Isolated spontaneous dissection of the superior mesenteric artery (SMA) is a comparatively rare disease, and symptoms vary from acute to chronic abdominal pain to no symptoms. However, it is difficult to diagnose; there is no consensus about medical treatment and the long-term consequences. Isolated spontaneous dissection of the SMA was believed to be a rare disease that required conventional surgery for treatment; however reports of SMA dissection have increased with the progression of diagnostic imaging, and surgery may not always be required. We reviewed 10 cases of isolated spontaneous dissection of the SMA that we experienced between January 1998 and December 2008. We performed conservative medical treatment with anticoagulants in 5 cases, advised bed rest in 4 cases, and performed endovascular treatment in 1 case. None of the cases needed surgery for treatment. There were 3 cases that required continuous administration of long-term anticoagulants or antiplatelet agents. There were no recurrences in a 4-year average observation period.

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【Purpose】 To evaluate the accuracy of ultrasonography (US) with a hand-held device for the diagnosis of acute appendicitis in the emergency room. 【Materials and Methods】 US with a hand-held device was performed by the fi rst author in 33 patients suspected of having appendicitis in the emergency room. From these 33 patients, 24 who subsequently underwent computed tomography (CT) or surgery were included in this study. The accuracy of US with the hand-held device for the diagnosis of acute appendicitis was evaluated based on the fi ndings of CT or surgery. 【Results】 CT and surgery were performed in 22 and 12 patients, respectively. Final diagnoses were acute appendicitis (n=18), terminal ileitis (n=2), pelvic infl ammatory disease (n=2), diverticulitis (n=1), and ureterolithiasis (n=1). The US yielded a sensitivity of 78% and a positive predictive value of 100%. The shortest distance between the abdominal wall and the appendix measured on CT was less than 40 mm in 11 patients. In ten (91%) of the 11 patients US with the hand-held device showed the swollen appendix. 【Conclusion】 US with a hand-held device is potentially useful in the positive identifi cation of acute appendicitis, but further investigation is needed to prove its utility in the routine diagnosis of acute appendicitis.

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When performing surgery for generalized or localized peritonitis, surgeons have traditionally carried out preventive drain insertion without any well-defined significance. At Iwate Prefectural Emergency Center between April 2002 and January 2006, the need to insert a drain was evaluated in 126 patients who had their abdominal wounds closed in a one-stage procedure following surgery for generalized or localized peritonitis caused by intestinal perforation. The subjects were stratified into 2 groups according to the time when they were treated : group D (n=79) in which the wounds were closed after intra-operative abdominal lavage and drain insertion (between April 2002 and December 2004) ; and group ND (n=47) in which the wounds were closed following intra-operative abdominal lavage only (January 2005 and thereafter). They were retrospectively examined for the development of surgical site infection, suture failure, ileus, duration of systemic inflammatory response syndrome and length of hospital stay. The overall incidence of complications was 67% and 42% in the D and ND groups, respectively (p=0.0070, χ2 test). The duration of stay was 21.3±9.7 and 17.8±9.0 days for groups D and ND, respectively (p=0.03, Wilcoxon test). It is possible that preventive drain insertion following surgery for peritonitis does not serve any purpose in the cases where the source of infection and the site of perforation have been controlled. Abdominal surgeons should reconsider the need for this procedure.

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Sixty-seven patients over the age of 80 with acute abdominal disease were admitted to our hospital from January 2000 to December 2008, and were clinically studied. Of the 67, 48 patients (71.6%) had a concomitant medical disease of some kind. Forty-seven patients (70.1%) were treated surgically. Nineteen patients (28.4%) had complications during their hospital stay, the majority of which were SSI or pneumonia, with both being found in 7 patients. Fifty-seven patients (85.1%) had a favorable post-admission course. Nevertheless 10 patients (14.9%) died from the original acute abdominal disease in four and other clinical conditions consisting of two cases of aspiration pneumonia, one suffocation, one sudden death, one renal failure, and one cancer. Mortality was significantly increased in those patients with poor activities of daily living (ADL). Patients who had concomitant medical disease or were complicated with other diseases had a significantly longer hospital stay. Surgical treatment by way of aggressive procedures should be indicated for the patients over 80 years of age with acute abdominal disease if they have no severe associated medical disease or are in poor general condition.

