Repeated Enterocutaneous Fistula in a Munchausen Syndrome Patient

Munchausen syndrome is a rare type of mental disorder in which the patient fakes illness to gain attention and sympathy. Patients may lie about symptoms, make themselves appear sick, or make themselves purposely unwell. We describe a case of repeated enterocutaneous fistula in Munchausen syndrome. A 53-year-old Japanese male was admitted to our hospital for the treatment of a high-flow enterocutaneous fistula. Surgery was performed two times, but the fistula recurred each time. Chopsticks with blood on them were coincidentally detected in the trash in the patient’s room. It was revealed that the enterocutaneous fistula was caused by self-mutilation. A psychiatrist was consulted, and the patient was diagnosed with Munchausen syndrome. The psychiatrist initiated treatment and the patient admitted the self-harm. His prolonged wound site was closed and he was able to be discharged. There has been no recurrence of the self-harm as of this writing, 3 years later. The treatment of Munchausen syndrome is difficult and early detection is important

Best Current Practices of Constructing and Operating Cloud Services with Virtualization Technologies

2011年3月11日に宮城県沖で発生した東日本大震災は, 地震・津波の直接的な被害が大きかった東北地方のみならず, 東日本全域に被害を及ぼした. 関東地方では, 福島第一原子力発電所が地震・津波によるダメージで運転停止に追い込まれたことや, 火力発電所の障害などにより東京電力の供給可能電力が著しく低下したとともに, 震災直後に計画輪番停電も実施され, 不安定な電力供給状況を前提とした対策を実施する必要性が認識された. 我々はこの電力逼迫と供給能力不安定な状況に対しての具体的な対応策として, 計算機仮想化技術を用いて, 低電力消費量でかつ不安定な電源供給状態においても24時間稼働が可能なサーバシステムを設計し, 実運用するに至った. 我々が設計・構築したelabクラウドは, 対応の迅速性が最優先課題であったため, 非常時に限られたハードウェアで作られたものでありながら, 構築時の工夫やその後のサーバ増設等によって, システム稼働開始後およそ一年弱安定して稼働を続けることに成功している. また, サーバシステムの運用においてはリスクマネジメントをどのように行うかが重要なポイントである. 我々はこの一年間のelabクラウドの運用を通じ, 仮想化技術がインシデント時のトラブルシュートに大いに有用性を発揮することを経験すると共に, VMの仮想ディスクを複製する技術がその有用性をより高めるということも議論した. 本稿では, この一年間の運用経験を, elabクラウドの構成・運用ポリシーと共にベスト・カレント・プラクティスとしてまとめた. そして, 2011年4月の移行作業や2012年1月のメールサーバのデータ復旧などの実作業の報告, 及びこれらから得られた知見として, リアクティブな対応における仮想化技術の恩恵について, またVMライブバックアップやホットクローニングといったプロアクティブな技術の必要性及び初期検討についての報告も行っている

Complete Endoscopic Submucosal Dissection of a Giant Rectal Villous Adenocarcinoma with Electrolyte Depletion Syndrome

An 81-year-old female consulted a local physician due to diarrhea. Since general fatigue and body weight loss were observed, she was admitted for detailed examination and treatment. Colonoscopy revealed a circumferential giant tumor with a maximum diameter of 10 cm in the rectum, and biopsy findings indicated villous adenoma. The tumor secreted a large amount of mucus, and a diagnosis of electrolyte depletion syndrome causing electrolyte disorders was made. We performed endoscopic submucosal dissection (ESD) as a less invasive procedure. The tumor was so big that the procedure had to be completed in two separate steps and it took 1,381 min in total. The tumor was histologically diagnosed as well-differentiated adenocarcinoma in high-grade adenoma located in the lower to upper rectum, invading into the mucosa without lymphatic or venous invasion. The stump of the resected specimen was negative for adenocarcinoma, however the horizontal stump was positive for adenoma. We administered steroid suppositories to prevent stenosis. After ESD, general fatigue and diarrhea disappeared and electrolyte disorders resolved. The patient had good clinical outcome without recurrence or stenosis

A case of total laparoscopic sigmoidectomy involving the use of needle forceps and transanal specimen extraction for sigmoid colon cancer

A 76-year-old male underwent endoscopic mucosal resection for a stage T1 tumour of the sigmoid colon. We performed laparoscopic sigmoidectomy through 5 ports using needlescopic instruments. The resected specimen was extracted from the abdominal cavity transanally. After attaching an anvil to the sigmoidal stump, the rectal stump was reclosed using an endoscopic linear stapler, and then, colorectal anastomosis was conducted using the double stapling technique. Performing transanal specimen extraction using needlescopic forceps improves aesthetic outcomes and reduces post-operative pain and the risk of abdominal incisional hernias. This method is an easy to introduce a form of reduced-port surgery because of its feasibility and conventional port arrangement. Hence, we consider that it is an option for minimally invasive surgery

Two Cases of Rectal Neuroendocrine Tumor Resection Combined with Dissection of the Circular Muscle Layer Using the Endoscopic Submucosal Dissection Technique

Generally, lesions of rectal neuroendocrine tumors (NETs) 10 mm or smaller are less malignant and are indicated for endoscopic therapy. However, the vertical margin may remain positive after conventional endoscopic mucosal resection (EMR) because NETs develop in a way similar to submucosal tumors (SMTs). The usefulness of EMR with a ligation device, which is modified EMR, and endoscopic submucosal dissection (ESD) was reported, but no standard treatment has been established. We encountered 2 patients in whom rectal NETs were completely resected by combined dissection and resection of the circular muscle layer using the ESD technique. Case 1 was an 8-mm NET of the lower rectum. Case 2 was NET of the lower rectum treated with additional resection for a positive vertical margin after EMR. In both cases, the circular muscle layer was dissected applying the conventional ESD technique, followed by en bloc resection while conserving the longitudinal muscle layer. No problems occurred in the postoperative course in either case. Rectal NETs are observed in the lower rectum in many cases, and it is less likely that intestinal perforation by endoscopic therapy causes peritonitis. The method employed in these cases, namely combined dissection and resection of the circular muscle layer using the ESD technique, can be performed relatively safely, and it is possible to ensure negativity of the vertical margin. In addition, it may also be useful for additional treatment of cases with a positive vertical margin after EMR