Laparoscopic repair for primary epigastric hernia containing falciform ligament: A case report and review of literature.

Falciform ligament herniation is a rare type of epigastric hernia. We report a case of a primary epigastric hernia containing a falciform ligament repaired using nonabsorbable barbed suture under laparoscopic surgery. A 74-year-old woman presented with discomfort in the upper abdomen. Physical examination revealed a 3-cm non-tender mass, and abdominal computed tomography revealed epigastric hernia with an incarcerated falciform ligament. By observation with a laparoscope, the fascial defect was single and 1.0 cm in diameter, thus sutured repair was selected. At 4 months follow-up, she had no complications or recurrence. The laparoscopic approach is useful for diagnosis and deciding a repair method of an epigastric hernia. The barbed suture closure system is convenient and effective for intracorporeal hernial defect closing. Both primary and incisional falciform ligament herniation have been reported in the past, and we reviewed six cases, including our case.

Predictive factors for developing acute cholangitis and/or cholecystitis in patients undergoing delayed cholecystectomy: A retrospective study.

BACKGROUND: /Objective: We evaluated the risk of acute cholangitis and/or cholecystitis while waiting for cholecystectomy for gallstones. METHODS: We retrospectively enrolled 168 patients who underwent cholecystectomy for gallstones after conservative therapy. We compared clinical data of 20 patients who developed acute cholangitis and/or cholecystitis while waiting for cholecystectomy (group A) with 148 patients who did not develop (group B). We investigated surgical outcomes and risk factors for developing acute cholangitis and/or cholecystitis. RESULTS: Preoperatively, significant numbers of patients with previous history of acute grade II or III cholecystitis (55.0% vs 10.8%; p < 0.001) and biliary drainage (20.0% vs 2.0%; p = 0.004) were observed between groups A and B. White blood cell counts (13500/µL vs 8155/µL; p < 0.001) and C-reactive protein levels (12.6 vs 5.1 mg/dL; p < 0.001) were significantly higher in group A than in group B; albumin levels (3.2 vs 4.0 g/dL; p < 0.001) were significantly lower in group A. Gallbladder wall thickening (≥5 mm) (45.0% vs 18.9%; p = 0.018), incarcerated gallbladder neck stones (55.0% vs 22.3%; p = 0.005), and peri-gallbladder abscess (20.0% vs 1.4%; p = 0.002) were significantly more frequent in group A than in group B. A higher conversion rate to open surgery (20.0% vs 2.0%; p = 0.004), longer operation time (137 vs 102 min; p < 0.001), and higher incidence of intraoperative complications (10.0% vs 0%; p = 0.014) were observed in group A, compared with group B. CONCLUSION: A history of severe cholecystitis may be a risk factor for acute cholangitis and/or cholecystitis in patients waiting for surgery; it may also contribute to increased surgical difficulty.

Localized multiple malignant epithelioid peritoneal mesotheliomas arising from the hepatoduodenal ligament and diaphragm: a case report.

BACKGROUND: Malignant peritoneal mesothelioma is a rare aggressive tumor of the peritoneum. We report a rare case of resection of multiple localized malignant peritoneal mesotheliomas. CASE PRESENTATION: A 55-year-old Japanese woman was admitted to our hospital because liver tumors were detected by abdominal ultrasonography during a screening examination. Blood examination findings, including tumor makers, were within normal ranges. She had no evidence of exposure to asbestos. Computed tomography showed four hypervascular, round liver tumors, one in the lateral liver segment adjacent to the hepatic hilus, and the other three on the liver surface. Computed tomography angiography revealed that the tumor in the lateral segment had strong enhancement and was fed from the left gastric artery. In contrast, the other tumors showed no enhancement, and were fed from the right inferior phrenic artery. Abnormal accumulation was identified in the four tumors only with 18F-fluorodeoxyglucose positron emission tomography. It was very difficult to obtain a definitive preoperative diagnosis, but surgical resection was performed because we considered potential malignancy. Laparotomy revealed the principal site of the tumor in the lateral segment was on the hepatoduodenal ligament, and all other tumors were on the diaphragm. A left lobectomy and partial diaphragmatic resection were performed. The final pathological diagnosis was multiple malignant epithelioid mesotheliomas. Our patient has had no recurrence for 20 months postoperatively. CONCLUSIONS: In general, malignant peritoneal mesotheliomas are classified as diffuse tumors, which are often unresectable and have a poor prognosis. However, early diagnosis and treatment, particularly with the localized type, as in our patient, could lead to long-term survival of the patient. We recommend that multiple malignant epithelioid mesotheliomas be included in the differential diagnosis for patients with subcapsular hepatic tumors.

