Internal hernia is not a common cause for intestinal obstruction. Among of those hernias, a very rare internal herniation through an abnormal defect in the broad ligament of the uterus is reported. A 77-year-old woman was admitted to the hospital because of abdominal pain and vomiting. CT examination demonstrated that the uterus deviated to the left and the right broad ligament was extended due to the distended small intestine. An internal herniation through a defect in the broad ligament suspected, but there was a history of undergoing an operation for ligation of the uterine tube and adhesive ileus was also probable. The patient was treated conservatively with a long tube, but no symptomatic remission was obtained. So, a strangulated herniation through a defect of the right broad ligament of the uterus was diagnosed and an operation was performed. At laparotomy, the ileum, approximately 40cm in length and 240cm proximal to the ileocecal valve, was herniated through an abnormal defect in the broad ligament of the uterus. Right round ligament was cut and the incarceration was reduced. This disease presents difficulty in preoperatively diagnosis, but CT examination is helpful in diagnosis. When we encounter patients with intestinal obstruction of unknown origin, CT examination must be performed.
Appendiceal diverticulum is rare. We encountered a case of appendiceal diverticulum with chronic appendicitis. A 56-year-old man presented to our hospital with right lower abdominal pain. An abdominal computed tomography (CT) scan showed swelling of the appendix body and the wall thickness of the base of the appendix. Due to the possibility of appendiceal tumor, we performed a laparoscopy-assisted ileocecal resection with lymph node dissection. The appendix had a diverticulum with chronic inflammation, but it did not have a neoplastic lesion.
Multidisciplinary therapy is essential in the treatment of borderline resectable pancreatic cancer involving the superior mesenteric artery (BR-SMA). We analyzed the outcomes of multidisciplinary treatment for BR-SMA and evaluated the efficacy of neoadjuvant therapy (NAT). We reviewed the clinical courses of 10 patients with BR-SMA. Seven patients were treated with preoperative neoadjuvant therapy (NAT group), and 3 patients underwent radical pancreaticoduodenectomy first (SF group). In the NAT group, the rate of R0 was 7/7 (100%), the induction rate of postoperative adjuvant chemotherapy (AC) was 6/7 (86%), and the first recurrence sites were the lung in 4 patients, and the liver and peritoneum in one patient each, respectively. In the SF group, the rate of R0 was 2/3 (67%) because of a positive pathological dissecting peripancreatic margin in 1 case. The induction rate of AC was 3/3 (100%), and the first recurrence sites were the liver in 2 patients, the peritoneum in 1, and a local site in 1. The disease free survival of the NAT group (median survival time [MST] 19.3 months) was significantly better than that of the SF group (MST 5.7 months) (log rank test, p=0.002). The median overall survival of the NAT and SF groups was 51.6 months and 19.5 months, respectively (p=0.128). An R0 resection could be performed in all cases in the NAT group. The NAT extended disease-free survival. We conclude that NAT is recommended in the treatment of BR-SMA.
We report the case of a 60-year-old man with an accessory spleen in the pelvis. He visited our outpatient clinic because of abdominal discomfort. Computed tomography (CT) showed an enhanced mass (40 mm in diameter) in the pelvis. Preoperative diagnosis was difficult even after magnetic resonance imaging and colonoscopy. The patient underwent surgery for suspicion of a gastrointestinal stromal tumor or malignant lymphoma of the rectum. Intraoperative findings showed a mass in the pelvis and a long cord-like tissue reaching the mass and arising from the great omentum; the mass was excised. Histopathologic examination indicated that the mass was splenic tissue, and feeding vessels were found in the cord-like tissue, which were determined to be derived from the left gastroepiploic artery and vein. Thus, we diagnosed it as an accessory spleen in the pelvis. An accessory spleen is not rare and can occur anywhere in the abdominal cavity. However, an accessory spleen in the pelvis is an infrequent finding, and only 9 other cases of an accessory spleen in the pelvis have been reported. Therefore, it is very difficult to make a correct diagnosis preoperatively. However, 7 of the 9 cases (77.8 %) of a pelvic accessory spleen had vascular pedicles from the great omentum or splenic hilum as feeding vessels; hence, determining the feeding blood vessels on dynamic CT may be useful for diagnosing an accessory spleen in the pelvis. Additionally, if the accessory spleen is symptomatic or has a vascular pedicle, surgeons should attempt to resect the accessory spleen in the pelvis using minimally invasive laparoscopy.
The patient was a 35-year-old Japanese man diagnosed with appendicitis with abscess formation. An appendectomy was performed, but a refractory surgical wound infection developed, and eventually a cutaneous-rectovesical fistula was detected. In a review of the first-time CT scan, a small high-density construction resembling a bone from a fish was detected in the ileum. The histopathological examination revealed granules of actinomyces. These findings suggested that abdominal actinomycosis due to intestinal mucosal breakage by the fish bone caused the secondary appendicitis, and that after the appendectomy, residual actinomyces caused the cutaneous-rectovesical fistula. After the diagnosis, total parenteral nutrition and a long-term administration of antibiotics improved the patient's clinical symptoms, and the fistula closed within a month. Antibiotics were administered for 6 months, and there has been no recurrence for 6-1/2 years. Because actinomycosis is difficult to diagnose based on the typical clinical features, a direct identification of the infecting organism from a tissue sample or from sulfur granules is required for the definitive diagnosis. Actinomyces is also known to cause fistula formation, and intestinal penetration caused by a fish bone may indicate abdominal actinomycosis. A rectovesical fistula requires surgical intervention in most cases, but in cases caused by abdominal actinomycosis, such a fistula may be cured by conservative therapy, as in our patient's case. It is important to consider the possibility of actinomycosis when a refractory rectovesical fistula is observed.
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