We evaluated 54 patients who were diagnosed intraoperatively as having a strangulating obstruction of the small bowel. They were divided into two groups：the necrotic group (n=30); and the non-necrotic group (n=24). There was no difference in the sex ratio, average age, past history of abdominal open operation, insertion of small intestinal tube and WBC counts between the groups. There were, however, significant differences in CRP (P=0.009), shock before operation (P=0.01), fever (P=0.03) and ascites during the operation (P=0.03). Concerning the CT scan findings, a closed-loop obstruction was the only significant difference. When a strangulating obstruction of the small bowel is suspected, accompanied by symptoms of shock or fever, small intestinal necrosis may be possible. Based on the CT findings, closed-loop obstruction and ascites are effective in the diagnosis of intestinal necrosis.
The aim of this study was to investigate the predictive factors for perioperative mortality after surgery for an oncologic emergency associated with colorectal cancer in the authors’ hospital. A total of 53 patients with a colorectal cancer oncologic emergency underwent surgery from January 2007 to December 2011, and were enrolled this study. Logistic regression analysis was used to determine the independent risk factors for perioperative death among the patients. A ROC curve analysis was then used to identify the best cut-off values. In the patients and surgical factors, OS for the POSSUM was an independent factor of the mortality, the odds ratio of which was 1.51, and the best cut-off point on the ROC curve was 17. In the preoperative factors, an ASA score 3 and over was an independent factor of the mortality, the odds ratio of which was 0.02.
We divided the patients who underwent emergency laparoscopic surgery for abdominal injury into penetrating trauma and blunt trauma groups, in order to retrospectively compare the rate of conversion from laparoscopic surgery to laparotomy, the reasons for the conversion to laparotomy, and any postoperative complications. We performed emergency laparoscopic surgery for 36 patients out of 112 patients who underwent surgery for abdominal injury in our hospital over the past 20 years. Among the injury types, blunt and penetrating traumas were observed in 17 and 19 patients, respectively. In 11 out of the 17 patients with blunt trauma, perforation of the digestive tract was confirmed, and mini-laparoscopic suture was performed for 5 patients. When 20 hours had passed from the injury in the patients with perforation, the frequency of conversion to laparotomy due to insufficient view caused by contamination was high. Among the 19 patients with penetrating trauma, only 2 exhibited perforation of the digestive tract. The incidences of unnecessary laparotomy and postoperative complications were 5.9% and 5.3% and 0% and 21%, respectively, in the blunt and penetrating trauma groups. No oversight of perforation of the digestive tract was confirmed. Regarding abdominal injury, laparoscopy is useful for the diagnosis of hollow organ injury, which is difficult to diagnose with CT, and the injury may be cured with a minimally invasive procedure under laparoscopic observation.
The recent endoscopic retrograde cholangiopancreatography (ERCP) rerated procedure mainly aims at intervention for pancreatico-biliary disease. In particular, it is essential to achieve selective bile duct cannulation (SBDC) for the treatment of the biliary tract. Conventional cannulation should be the first step method to be undertaken for a trainee. However, we have encountered situations in which SBDC was difficult. For a rate of successful SBDC and post-ERCP pancreatitis, it was reported that the rate of successful SBDC within ten minutes was 71.3％ and the rate of post-ERCP pancreatitis increased when the SBDC time period was over ten minutes. Recently, to overcome these issues, some alternative cannulation methods using a guide-wire technique have emerged, e.g. wire-guided cannulation (WGC), pancreatic guide-wire cannulation (PGC) and trans-pancreatic precut sphincterotomy (TPS). It should be mandatory to acquire these techniques even for the trainee, therefore, we focused on some tips as to how to perform SBDC using these techniques referring to some current results and our data, especially in PGC and TPS.
Even in the hands of experienced endoscopists, biliary cannulation may fail in up to 5%-10% of all endoscopic retrograde cholangio-pancreatography (ERCP) procedures. Several precut techniques have been performed with either a needle-knife sphincterotome or a pull type sphincterotome to increase the rate of cannulation. Needle-knife precutting papillotomy (NKPP) is one of the standard precut technique. However, NKPP has been considered a risk factor for adverse events such as post-ERCP pancreatitis, bleeding and perforation. NKPP starting at the orifice is in particular the most basic maneuver among the precut techniques, but it has been considered more hazardous than the other precut techniques. Therefore, it is required to master this maneuver to become an expert. The goals of our NKPP procedure are incision of the narrow distal segment and separation of the biliary and pancreatic ducts. To achieve this, it is important to identify the sphincter and inner bile duct mucosa after cutting with the needle-knife. There are two critical points when performing Ban NKPP. The first point is understanding the anatomy of the ampulla of Vater, and the second is to precisely control the length, direction and depth of the incision. Understanding these points provides a more safe and effective precut technique.
