Presumption of a suspect based on the skin fragment attached the rope

An eight-year-old girl (second-year of elementary school) was strangled in an irrigation canal near her house and was left unconscious. The body of a male who hanged himself to death was discovered on the next day. The hanging mark on the neck of the man and the ligature mark on the neck of the girl were caused by double nooses of a rope, the width of the rope mark was nearly the same, and similar Zwischenkammblutung (subcutaneous bleeding in the middle of the rope mark) was observed in both cases. Therefore, we evaluated whether the marks were caused by the same rope. As a result, the DNA type of the skin fragment (keratinized epithelial cells) attached to the rope used by the man to hang himself was identical to that of the girl. On the basis of this evidence, the man who hanged himself to death was presumed to be the suspect who strangled the girl.     

Factors predicting mortality in emergency abdominal surgery in the elderly

ABSTRACT: OBJECTIVE: This study aimed to investigate clinical features of abdominal emergency surgery in elderly patients, and to determine factors predicting mortality in these patients. METHODS: The study population included 94 patients aged 80 years or older who underwent emergency surgery for acute abdominal diseases between 2000 and 2010. Thirty-six patients (38.3%) were male and fifty-eight patients (61.7%) were female (mean age, 85.6 years). Main outcome measures included background of the patient's physical condition (concomitant medical disease, and performance status), cause of disease, morbidity and mortality, and disease scoring system (APACHE II, and POSSUM). Prognostic factors affecting mortality of the patient were also evaluated by univariate analysis using Fisher's exact test and Mann- Whitney U-test, and by multivariate analysis using multiple logistic regression analysis. RESULTS: Of the 94 patients, 71 (75.5%) had a co-existing medical disease; most patients had hypertension (46.8%). The most frequent surgical indications were acute cholecystitis in 23 patients (24.5%), followed by intestinal obstruction in 18 patients (19.1%). Forty-one patients (43.6%) had complications during hospital stay; the most frequent were surgical site infection (SSI) in 21 patients (22.3%) and pneumonia in 12 patients (12.8%). Fifteen patients died (overall mortality, 16%) within 1 month after operation. The most common causes of death were sepsis related to pan-peritonitis in 5 patients (5.3%), and pneumonia in 4 patients (4.3%). Multiple logistic regression analysis showed that time from onset of symptoms to hospital admission and the POSSUM scoring system could be prognostic factors for mortality. CONCLUSIONS: Mortality in elderly patients who underwent emergency surgery for acute abdominal disease can be predicted using the disease scoring system (POSSUM) and on the basis of delay in hospital admission. Keywords.     

Accurate diagnosis and treatment of Vibrio vulnificus infection: a retrospective study of 12 cases

Background and aimsVibrio vulnificus causes an infectious disease that has extremely poor convalescence and leads to necrotic fasciitis. In this study, we sought to define the characteristic epidemiology of V. vulnificus infection and clarify its diagnosis at the global level.MethodsOver a period of 10 years, we investigated the appearance of symptoms, underlying conditions, treatment, and mortality in 12 patients (eight men, four women; >50 years old; average age, 66 years,) infected with V. vulnificus.ResultsThe development of symptoms occurred primarily between June and September, a period during which seawater temperature rises and the prevalence of V. vulnificus increases. All patients had underlying diseases, and seven patients reported a history of consuming fresh fish and uncooked shellfish. The patients developed sepsis and fever with sharp pain in the limbs. Limb abnormalities were observed on visual examination. All patients underwent debridement; however, in the survival group, the involved limb was amputated early in 80% patients. The mortality rate was 58.3%.ConclusionRecognition of the characteristic epidemiology and clinical features of this disease is important, and positive debridement should be performed on suspicion. When the illness reaches an advanced stage, however, amputation should be the immediate treatment of choice.     