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We analyzed 485 elderly patients over 80 years of age who had undergone urgent abdominal surgery at Hyogo Prefectural Awaji Hospital from April 1985 to August 2007 in comparison with 629 patients 70～79 years in the same period, and investigated the patients over 80 years of age in the previous period until December 1998 and the latter period from January 1999. The mean age was 85 years old (99 years old being the oldest). Ileus, of which 54.5% of the cases were colorectal cancer had increased in the latter period by the disease distinction. Acute mesenteric occlusion had occurred in the patients over 80 years old more frequently than in the 70～79 years age group. Postoperative mortality in the patients due to acute mesenteric occlusion or rupture of abdominal aortic aneurysms caused by cardiovascular disease was high through the previous and later period. Postoperative occurrence of serious cerebral or cardiac vascular disease was the characteristic cause of death in elderly patients. It is important to take measures to avoid reoperation for postoperative complication because all these patients died. Careful diagnosis and treatment should be made in consideration of comorbidities of cardiovascular disease frequently seen in elderly patients.

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Thirty-five elderly patients aged 80 years or older, who were brought to our hospital during the 7 year period from 2002 to 2008 and were operated on for abdominal emergency diseases, were examined. Among those patients, 89% had preoperative comorbidities, and 74% had postoperative complications. The mortality rate was also high (28.6%). Cardiovascular diseases, malignancies, and diabetes mellitus were common preoperative comorbidities, and pneumonia, pulmonary atelectasis, heart failure, arrhythmias, delirium, and opening of surgical wounds were common postoperative complications. Measures for supporting organ failure, such as artificial ventilator, blood dialysis and catecholamine administration, were frequently used in many cases.

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【Background】 Emergency surgery in the elderly is being performed with increasing frequency. We retrospectively evaluated the risk of emergency abdominal surgery in the elderly using the POSSUM scoring system. 【Methods】 A total of 43 elderly patients over 80 year of age who underwent emergency abdominal surgery between 1990 and 2008 were enrolled in this study. Patients were divided into two groups, 30 patients with postoperative complications and 13 patients with no complications, and POSSUM scores were compared. 【Results】 Six patients died postoperatively. All POSSUM scores were significantly higher in the group with complications than in the group without complications (p<0.01). When ‘high risk' was defined as a predicted POSSUM morbidity rate of 70% or more, the incidence rate of postoperative complications was 90.6% in the high risk group, which was significantly higher than that in the low risk group (9.1% : p<0.01). 【Conclusion】 The POSSUM scoring system is useful for predicting postoperative morbidity following emergency abdominal surgery in the elderly when the cut off value for predicted POSSUM morbidity rate was 70% or higher. This system could also provide useful information for assessing the risks of surgery and for informed consent in the elderly patient.

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From 2001 to 2007, 106 elderly patients (over 70 years old) with acute cholangitis and cholecystitis underwent surgical treatment. They were classified into three grades under the JPN guidelines. In 53 acute cholangitis patients of acute cholangitis, 13 had mild, 32 had moderate and 8 had severe disease. Delayed operation were performed in all mild patients. Of the 32 moderate patients 27 underwent delayed operations, one had an emergency operation, post-PTBD operations were performed in 3, and one underwent an operation after ENBD. In the 8 severe patients, post-PTBD operations were performed in 2, and 6 underwent emergency operations. In the 53 patients with acute cholecystitis, 20 had mild, 14 had moderate and 19 had severe disease. Thirty-two of the mild and moderate patients underwent delayed operations and a post-PTBD operation and emergency ileus surgery were carried out in one patient each. In the 19 severe patients post-PTBD operations were performed in 6 patients with pericholecystic abscesses, emergency operations were performed in 7 necrotizing cholecystitis patients and delayed operations were performed in the remaining patients. Because acute cholangitis and cholecystitis in the elderly are difficult to cure by simply following the JPN guidelines, these patients should be managed individually.

