A Case of Acute Colonic Pseudo-Obstruction and Anastomotic Leakage After Sigmoidectomy for Sigmoid Volvulus.

Acute colonic pseudo-obstruction (ACPO) is characterized by significant colonic distension without a mechanical obstruction. We present a case of an 83-year-old male who developed ACPO following laparoscopic surgery for sigmoid volvulus. This report details the patient's postoperative journey, highlighting the diagnostic and management challenges encountered. Despite various medical interventions, the patient's condition necessitated further surgical attention due to complications. This case underscores the importance of early diagnosis and aggressive management in ACPO to prevent life-threatening consequences and improve patient outcomes.

Sigmoid Colon Perforation in Diffuse Large B-Cell Lymphoma Due to Tacrolimus-Induced Immunodeficiency: A Case Report.

The sigmoid colon is an uncommon site for the origin of primary malignant lymphomas in the GI tract. Additionally, immunosuppressive agents, widely used in treating autoimmune diseases, have been associated with the induction of malignancies, including lymphoproliferative disorders. In this report, we present a rare case of GI perforation suggesting a link between immunosuppressive therapy, particularly tacrolimus treatment, and diffuse large B-cell lymphoma (DLBCL). A 75-year-old female patient presented with abdominal pain to our ER. She had a medical history of polymyositis and interstitial pneumonia, treated with the immunosuppressant tacrolimus. An abdominal CT scan revealed free gas in the abdominal cavity, leading to a diagnosis of GI perforation. The patient exhibited generalized peritonitis and underwent emergency surgery the same day. During surgery, a perforation in the sigmoid colon was identified, and a Hartmann procedure was performed. Postoperative pathology showed CD20+, CD30+, CD5-, CD10-, BCL6+, MUM1+, and MIB-1 LI of 50-60%. The diagnosis of DLBCL was confirmed, classified as EBV-positive diffuse large B-cell lymphoma, not otherwise specified (NOS), in the sigmoid colon, with positive EBER-ISH, LMP-1, and EBNA2 findings. Given her history of immunosuppressant use, she was categorized as having other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD), according to the WHO Classification of 2017. This case highlights the importance for clinicians to consider the risk of oncogenesis associated with the prolonged use of immunosuppressive agents.

A Case of Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (LAPEG) for Gastric Volvulus.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is the standard modality for long-term enteral nutrition for patients with dysphagia. Compared with open gastrostomy, though PEG is an extremely safe procedure with fewer complications, there are severe cases due to anatomical features. For these cases, laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) is the optimal method. CASE PRESENTATION: A 52-year-old man had a disturbance in swallowing because of cerebral infarction. We attempted PEG under gastrointestinal fiberscope (GIF) and colon fiberscope inspection; however, the procedure was unsuccessful because it was impossible to move the transverse colon downward. We therefore attempted LAPEG to observe the stomach and other organs. Under laparoscopic observation, we diagnosed gastric volvulus, classified as the organo-axial type. For this reason, inserting the tube through the skin was very difficult. We easily corrected the gastric volvulus by using laparoscopic forceps and were finally able to place the PEG tube safely. DISCUSSION: Gastric volvulus is rare in clinical practice. The treatment of gastric volvulus depends on whether mucosal ischemia is present. Endoscopic reduction of gastric volvulus is effective for many patients. Surgical treatment should be considered for patients with gastric volvulus that frequently recurs. In our patient, completely inserting the GIF was impossible; therefore, we could not correctly diagnose gastric volvulus. Laparoscopy-assisted PEG is a useful and safe technique for placing a gastrostomy tube in patients presenting with anatomical difficulties. Moreover, in our patient, gastropexy was performed with PEG. Therefore, LAPEG may be used to prevent the recurrence of gastric volvulus. Gastropexy is a useful option in LAPEG. CONCLUSIONS: Laparoscopy has the advantage of allowing a direct inspection of the stomach while gastrostomy is performed and may reveal complications to PEG insertion. Furthermore, in our patient, gastropexy was performed with PEG.

Aneurysms of Pancreaticoduodenal Artery due to Median Arcuate Ligament Syndrome, Treated by Open Surgery and Laparoscopic Surgery.

INTRODUCTION: There are many possible causes of an abdominal visceral aneurysm, including the obstruction of the celiac artery by the median arcuate ligament (MAL). We report two cases of an aneurysm of the pancreaticoduodenal artery due to MAL syndrome that we treated surgically. CASE PRESENTATION: Case 1: a 66-year-old Japanese woman was diagnosed with a rupture of an aneurysm of the inferior pancreaticoduodenal artery. Because of the difficulty of endovascular therapy, we performed an emergency operation. We chose an abdominal operation, and the postoperative course was uneventful. Case 2: a 75-year-old Japanese man presented at our hospital with acute abdominal pain, nausea, and cold sweat. Our experience of treating MAL syndrome in case 1 enabled us to diagnose the disease accurately. We chose laparoscopic surgery, and the postoperative course was uneventful. DISCUSSION: There are several treatment choices for an aneurysm of the pancreaticoduodenal artery due to MAL syndrome. We have performed only a release of the MAL for treatment, but it is difficult to conclude whether only releasing the MAL is enough to ensure a positive long-term prognosis. Regular follow-up is needed in such cases. CONCLUSION: Laparoscopic surgery can be considered one of the options for MAL syndrome.

