[Gastrectomy of a GIST with Diaphragmatic Repair Utilizing the Fascia Lata-A Case Report].

A 73-year-old man was admitted with the chief complaint of upper abdominal discomfort.After close examination, he was diagnosed with a huge stomach gastrointestinal stromal tumor(GIST)that occupied the upper left abdomen with a maximum diameter of 150 mm.The patient was referred to our department for surgery.The border between the tumor and spleen was unclear on CT images.As the diaphragm was thinned due to compression by the tumor, gastrectomy with splenectomy and partial resection of the diaphragm was planned.For the diaphragmatic defects, a simple closure was considered at first. However, artifacts have a high risk of infection when the defect holes are too large.Therefore, in this case, we attempted to repair the diaphragm hole with the autologous fascia lata.Intraoperatively, while the tumor was resected with 1 more layer of the diaphragm, the diaphragm itself was thinned, resulting in a defect hole of about 60×80 mm.Therefore, an 80×110mm fascia lata was harvested, and the diaphragm was repaired.Fascia lata can be conveniently harvested as a free graft.In addition, the fascia of the thigh has the advantage of being more resistant to infection than artificial materials.In addition, there was no functional failure due to collection, and special plastic surgery techniques and tools were unnecessary.Thus, it is a useful reconstruction material for general surgeons.Here we report the details of the surgery along with a review of the literature.

Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis.

The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Huge rectovesical fistula due to long-term retention of a rectal foreign body: A case report and review of the literature.

INTRODUCTION: Most patients with foreign bodies in their rectums present to medical institutions within a few days. In this report, we describe a foreign body in the rectum in situ for 5 months that resulted in a huge rectovesical fistula 4cm in diameter, requiring emergency laparotomy. PRESENTATION OF CASE: A 59-year-old man, who had undergone rectal foreign body extraction via the anal canal without any complications 7 years previously, presented with abdominal pain and diarrhea. Computed tomography revealed a cup-shaped rectal foreign body and huge rectovesical fistula. We performed an emergency laparotomy. There was no contaminated ascites. The adhesion around the fistula was too stiff to be dissected. We incised the rectal wall, excised the ceramic cup-shaped foreign body, and detected a fistula approximately 4cm in diameter. We performed sigmoid colostomy, and the incised rectal wall and the bladder wall were sutured, and the residual rectum was supposed to function as a part of the bladder. After the surgery, no severe complications occurred. The patient told us that he inserted the foreign body himself 5 months earlier, and urine had appeared in the stool in the previous month. DISCUSSION: A long-term retained rectal foreign body is very rare and could create an abnormal huge fistula between the pelvic organs because of prolonged pressure on the walls of the pelvic organs. CONCLUSION: In patients with a long-term retained rectal foreign body, we should prepare for surgical treatment of not only the rectum but also the other pelvic organs.

What are the appropriate indicators of surgical difficulty during laparoscopic cholecystectomy? Results from a Japan-Korea-Taiwan multinational survey.

BACKGROUND: Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC. METHODS: A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT. RESULTS: The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons. CONCLUSIONS: Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

Adult intussusception: a retrospective review.

BACKGROUND: Intussusception is common in children but rare in adults. The goal of this study was to review retrospectively the symptoms, diagnosis, and treatment of intussusception in adults. METHODS: From 1997 to 2013, we experienced 44 patients of intussusception in patients older than 18 years. The patients were divided into enteric, ileocolic, ileocecal, and colocolonic (rectal) types. The diagnosis and treatment of these patients were reviewed. RESULTS: Of the 44 patients of adult intussusception, 42 were diagnosed with abdominal ultrasonography and abdominal computed tomography. There were 12 patients of enteric intussusception, six patients of ileocolic intussusception, 16 patients of ileocecal type intussusception, and 10 patients of colonic (rectal) intussusception. Among them, 77.3 % were associated with a tumor. Among 12 patients of enteric intussusception, three were associated with a metastatic intestinal tumor, and one was associated with a benign tumor. Among six patients of ileocolic intussusception, two patients were associated with malignant disease. Also, 93.8 % of ileocecal intussusceptions were associated with tumors, 80.0 % of which were malignant. Similarly, 90.0 % of colonic intussusceptions were associated with malignant tumors. Intussusception was reduced before or during surgery in 28 patients. Surgery was performed in 41 patients, and laparoscopy-assisted surgery was performed for ab underlying disease in 12 patients. CONCLUSIONS: Preoperative diagnoses were possible in almost all patients. Reduction greatly benefited any surgery required and the extent of the resection regardless of the underlying disease and surgical site.