During or after ERCP procedures, various adverse events can happen. ERCP is associated with more frequent complications compared with other endoscopic procedures. In this review, the current situation regarding ERCP-related complications is discussed. Bleeding can be caused particularly by a sphincteroplasty, among which life-threatening bleeding necessitating IVR can sometimes occur. Perforations are reportedly classified under three categories：gastrointestinal perforation, periampullary perforation, and bile duct perforation. Gastrointestinal perforation usually requires surgical management. Post-ERCP pancreatitis (PEP) is the most frequent complication. Pancreatic stent, wire guided cannulation and NSAIDs appear to be effective to prevent PEP. Cholangitis and cholecystitis may happen after ERCP, most of which can be treated with biliary drainage. There can be various stent-related complications which are treated with treatments specific to each event. During lithotomy, basket impaction may happen although it is rare. In this case, the use of endotriptor or ESWL are effective methods. ERCP-related complications are inevitable, and sometimes become serious, so the most important thing is to diagnose complications accurately and rapidly and conduct appropriate management for them.
Endoscopic sphincterotomy (EST) is the basic endoscopic surgical technique for pancreatobiliary disease. Severe hemorrhage is one of the major lethal complications associated with EST. In the case of oozing type bleeding, it is relatively easy to get hemostasis by spraying a mixture of epinephrine and saline or a thrombin solution. However, in the case with severe bleeding, endoscopic hemostasis techniques are needed. Endoscopic hemostatic methods such as localized injection treatment of hypertonic saline epinephrine solution (HSE), astriction using a balloon catheter or a fully covered self-expandable metal stent, a clipping technique or a thermocoagulation technique are used for severe hemorrhage after EST. It is important to choose the appropriate hemostatic technique for each case. In addition, for those cases resistant to endoscopic hemostasis, invasive radiology or a surgical procedure should be performed without delay.
ERCP has become an essential technique for the diagnosis of biliopancreatic disease. Various therapeutic techniques using ERCP have been developed and are widely used in the clinical setting. However, ERCP and related techniques are generally highly technical methods and complications associated with ERCP are potentially severe. Of all these ERCP-associated complications, retroperitoneal perforation is associated with a high mortality rate and must be diagnosed and dealt with promptly. We experienced ten cases of retroperitoneal perforation as an ERCP-associated complication among 4,076 ERCP procedures performed at our institution between January 1999 and May 2015 (0.25% of all ERCP procedures). We investigated the cause and management in these cases. When retroperitoneal perforation during ERCP is suspected, decompression is considered, for example by endoscopic biliary tract drainage or a nasogastric tube, and CT imaging is always performed after ERCP to confirm the severity of the retroperitoneal perforation. Emergency surgery is generally performed if fluid accumulation is observed in the retroperitoneal space on the CT scan immediately after ERCP and there are symptoms of fever or pain. Patients with only retroperitoneal emphysema on CT immediately after ERCP or patients with only a small volume of retroperitoneal fluid accumulation and no symptoms are monitored and undergo conservative treatment. Monitored patients are followed up over time for pain and retroperitoneal liquid accumulation on CT; if the symptoms or scan findings worsen, urgent consideration is given to emergency surgery before it is too late.
Endoscopic biliary drainage has been recommended for treatment of jaundice and acute cholangitis associated with pancreatic head tumors in the Tokyo Guidelines 2013. We investigated the procedures used for difficult endoscopic biliary stenting. From April 2012 to August 2013, 274 patients underwent endoscopic biliary stenting, with 5 patients (1.8%) showing difficulty in the stenting. These comprised 3 patients with difficult biliary cannulation and 2 patients with duodenal stenosis. All these patients underwent percutaneous transhepatic biliary drainage (PTBD), performed with the internal PTBD tube fistula. One in 3 patients with difficult biliary cannulation was treated with endoscopic biliary stenting using the rendezvous technique after PTBD. Two patients with duodenal stenosis were treated with duodenal stenting followed by endoscopic biliary stenting. No complications were seen in any of the patients. The gold standard for biliary obstruction caused by pancreatic head tumors is endoscopic biliary drainage, but difficult cases exist. In cases of difficult biliary stenting, it is important to use the technique of interventional radiology.