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The risk of colorectal perforation increases concomitantly with colorectal cancer and colonic diverticula, particularly when these morbidities are found in the elderly. The incidence rate of this complication begins to increase significantly in patients over the age of 75. It is well documented that colorectal perforations usually lead to severe bacterial peritonitis and induce septic shock, possibly progressing to multiple organ failure. It is therefore a condition that needs quick diagnosis. Particular care must be taken in elderly populations because of the relative lack of specific symptoms like peritonitis, thus increasing the time to diagnosis. Since 2001, we have retrospectively examined the clinical prognosis of elderly patients with colorectal perforations (N=32). The overall mortality rate was 37.5%. The time from onset of perforation to surgery was signifi cantly shorter in surviving cases than in cases that ended in death, either during the operation or post-operatively. The leading cause of perforation was colorectal cancer and the most common site was the sigmoid colon. The risk of mortality is particularly pronounced in patients whose preoperative status involved septic shock (57.1%), leukopenia (62.5%) and disseminated intravascular coagulation (71.4%) : these conditions were thus considered to be key prognostic factors. Most cases involved the use of Hartmann's operation, and half of the cases were additionally treated with hemoperfusion such as PMX or CHDF. However, even with intensive combined care using hemoperfusion, there was poor perioperative survival in the elderly group. In order to have better outcomes in elderly patients, a complete physical examination is necessary, and the treatment plan depends on the patient's overall condition and whether the peritonitis is localized.

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Among patients with ulcerative colitis (UC), the number of elderly (60 years and older) has been increasing to comprise about 10% of all recent cases. However, those who undergo emergency surgery have an extremely poor prognosis. We found that 8 of 21 such cases (38.1%) who received emergency surgery died following the operation, while only 1 of 67 (1.5%) died during elective surgery. Thus, the prognosis for elderly patients undergoing emergency surgery was significantly worse. In contrast, no significant difference was observed in regard to the prognosis between emergency and elective surgery patients younger than 60 years old. In the elderly patients who underwent emergency surgery, respiratory tract infection and sepsis resulting from MRSA or mycotic infection were frequently noted as the cause of death. We considered that elderly patients with severe or fulminant UC have lower levels of physical reserve, leading to a poor prognosis in emergency surgery situations. Accordingly, it is considered extremely important for the digestive tract internist and surgeon to work closely, and perform the operation in a timely manner.

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To evaluate the medical costs of emergent abdominal operations in the elderly, we investigated 173 consecutive patients who were over 45 years old visiting our hospital between June 2004 and June 2008. We divided the patients into 3 groups according to the age : middle age (67 cases), from 45 to 64 years old ; younger senior (43), from 65 to 74 years old ; older senior (63), over 75 years old. The concomitant diseases, indications for the operation and medical costs were compared among the three groups. The prevalence of concomitant diseases increased significantly according to the age : middle age (40.3%)<younger senior (79.1)<older senior (85.7). The mortality rates in the presence of concomitant diseases also increased according to the age : middle age (11.1%)<younger senior (14.2)<older senior (22.6). There were no cases of death in the middle and younger senior groups, while the mortality group in the older senior group was 20%. There were no significant differences in the rate of hospital admissions or total medical costs among the three groups. However, the daily medical costs in the absence of concomitant diseases were different among the three groups : middle age, 59,490 yen ; younger senior, 76,600 yen ; older senior, 108,980 yen. When preoperative complications were not taken into account while calculating the medical expenses, it became apparent that the daily medical costs for the emergent abdominal operations increased significantly according to the age of the patients.

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We experienced 2 cases of self-inflicted gastric penetrating injuries with a kitchen knife. Both patients were transferred just after the injuries. A dynamic CT scan in arterial phase showed the extravasation of contrast medium from the injured organ. We performed an emergency laparotomy. In both cases, the patients' findings were penetrating injuries through the anterior and posterior gastric walls. We repaired the injuries and the patients had good postoperative courses. Various kinds of examination have been made to decide the indication of laparotomy for abdominal stab wounds, but in recent years the usefulness of CT examination has been outstanding. In our cases, besides the contrast extravasation, it was helpful for the detection of the actual sites of injury to identify ascites in bursa omentalis. In addition, the injured portions of the abdominal wall and organs were not close to each other, which would be caused by the difference in posture at the time of injury and also the positioning during the CT scan. Considering the movement of organs by posture enables a more correct preoperative diagnosis.

