Transabdominal Approach for Spontaneous Oesophageal Perforation: A Review of Four Cases

Spontaneous oesophageal perforation is an uncommon and life-threatening disease. Although several methods of treatment have been proposed, surgical treatment is considered the standard procedure. Primary repair using the transthoracic approach is the most common. However, few studies have evaluated the characteristics of the transabdominal approach. This study aimed to investigate the clinical outcomes of spontaneous oesophageal perforation that was surgically treated using the transabdominal approach. We retrospectively reviewed all patients with spontaneous oesophageal perforation who were admitted to the surgical department of our institution between November 2010 and April 2017, and identified a total of four patients. Data including demographic factors (age and sex), location of perforation, time to operation, operative method, complications, length of hospital stay, and postoperative recovery were reviewed. In all four cases, we treated the defect using the transabdominal approach, which provides a good surgical field of view. The aims of operative intervention, namely primary repair and access for enteral feeding, can be achieved using this approach. The most commonly observed complication was pyothorax, and we suggest the addition of intrapleural drainage for its prevention. Dysgraphia was observed in two patients, which improved with conservative treatment. The overall mortality rate was 0%. Our results demonstrate that primary repair using the transabdominal approach is safe and effective for the management of spontaneous oesophageal perforation. Addition of intrapleural drainage can improve the outcome associated with this approach

Effective Appendix Stump Closure Using the Doubleshanked Titanium Ligation Clip (DS Clip): A Case Report

Background: During laparoscopic appendectomy, several methods and devices can be used to close the appendicular stump, such as endoloops, linear staplers, clips, and open purse-string sutures. The Double-shanked Titanium Ligation Clip® (DS clip; B. Braun Aesculap, Tuttlinger, Germany), a new device that can be used to close the appendicular stump, was approved for use in Japan in March 2015. We report a case of effective appendix stump closure using DS clips. Case presentation: An 81-year-old man was admitted to our hospital with complaints of severe pain in the right lower quadrant of the abdomen. Abdominal contrast-enhanced computed tomography showed a thickened appendix (1.7 cm in diameter) with fecal stones, while acute inflammatory signs were visible around the appendix. He was diagnosed with acute appendicitis for which laparoscopic appendectomy was performed with a curative intent. It was difficult to mobilize the cecum because of inflammation, so we attempted to use DS clips instead of linear staplers. A histological examination revealed gangrenous appendicitis. The patient’s postoperative course was uneventful and he was discharged 10 days postoperatively. We also used DS clips to close the appendicular stump in 12 other cases. We observed no intra- or postoperative complications and no cases of mortality. Conclusion: The management of an appendicular stump using DS clips during laparoscopic appendectomy was simple, safe, and cost-effective. DS clips may be an alternative method to linear staplers

A Rare Case Oesophageal Perforation by a Fish Bone, Leading to Pericardial Penetration and Cardiac Tamponade

An 82-year-old woman swallowed a fish bone and presented to our hospital 3 days later when she had breathing difficulty and became hypotensive. Chest computed tomography (CT) showed a linear structure with high bone density extending from the oesophagus into the pericardium, along with pericardial effusion, air, and a left pleural effusion. We diagnosed the patient with oesophageal perforation by a foreign body (a fish bone) leading to pericardial penetration, cardiac tamponade, and left empyema. The patient underwent emergency surgery. Pericardial fenestration and drainage of the pericardial and thoracic cavities were performed. Chest CT showed a recurrent abscess cavity in the pericardium on day 6. A pigtail catheter was placed in the recurrent abscess cavity under CT guidance for drainage. The patient gradually improved and was discharged after 5 months

Factors in glucocorticoid regimens associated with treatment response and relapses of IgG4-related disease: a multicentre study

Glucocorticoids (GC) are effective for treating IgG4-related disease (IgG4-RD); however, relapse is often observed. We conducted a retrospective multicentre study to investigate risk factors in GC regimens associated with relapses of IgG4-RD. Data on 166 patients with definitive IgG4-RD diagnosis were collected from 12 institutions. Comprehensive surveillance of clinical backgrounds and GC regimens as well as multivariate analysis of factors associated with treatment responses and relapses was performed. To determine the initial maximal GC dose, the patients were stratified into three groups depending on the initial prednisolone (PSL) dosage: 0.7 mg/kg/day. The multivariate analysis extracted the disease duration and reduction speed of initial GC dose. Patients treated with initial GC 0.7 mg/kg/day of PSL showed higher relapse rates than those treated with 0.4–0.69 mg/kg/day. The relapse rates were significantly higher in patients with fast reduction of the initial dose (>0.4 mg/day) than in patients with slow reduction (<0.4 mg/day). To avoid relapse, 0.4–0.69 mg/kg/day of initial PSL with slow reduction speed (<0.4 mg/day) is needed in the early treatment of IgG4-RD