Repair of incisional hernia with prolene hernia system

A 70-year-old woman was admitted to our hospital with a complaint of bulging in the right lower portion of the abdomen. The bulging was in accordance with an old operative scar for appendicitis. The findings of computed tomography (CT) showed defects in the abdominal muscles and the protrusion of the intestine into the subcutaneous fat. The patient was diagnosed with incisional hernia after appendectomy and underwent are pair of the incisional hernia, using the prolene hernia system double-layer mesh. The patient’s post-operative course was excellent. Recently, the prolene hernia system, double-layer mesh was reported to be effective for groin hernias due to its advantageous protection the recurrence through reinforcement of the patient’s myopectrial orifice. It is suggested that this new device is also useful for small incisional hernias

Rectus sheath hematoma in an elderly woman under anti-coagulant therapy

Rectal sheath hematoma has been a well-known clinical entity from the ruin of the ancient Greece. It is relatively rare, however, to encounter this abdominal disorder in the clinical setting. Furthermore, the initial symptoms of rectus sheath hematoma are often similar to those of acute abdominal disorders. Therefore, the majority of the patients with rectus sheath hematoma have been treated with operative procedures because of the difficulty of a differential diagnosis from other abdominal disorders. We recently treated a 74-year female diagnosed with rectus sheath hematoma with the anticoagulants after an episode of cerebral infarction. From the findings of the physical examinations, ultrasound, and computed tomography, we could correctly diagnose, and could treat her with completely conservative methods without any invasive techniques. It is stressed that it is important to recognize this entity of rectus sheath hematoma when patients are examineed, after complaining of acute abdominal pain and with evidence abdominal masses in the clinical setting

Perioperative immune responses in cancer patients undergoing digestive surgeries

<p>Abstract</p> <p>Background</p> <p>Th1/Th2 cell balance is thought to be shifted toward a Th2-type immune response not only by malignancy but also by surgical stress. The aim of this study was to estimate perioperative immune responses with respect to the Th1/Th2 balance in patients with gastrointestinal cancer.</p> <p>Methods</p> <p>Ninety-four patients who underwent abdominal surgeries were divided into three groups: gastric resection (n = 40), colorectal resection (n = 34) and hepatic resection (n = 20). Twelve patients undergoing laparoscopic cholecystectomy and 20 healthy subjects were served as control groups. Intracellular cytokine staining in CD4+ T lymphocytes was identified to characterize Th1/Th2 balance. Th1/Th2 balance was evaluated before operation and until postoperative days (POD) 14.</p> <p>Results</p> <p>The preoperative Th1/Th2 ratio was significantly lower in patients with malignancy compared with control. The Th1/Th2 ratio of patients in all groups decreased significantly postoperatively. Th1/Th2 balance on POD 2 in patients with malignancy was significantly decreased compared to patients with laparoscopic cholecystectomy, but there were no significant differences among the four groups on POD 14.</p> <p>Conclusion</p> <p>Patients with malignancy showed an abnormal perioperative Th1/Th2 balance suggesting predominance of a type-2 immune response. Major abdominal surgeries induce a marked shift in Th1/Th2 balance toward Th2 in the early postoperative stage.</p

Experimental study of combined treatment with tacrolimus and donor splenocytes via the portal vein in small bowel transplantation