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A 41-year-old male with sudden onset of epigastric pain was brought to our hospital by ambulance. He had not previously undergone any surgery. On physical examination, the abdomen was tender with muscular guarding in the umbilical region. A computed tomography (CT) scan of the abdomen revealed the presence of ascites, dilated small bowel and convergence of the mesentery suggestive of a strangulated internal abdominal hernia and an emergency operation was performed. Following laparotomy, a loop of the small intestine, approximately 1m in length, had herniated through a hole in the great omentum with resultant necrosis, thus confirming the diagnosis of a transomental hernia. The incarcerated bowel was in the ileum 3m10cm distal to the ligament of Treitz. The hole was opened and the necrosed portion of the small intestine was resected. The postoperative course was uneventful and the patient was discharged from the hospital on day 10. Internal hernias are an uncommon disease. The transomental hernia is particularly rare and it was difficult to make a correct diagnosis preoperatively. Recently some authors have reported that abdominal CT has been useful to make preoperative diagnosis. We report on a case of transomental hernia diagnosed as a incarcerated internal hernia by abdominal CT and demonstrated by surgery.

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A female in her 70's visited our department complaining of abdominal fullness. Abdominal X-ray examination revealed marked gastric dilatation, but the patient's symptom improved decompression with a nasogastric tube. Two days later, sudden abdominal pain appeared and she visited our department again. Abdominal X-ray and CT images revealed marked gastric dilatation with free air, and an emergency operation was performed under a diagnosis of upper gastrointestinal tract perforation. We found a 3.0×3.0 cm perforation at the upper and anterior part of the stomach body, and laceration of the gastrocolic ligament. The stomach wall at the perforation had thinned with no ulcer, and a tumor. The bursa omentalis was full of a large quantity of food debris. There was no abnormality at the posterior part of the perforated region, and the duodenum ran in front of the abdominal esophagus. At admission, the CT and abdominal X-ray images at the first examination showed obvious gastric dilatation with a double mirror image, equal to the volvulus of stomach. Although an uncommon situation, this case highlight the possibility of gastric perforation caused by short-axis gastric volvulus in patients with Parkinsonism.

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A 41-year-old female visited a clinic with gait disturbance accompanying an increasing abdominal mass. She was referred to our department for diagnosis and treatment. CT images revealed that the bulky 45cm tumor occupied the whole abdomen and extended into the pelvic cavity, and her intraabdominal organs were displaced to the right dorsal aspect of the abdomen. She could not tolerate the supine position because of chest discomfort, and exhibited bilateral leg edema. Because cardiac arrhythmia accompanied hypotension, we decided to perform emergency surgery. The tumor measured 45×40×17cm, weighed 17kg, and was diagnosed as a left ovarian tumor. Postoperatively she became hemodynamically stable and was discharged on the eighth postoperative day. Removal of a bulky abdominal tumor is sometimes associated with intraoperative and immediately postoperative hemodynamic instability. For removal of such a tumor, close cooperation between surgeons and anesthesiologists is essential.

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An 83-year-old woman who had undergone Miles operation for rectal cancer in 1996 was admitted to our hospital with abdominal pain in August 2003. Her abdomen showed inflamed skin and tenderness around the colostomy. An abdominal CT scan showed a rupture of the wall of the colostomy stoma limb and abnormal gas around the stoma limb in the abdominal wall. An emergency operation was performed under the tentative diagnosis of penetration of the sigmoid colostomy within the abdominal wall and sepsis. Following laparotomy, there was no remarkable finding except for the parastomal hernia. After the skin incision was made around the stoma, necrotic change was noted in the sigmoid colon within the abdominal wall with multiple penetration. There were several amounts of fecal leakage from the perforated portion forming the abscess cavity. We resected the colostomy together with the parastomal abdominal wall, and the stoma was revised. A final diagnosis of stercoral perforation was made, based on the operative findings and pathological studies. The postoperative course was uneventful and the patient was discharged on postoperative day 26. Since the perforated portion and abscess cavity was limited within the abdominal wall which was en-bloc resected, the patient did not demonstrate any serious postoperative complications.

