Rapidly progressing severe coagulopathy and thrombocytopenia in extreme anorexia nervosa patient with small bowel strangulation: A case report.

INTRODUCTION: Anorexia nervosa (AN) is characterized by severe dietary restriction or other weight loss behaviors motivated by a strong fear of body weight gain and a disturbed body image. In this paper, we report a case of an extreme AN patient, in whom severe coagulopathy and thrombocytopenia rapidly progressed with strangulation obstruction. PRESENTATION OF CASE: A female patient in her 20's with previous history of AN came to our hospital complaining acute onset abdominal pain. Her body mass index at presentation was 12.1 kg/m2; thus, she was classified as an "extreme" AN (BMI <15) according to DSM-5 classification. Abdominal CT scan showed small bowel obstruction without strangulation. Although severe leukopenia appeared soon after admission, platelet count and coagulation tests were maintained relatively well. Due to her severe malnutrition, we proposed nutritional therapy and subsequent surgical adhesiolysis; however, she refused any kind of nutritional therapy. On admission day 13, she suddenly developed a strangulation obstruction. At the same time, severe coagulopathy and thrombocytopenia rapidly progressed. Emergency laparotomy was performed using a massive blood transfusion. Bowel strangulation was successfully released; however, intraabdominal bleeding was repeated postoperatively and three more operations were required until complete hemostasis and abdominal closure. After long rehabilitation, she was discharged from our hospital on day 116. DISCUSSION: The medical comorbidities associated with AN extend various organ systems; among them, the hematologic complication can be a life-threatening problem during emergency surgery for a patient with AN. CONCLUSION: Knowledge about the pathophysiology of AN is quite essential for all surgeons.

The first case of robotic-assisted transabdominal retrorectus repair for incisional hernia in Japan.

Extraperitoneal mesh repair for ventral hernia has garnered attention and its rate has been increasing due to concerns for the potential complications of intraperitoneal mesh repair. Recently, robotic-assisted ventral hernia repair is highlighted as a solution to the technically demanding nature of laparoscopic transabdominal or enhanced-view totally extraperitoneal retrorectus ventral hernia repair. A 78-year-old man, who had undergone robot-assisted radical prostatectomy 10 months earlier, presented with an incisional hernia of European Hernia Society Classification M3W2, length 4 cm, width 5 cm with rectus diastasis. A right single-docking robotic-assisted transabdominal retrorectus repair was performed using a 21 by 14 cm self-gripping mesh and anterior wall reconstruction was done by 0 barbed nonabsorbable running suture. There were no complications and recurrence observed during a 7 months postoperative period. Single-docking robotic-assisted transabdominal retrorectus repair was considered a good option for midline moderate-size incisional hernias from the point of view of the ease of suturing, adequateness of dissection and prevention of bowel injury.

Implementation of advance care planning decision aids for patients undergoing high-risk surgery: a field-testing study.

BACKGROUND: Patients undergoing high-risk surgery are at a risk of sudden deterioration of their health. This study aimed to examine the feasibility of the development of two patient decision aids (PtDAs) to assist patients undergoing high-risk surgeries in informed decision-making about their medical care in a crisis. METHODS: This field testing implemented two PtDAs that met the international criteria developed by the researchers for patients before surgery. Study participants were patients scheduled to be admitted to the intensive care unit after surgery at one acute care hospital in Japan and their families. The study used a mixed-methods approach. The primary outcome was patients' decision satisfaction evaluated by the SURE test. Secondary outcomes were the perception of the need to discuss advance care planning (ACP) before surgery and mental health status. The families were also surveyed on their confidence in proxy decision-making (NRS: 0-10, quantitative data). In addition, interviews were conducted after discharge to assess the acceptability of PtDAs. Data were collected before (preoperative outpatients, baseline: T0) and after providing PtDAs (in the hospital: T1) and following discharge (T2, T3). RESULTS: Nine patients were enrolled, of whom seven agreed to participate (including their families). The SURE test scores (mean ± SD) were 2.1 ± 1.2 (T0), 3.4 ± 0.8 (T2), and 3.9 ± 0.4 (T3). The need to discuss ACP before surgery was 8.7 ± 1.3 (T1) and 9.1 ± 0.9 (T2). The degree of confidence in family surrogate decision-making was 6.1 ± 2.5 (T0), 7.7 ± 1.4 (T1), and 8.1 ± 1.5 (T2). The patients reported that using PtDAs provided an opportunity to share their thoughts with their families and inspired them to start mapping their life plans. Additionally, patients wanted to share and discuss their decision-making process with medical professionals after the surgery. CONCLUSIONS: PtDAs supporting ACP in patients undergoing high-risk surgery were developed, evaluated, and accepted. However, they did not involve any discussion of patients' ACP treatment wishes with their families. Medical providers should be coached to provide adequate support to patients. In the future, larger studies evaluating the effectiveness of PtDAs are necessary.

[Preoperative diagnosis of nonrecurrent inferior laryngeal nerve--usefulness of CT and ultrasonography].

