[A case of duodenal perforation due to ingested fishbone with retroperitoneal abscess formation where surgical drainage was necessary after endoscopic removal].

A female in her 60s was referred to our institution with epigastric pain and abdominal fullness persisting for one week. She was afebrile and mild abdominal tenderness was found on physical examination. Computed tomography (CT) revealed free air, and the dirty fat sign outside the duodenal wall. Her previous CT had not shown causative findings such as duodenal diverticula. A slightly high-attenuated linear structure penetrating the duodenal wall at the second portion was suspected after review of present CT images. Based on the history of her current illness, the possibility of mackerel bone ingestion was considered. Esophagogastroduodenoscopy (EGD) revealed a fishbone sticking out of the duodenal wall, which was extracted with biopsy forceps. Although antibiotic treatment under fasting was continued, the formation of retroperitoneal abscess was detected by CT on the 6th postprocedural day. Given that she also developed a high fever, surgical drainage was performed. The patient was discharged on the 15th postoperative day. Thus, in cases of duodenal perforations, a fishbone should be taken into account as a possible cause. Even if endoscopic removal was initially selected, careful observation is mandatory and an additional treatment should be considered depending on the clinical course.

Successful laparoscopic cholecystectomy for acute cholecystitis with kyphoscoliosis by the devised placement of trocar ports: A case report.

INTRODUCTION: Kyphoscoliosis, which is a deformity of the spine caused by aging and osteoporosis, results in various surgical difficulties for laparoscopic cholecystectomy (LC) due to low-lying costal arches, such as a small abdominal working space, disturbance of the surgical view and decreased controllability of the surgical instrument. PRESENTATION OF CASE: We herein report the case of a 92-year old woman with severe kyphoscoliosis who was diagnosed with Grade II acute cholecystitis. Taking her general status into consideration, emergency percutaneous transhepatic gallbladder drainage (PTGBD) was initially performed. After PTGBD, the patient's physical status and systemic inflammation markedly improved. She then underwent interval LC. The surgical view of the upper abdomen including the gallbladder was entirely interrupted by bilateral low-lying costal arches with adhesion to the greater omentum. To access the gallbladder without interruption by the low-lying costal arch, the first umbilical port was changed to a multi-port with surgical glove and an additional port was added in the left abdomen. Consequently, LC was safely accomplished with the creation of the critical view. DISCUSSION: A low-lying costal arch due to kyphoscoliosis can prevent surgeons from accessing the gallbladder. LC with the standard 4-port method could not be accomplished because of insufficient lifting of the low-lying costal arch. Devised placement of the ports is needed to access the gallbladder between bilateral low-lying costal arches. CONCLUSION: A transumbilical multi-port and left abdominal port may be effective for successful LC of acute cholecystitis with kyphoscoliosis.

A Case of Malignant Biliary Obstruction with Severe Obesity Successfully Treated by Endoscopic Ultrasonography-Guided Biliary Drainage.

Here, we present a case of malignant biliary tract obstruction with severe obesity, which was successfully treated by endoscopic ultrasonography-guided biliary drainage (EUS-BD). A female patient in her sixties who had been undergoing chemotherapy for unresectable pancreatic head cancer was admitted to our institution for obstructive jaundice. She had diabetes mellitus, and her body mass index was 35.1 kg/m2. Initially, endoscopic retrograde cholangiopancreatography (ERCP) was performed, but bile duct cannulation was unsuccessful. Percutaneous transhepatic biliary drainage (PTBD) from the left hepatic biliary tree also failed. Although a second PTBD attempt from the right hepatic lobe was accomplished, biliary tract bleeding followed, and the catheter was dislodged. Consequently, EUS-BD (choledochoduodenostomy), followed by direct metallic stent placement, was performed as a third drainage method. Her postprocedural course was uneventful. Following discharge, she spent the rest of her life at home without recurrent jaundice or readmission. In cases of severe obesity, we consider EUS-BD, rather than PTBD, as the second drainage method of choice for distal malignant biliary obstruction when ERCP fails.

A case of hepatic inflammatory pseudotumor protruding from the liver surface.

We report a case of a resected hepatic inflammatory pseudotumor (IPT) protruding from the liver surface. A 69-year-old male with diabetes mellitus was admitted to hospital for investigation of an hepatic mass. An irregularly shaped, low-echoic mass measuring 21 × 18 mm was identified by ultrasound in S6. On computed tomography, the tumor appeared to be growing extrahepatically. After contrast enhancement, the lesion showed persistent peripheral enhancement, while the central part was hypoenhanced. On T2-weighted magnetic resonance imaging (MRI), the central portion of the lesion was hyperintense compared with the periphery. EOB-enhanced MRI revealed the mass to be being hypointense in contrast to the surrounding liver parenchyma in the hepatobiliary phase. On diffusion-weighted images, the lesion was hyperintense. Percutaneous biopsy was not attempted to avoid tumor cell dissemination. The patient underwent partial hepatectomy because of suspected malignancy. Histopathological examination of the resected specimen revealed fibrotic tissue and abundant vessels in the periphery, while a massive infiltration of inflammatory cells and fewer vessels were observed in the center. The patient was finally diagnosed with hepatic IPT of the fibrohistiocytic type.