[A case of acute afferent loop syndrome treated by endoscopic decompression].

A 67-year-old woman underwent distal gastrectomy (Billroth type II reconstruction) for gastric ulcer perforation in March, 2001. In October of the same year, she was admitted to our hospital with a diagnosis of acute afferent loop syndrome with severe acute pancreatitis. The patient was successfully treated by endoscopic decompression of the afferent loop, followed by continuous drainage. Combined use of decompression and percutaneous abscess drainage was effective for the management of the retroperitoneal abscess. The most common treatment strategy employed for acute afferent loop syndrome is surgical therapy, however, the experience in this patient suggests that endoscopic drainage, which is less invasive, may also be considered.

Etiology of intestinal obstruction in patients without a prior history of laparotomy or a detectable external hernia on physical examination.

We evaluated the preoperative determination of the etiology and effectiveness of the diagnostic modalities, as well as the incidence of various causes of intestinal obstruction (IO) from 1981 through 2001 at a university-affiliated emergency center. Patients with a history of prior laparotomy or evidence of hernia on physical examinations were excluded. Eighty-three patients with surgically or endoscopically proven IO were reviewed. The most common cause of IO in the group with enteric obstruction was hernia while that in the group of colonic obstruction was carcinoma. Of the first preoperative diagnostic modalities to correctly determine the cause of obstruction, the most common were contrast enema and colonoscopy. Preoperative determination of the etiology was possible in 67% of the patients and was significantly more common in patients with colonic obstruction than in those with enteric obstruction.

Solid and cystic tumor of the pancreas with massive hemoperitoneum.

A case of a solid cystic tumor (SCT) of the pancreas with massive hemoperitoneum occurring in a 31-year-old woman is reported. She was admitted with abdominal pain and rebound tenderness. Computed tomography (CT) disclosed a large tumor consisting of both solid and cystic components in the body of the pancreas. Within 12 hours after admission, she exhibited exacerbation of pain and hemoperitoneum on CT with deterioration of general condition and anemia. Celiac artery angiography demonstrated the tumor as a hypovascular mass. SCT of the pancreas was suspected, and emergent laparotomy was performed. In the surgical procedure, tumor in the body of the pancreas with rupture was detected. Distal pancreatectomy was performed with removal of the regional lymph nodes. There was no evidence of metastatic disease in the abdomen. The cut surface of the tumor exhibited areas of cystic degeneration containing hemorrhagic friable materials. Microscopically, the tumor cells were mainly cubic or cylindrical peripherally in pseudo-papillary formation. Postoperative recovery was normal and she was discharged on the 15th postoperative day. Three years after operation, she is free of disease without findings of recurrence.

[A clinical study of liver abscesses at the Critical Care and Emergency Center of Iwate Medical University].

We studied 13 emergency cases of liver abscess. Five cases of septic shock or clouding of consciousness were identified on admission. Six patients had diabetes mellitus. Twelve patients met the diagnostic criteria for systemic inflammatory response syndrome, and nine met the criteria for disseminated intravascular coagulation. Plasma endotoxin levels improved rapidly after drainage. Causative organisms were isolated in all patients, and the most common organism was Klebsiella pneumoniae (seven cases). Percutaneous transhepatic abscess drainage (PTAD) was performed not only in single cases but also in multiple cases with main huge abscesses. Surgical treatment was performed in the following three cases: a ruptured abscess, an ineffective PTAD, and a case of peritonitis after PTAD. Irrigation of abscesses with strong acidic electrolyzed water revealed a significant decrease in treatment duration. In the majority of our cases, severe conditions were identified on admission. Strong acidic electrolyzed water was useful for management of PTAD.

Pulmonary involvement in Crohn's disease report of a case and review of the literature.