Retroperitoneal hematoma from lumbar artery as an unusual complication after rectal perforation with massive retroperitoneal emphysema.

The patient was a 54-year-old woman diagnosed with adult Still's disease, undergoing high-dose steroid and immunosuppressant therapy for 5 years, who was admitted to our hospital with abdominal pain. Computed tomography (CT) revealed pneumoperitoneum around the rectum and a large quantity of retroperitonal emphysema around the inferior vena cava, aorta and left kidney. An emergency laparotomy was performed. Intraoperative observation revealed a perforation on the mesenteric side of the rectum due to diverticulum, and Hartmann's operation was performed. Deep tenderness and anemia were observed 4 days postoperatively. CT revealed extravasation in the left retroperitoneal space and a retroperitoneal hematoma, and emergency embolization of lumbar arteries was performed. Retroperitoneal bleeding associated with peritonitis after surgery is very rare. We surmised that higher-dose immunosuppressive therapy and gastrointestinal perforation with emphysema in the retroperitoneum induced lumbar artery bleeding. Clinicians should consider these factors as a potential cause of retroperitoneal hematoma.

Effectiveness of traditional Japanese herbal (kampo) medicine, daiobotanpito, in combination with antibiotic therapy in the treatment of acute diverticulitis: a preliminary study.

In traditional Japanese herbal (Kampo) medicine, daiobotanpito (DBT) or Da Huang Mu Dan Tang in Chinese has been used in medical treatment of acute diverticulitis for many years based on the experience. Our aim was to investigate whether the treatment of acute diverticulitis can be treated with intravenous antibiotics plus orally administrated DBT than intravenous antibiotics alone. A retrospective nonrandomized open-label trial was established to compare patients with acute diverticulitis who received oral DBT associated with intravenous antibiotics with those who received intravenous antibiotic alone. We included 34 patients, eleven patients in group 1 with DBT and 23 patients in group 2 without DBT. Both groups were comparable in patient demographics and clinical characteristics. There was a significantly better outcome in the group treated with DBT than in the group without DBT when comparing duration of fever, abdominal pain, and antibiotics administration. A trend toward a day shorter mean hospital stay and fasting was seen in group 1, although this did not reach statistical significance. In conclusion, most patients with acute diverticulitis can be managed safely with oral DBT. Although randomized, double-blind study must be done, we could show the possibility to use daiobotanpito as an additional option in treating acute diverticulitis.

[A case of unresectable HER2-positive advanced gastric cancer successfully treated by combination therapy with trastuzumab and paclitaxel].

A 54-year-old man was referred to our hospital for close examination and treatment of an advanced gastric cancer. Gastrointestinal endoscopic examination showed a type 3 tumor, which was diagnosed as well-differentiated adenocarcinoma, and computed tomography showed multiple enlarged liver metastases in both the lobes. He underwent gastrojejunostomy and was treated with S-1 and cisplatin combination chemotherapy. However, after 4 courses of chemotherapy, progression of disease occurred. Because the human epidermal growth factor receptor type 2(HER2) test was positive, we started trastuzumab and paclitaxel combination chemotherapy as a second-line treatment. After administration of 7 courses of trastuzumab and 5 courses of paclitaxel, the primary lesion and multiple liver metastases were greatly reduced. Trastuzumab and paclitaxel combination chemotherapy appears to be an effective treatment for HER2-positive advanced gastric cancer.