BACKGROUND AND OBJECT: The right nonrecurrent inferior laryngeal nerve (NRILN), which is usually associated with the right aberrant subclavian artery, is a risk factor of nerve injury during thyroid surgery. Therefore the presence of the NRILN should be diagnosed if possible before surgery. The aim of this study was to investigate the usefulness of computed tomography (CT) and ultrasonography (US) for preoperative diagnosis of the right-sided NRILN. SUBJECTS AND METHODS: We reviewed 1,561 patients who underwent thyroid surgery, during which the right inferior laryngeal nerve was exposed, at Yamashita thyroid and parathyroid clinic from April 2006 to April 2012. All medical records, CT findings and ultrasonograms of these patients were reviewed retrospectively. RESULTS: We recognized 11 patients who had the right-sided NRILN from the total of 1561 patients (0.71%). Ten of 1086 patients who underwent CT, had a right aberrant subclavian artery. CT findings were enabled us to predict the existence of the right NRILN before surgery. The sensitivity and specificity of CT for detection of the right-sided NRILN were 100% and 100%. On the other hand, we could detect the bifurcation of the innominate artery in 116 of 140 patients with cervical US before surgery, and therefore could confirm that the right inferior laryngeal nerve of the 116 patients was normal. The bifurcation of the other patients was not detectable and one of the 24 patients only had the right-sided NRILN during surgery. The sensitivity and specificity of cervical US for detection of the right-sided NRILN were 100% and 83.5% respectively. CONCLUSIONS: Although CT is extremely useful for preoperative diagnosis of the right-sided NRILN because of its accuracy, cervical US is also a good method for making sure that the right inferior laryngeal nerve is normal.

Surgically proven normocalcemic primary hyperparathyroidism: speculation of the possible role of estrogen in the etiology of this disease in premenopausal women.

We herein report a rare case of surgically proven normocalcemic primary hyperparathyroidism (NCHPT). A premenopausal 51-year-old woman was referred to our clinic because parathyroid adenoma was detected on neck ultrasonography (US). The patient's serum calcium concentration was 9.3 mg/dL and the intact parathyroid hormone (PTH) level was 128.8 pg/mL. The findings of almost all other examinations were also compatible with a diagnosis of NCHPT. Then, parathyroidectomy was performed. The serum calcium and PTH concentrations reduced significantly but remained within the normal ranges. A histological examination demonstrated parathyroid adenoma. A review of this case and the associated literature suggests that estrogen plays a significant role in the etiology of NCHPT in premenopausal women.

Idiopathic orbital myositis associated with Graves' disease.

A 52-year-old man was referred to our clinic. One week before his visit, he had complained of left eye pain and double vision. His clinical features were exacerbated. Despite the acute onset, which is atypical of thyroid eye disease (TED), TED was suspected due to the patient's history of Graves' disease (GD). After conducting clinical examinations and orbital magnetic resonance imaging, the patient was diagnosed with idiopathic orbital myositis (IOM), and intravenous glucocorticoid therapy was administered. After treatment, the patient's clinical manifestations dramatically improved. This is a rare case in that the history of GD made it difficult to differentiate IOM from TED.

Severe hypocalcemia complicated by postsurgical hypoparathyroidism and hungry bone syndrome in a patient with primary hyperparathyroidism, Graves' disease, and acromegaly.

We herein report a case of severe postsurgical hypocalcemia associated with primary hyperparathyroidism (pHPT), Graves' disease (GD) and acromegaly (AC). A 54-year-old woman was referred to our clinic for treatment of pHPT and GD. She also had active AC and was clinically diagnosed as multiple endocrine neoplasm type 1 because of pHPT and AC. Two enlarged parathyroid glands were detected by preoperative examinations. We performed total parathyroidectomy and thyroidectomy. After the operation, she showed severe hypocalcemia induced by postsurgical hypoparathyroidism and hungry bone syndrome. This is a rare case of postsurgical severe hypocalcemia associated with pHPT, GD and AC.

Successful treatment of anaplastic thyroid carcinoma with a combination of oral valproic acid, chemotherapy, radiation and surgery.

Anaplastic thyroid carcinoma (ATC) is the most aggressive of thyroid cancers whose treatment is not yet established and mortality is extremely high. Recent in vitro studies have shown that valproic acid (VA), a newly identified histone deacetilase (HDAC) inhibitor, induces apoptosis, modulates differentiation gene expression of thyroid tumors and enhances the sensitivity of anaplastic cancer cell lines to doxorubicin. We report a case of successful treatment of anaplastic thyroid carcinoma with a combination of oral valproic acid, chemotherapy consisting of cisplatin and doxorubicin, external and intra-operative radiation and surgery. Tumor volume decreased by 50.7% under CT measurement and 44.6% under sonogram measurement over the course of the treatment. No significant rebound of tumor size was observed between each cycle of chemotherapy. Serial cytology performed via fine needle aspiration (FNA) presented a rapidly changing profile of cell types, starting with anaplastic and proceeding through increasingly well differentiated presentations. Only microscopic remnants of ATC cells were found in the histological examination of the resected thyroid. Ga scintigraphy and whole body PET scan six months after surgery revealed no evidence of recurrence or metastasis. As of Nov. 22, 2008, the patient is alive and disease free two years after diagnosis.