Crohn's disease (CD) is a granulomatous systemic disorder of unknown etiology. Obvious pulmonary involvement is exceptional in patients with CD. We report a case of a 38-year-old man who suffered from CD for more than 14 years and was treated with oral steroids for more than 10 years. Surgical excision of parts of the ileum was performed for life-threatening ileal bleeding caused by CD. After acute tapering of oral steroids, pulmonary symptoms and radiologic abnormalities were noted. Lung biopsy through thoracoscopy was performed and revealed signs of chronic inflammation with multiple subepithelial noncaseating and epithelioid granulomas on pathologic examination. Intravenous steroids were required in the initial management of life-threatening pulmonary dysfunction after diagnostic thoracoscopy and led to marked improvement. Tuberculocidal therapy was performed until all microbiological cultures were negative. Oral steroid dosage had slowly been tapered over 1 month. He was discharged with clinical and radiologic improvements. After 36 months, the patient's condition is stable on continued treatment with prednisolone and mesalazine.

Peliosis hepatis during postpartum period: successful embolization of hepatic artery.

Peliosis hepatis is a rare disorder characterized by the presence of blood-filled spaces in the liver, and it usually has a chronic presentation pattern. It has been reported mainly in adult patients in association with various pharmacological agents and infections. The present report concerns a postpartum patient in whom peliosis hepatis initially presented as active intraperitoneal hemorrhage from peliotic liver lesions, with no obvious etiology. We report here a 31-year-old woman who developed symptomatic peliosis hepatis and underwent superselective hepatic artery embolization, with control of the bleeding. We also present the sonographic, computed tomographic, and magnetic resonance images and laparoscopic findings. The patient recovered well and was discharged without any complaints. The pathogenesis in this patient remains unclear, but it is suggested that in her case estrogens and progesterone could not have been responsible for the development of peliosis hepatis.

Laparoscopic paracecal hernia repair.

The diagnosis and treatment of internal abdominal hernia usually require laparotomy. We report a case of preoperative diagnosis and laparoscopic repair of paracecal hernia. A 90-year-old woman was referred with features of a well-established small bowel obstruction (SBO). Computed tomography and a small bowel contrast examination showed a paracecal hernia. With the patient under general anesthesia, laparoscopic surgery was carried out with the use of pneumoperitoneum, and an easy reduction of the incarcerated intestinal loop was achieved by gentle traction of the intestine. The bowel was assessed for viability and showed no evidence of nonviability. The abnormal orifice in the paracecal region was observed. The orifice was closed with 3-0 PDS II (polydiaxonone) sutures laparoscopically. A laparotomy was avoided, and the patient recovered without significant complications. We conclude that laparoscopy can play a useful role in the treatment of internal hernia causing SBO when an obstructive lesion has been detected and decompression accomplished preoperatively.

Selective application of laparoscopic intervention in the management of isolated bowel rupture in blunt abdominal trauma.

BACKGROUND: Recently, laparoscopy has been used as an effective diagnostic and therapeutic modality for traumatic injury and peritonitis. However, its clinical benefits are still under evaluation. The aim of this study was to assess the feasibility and safety of this technique, in comparison with traditional laparotomy, in the management of isolated bowel rupture. A further aim was to evaluate possible predictive clinical factors in the management of isolated bowel rupture. INDICATIONS: Patients with definite or suspected isolated gastrointestinal perforation who were hemodynamically stable underwent laparoscopic surgery for diagnosis and treatment. METHODS AND RESULTS: The traditional laparotomy control group (Group A, historical controls) included patients from a prior study. In this previous study, carried out between 1993 and 1997, 23 consecutive cases of traumatic gastrointestinal perforation were treated with traditional laparotomy. Retrospectively, 13 of these 23 cases would have been eligible for laparoscopic intervention. The laparoscopic group (group B) was made up of cases seen at our institution from 1998 to 2000. Of the 13 consecutive cases of traumatic gastrointestinal perforation, only one required immediate traditional laparotomy. Just one of the 12 cases of gastrointestinal perforation approached laparoscopically had to be converted to a traditional laparotomy. The following variables were evaluated in both groups: patient background, time from accident to onset of operation, operative time, blood loss, time to oral intake, incidence of peritoneal contamination, length of hospital stay, mortality, and intraoperative and postoperative complications. There were no statistical differences in age, gender ratio, and injury severity score (ISS). The mean operative times were 132.3 +/- 58.7 minutes and 143.6 +/- 27.3 minutes in group A and group B, respectively. The mean blood loss was 266.8 +/- 277.8 mL in group A and 57.6 +/- 57.1 mL in group B. The blood loss in group B was significantly lower (P =.0084) than that in group A. There were no significant differences in intraoperative and postoperative complications, hospital stay, and mortality between the two groups. CONCLUSIONS: Laparoscopic intervention offers better results in the management of patients with blunt abdominal trauma and isolated bowel rupture.