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In August 2008, a 78-year-old male underwent an endoscopic colonic polypectomy at a nearby hospital. Starting from the next day, the patient complained of abdominal bloating and abdominal pain, and a radiographic examination revealed intraperitoneal free gas, and therefore the patient was referred to our center with a suspected lower gastrointestinal perforation. An emergency laparotomy was performed on the same day, and a perforation measuring 8 mm in diameter was found in the anterior wall of the sigmoid colon. Since the intraperitoneal contamination was minor, a single-stage closure of the perforation was performed. It was accompanied by an esophageal hiatal hernia and emphysematous changes were observed consisting of an aggregation of small bubbles surrounding the hernia. The patient had a good postoperative course and he was transferred to a local hospital on Day 27. Since the image findings showed no appearance of gas in the retroperitoneal route, this case was believed to be a rare case of mediastinal emphysema that was caused by the entrance of intraperitoneal free gas via an esophageal hiatal hernia.

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The procalcitonin test (PCT) is a useful diagnostic marker of sepsis and has been adopted by the Japanese Health Insurance System. We experienced two cases of peritonitis in whom the antibiotic therapy was decided with real-time PCT measurement. Case1 : An 80-year-old male underwent sub-total colectomy and ileostomy for treatment of toxic megacolon due to ulcerative colitis. His pre-operative serum procalcitonin level was 4.34ng/mL. Postoperative antibiotic therapy was stopped when the serum procalcitonin level decreased to 0.27ng/mL, in spite of a WBC count of 18,000/mm³ and a C-reactive protein (CRP) level of 8 mg/mL on post-operative day (POD) 7. Thereafter, inflammation did not aggregate. However the patient developed aspiration pneumonia on POD 13. The serum procalcitonin level rose again to 10.8ng/mL. Antibiotic therapy was again effective and was stopped when the serum procalcitonin level decreased to 0.14ng/mL in spite of a WBC count of 7,500/mm³ and a CRP level of 5.1mg/mL. Thereafter the patient's course was uneventful. Case2 : a 77-year-old male underwent a Hartmann procedure for an intra-pelvic abscess due to invasive rectal cancer. When the pre-operative serum procalcitonin level of 4.34ng/mL decreased to 0.14ng/mL in spite of a WBC count of 10,800/mm³ and a CRP level of 2.85mg/mL on POD 7, antibiotic therapy was stopped and the patient had a good course thereafter. In future, clinical evaluation for PCT levels in various bacterial infections is needed in Japan. These cases highlight the possibility that the serum procalcitonin level is a novel and useful marker that enables the appropriate indication for antibiotics to be determined in patients with abdominal sepsis.

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Afferent loop syndrome is a severe post-operative complication, which needs prompt diagnosis and treatment. We describe herein a case of afferent loop syndrome 35 years after distal gastrectomy, which could be diagnosed in an early stage, and successfully treated by elective surgery following endoscopic drainage. A 68-year-old man was admitted to our hospital complaining of abdominal distention and palpitation. His past history included a distal gastrectomy performed 35 years previously. Computed tomography revealed a dilated duodenum and findings suggestive of acute pancreatitis, and the afferent loop stenosis of the Billroth-II reconstruction was confirmed with contrast radiography of the upper gastrointestinal tract as well as the endoscopic examination. The diagnosis of acute afferent loop syndrome was made, and the endoscopic drainage of the afferent loop using a transnasal tube was indicated. This transnasal tube was later replaced by a longer, wider-diameter tube to allow adequate drainage, and the contrast radiography performed thereafter reveled duodenal perforation to the retro-peritoneal space, which was conservatively treated by drainage. The symptoms improved gradually, and after the removal of the long tube, the patient underwent elective surgery to prevent recurrence. The previous operation was a gastrectomy with Billroth-II reconstruction without Brauns anastomosis in the anterior anastomosis of the colon. The afferent loop was long, turned and twisted, which probably caused the stenosis. The stenosis was removed and Brauns anastomosis performed. The patient had a favorable progression and was discharged on the 11th post-operative day.