Comparison of the early results of transanal hemorrhoidal dearterialization and hemorrhoidectomy using an ultrasonic scalpel.

PURPOSE: Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (THD surgery) is a new approach for treating hemorrhoids. The early results of the procedure are presented and compared with those of hemorrhoidectomy using an ultrasonic scalpel (US surgery). METHODS: Thirty-six patients with grade III hemorrhoids underwent the THD surgery and were compared with a cohort of 30 patients with grade III or IV hemorrhoids who were assigned to US surgery in a previous randomized trial. RESULTS: The pain scores were significantly lower in the THD patients on days 6 and 7 after the operation. The number of analgesic tablets consumed during the first postoperative week in the THD patients was significantly lower than that in the US patients. The blood loss was significantly greater in the THD patients. The hospital stay and length of time until the first defecation after surgery were both significantly shorter in the THD patients. The postoperative complications were comparable between the two groups of patients. CONCLUSION: The THD surgery was as effective as the US surgery for the treatment of hemorrhoids in the short term. THD surgery might be a preferred treatment because it is associated with a similar complication rate and short-term results, but results in lower postoperative pain and analgesic requirements compared with the US surgery.

Laparoscopic surgery for colon cancer: a review of the fascial composition of the abdominal cavity.

Laparoscopic surgery has generally been performed for digestive diseases. Many patients with colon cancer undergo laparoscopic procedures. The outcomes of laparoscopic colectomy and open colectomy are the same in terms of the long-time survival. It is important to dissect the embryological plane to harvest the lymph nodes and to avoid bleeding during colon cancer surgery. To date, descriptions of the anatomy of the fascial composition have mainly involved observations unrelated to fundamental embryological concepts, causing confusion regarding the explanations of the surgical procedures, with various vocabularies used without definitions. We therefore examined the fascia of the abdominal space using a fascia concept based on clinical anatomy and embryology. Mobilization of the bilateral sides of the colon involves dissection between the fusion fascia of Toldt and the deep subperitoneal fascia. It is important to understand that the right fusion fascia of Toldt is divided into the posterior pancreatic fascia of Treitz dorsally and the anterior pancreatic fascia ventrally at the second portion of the duodenum. A comprehensive understanding of fascia composition between the stomach and transverse colon is necessary for dissecting the splenic flexure of the colon. As a result of these considerations of the fascia, more accurate surgical procedures can be performed for the excision of colon cancer.

Broad ligament hernia successfully treated by laparoscopy: Case report and review of literature.

We report a case of a 36-year-old woman with a history of caesarean section who presented with small bowel obstruction. Abdominal multi-detector CT showed discontinuity of the small bowel near the broad ligament on the left. We made a provisional diagnosis of an internal hernia through a defect in the broad ligament and performed laparoscopic exploration, which revealed a viable ileal loop incarcerated by the broad ligament. Multi-detector CT may be useful for diagnosing this type of defect preoperatively, whereby open surgery can be avoided.

Serum aluminum levels in dialysis patients after sclerotherapy of internal hemorrhoids with aluminum potassium sulfate and tannic acid.