Appendiceal mucocele and peritoneal inclusion cyst mimicking right adnexal masses: a diagnostic challenge in gynecologic practice

Mucocele of the appendix (MA) is an uncommon disease. Preoperative differential diagnosis of MA and a peritoneal inclusion cyst (PIC) from gynecologic diseases is still a challenge. We herein report a very rare case with MA and PIC. As far as we know, this is the first report of a case having MA and PIC found simultaneously at surgery. A 31-year-old woman complained of lower abdominal pain and high fever. Based on her symptoms and laboratory tests, pelvic inflammatory disease (PID) was considered to be the most probable diagnosis. She underwent antibiotics therapy and her conditions subsided. However, ascites reappeared in a month, and ultrasound and MRI demonstrated a right ovarian cyst and a suspected right hydrosalpinx. Laparotomy revealed large PIC and MA with normal bilateral adnexa. Patients with an adnexal mass or symptoms suggesting PID should be examined carefully considering such conditions in a daily gynecologic practice.     

Sudden death from ischaemic heart disease in a female patient with Sjögren syndrome: a case report

Primary Sj?gren syndrome (SjS) has a comparatively good prognosis except when it is complicated by non-Hodgkin's lymphoma. We performed an autopsy on a young female patient with primary SjS who had died suddenly during a meal, and we discuss the relationship between primary SjS and the cause of death. Eosinophilic change of the cardiomyocytes and severe arteriolosclerosis were observed within the myocardium. In the conduction system, lymphocyte infiltration was detected in the bundle of His, in addition to arteriosclerosis in the sinoatrial node and atrioventricular node arteries. The cause of death was diagnosed as ischaemic heart disease induced by arteriolosclerosis: its development can probably be attributed mostly to primary SjS. It should thus be kept in mind that primary SjS can occasionally result in the development of cardiovascular complications, such as ischaemic heart disease, as well as systemic lupus erythematosus or rheumatoid arthritis.     

Laparoscopic pancreatic cystgastrostomy

Background/Purpose: Internal drainage of acute pancreatic pseudocysts is indicated after the first 6 weeks of pseudocyst documentation. It is also indicated for symptomatic chronic pseudocysts 6 cm or more in diameter. When a pseudocyst is in close contact with the posterior wall of the stomach, it is best drained by pseudocyst gastrostomy. Methods: Intragastric surgical techniques were used in 18 patients with retrogastric pseudocysts. Intragastric ports were successfully placed in all patients, and the presence of pseudocysts was confirmed by needle aspiration in 17. Results: The intragastric approach was successful in 14 patients. In three cases a small abdominal would 8 cm in length was needed. The reasons for such conversion included uncontrollable bleeding from the cystic wall in two cases and a cystic wall in contact with, but not adherent to, the posterior gastric wall in one. Bleeding was controlled through a gastrotomy, and cystgastrostomy was performed. The wound required for conversion was much smaller than that needed for planned open surgery. These procedures are called laparoscopy-assisted cystgastrostomy. Good short- and long-term results were obtained. One patient, in whom the cystgastrostomy was too small, developed a cyst infection and underwent reoperation. Except for this case, no recurrence was observed, and no further treatment was needed. Conclusions: This experience demonstrates that cystgastrostomy with the intragastric surgical technique is a safe, less invasive procedure for effectively draining a retrogastric pseudocyst. Received: April 20, 2002 / Accepted: May 13, 2002 Offprint requests to: T. Mori     

The giant schwannoma in the pelvic cavity: a case report

A 62-year-old man presented with a giant tumor in the pelvic cavity that was incidentally revealed by abdominal ultrasonography. Abdominal magnetic resonance imaging showed the heterogenous tumor in the pelvis with cystic components. The tumor was 10.8 × 10.5 × 11.7 cm in diameter and adhered to the sacral wall. The tumor was extirpated following diagnosis as a benign neurogenic tumor by needle biopsy. The pelvic cavity was occupied by the tumor rigidly adhered to the sacrum. The histopathological diagnosis of the specimen was benign schwannoma, type Antoni A.     