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A 38-year-old woman was referred and admitted to our hospital because of anal pain and vertigo. She had been diagnosed as having type 1 neurofibromatosis at the age of 16 years. On admission she presented with hemorrhagic shock and severe pain in the anal and right gluteal region. Her hemoglobin level was 7.9g/dL and computed tomography demonstrated hematomas in the subcutaneous space in lower pelvis and right gluteal region. Blood transfusion did not improve the anemia and pain worsened. Angiography demonstrated rupture of the median sacral artery at the lower sacral level and embolization with coils and gel foam was performed. There was no evidence of any tumor in the pre-sacral space on either CT and MRI, and we thus concluded that the rupture was due to the fragility of the arterial wall associated with type 1 neurofibromatosis.

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A 31-year-old man who developed sudden lower abdominal pain and vomiting was referred to our hospital's emergency room by a local physician due to increased abdominal pain on the day after onset. Tenderness and muscular guarding centered in the lower abdomen were observed in the initial examination, and abdominal contrast CT showed ascites retention, a dilated small intestine in the lower abdomen, and mesenteric convergence. Strangulated ileus was diagnosed 18 hours after onset and emergency surgery was performed. Upon laparotomy, 500mL of hemorrhagic ascites was found in the abdominal cavity and about 80cm of the ileum was strangulated by a band about 2cm in length from 10cm orally from the antimesenteric side of the ileum toward the mesentery of the small intestine. Surgical excision of the band and partial resection of the ileum were performed. The band was a granuloma with infiltration of multinucleated white blood cells, and a necrotized worm was found inside. The worm was identified as Anisakis simplex, sensu stricto, with the polymerase chain reaction (PCR) method, and the final diagnosis was strangulated ileus by extra-gastrointestinal anisakiasis. This case shows that an extra-gastrointestinal anisakiasis should be kept in mind as a possible cause of strangulated ileus in a patient with no history of laparotomy.

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A 59-year-old man was admitted to our hospital with severe abdominal pain and a high temperature. Abdominal-CT revealed a solid tumor about 8cm in diameter continuing to the small intestine. The laboratory data revealed marked elevation of WBC and CRP levels. An emergency operation was carried out under the diagnosis of peritonitis. Fistula formation was confirmed in the small intestine contiguous with the tumor. We performed a partial resection of the small intestine and sigmoid colon. The tumor was composed of solid and necrotizing regions. Histopathological findings showed that the tumor was composed of proliferative spindle-shaped cells. Because the tumor cells were positive for c-kit, we diagnosed the tumor as GIST of the small intestine. A case of perforated gastrointestinal stromal tumor of small intestine is herein described with a brief review of the literature.

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A 83-year-old bedridden female who had had abdominal pain for 4 days was brought to our hospital by ambulance in October 2008. She had undergone a percutaneous endoscopic gastrostomy (PEG) in August 2006 because of aspiration pneumonia. Six months after the PEG (in February 2007), the PEG catheter was removed to allow adequate oral intake. On arrival at our hospital, the patient's abdomen was distended with tenderness and muscular defense. The laboratory examination revealed elevation of infl ammatory responses. Computed tomography demonstrated a large amount of free air, and a hole in the stomach. On basis of these pieces of evidence, a preoperative diagnosis of gastric perforation was made leading to an urgent laparotomy. A 1cm perforation of the anterior wall was recognized intraoperatively, situated below the skin scar of the PEG. A defi nitive diagnosis was made of gastric perforation at the site where the PEG had been performed, and an omental plug was constructed. The patient's postoperative course was uneventful, and she was discharged from hospital 10 days after the operation.

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