We previously reported that the combined treatment of perioperative administration of donor splenocytes via the recipient's portal vein (DSPV) and a short-course Tacrolimus significantly prolonged the survival of fully allogenic grafts in rat small bowel transplantation (SBTX). In the present study we examined whether this effect depended on the quantity of the administered alloantigens in DSPV. In addition, we examined the expression of the surface antigen on T cells of the splenocytes and the induced toleragenic factor, according to the tolerant recipients which in our previous report had shown the prolongation of allogenic transplant small bowel graft survival by the combined treatment of DSPV (1×108 donor splenocytes) and a short-course Tacrolimus. Donor splenocytes were prepared from Brown-Norway (BN (RT1n)) rat spleens for Lewis (LEW (RT1l)) recipients. The recipients (n=10), treated with a short course of Tacrolimus (0.5mg/kg, 0 to 3 days postoperatively) only showed graft rejection with an average of 6.3±1.0 days postoperatively. However, the combined treatment, consisting of DSPV of 1×108 donor splenocytes and a short course Tacrolimus significantly prolonged graft survival to 12.7±2.1 days (n=12, P<0.01). DSPV of less than 1×108 donor splenocytes (5×107 cells and 2.5×107) could not prolong the graft or animal survival under a short-course Tacrolimus treatment. In the tolerant recipients, the CD4 and CD8 percentages of splenocytes were not significantly different from those of control rats or recipients that were treated with short-course Tacrolimus alone. Neverthless, the percentage of Tcr-αβ+ cells expressing IL-2 receptor (R) was significantly lower than in either control rats or the recipients with short-course Tacrolimus. In the suppression assay to one-way mixed lymphocyte response, a toleragenic factor was suggested to the present in the serum of the tolerant recipients. In the present study, it was suggested that the effects of the combined treatment of DSPV and short-course Tacrolimus for the prolongation of graft survival in the rat allogenic SBTX should depended on the quantity of the antigens administered into the portal vein. The beneficial effects of this treatment were reflected in the suppression of IL-2R on the recipient's splenocytes, and tolerogenic factor(s) might subsequently be induced in the tolerant recipient's serum

Sivelestat Sodium Hydrate ト エンドトキシン キュウチャク リョウホウ トノ ヘイヨウ リョウホウ ガ ユウヨウ デ アッタ ARDS ノ イチレイ

We report here a case of Acute Respiratory Distress Syndrome（ARDS）due to perforation of the sigmoid colon, for which therapy with Sivelestat Sodium Hydrate（SSH, Elaspol）and Polymyxin B-immobilized Direct Hemoperfusion（PMX-DHP）was shown to be effective. An 88-yearold woman was admitted to our hospital because of abdominal pain. Abdominal computed tomography showed free air present in the liver and near the sigmoid colon. These results suggested sigmoid colon perforation, and we performed Hartmann’s operation and drainage. After operation, her blood pressures and the PaO2/FiO2 ratio decreased. The patient was then diagnosed septic shock and ARDS ; and PMX-DHP was performed, followed by the initiation of SSH administration. After therapy, she showed improvements in her conditions of septic shock and ARDS. It is inferred that therapy with PMX-DHP and SSH is effective for ARDS in view of an observed two-fold suppression in vascular endothelial cell damage

トウイン ニオケル ダイタイ ヘルニア シュジュツ 26ショウレイ ノ リンショウテキ ケントウ

We performed this study to investigate the differences in clinical features between incarcerated femoral hernias and non-incarcerated cases. We operated on 26 patients with a femoral hernia from April 1989 to December 1998. Twenty-four patients were female and two were male. Thir mean age at the time of operation was 68.2±15.4 years, and those older than 60 years were remarkably high. All females had a history of abortion more than twice. Eighteen of 26 (69.2%) hemoral hernias occurred on the right side, 7 on the left, and 1 on both sides. Those with an incarcerated hernia were 46.2% (12/26). Almost all patients without incarceration had only femoral tumors or swelling. On the contrary, a large number of the patients with an incarcerated hernia complained of abdominal or femoral pain, suggesting a hernial strangulation. Significant increases in white blood cell counts were recognized in the incarcerated cases compared to those without incarceration (9158.3± 2155.3 vs 6602.9±1049.5/mm3, respectively;P=0.0001). Additionally, the postoperative hospitalization periods of the patients with incarcerations were remarkably prolonged compared to those without an incarceration. According to the contents of the hernia in the 12 patients with incarcerations, we detected the small bowel in 9 and the grater omentum in 3. Six of 9 patients with an incarcerated small bowel had necrotic complications of strangulated small bowel. However, there was no clinical difference compared to the other 6 patients without a necrotic small bowel. In conculusion, we should recognize the possibility of femoral hernias in the treatment of patients complaining of a tumor or pain in the femoral triangle

