Toshihiro Tsubono

A case of bilateral obturator hernias: Image diagnosis and description of a retropublic operative approach

A case of bilateral obturator hernias which was diagnosed by ultrasonography (US) and computed tomography (CT), and repaired by a retropublic extraperitoneal operative approach under spinal anesthesia is reported herein. A 91-year-old woman presented with lower abdominal and left groin pain consistent with a Howship-Romberg sign. US demonstrated an image of the bowel projecting from the small pelvic space to the left thigh with a to-and-fro movement of the bowel contents. The definitive diagnosis of an incarcerated left obturator hernia was made by CT which also revealed a mass in the right obturator foramen. Surgery was performed through a retropublic extraperitoneal approach under spinal anesthesia. No necrosis was observed in the incarcerated bowel and resection was not necessary. A simple hernial sac was found in the right obturator canal. The operation using the retropublic extraperitoneal approach was successful and we believe it to be the most effective procedure for obturator hernias which have been diagnosed early.

Hepatic portal venous gas associated with cholangitis following pancreaticoduodenectomy : report of a case

A 63-year-old man developmented fever and shock 2 weeks after undergoing a pancreaticoduodenectomy for carcinoma of the gallbladder with duodenal involvement. Computed tomography (CT) of the abdomen showed transient hepatic portal venous gas in the right lobe of the liver, which had probably been induced by obstruction of the bilioenteric anastomosis by the biliary drain. The gas and bacteria, both of which are commonly observed in cases of bilioenteric anastomosis, may have been diffused through the sinusoid into the portal venous system. Thus, hepatic portal venous gas could be a serious sign when it develops in patients with cholangitis following bilioenteric anastomosis.

Hepatic functional reserve in patients with obstructive jaundice: An assessment by the redox tolerance test

PURPOSE Hepatic mitochondrial response to oral glucose load (redox tolerance test) was evaluated as an indicator of hepatic functional reserve of patients with obstructive jaundice. PATIENTS AND METHODS The redox tolerance test was performed in 29 patients with obstructive jaundice before percutaneous transhepatic biliary drainage and 2 weeks after the procedure. RESULTS The redox tolerance index (RTI) before drainage was not related to conventional parameters other than albumin, but was significantly associated with bilirubin half-life (P < 0.01). Of 19 patients with an RTI > or = 0.5 before drainage, all maintained similar values after drainage and experienced satisfactory clinical courses, even after major surgery. Of 10 patients with an RTI < 0.5 before drainage, 5 showed improvement and 5 deteriorated after drainage. Four of the latter 5 died within 60 days after drainage. The hospital mortality was significantly greater in patients with initial RTI < 0.5 than in patients with RTI > or = 0.5 (P < 0.01). CONCLUSION The redox tolerance test is useful for evaluating hepatic functional reserve and prognosis in patients with obstructive jaundice.

Short-and long-term outcomes of surgery for diffuse peritonitis in patients 80 years of age and older

PurposeWe evaluated the impact of advanced age on the morbidity, mortality, and long-term outcome after emergency surgery for diffuse peritonitis.MethodsWe retrospectively evaluated the mortality and morbidity rates in 36 patients who were 80 years of age or older and who had undergone emergency surgery for diffuse peritonitis, and calculated 5-year survival by the Kaplan-Meier method. Factors compromising prognosis were identified by univariate and multivariate analyses.ResultsThe median patient age was 84 years (range, 80–97 years); 16 patients were men and 20 were women. Preoperative concomitant disease was present in 81% of patients; cardiac disease was most common. Sites of visceral perforation were in the upper gastrointestinal tract in five patients, colon or rectum in 30, and gallbladder in 1. The postoperative morbidity rate was 72%, the surgical mortality rate was 11%, and the in-hospital mortality rate was 28%. The median hospital stay was 56 days. The median survival was 41 months, with a 5-year survival rate of 23%. A multivariate analysis identified number of failing organs as the only independent adverse prognostic factor (P < 0.001; relative risk 5.51, 95% confidence interval 1.97–15.4).ConclusionsElderly patients with diffuse peritonitis had an unsatisfactory rate of short-term morbidity and mortality compared with those undergoing elective surgery. Postoperative organ failure was most likely to compromise survival.

The redox tolerance test as a measure of hepatic function in patients with obstructive jaundice

Abstract The redox tolerance test was performed before percutaneous transhepatic biliary drainage, in 15 patients with obstructive jaundice, and repeated 2 weeks after. Four patients without jaundice were evaluated as a control group. No difference was found in the redox tolerance index between the controls and the group with good bilirubin clearance. On the contrary, the redox tolerance index was significantly lower in the group with poor bilirubin clearance. No significant change in the redox tolerance index was revealed after percutaneous drainage. However, of four patients whose indices were smaller than 0.5 before biliary drainage, three died after developing cholangitis. The redox tolerance test is useful for evaluating hepatic function and predicting outcome in patients with obstructive jaundice.

Upper Gastrointestinal Hemorrhage in a Patient with Choledochoduodenal Fistula.

傍乳頭部総胆管十二指腸瘻から動脈性出血をきたした1例を経験した. 症例は68歳の男性, 急性胆嚢炎に対して経皮経肝胆嚢ドレナージ術が施行され, 胆道造影で総胆管結石症と診断された. 総胆管十二指腸痩は胆嚢ドレナージの1週間後に発生した. 胆嚢摘出術, 総胆管切開・Tチューブドレナージ術を施行したが, 第13病日 (瘻孔形成後約3週間) に胆道出血と下血をきたしショックとなった. 内視鏡的止血術, 動脈塞栓術が不能であったため, 緊急手術で十二指腸を切開すると瘻孔内の膵実質より動脈性出血がみられた. 膵実質を含めて出血点を刺入結紮することにより止血しえた. 術後再出血はみられず胆管炎も発生していない. 総胆管十二指腸瘻出血は瘻孔形成後早期に発生しうる合併症であり, 経過観察に際しては十分念頭におくべき病態であると思われた.