Dural cyst at the foramen magnum

A 69-year-old male presented with a rare dural cyst manifesting as numbness and pain in the limbs. Magnetic resonance imaging revealed a mass anterior to the medulla oblongata appearing as low intensity on T(1)-weighted and high intensity on T(2)-weighted imaging, with no enhancement. A cystic lesion ventral to the medulla oblongata was removed via the lateral suboccipital transcondylar approach. Histological examination showed the wall of the cyst consisted of fibrous connective tissue with a dense zone and a loose zone, similar to the structure found in the dura mater. The lesion was diagnosed as dural cyst. Dural cysts can be defined as cyst with the wall consisting of dura mater-like fibrous tissue, and attached to the dura mater. The origin of the present dural cyst was considered to be congenital.     

Radiofrequency ablation with hand-assisted laparoscopic surgery for the treatment of hepatocellular carcinoma in the caudate lobe

OBJECTIVE: To assess the feasibility and safety of radiofrequency ablation (RFA) with hand-assisted laparoscopic surgery (HALS) for hepatocellular carcinoma (HCC) in the caudate lobe with severe liver dysfunction. SUMMARY BACKGROUND DATA: HCC in the caudate lobe remains one of the most difficult locations where various treatments tend to pose problems regarding the optimal surgical approach. The technique of HALS has thus been proposed as a useful method for performing a safe RFA therapy. For this study, we assessed the feasibility and safety of RFA with HALS for the treatment of HCC in the caudate lobe with liver dysfunction. PATIENTS AND METHODS: Between July 1999 and February 2005, 5 patients who suffered from HCC in the caudate lobe were indicated for RFA. The percutaneous puncture was difficult and all patients have severe liver dysfunction with viral chronic hepatitis. Therefore, RFA was assisted by an inserted hand through a minimal skin incision under laparoscopic inspection. An intraoperative endoscopic ultrasound examination was performed before RFA to determine the tumor region. The hand-assisted minimal dissection around the caudate lobe was required to detect tumor and avoid injuries of other tissues. RFA for HCC was performed using a cooled-tip (Radionics Inc, Burligton, MA) connected to a RF generator under the programmed cyclic impedance. RESULTS: The surgical procedures consisted of 5 RFA to tumors in the caudate lobe with HALS, which was performed safely, and a postoperative computed tomography scan revealed a sufficient ablation in all patients. There was no operative mortality but 1 patient had minor bile leakage, which was treated conservatively, and all patients recovered and thus were eventually discharged. One patient had local recurrence after 3 months, 3 patients had tumor recurrences in another segment after 6 months. At a mean follow-up 32.2 months, all patients were still alive. CONCLUSIONS: RFA with HALS is considered to be a safe and feasible technique for HCC in the caudate lobe with liver dysfunction.     

Intraoperative radiotherapy for oncological and function-preserving surgery in patients with advanced lower rectal cancer

Backgrounds Pelvic autonomic nerve preservation (PANP) with lateral lymph node dissection (LLND) has been introduced in rectal cancer surgery in Japan; however, its indication has not been standardized yet. Materials and methods Forty-four patients with advanced lower rectal cancer were randomized to either the standard treatment group (control group) or the intraoperative radiotherapy (IORT) group. All patients underwent potentially curative resection of the rectum with total mesorectal excision. The control group underwent bilateral LLND and limited PANP. The IORT group underwent bilateral LLND, complete PANP, and IORT. Patients allocated to the IORT group received IORT to the bilateral preserved pelvic nerve plexuses. Patients’ clinicopathologic parameters, postoperative complications, voiding function, and prognosis were compared between the two groups. Results Among 44 patients enrolled, three patients were excluded from the analysis, resulting in 19 patients in the IORT group and 22 patients in the control group. Patients’ demographic and pathological parameters and postoperative complications were well balanced between the two groups. Oncological outcomes including overall and disease-free survival were also similar. Local recurrence was observed in one patient in each group. Among the 34 patients not complicated with intrapelvic abscess, the mean duration of urinary catheter indwelling was 8 days in the IORT group and 13 days in the control group (p = 0.055). In the long term, medication for urination was necessitated in four patients in the control group, whereas in none in the IORT group (p = 0.059). Discussions Oncological outcomes in the IORT group are equal to those in the control group, and voiding functions in the IORT group are superior to those in the control group. These results suggest that IORT may be useful to expand the indication of complete PANP with LLND for advanced lower rectal cancer.