ダイチョウ センコウ ショウレイ ニ タイスル エンドトキシン キュウチャク リョウホウ ノ ケントウ

The aim of this retrospective study was to investigate the therapeutic results of Polymyxin Bimmobilized Direct Hemoperfusion（PMX-DHP）for colorectal perforation. The study subjects were 40 patients with colorectal perforation surgically treated from 1993 through 2004, of whom 18 underwent PMX-DHP after operation（P group）and 22 underwent operations only（N group）. Although there was no significant difference between the two groups in the overall mortality rate, the mortality rate for ARDS was significantly lower in the P group than in the N group. There was a statistically significant correlation between the P/F ratio and the time interval from the disease onset（r=－0.590, p=0.0009<0.001）. The time lag from disease onset to operation and the length of PMX-DHP period were significantly longer in the death group than in the survivor group. We anticipate that PMX-DHP for colorectal perforation proves effective in reducing deaths from ARDS. For an effective facilitation of PMX-DHP, the procedure should be started as soon as possible from the onset of the disease

ニボルマブによる重症筋無力症

A ７０s female suffering from recurrent gastric cancer presented with ptosis, dysphagia and lower limb and neck muscles weakness with elevation of serum CK levels after second treatment with the immune checkpoint inhibitor nivolumab. The symptoms suggested myasthenia gravis （MG）, although anti-acetylcholine receptor antibody and muscle-specific receptor tyrosine kinase antibody were negative. Steroid treatment quickly normalized CK levels and relieved MG symptoms. Nivolumab-induced MG can rapidly become severe and potentially fatal, and a prompt and accurate response is desirable

Clinical study of strangulation obstruction of the small bowel

Early diagnosis of strangulation obstruction is very important for surgeons because delayed diagnosis often leads to severe complications. Thirty patients underwent an operation because of small bowel obstruction between April, 1993 and December, 1999. In the present study, we examined the differences in clinical findings between simple obstruction and strangulation obstruction. In addition, we examined the manifestation of systemic inflammatory response syndrome (SIRS) and whether it is useful for early diagnosis of strangulation obstruction, and whether it is correlated with the severity of ischemia due to strangulation. Tenderness was examined in all patients and signs such as abdominal irritation were detected more often in patients with strangulation obstruction than in the patients with simple obstruction. According to SIRS, the large number of the patients with strangulation obstruction showed SIRS before operation and the manifestation of SIRS correlated well with the length of the necrosis in the strangulated small bowel. We recognized the importance of anamnesis and clinical findings in examinations of small bowel obstruction, furthermore, it was suggested that SIRS should be the warning sign for strangulation obstruction

Giant gastrointestinal stromal tumor, associated with esophageal hiatus hernia

An 85-year-old woman was admitted to our hospital because of vomiting. An upper gastrointestinal series what showed a large esophageal hiatus hernia, suggesting an association with extrinsic pressure in the middle portion of the stomach. An upper gastrointestinal endoscopic examination showed severe esophagitis and a prominent narrowing in the middle portion of the stomach, however, it showed normal gastric mucosa findings. CT and MRI revealed a large tumor extending from the region of the lower chest to the upper abdomen. From these findings, the tumor was diagnosed as gastrointestinal stromal tumor(GIST), which arose from the gastric wall and complicated with an esophageal hiatus hernia. We performed a laparotomy, however, the tumor showed severe invasion to the circumferential organs. Therefore, we abandoned the excision of the tumor. Histologically, the tumor was composed of spindle shaped cells with marked nuclear atypia and prominent mitosis. The tumor cells were strongly positive for CD34 and c-kit by immunohistochemical examination. From these findings, the tumor was definitely diagnosed as a malignant GIST. As palliative treatment, we implanted a self-expandable metallic stent in the narrow segment of the stomach. The patient could eat solid food and was discharged. In the treatment of esophageal hiatus hernia, the rare association of GIST should be considered