A 20-year-old female with pain in the upper abdomen was referred to our hospital for treatment of gallstones. Preoperative ERCP revealed a circular structure in the hilar bile duct. This biliary anomaly was diagnosed as a communicating accessory bile duct (CABD). Cystic duct was branching from it. Laparoscopic cholecystectomy was performed safely for preoperative ENBDT. It is very important to confirm biliary tract anomaly, especially for juvenile cholelithiasis.
An 87-year-old male admitted as an emergency with abdominal pain, diarrhea, and vomiting. At the time of admission there was severe tenderness over the whole abdomen. In addition, the serum CEA level was raised as high as 552.6ng/mL, suggesting a high inflammatory reaction. The CT imaging revealed an accumulation of ascites and free air. The patient was diagnosed as having a perforation in the digestive tract and an emergency operation was performed. Necrosis was observed broadly from the transverse to recto-sigmoid colon, so we performed Hartman’s operation. A blood test which was performed 22 days after the operation revealed that the serum CEA level had normalized to 2.4ng/mL and no malignancy was seen in the pathological examination. The final diagnosis was necrotic ischemic colitis. This may be a rare situation, but severe ischemic colitis can be involved in the pathogenesis of high serum CEA levels.
A 73-year-old woman with 3-day-long right lower abdominal pain and high fever was referred to our hospital under the diagnosis of ileus. Her abdomen was distended with tenderness throughout the abdomen. Computed tomography showed free air at subphrenic region and portal vein gas in the left lobes of the liver. It also revealed the distension and pneumatosis cystoides of the small intestine wall. An emergency operation was carried out under the diagnosis of peritonitis due to perforation of some part of bowel necrosis. Operative findings showed the small intestine was dilated but not necrotic. Following a precise examination of the ileocecal region, a perforated and necrotic appendix was discovered. An appendectomy and abdominal drainage were performed. According to the literature reports, cases of the hepatic portal venous gas due to perforated appendicitis are rare, with our case being the 7th case in Japan.
A-44-year-old woman presenting with a one-day history of abdominal pain was hospitalized. Abdominal CT imaging revealed dilatation of the small intestine and stenosis of the distal ileum. Emergency surgery was performed under the preoperative diagnosis of small bowel obstruction. A kinking stenosis of the terminal ileum was found intraoperatively to have caused the obstruction, therefore, ileocecal resection was performed. Histopathology revealed endometriosis of the ileum.
A 53-year-old man visited a local clinic with sudden onset of abdominal pain and thereafter he was referred to our hospital for further examination. CT imaging showed the presence of a retroperitoneal hematoma measuring 15cm in diameter around the right anterior pararenal space. Emergency angiography showed multiple aneurysms in the branches of the jejunal artery, left gastric artery and inferior gastroduodenal artery and extravasation of contrast medium was detected from the posterior inferior pancreatoduodenal artery. TAE was performed, but adequate hemostasis could not be obtained. Thus, operative hemostasis was selected and a ligation of the posterior pancreatoduodenal artery was performed. After the operation, stenosis of the duodenum due to ischemia occurred, but it could be successfully treated endoscopically. This patient was diagnosed as having segmental arterial mediolysis (SAM) based on his clinical features. SAM is a rare arteriopathy of unknown origin and it is usually found when intraabdominal hemorrhage occurs caused by rupture of an aneurysm. Conservative treatment with IVR is sometimes anatomically difficult in a case of rupture of branches of the pancreaticoduodenal artery and various complications might occur after TAE. When treating SAM of branches of the pancreaticoduodenal artery accompanied by rupture, it is important to select the optimal treatment including surgery.
