A Novel Method for Real-Time Audio Recording With Intraoperative Video

OBJECTIVE Although laparoscopic surgery has become widespread, effective and efficient education in laparoscopic surgery is difficult. Instructive laparoscopy videos with appropriate annotations are ideal for initial training in laparoscopic surgery; however, the method we use at our institution for creating laparoscopy videos with audio is not generalized, and there have been no detailed explanations of any such method. Our objectives were to demonstrate the feasibility of low-cost simple methods for recording surgical videos with audio and to perform a preliminary safety evaluation when obtaining these recordings during operations. DESIGN We devised a method for the synchronous recording of surgical video with real-time audio in which we connected an amplifier and a wireless microphone to an existing endoscopy system and its equipped video-recording device. We tested this system in 209 cases of laparoscopic surgery in operating rooms between August 2010 and July 2011 and prospectively investigated the results of the audiovisual recording method and examined intraoperative problems. SETTING Numazu City Hospital in Numazu city, Japan. PARTICIPANTS Surgeons, instrument nurses, and medical engineers. RESULTS In all cases, the synchronous input of audio and video was possible. The recording system did not cause any inconvenience to the surgeon, assistants, instrument nurse, sterilized equipment, or electrical medical equipment. Statistically significant differences were not observed between the audiovisual group and control group regarding the operating time, which had been divided into 2 slots-performed by the instructors or by trainees (p > 0.05). CONCLUSIONS This recording method is feasible and considerably safe while posing minimal difficulty in terms of technology, time, and expense. We recommend this method for both surgical trainees who wish to acquire surgical skills effectively and medical instructors who wish to teach surgical skills effectively.

Internal hernia associated with colostomy after laparoscopic abdominoperineal resection

We herein describe a case with an internal hernia that developed after laparoscopic abdominoperineal resection for rectal cancer. The small intestine passed through the space between the sigmoid colon loop of the stoma and the abdominal wall. Internal hernias associated with colostomy are rare; however, the condition is an important complication, because it causes ischemia in both the herniated intestine and the sigmoid colon pulled through the abdominal wall as a stoma.

Assessment of residual liver functional reserve after portal embolization with positron emission tomography usingl-[methyl-11C] methionine and computed tomography

Hepatic functional reserve after portal embolization was assessed in eight patients according to the functional volume index (FVI), a new index obtained using positron emission tomography (PET) withl-[methyl-11C] methionine. FVI in residual liver was 1744–5252 (mean, 3441) (normal range, 3106–6211) before percutaneous transhepatic portal embolization (PTPE) and 2457–6906 (mean, 4590) after PTPE. FVI exceeded 4000 in five patients and did not reach 4000 in three patients after PTPE. Two patients with FVI values of more than 4000 survived after hepatectomy and one with FVI under 4000 died of liver failure. FVI is a useful criterion for determining indications for PTPE; a value exceeding 4000 is needed before major hepatectomy can be safely performed after PTPE.

Corkscrew oesophagus on virtual endoscopy

A 52-year-old man visited our hospital to have a general checkup. Routine gastrointestinal endoscopy showed a twisted lumen with a corkscrew appearance in the distal oesophagus. No other abnormality was identifi ed (fi gure A). Our patient did not have any symptoms of dysphagia or retrosternal pain. A single-contrast barium examination of his oesophagus confi rmed a spiral staircase peristalsis and an absence of peristalsis in the oesophageal body. CT of the mediastinum was done, and virtual endoscopy of the oesophagus showed the typical features of corkscrew oesophagus (fi gure B). Although manometry might be necessary to diagnose corkscrew oesophagus, we did not recommend this to our patient because his corkscrew oesophagus had been diagnosed, without any previous symptoms. In the future, our patient will need to be treated with drugs such as muscle relaxants and anxiolytic agents, in conjunction with either antirefl ux therapy or surgical myotomy. Currently, we only advise him not to consume cold fl uids to prevent the development of symptoms.