A case of a penetration of the duodenum by a needle with migration to the pancreas in a 50-year-old man is reported herein. The patient was referred to us with a chief complaint of diarrhea. An abdominal plain roentgenogram showed a needle in the upper abdominal area. An abdominal computed tomography scan and contrast X-ray revealed the foreign body to be located outside of the duodenum and in the head of the pancreas. An emergency operation was therefore performed on the first day and the needle in the head of the pancreas was thus extirpated safely. A perforation of the gastrointestinal tract by an ingested foreign body is difficult to accurately and quickly diagnose when no peritonitis or abscess formation is observed. Therefore, the use of contrast X-ray is considered to be useful in the diagnosis of such a perforation.

Objective: Disturbed renal function may play an important role in the clinico-pathological presentation of primary hyperparathyroidism (pHPT). We studied the influence of renal function on the clinicopathological characteristics of 141 patients (123 women and 18 men) with surgically proven pHPT. Methods: The 141 patients were assigned to one of two groups based on creatinine clearance (C cr ) level: a renal insufficiency group (n ¼ 37) in which C cr of patients was ,70 ml/min and a normal renal function group (n ¼ 104) in which C cr was $ 70 ml/min. Clinical presentation and biochemical indices were evaluated and compared between the two groups. Results: Age, and frequency of hypertension and of diabetes mellitus were significantly (P , 0.001, P , 0.05 and P , 0.05 respectively) higher in the renal insufficiency group than in the normal renal function group. Serum levels of calcium, intact parathyroid hormone and bone Gla protein were significantly (P , 0.05) higher and the excised parathyroid weighed significantly more (P , 0.05) in the renal insufficiency group than in the normal renal function group; however, serum 1,25-dihydroxyvitamin D (1,25(OH) 2 D) and 24 h urinary calcium excretion were significantly (P , 0.001 and P , 0.05 respectively) lower in the former than in the latter group. There was a significant inverse correlation between C cr level and serum calcium (r ¼ 0.315, P , 0.001) and a significant positive correlation between C cr level, 1,25(OH) 2 D (r ¼ 0.315, P , 0.001), and 24 h calcium excretion (r ¼ 0.458, P , 0.0001). Conclusions: Clinico-pathological features of pHPT were notably influenced by even moderate renal insufficiency. Urinary calcium excretion decreased according to the decrease in glomerular filtration rate. Therefore, endocrinologists need to appraise urinary calcium excretion and renal function of pHPT patients when considering surgery or in discriminating familial hypocalciuric hypercalcemia.

BackgroundParacecal hernias, also known as pericecal hernias, are an exceptionally rare type of internal hernia. We report a unique case of paracecal hernia due to membranous adhesion of the omentum to the right paracolic gutter.Case presentationAn 86-year-old female was admitted to our hospital with vomiting and abdominal pain. Laboratory findings showed a slightly elevated C-reactive protein level. Computed tomography scan showed dilated loops of the small intestine in the right paracolic gutter with medial displacement of the cecum and ascending colon. Internal hernia around the cecum due to postoperative adhesion after appendectomy was suspected, and she underwent emergency laparotomy. Intraoperative findings revealed the adhesion between the omentum and right paracolic gutter forming a cavity with the small intestine incarcerated. No abnormal adhesion in the ileocecal region was seen. We transected the omental adhesion from the orifice to the far end of the cavity near the hepatic flexure of the colon to release strangulation and to prevent recurrence. The patient was discharged on postoperative day 14 without complications.ConclusionsParacecal hernias have a type of membranous adhesion of the omentum to the right paracolic gutter. Surgeons should be aware of this paracecal hernia type, when they encounter the internal hernia.

We describe our modification of the reversed T-shaped sternotomy. The conventional technique consists of a limited upper sternotomy with transverse division of the sternum. Our modification involves shifting the transverse division lines one costal space between the right and left sides for perfect apposition of the divided upper and lower sternum. This technique can be used for patients with thyroid cancer and mediastinal lymph node metastasis and for those with a mediastinal tumor or certain cardiac disorders.

INTRODUCTIONGallstone ileus (GI) results from the passage of a stone through a cholecystoenteric fistula, subsequently causing a bowel obstruction. The ideal treatment procedure for GI remains controversial.PRESENTATION OF CASEA 63-year-old female was admitted to our hospital following persistent nausea and vomiting for 7 days. Computed tomography revealed a partially calcified 4-cm circular object in the jejunum, and the proximal intestine was dilated, with concomitant pneumobilia. Based on the preoperative diagnosis of GI, enterotomy with stone extraction by single-incision laparoscopic surgery (SILS) was performed. The patient's postoperative course was uneventful, and the cholecystoduodenal fistula closed spontaneously 4 months after the surgery.DISCUSSIONRecent studies have reported that enterotomy with stone extraction alone is associated with better outcomes than with more invasive techniques. This case also suggests that enterotomy with stone extraction alone and careful postoperative follow-up is feasible for the management of GI. Although the use of laparoscopy in the management of GI has been described previously, laparoscopic surgery has not been widely performed, and SILS is not generally performed. When only this less demanding procedure is required, laparoscopic surgery, including SILS, can be a viable option.CONCLUSIONSILS can be an alternative surgical procedure for the management of GI.