PURPOSE: Aluminum potassium sulfate and tannic acid (ALTA) is an effective sclerosing agent for internal hemorrhoids. However, it is contraindicated for patients with chronic renal failure on dialysis, because the aluminum in ALTA can cause aluminum encephalopathy when it is not excreted effectively. We conducted this study to measure the serum aluminum concentrations and observe for symptoms relating to aluminum encephalopathy in dialysis patients after ALTA therapy. METHODS: Ten dialysis patients underwent ALTA therapy for hemorrhoids. We measured their serum aluminum concentrations and observed them for possible symptoms of aluminum encephalopathy. RESULTS: The total injection volume of ALTA solution was 31 mL (24-37). The median serum aluminum concentration before ALTA therapy was 9 µg/L, which increased to 741, 377, and 103 µg/L, respectively, 1 h, 1 day, and 1 week after ALTA therapy. These levels decreased rapidly, to 33 µg/L by 1 month and 11 µg/L by 3 months after ALTA therapy. No patient suffered symptoms related to aluminum encephalopathy. CONCLUSIONS: Although the aluminum concentrations increased temporarily after ALTA therapy, dialysis patients with levels below 150 µg/L by 1 week and thereafter are considered to be at low risk of the development of aluminum encephalopathy.

Acute cholecystitis with bacteremia caused by Pasteurella multocida.

BACKGROUND: Pasteurella multocida is a commensal organism present in the oral cavities of many animals. It can cause various infections including soft tissue, joint, and respiratory infections in human beings, but intra-abdominal infection by P. multocida is rare. We report our experience with a case of acute cholecystitis with bacteremia caused by P. multocida. CASE REPORT: The patient was a 39-year-old female who underwent emergency laparoscopic cholecystectomy for acute cholecystitis. The patient's blood and bile cultures were positive for P. multocida. She kept a dog and a cat as pets, but denied having had any bites or major scratches. Our investigation did not find that she had any sign of other potential sources of infection. CONCLUSION: Acute cholecystitis can be a primary source of Pasteurella bacteremia in a previously healthy, young patient.

Differentiating a large abdominal cystic lymphangioma from multicystic mesothelioma: report of a case.

We report a case of retroperitoneal cystic lymphangioma in a 30-year-old woman who presented with abdominal distention and pain. Imaging studies revealed a large, thin-walled multicystic mass occupying the whole abdomen. Based on a preoperative diagnosis of multicystic mesothelioma, we performed laparotomy, which revealed a tumor arising from the gastropancreatic ligament in the posterior wall of the omental bursa. We resected the tumor completely, without the adjacent viscera. The final pathological diagnosis was cystic lymphangioma, based on the immunohistochemical findings of positive CD31 and CD34 expression, the presence of smooth muscle confirmed by smooth muscle antigen and desmin, and negative calretinin, WT-1 and cytokeratins 5/6 expression. Multicystic mesotheliomas and cystic lymphangiomas are so similar in morphology that immunohistochemical staining should be fully utilized to differentiate them.

Reappraisal of the vascular anatomy of the colon and consequences for the definition of surgical resection.

INTRODUCTION: Databases of information on surgical treatment for colorectal cancer have been created in various countries and data have started to be released. The most important facets of research for statistical processing include the methodology and firm definitions of content. However, for trials involving colorectal cancer, the applicable terminology has not been defined, and much bias is frequently encountered. Starting from definitions of the colon and vascular system of the colon, we propose definitions of surgical procedures for colorectal cancer. METHODOLOGY: This paper reviews the colon segments and vascular anatomy of the colon. If surgical treatment of colon cancer is considered from this perspective, we can see that definitions for these surgical procedures are lacking. The definition of surgical treatment would also allow clarification of the range of lymph node dissection. In general, surgical procedures and the area of surgical lymph node dissection are both defined according to the basic structure of the associated arteries. However, the existing descriptions are not based on a definition of the arteries. We therefore tried to establish the most useful nomenclature for the arterial system of the large intestine for colorectal surgeons and reviewed the frequency of important arterial variations. Using the resulting definitions, we provided consistent definitions for colon cancer surgery. CONCLUSION: The segments of the colon need to be defined. In surgery, procedures are performed using the arteries as indicators, so vessels originating from the superior and inferior mesenteric arteries are referred to as arteries, with others are referred to as branches. Surgical treatment of colon cancer can be defined from the relationship between these arteries. For the first time, this may allow proper application of statistics for the treatment of colon cancer.