A 38-year-old female had complained of left upper-quadrant pain after dinner on the previous day. She was referred to our hospital with a suspected internal hernia. An abdominal CT scan showed accumulation of the small bowel in the left upper abdomen and lower dislocation of the transvers colon. The preoperative diagnosis was a left paraduodenal hernia with the absence of strangulation, so elective surgery was performed the following day. Laparoscopy revealed that the hernia orifice existed in the left side of Treitz ligament. Approximately 2.5m of the herniated small bowel was easily reduced into the abdominal cavity. The hernia orifice was closed intracorporeally with interrupted sutures. The patient had an uneventful postoperative course and was discharged on the 8th postoperative day. A CT scan is considered to be an excellent diagnostic method for paraduodenal hernias and laparoscopic surgery is an efficient surgical treatment for this pathology. We report herein on a case of left paraduodenal hernia that was diagnosed preoperatively and treated laparoscopically, with reference to the relevant literature.
A 70-year-old female ingested 150mL of acidic cleaner in a suicide attempt. She attended a local clinic for treatment. However her vital signs rapidly deteriorated on the 2nd day after admission. She was then referred to the emergency and critical care center of Nagasaki University Hospital. An upper endoscopic examination on admission showed that the entire circumference of the esophageal mucosa appeared red and eroded, and the gastric mucosa appeared black. We found a large quantity of ascites and a necrotic ileocecum. It seemed difficult to reconstruct the digestive tract, since almost all of the small intestine had become red and edematous. We therefore performed a distal gastrectomy, gastrostomy, ileocecal resection and ileostomy without reconstruction. She was able to leave the emergency and critical care center on the 30th hospital day. Although almost all of the digestive tract, from the esophagus to the ileum, had been damaged, we could save this patient with the need for intestinal resection. Cases with necrosis of the digestive tract caused by ingestion of acidic substances rarely have damage reaching to the ileocecum.
A fifty-five-year-old man was admitted to our hospital with back pain and right lower limb pain with redness, swelling and tenderness in the right abdominal wall. An abdominal X-ray film showed free air image in the hepatic flexure and the right abdominal wall. CT findings showed wall thickness from the terminal ileum to the ascending colon, and a retroperitoneal abscess and a subcutaneous emphysema that infiltrated the iliopsoas, transverse obliquus muscle and latissimus dorsi. The laparotomy showed a perforation 2cm in diameter in the ascending colon. After resection of the ascending colon and cecum, drainage was performed. The pathological findings showed inflammation, fibrosis and abscess formation around the perforated diverticulum, and many diverticula in the appendix, cecum and ascending colon.
A 57-year-old woman was admitted to our hospital with upper abdominal pain and melena. BA duodenal Brunner's tumor was suspected 4 years previously. This time the patient was diagnosed as having gastrointestinal bleeding and an intussusception into the jejunum along with a Brunner's tumor, based on abdominal CT scans and duodenal endoscopy. Twelve hours after admission, severe abdominal pain and vomiting occurred. Emergency endoscopy was performed obstruction of duodenum was diagnosed because of the tumor, but endoscopic treatment was impossible. On laparotomy, the tumor was palpated over by the ligament of Treitz and the superior part of the duodenum had prolapsed into the jejunum. The intussusception was relieved and a duodenectomy was performed. Based on the postoperative pathology, the duodenal tumor was diagnosed as a Brunner’s tumor.
A 70-year-old man with essential thrombocythemia (ET), being treated with oral administration of aspirin and hydroxyurea, presented with fever and abdominal pain. His platelet count was 65.4×104/μL, while coagulation parameters were within normal ranges. Computed tomography revealed a linear structure penetrating the small intestine. Penetration by a fish bone was suspected because of a recent history of fish consumption. Emergency surgery was performed to extirpate the fish bone. However, a tendency to bleed was noted just after the surgery. On postoperative day (POD) 7, fever and abdominal pain appeared, which was accompanied by the accumulation of intestinal fluids from the drainage hole. Percutaneous abscess drainage was performed for peritonitis due to sutural leakage. Subsequently, sutural leakage was observed and the patient was discharged on POD 55. A surgical patient with ET is relatively rare and perioperative management of the pathological characteristics is difficult. We report herein on a case of gastrointestinal penetration by a fish bone in a patient with ET and review the pertinent literature.
