Combined laparoscopic and thoracoscopic repair of adult right-sided Bochdalek hernia with massive liver prolapse: A case report

BACKGROUND A Bochdalek hernia(BH)is a congenital diaphragmatic hernia that often develops in the neonatal period.BH typically occurs on the left side of the diaphragm.A right-sided BH in an adult is rare.CASE SUMMARY A 45-year-old man was referred to our hospital because of an abnormal shadow seen on chest radiography during a medical check-up.A chest radiograph showed elevation of the right hemidiaphragm.Computed tomography showed prolapse of multiple intraabdominal organs into the right thoracic cavity,corresponding to a right-sided BH.The herniated contents included the stomach,transverse colon,and left lobe of the liver.The left lobe of the liver was enlarged,particularly the medial segment.Laparoscopic surgery was performed.However,the left lobe of the liver was completely trapped in the thoracic cavity.Therefore,thoracoscopic manipulation had to be performed to return the liver to the abdominal cavity.The hernia was repaired with interrupted nonabsorbable sutures and reinforced with mesh.CONCLUSION Combined laparoscopic and thoracoscopic surgery was successfully performed for right-sided BH with massive liver prolapse and abnormal liver morphology.

Need for pancreatic stenting after sphincterotomy in patients with difficult cannulation

AIM:To investigate the need for pancreatic stenting after endoscopic sphincterotomy(EST)in patients with difficult biliary cannulation.METHODS:Between April 2008 and August 2013,2136 patients underwent endoscopic retrograde cholangiopancreatography(ERCP)-related procedures.Among them,55 patients with difficult biliary cannulation who underwent EST after bile duct cannulation using the pancreatic duct guidewire placement method(P-GW)were divided into two groups:a stent group(n=24;pancreatic stent placed)and a no-stent group(n=31;no pancreatic stenting).We retrospectively compared the two groups to examine the need for pancreatic stenting to prevent post-ERCP pancreatitis(PEP)in patients undergoing EST after biliary cannulation by P-GW.RESULTS:No differences in patient characteristics or endoscopic procedures were observed between the two groups.The incidence of PEP was 4.2%(1/24)and29.0%(9/31)in the Stent and no-stent groups,respectively,with the no-stent group having a significantly higher incidence(P=0.031).The PEP severity was mild for all the patients in the stent group.In contrast,8 had mild PEP and 1 had moderate PEP in the no-stent group.The mean serum amylase levels(means±SD)3 h after ERCP(183.1±136.7 vs 463.6±510.4 IU/L,P=0.006)and on the day after ERCP(209.5±208.7vs 684.4±759.3 IU/L,P=0.002)were significantly higher in the no-stent group.A multivariate analysis identified the absence of pancreatic stenting(P=0.045;odds ratio,9.7;95%CI:1.1-90)as a significant risk factor for PEP.CONCLUSION:In patients with difficult cannulation in whom the bile duct is cannulated using P-GW,a pancreatic stent should be placed even if EST has been performed.

Enteral metallic stenting by balloon enteroscopy for obstruction of surgically reconstructed intestine

We present three cases of self-expandable metallic stent(SEMS) placement using a balloon enteroscope(BE) and its overtube(OT) for malignant obstruction of surgically reconstructed intestine. A BE is effective for the insertion of an endoscope into the deep bowel. However, SEMS placement is impossible through the working channel, because the working channel of BE is too small and too long for the stent device. Therefore, we used a technique in which the BE is inserted as far as the stenotic area; thereafter, the BE is removed, leaving only the OT, and then the stent is placed by inserting the stent device through the OT. In the present three cases, a modification of this technique resulted in the successful placement of the SEMS for obstruction of surgically reconstructed intestine, and the procedures were performed without serious complications. We consider that the present procedure is extremely effective as a palliative treatment for distal bowel stenosis, such as in the surgically reconstructed intestine.

日本肝胆胰外科协会认证体系下外科医师手术安全性的评估

背景 评估通过日本肝胆胰外科协会认证体系的外科专家手术安全性。方法分析2012年至2015年期间日本肝胆胰外科协会认证体系医院有关肝胆胰外科手术死亡数据。将肝胆胰外科手术中28种类型手术定义为高水准肝胆胰手术。主刀或第一助手完成高水准肝胆胰手术超过100例外科医师方可成为认证教官，每年开展高水准肝胆胰手术超过30例方可成为认证医院，认证专家必须是主刀完成超过50例高水准肝胆胰手术且经认证教官培训。

Angiodysplasia Presenting with Multiple Polypoid Lesions: An Unusual Cause of Small Bowel Obstruction

Angiodysplasia (AD), a morphologic vascular abnormality, is a common cause of gastrointestinal bleeding. We present a rare case of polypoid AD lesions. Three years after treatment for adhesive bowel obstruction, a 57-year-old man was admitted with recurrent abdominal distension, anorexia, and lower extremity edema. Computed tomography showed his dilated proximal and collapsed distal small bowel loops had disparate calibers. The transition point demonstrated mucosal enhancement and mesenteric lymphadenopathy. We observed small intestinal wall outpouching with strong mucosal enhancement and polypoid lesions dotting the dilated intestine. Intraoperative findings revealed a hard but elastic intraluminal nodule causing small bowel obstruction and the outpouching’s occurrence on the ileum’s antimesenteric border. We performed partial resection of the small intestine involving the nodule and Meckel’s diverticulum. Macroscopically, the nodule, diverticulum, and intestinal mucosa had polypoid lesions. Histopathologically, these lesions had foci within dilated thin- or thick-walled vascular channels in the submucosa, without specific histological abnormalities. These features led to a diagnosis of AD.