Small bowel metastasis of uterine cervical adenocarcinoma.

A few cases of small bowel metastasis from uterine cervical cancer have been previously reported. All reported cases were connected to squamous cell carcinoma, while none were associated with cervical adenocarcinoma. This report is of a rare case of cervical adenocarcinoma that haematogenously metastasised to the small intestine, and which caused a perforation and small bowel obstruction metachronously. An 84-year-old woman was admitted to our hospital with vaginal bleeding. She was diagnosed with FIGO stage III cervical adenocarcinoma by imaging and pathohistological examinations. Three months after receiving radiation therapy to control the bleeding, surgery was performed twice; the first operation for small bowel perforation and the second for small bowel obstruction. She was then diagnosed with haematogenous metastasis of cervical adenocarcinoma to the ileum according to the operative, histopathological and immunopathological findings.

Anal function after ligation of the intersphincteric fistula tract.

BACKGROUND: Although the ligation of the intersphincteric fistula tract is a promising anal sphincter-saving procedure for fistula-in-ano, the objective assessment of the sphincter preservation remains unknown. OBJECTIVE: The primary end point was to measure the anal function before and after this procedure. The secondary end point measured was cure of the disease. DESIGN: This study is a prospective observational study. SETTING: This study was conducted at the Department of Surgery, Kameda Medical Center, Japan, from March 2010 to August 2012. PATIENTS: Twenty patients with transsphincteric or complex fistulas were evaluated. INTERVENTIONS: All patients underwent the ligation of the intersphincteric fistula tract with a loose seton for anal fistulas. MAIN OUTCOME MEASURES: Anal manometric study was performed before and 3 months after the procedure. Fecal incontinence was evaluated by using the fecal incontinence severity index. Failure was defined as nonhealing of the surgical wound or fistula. RESULTS: The median operation time was 42 minutes. No intraoperative complications were documented. The median follow-up duration was 18 (3-32) months. No patients reported any incontinence postoperatively. The median score of the fecal incontinence severity index before and 3 months after the procedure was 0. The median maximum resting pressure measured before and after operation were 125 (71-175) cm H2O and 133 (95-169) cm H2O. The median maximum squeeze pressure measured before and after operation were 390 (170-815) cm H2O and 432 (200-902) cm H2O. There were no significant postoperative changes in either the resting pressure or the squeeze pressure. Primary healing was observed in 19 (95%) patients, and the median healing time was 7 weeks; 1 wound remained incompletely healed. LIMITATIONS: Short-term follow-up may not justify the use of the term definitive cure. CONCLUSION: The ligation of the intersphincteric fistula tract with a loose seton showed no postoperative deterioration on anal sphincter function with favorable healing rates.

A randomized, prospective, double-blind, placebo-controlled trial of the effect of diltiazem gel on pain after hemorrhoidectomy.

BACKGROUND: Spasm of the internal anal sphincter is considered to be one of the causes of pain in anal diseases. We have evaluated the effects of topical diltiazem on postoperative pain after hemorrhoidectomy. METHODS: Sixty-two patients were randomly assigned to receive a 2 % diltiazem gel (n = 32) or a placebo gel (n = 30) after hemorrhoidectomy. Patients applied the gel to the anal region three times per day for 14 days. Pain both in the resting state and on defecation ranged from 0 to 10 on a numerical rating scale, and the number of prescribed loxoprofen tablets (Loxonin) were recorded and confirmed daily by telephone. Any morbidity during the follow-up period was recorded. RESULTS: Both pain scores during defecation and the number of analgesic tablets consumed tended to be lower in the diltiazem group, although they did not reach statistical significance (P = 0.09, P = 0.12, respectively). Total number of complications was significantly higher in the diltiazem group, but each incidence of complications, including itching sensation, headache, and dizziness was not statistically different. CONCLUSIONS: Perianal application of 2 % diltiazem gel after hemorrhoidectomy has the potential to reduce postoperative pain during defecation.