Group A Streptococcal Toxic Shock-Like Syndrome in a Male Presenting as Primary Peritonitis: A Case Report and a Review in Japan.

BACKGROUND: Streptococcal toxic shock-like syndrome (TSLS) is a severe infection caused by group A hemolytic streptococcus. It is clinically characterized by rapidly progressive septic shock and multiple organ failure within just a few hours. TSLS presenting as primary peritonitis is rare, especially in a male. Herein, we report a case of TSLS in a male presenting with primary peritonitis, with a review of 25 cases in Japan. CASE PRESENTATION: A 51-year-old male was referred to our hospital with abdominal pain and hypotension. We made a preoperative diagnosis of peritonitis with septic shock and performed an emergency operation. Intraoperative findings indicated no marked origin of the peritonitis. Preoperative blood culture showed the presence of group A hemolytic streptococcus. The patient required intensive care involving artificial respiration, abdominal drainage and cytokine absorption therapy, and was discharged on postoperative day 25. CONCLUSION: TSLS in a male presenting as primary peritonitis is rare. Although this condition is a severe infection, it can be treated by multimodal therapy.

Mixed Neuroendocrine Carcinoma and Squamous Cell Carcinoma of the Colon: Case Report and Literature Review.

Neuroendocrine carcinoma (NEC) of the colon is very rare, and squamous cell carcinoma (SCC) of colon cancer is rare. We recently treated a patient with both NEC and SCC that initially presented as multiple unresectable liver and lung metastases. A 68-year-old Japanese man was referred to our hospital because of diarrhea with descending colon cancer obstruction. He underwent a left colectomy. Based on immunohistochemistry results, we diagnosed mixed NEC and SCC, the primary lesion location of which was probably the lung in the final pathologic examination. He began systemic palliative chemotherapy with CDDP and CPT-11. After 3 months of treatment, shown the progressive disease, we started CDDP and VP-16. The patient was not eligible for additional chemotherapy after 2 months.

Impact of Left Colonic Artery Preservation on Anastomotic Leakage in Laparoscopic Sigmoid Resection and Anterior Resection for Sigmoid and Rectosigmoid Colon Cancer.

OBJECTIVES: To investigate the effect of left colonic artery (LCA) preservation on laparoscopic sigmoidectomy outcomes METHODS: We identified 447 consecutive patients who underwent laparoscopic sigmoidectomy at our hospital group between January 2010 and December 2016. We divided the patients into groups with and without LCA preservation and with and without anastomotic leakage (AL). We compared the patient age and gender, tumor location, stage, D2/D3 lymph node dissection, comorbidities, operating time, and blood loss between these groups. Univariate and multivariate analyses were performed to determine the risk factors for AL. RESULTS: There were significant differences in age, sex, tumor location, D2/D3 lymph node dissection, hypertension, operating time, blood loss, and AL for groups with and without LCA preservation. There were significant differences in sex, tumor location, and LCA preservation for groups with and without AL. Multivariate analysis showed male sex (hazard ratio (HR) = 6.37, 95% confidence interval (CI) 2.39-20.6; p < 0.0001), non-LCA preservation (HR = 5.01, 95% CI 1.41-31.8.0; p = 0.01), and rectosigmoidal tumor location (HR = 2.51, 95% CI 1.15-5.61; p = 0.01) as significant independent risk factors for AL. CONCLUSIONS: Based on the results obtained by performing laparoscopic operation for sigmoid colon cancer and rectosigmoid cancer, the LCA preservative procedure is warranted for prevention of AL.

A Case of Segmental Arterial Mediolysis Presenting as Mucosal Gastric Hematoma.

BACKGROUND: Although segmental arterial mediolysis (SAM) has been increasingly recognized as arteriopathy and there are some case reports about SAM, it is still very rare. It is characterized clinically by aneurysm, dissection, stenosis, and occlusion within splanchnic arterial branches, causing intra-abdominal hemorrhage or bowel ischemia. Mortality is as high as 50% in acute events. CASE PRESENTATION: A 51-year-old man was referred to our hospital with hematemesis. Gastroscopy revealed a submucosal-like tumor on the posterior wall of gastric angle with ulceration. Computed tomography indicated a tumor measuring 65 × 50 mm in the stomach, which was suspected to have invaded into the pancreas. Significant hematemesis recurred; the patient developed shock and underwent emergency distal gastrectomy, distal pancreatectomy, and splenectomy. The pathology and the clinical course were compatible with SAM splenic artery rupture causing retroperitoneal hemorrhage that penetrated into the stomach. After that surgery, aneurysm of common hepatic artery ruptured and coil embolization was performed. CONCLUSION: SAM is an important cause of intra-abdominal or retroperitoneal hemorrhage in patients without underlying disease. SAM typically presents as intra-abdominal hemorrhage, but, in this case, the retroperitoneal hemorrhage penetrated into the stomach and it looked like a submucosal tumor.