A 31-year-old man was admitted to our hospital with abdominal pain. Abdominal CT imaging showed a “target sign” in the transverse colon, the patient was thus diagnosed as having an intussusception, and an emergency operation was performed. Intraabdominal reference with the laparoscope demonstrated the colocolic type of intussusception in the transverse colon. Because laparoscopic reduction was difficult to achieve, we performed a manual reduction under laparotomy. After manual reduction, the absence of organic disorders in the invaginated colon was confirmed. A partial resection of the colon mucosa which formed the intussusception was performed. The postoperative course was uneventful and the patient was discharged on the 9th postoperative day. Pathological examination of the resected mucosa specimen revealed evidence of an inflammatory infiltrate with some erosion. Since idiopathic intussusception in an adult is rare, we report herein on this case with a review of the relevant literature.
We herein report on a case of acute abdomen, as the first presentation of spontaneous bacterial peritonitis caused by Neisseria gonorrhoeae, which was treated by laparoscopic drainage. A 20-year-old woman attended the emergency room with severe lower-abdominal pain and fever. CT imaging showed bowel dilatation. Obvious findings of appendicitis were not found. Since her sex partner was found to have a history of recent treatment of gonococcal urethritis, and her vaginal discharge was purulent, pelvic inflammatory disease (PID) was strongly suspected. After collection of endocervical specimen, the patient underwent laparoscopic drainage, which showed her pelvic cavity was covered with yellowish-white pus with hyperviscosity. Ceftriaxone sodium and minocycline hydrochloride were initiated, and the post-operative course was uneventful. She was discharged on the 4th post-operative day. N. gonorrhoeae nucleic acid was identified from her endocervical specimen, which was negative for Chlamydia trachomatis. Gonococcal peritonitis is relatively rare but causes intense pain, and it should be considered as a possible cause of acute abdomen. Laparoscopic drainage could be useful not only for making the correct diagnosis of PID, but also to prevent peritoneal adhesion and shorten the hospital stay.
A 19-year-old male was conveyed to hospital by ambulance with abdominal contusion due to a traffic accident. A diagnosis of traumatic duodenal injury was made based on the CT examination, and emergency surgery was planned. Injury to the duodenum (second and third portion) and the right transverse colon was found, for which we performed an end-to-side duodenojejunostomy and right hemicolectomy. The patient was discharged uneventfully on postoperative day 32. Traumatic duodenal injury is often difficult to diagnose. However, if surgery is delayed, the risk of intestinal leakage is higher and the survival rate may be significantly reduced. Rather than performing only a simple closure, it is important to decompress the anastomosis and protect it from the digestive juices. Also, to eliminate any oversight, it is necessary to perform Kocher's maneuver decisively. If diagnosis can be made early after injury, a highly invasive pancreatoduodenectomy can be avoided and an appropriate procedure selected, thus offering a better chance of survival.
We present herein on a case of a spontaneous bladder rupture after radiation with a review of the relevant literature. A 68-year-old female was admitted to our hospital for sudden onset lower abdominal pain. She had undergone a radical hysterectomy for uterine cervical cancer and received post-operative concurrent radiation therapy 23 years previously. Her abdominal pain suddenly increased two hours after admission, and leukopenia and metabolic acidosis occurred consecutively. The abdominal CT showed the ascitic onset, and the patient went into shock. An emergency laparotomy was performed with a diagnosis of strangulation ileus and/or bowel perforation. We noted perforation in the cupular part of the bladder, and a primary closure was made. The postoperative course was uneventful. Whenever diagnosing a patient with the acute peritonitis symptoms, who had previously received irradiation of the lower abdominal region, we should consider the possibility of urinary bladder rupture.
Case 1 was a woman in her seventies who was admitted to our hospital complaining of epigastralgia. An abdominal computed tomography （CT） scan showed a duodenal diverticulum and air in the retroperitoneum. She was diagnosed as having perforation of the duodenal diverticulum. She was treated conservatively because she had minimal fluid collection in the retroperitoneum and the onset was quite recent. Her symptoms reduced and she was discharged from the hospital on day 19. Case 2 was a woman in her seventies who was admitted because of abdominal pain which has lasted for three days. An abdominal CT scan showed a duodenal diverticulum and air and fluid collection in the retroperitoneum. She was diagnosed as having a perforated duodenal diverticulum. We performed an emergency laparotomy, direct closure of the perforated diverticulum, an omental patch, gastrojejunostomy, and drainage of the duodenum and biliary tract. She recovered without complications and was discharged from the hospital on day 20. Perforation of a duodenal diverticulum is a relatively rare condition；abdominal CT is useful for diagnosing this disease. Conservative management is possible if the condition is diagnosed at an early stage.