Translation and validation of the Japanese version of the fecal incontinence quality of life scale.

PURPOSE: The aim of the study was to conduct a psychometric evaluation of the fecal incontinence quality of life scale (FIQL) in the Japanese language using rigorous methodologies. METHODS: The FIQL was translated into Japanese. After being linguistically validated, the Japanese version of the FIQL was administered to a sample of 119 patients who completed the questionnaire at baseline and again after 2 weeks. The patients filled out a general questionnaire regarding health (the Short-Forum 36 Health Survey), and the severity of incontinence was assessed at baseline (Wexner scale). RESULTS: Internal consistency was good/excellent for all scales (Cronbach's alpha >0.70, between 0.72 and 0.94). Stability over time was good for all scales (Intra-class correlation >0.80, between 0.86 and 0.93). The four scales of the FIQL were significantly correlated with the scales of the generic questionnaire on health (P < 0.0001) and the Wexner scale (P < 0.0001). The mean FIQL score improved significantly after treatment in the 22 patients whose Wexner scale scores decreased >4 points, thus indicating good sensitivity in all four scales and the total scale. CONCLUSIONS: The linguistic and psychometric evaluation demonstrated the validity of the Japanese version of the FIQL.

Pinch-off syndrome: transection of implantable central venous access device.

As the population of people with cancer increases so does the number of patients who take chemotherapy. Majority of them are administered parentally continuously. Implantable central venous catheter device is a good choice for those patients; however, severe complication would occur concerning the devices. Pinch-off syndrome is one of the most severe complications. The authors report a severe case of pinch-off syndrome. The patient with the implantable central venous device could not take chemotherapy because the device occluded. Further examination revealed the transection of the catheter. The transected fragment of the catheter in the heart was successfully removed by using a loop snare placed through the right femoral vein.

Granular cell tumor of the common bile duct: a Japanese case.

Granular cell tumor (GCT) of the biliary system is rare. It is reported that it occurs more commonly in young black women. We report here our seldom experience of a Japanese case in whom icterus was found as a first symptom just after a caesarean operation. A 36-year-old Japanese woman developed icterus after delivery by the Caesarean operation. A surgical operation was performed without can deny that there was a tumor-related change in a bile duct as a result of examination for various images. As a result of pathological evaluation, GCT was diagnosed. By the preoperative organization biomicroscopy result, it was not able to be attachd a right diagnosis. It was thought that this tumor, although rare, should be considered as one of the causes of biliary stenosis in the younger population.

Quality of life in patients with chronic anal fissure after topical treatment with diltiazem.

AIM: To assess the physical and mental health of fissure patients before and after topical treatment with diltiazem. METHODS: Consecutive patients were enrolled prospectively into the study. Quality of life was measured with the short-forum 36 health survey (SF-36) before and after 6-wk treatment with diltiazem. Patients scored symptoms of pain, bleeding, and irritation using numeral rating scales at the initial and follow-up visits. Fissure healing was assessed and side effects were noted. RESULTS: Fissures healed in 21 of 30 (70%) patients. There were significant reductions in the scores of pain, bleeding, and irritation after 1 wk of treatment, respectively. Four patients experienced perianal itching and one patient reported headache. When measured at baseline, pain and irritation showed a negative impact on two of the eight subscales on the SF-36, respectively (bodily pain and social functioning for pain; vitality and mental health for irritation). Repeating the SF-36 showed an improvement in bodily pain (P = 0.001). Patients whose fissures healed reported an improvement in bodily pain, health-perception, vitality, and mental health (P < 0.05). CONCLUSION: Successful treatment of chronic anal fissure with topical diltiazem leads to improvement in health-related quality of life.