Pneumothorax as a presenting manifestation of early sarcoidosis.

Pneumothorax rarely develops sarcoidosis. A 21-year-old man with early sarcoidosis presenting as pneumothorax is reported. The patient came to our institute with severe chest pain and dyspnea. Plain chest roentgenograms revealed pneumothorax in the left lung. A chest tube was inserted to inflate the lung. Subsequent computed tomography demonstrated subpleural blebs in the upper lobe of the left lung. Continuous treatment with tube drainage was performed. However, surgical intervention was needed since long-term tube drainage turned out to be unsuccessful. Thoracoscopic partial extirpation on the left upper lobe was performed. The histology of the obtained lung tissue showed non-caseating granulomas composed of epithelioid cells and occasional giant cells. A diagnosis of sarcoidosis was made on the basis of the histological report. Although early sarcoidosis presenting as pneumothorax is rare in young patients, the possibility of a sarcoidosis should be considered.

Pneumoperitoneum without perforation of the gastrointestinal tract.

Pneumoperitoneum (PP) is usually the result of perforation of the gastrointestinal (GI) tract with associated peritonitis. However, other rare causes, including spontaneous PP incidental to intrathoracic, intra-abdominal, gynecologic, and miscellaneous other origins not associated with a perforated GI tract have been described in the literature. Six cases of PP without any perforated GI tract are reported. Three patients with generalized peritonitis underwent exploratory laparotomy or laparoscopy when clinical examinations suggested an acute abdomen. At surgical procedure, perforated pyometra, perforated liver abscess and a ruptured necrotic lesion of a liver metastasis were documented in these patients, respectively. We also saw 3 PP patients not associated with peritonitis. Two patients with PP caused by pneumatosis cystoides intestinalis were encountered, 1 was managed conservatively and the other received diagnostic laparoscopy. A patient in whom pneumomediastinum and pneumoretroperitoneum were accompanied by PP caused by an alveolar rupture based on decreased pulmonary compliance due to malnutrition was managed conservatively. The history of the patient and knowledge of the less frequent causes of PP can possibly contribute towards refraining from exploratory laparotomy in the absence of peritonitis.

Intussusception in adults: a 21-year experience in the university-affiliated emergency center and indication for nonoperative reduction.

BACKGROUND: While intussusception is relatively common in children, it is rare in adults. METHODS: We retrospectively reviewed the records of all patients older than 18 years with the diagnosis of intussusception between 1981 and 2001. RESULTS: Eleven patients with surgically or endoscopically proven intussusception were encountered at the University-affiliated emergency center. The patients ranged in age from 19 to 88 years with a mean age of 45 years. Males predominated by a ratio of 7:4. Most patients (82%) presented with symptoms of bowel obstruction. The mean duration of symptoms was 4.5 days with a range of 4 h to 25 days. Correct pre-treatment diagnosis was made in 82% of the patients using abdominal ultrasonography and computed tomography (CT). The causes of intussusception were organic lesions in 64% of the patients, postoperative in 18% and idiopathic in 18%, respectively. 73% of patients had emergency operations, and an attempt at nonoperative reduction was performed and completed successfully in 3 patients with ileo-colic or colonic type of intussusception. There have been no cases of morbidity or mortality in our series and no recurrence has occurred up to the present time. CONCLUSIONS: Abdominal ultrasonography and CT were effective tools for the diagnosis of intussusception. Patients with ileo-colic and colonic intussusception without malignant lesions could be good candidates for nonoperative reduction prior to definitive surgery.