A 49-year-old man was admitted to an emergency for watery diarrhea which has lasted for 7 days and general malaise. Computed tomography (CT) revealed a thrombotic obstruction in the superior mesenteric vein, portal vein and splenic vein. Intraabdominal free air, massive intestinal edema and ascites suggested intestinal necrosis and perforation, necessitating an emergency laparotomy. The massive intestine was necrotic and intraoperative ultrasonography showed thrombosis of the superior mesenteric vein, portal vein and the splenic vein. We resected the necrotic intestine and performed an ileostomy. We could not perform a thrombectomy because the portal vein thrombus extended to the distal intrahepatic portal vein. Despite intensive care he died of sepsis and multiple organ failure 3 days later. Salmonella enterica was detected from his blood, ascites and abscess fluid. We herein report on a very rare case of Salmonella infection causing severe sepsis and massive portal thrombosis in an unimmunocompromised healthy adult male.
A 57-year-old man was diagnosed as having cholecystitis in 2008, but he did not go to the hospital. He was hospitalized because of abdominal pain and vomiting, and diagnosis of gallstone ileus in September 2014. An abdominal CT scan showed a 30-mm calculus stone in the 3rd portion of the duodenum, and it moved into the jejunum. The operation was conducted because remission and relapse of the ileus symptoms were repeated. Enterolithotomy was performed with single-port laparoscopic surgery. We consider that a laparoscopic operation is the best alternative choice of procedure for calculus stones in the small intestine. We consider that the same minimal invasive operation is feasible for duodenal impact stones, because a lot of reports show that this stone moves up to the small intestine. We could see the movement of the calculus, and achieve completely minimal invasive surgery. We report herein on this rare case with ba literature review.
A 26-year-old woman had an accident on her bicycle as a result of which the tip of the bicycle handlebar, hit her upper abdomen hard. She was taken to our hospital by ambulance due to worsening pain 4 hours after the accident. Physical examination revealed diffuse abdominal tenderness with upper abdominal peritoneal irritation, and the serum amylase concentration was very high. Abdominal CT showed ascites and a high-density area at the pancreatic body. A pancreas laceration was diagnosed. Emergency surgery was performed 6 hours after the accident. Laparotomy showed a typeⅢb pancreatic injury. The Bracey method was performed in order to preserve pancreatic and splenic function. Postoperatively, there were no pancreatic fistulae or anastomotic leakage. The blood glucose level remained normal, and exocrine pancreatic function has been preserved at eight years after discharge. It is considered that the Bracey method is a suitable and safe procedure for type Ⅲb pancreatic injuries.
It is well known that a severe pelvic fracture with perineal injury might be complicated by various infections, especially occurring in perineal areas, following critical sepsis. We have saved a patient suffering from an open-book type pelvic fracture with rectal injury and broad perineal laceration, traumatic brain injury, and chest trauma, as we performed damage control strategy. In particular, we used a commercially available anal catheter as a fecal diversion for the prevention of perineal infection. We suggest that this catheter diversion method is very easy as well as highly effective for the prevention of perineal infection after severe pelvic trauma.
An 86-year-old woman with a 4-day history of recurrent abdominal pain was transferred to our hospital because of sudden onset of severe generalized abdominal pain. Her abdomen was flat, but severe tenderness, muscle guarding and rebound tenderness were present. CT imaging showed free air on the surface of the liver and mild ascites around the liver and spleen. An ileoileal intussusception was found, which contained a tumor. After the diagnosis of tumor-induced intussusception and peritonitis due to intestinal perforation, an emergency operation was performed. An anterograde intussusception was detected at 60cm proximal to the terminal ileum, and a mass was confirmed in it. Moreover, A small perforation existed just proximally to the intussuscepted intestine. Partial resection of about 60cm of the ileum was performed, including the intussuscepted and perforated intestine. In the resected specimen, a pedunculated submucosal tumor measuring 65mm in diameter at the front of the intussusception site, and an inflammatory fibroid polyp （IFP）were diagnosed histologically. It is important to consider IFP as a potential cause of intussusception and perforation of the small intestine in adults.