Eighteen cases of pyogenic liver abscess were reviewed in regard to treatment and outcome. Percutaneous transhepatic abscess drainage and systemic antibiotic therapy were performed in all cases. The results revealed efficacy in 6/18 (E group), moderatel efficacy in 10/18 (M group), and no efficacy in 2/18 (N group). Additional treatment was performed in the M and N groups. Transcatheter hepatic arterial infusion with antibiotics was performed in 7 patients, and high-dose oral metronidazole therapy was performed in 8 patients. The arterial antibiotic infusion was effective in 5 patients, and the metronidazole therapy was effective in 6 patients. Three patients did not improve in response to drainage plus arterial antibiotic infusion or to metronidazole therapy. Combination therapy consisting of arterial antibiotic infusion and metronidazole therapy was performed in these three patients and was effective. In conclusion, abscess drainage plus antibiotic therapy is the most important initial treatment for pyogenic liver abscess thought to be due to bacterial translocation, but if it is not effective, arterial antibiotic infusion and metronidazole therapy are useful.

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[Aim] To clarify the risk factors for prolonged postoperative hospital stay indicating an endpoint of minimally invasive treatment, we analyzed cases of acute cholecystits. [Patients and Methods] Between April 1998 and December 2002, 312 patients underwent cholecystectomy for gallbladder or common bile duct stones. Of the 312 patients, 141 patients (45.1%) were diagnosed as having acute cholecystitis, admitted as emergencies, and treated by cholecystectomy. These 141 patients were divided into two groups: (a) a short hospital stay group (postoperative hospital stay no more than 7 days) and (b) a long hospital stay group (postoperative hospital stay over 7 days), and risk factors that prolonged the duration of the postoperative stay were analyzed. [Results] Age, history of upper abdominal operation, body temperature, serum CRP level presence of common bile duct stones, interval between admission and operation, duration of operation, conversion to laparotomy, and postoperative complications were significant risk factors for prolonged hospital stay in the univariate analysis. History of upper abdominal operation, body temperature, and age were significant risk factors for prolonged hospital stay in the multivariate analysis. [Conclusions] These risk factors are useful for obtaining preoperative informed consent and preparing a postoperative schedule for the clinical pathway.

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Acute appendicitis is now commonly treated by laparoscopic appendectomy. Patients who underwent operations for acute appendicitis performed in our hospital over the past three years were divided into a laparoscopic group and and an open-surgery group and compared with respect to the following parameters: sex, age, postoperative start, of oral feeding frequency of painkiller use, operation time, incidence of complications, total cost, and length of hospital stay. The results showed a longer operation time, lower incidence of complications, higher cost, and shorter hospital stay in the laparoscopic group than in the open-surgery group. The subjects were also classified into a mild disease group and a severe disease group and compared in terms of the same parameters. The advantage of laparoscopic appendectomy was highly evident in the severe disease group, but in the mild disease group the incidence of complications in the laparoscopic surgery group was to the incidence in the open surgery group. These results suggest that laparoscopic appendectomy may become the first choice of treatment for acute appendicitis.

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Untreated panperitonitis poses a poor prognosis, and requires emergency surgery. The type of drainage required, however, differs with the individual cases. We discuss drainage methods and postoperative drain management, reviewing recent issues in drainage control and abdominal compartment syndrome.

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In pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD), pancreaticointestinal anastomosis is conducted to reconstruct the organs involved. Potential anastomotic complications, however, may become fatal. We discuss such complications and the drainage applicable.Among the 258 cases with PD or PPPD we treated, 63 underwent pancreatic stump purse string suturing and pancreaticoduodenal double-layer suturing up to 1989, follwed by 195 undergoing pancreaticojejunal close contact anastomosis from 1990 on. Complications occurred in 11 of the 258 (4.26%) but this dropped to 3 of the 195 (1.54%). The latter 3 were treated conservatively using extended drainage. The key to a successful outcome is to place the drain at a point on the abdominal wall nearest to the anastomotic site at the anterior surface where it will not interfere with healing rather than through the posterior surface. We currently use a silicone Penrose drain, since it is soft, but such drains must not be left in place any longer than necessary.

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We report the results of percutaneous abdominal abscess drainage in 161 procedures (115 cases). Postcontrast CT was used to plan the puncture route and to select the guidancemodality, resulting in 95 recoveries (83%), 17 deaths (15%), and 3 surgeries (2%), by the procedures, obtained. Ultrasound-guided puncture were done in 132 procedures (82%), CT-guided in 21 (13%), and fluoroscopic-guided in 8 (5%). CT guidance was used in the pelvis and retroperitoneum and fluoroscopic guidance in cases of fistula developing after drains were removed. Percutaneous abdominal abscess drainage is thus a safe, useful intervention.

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Subjects were 29 patients undergoing drainage for liver abscesses, including 3 undergoing repeated drainage, in the last 20 years. They were 16 men and 10 women with a mean age of 59.9 years, a mean bospitalization of 74.8 days, and a mean drain insertion duration of 38.6 days. Most patients reporped fever. Of these, 9 had hepatocellular carcinoma, comprising the highest percentage. Seven underwent drainage before surgery and 22 after ward. Ten underwent hepatectomy (including micro-wave coagulonecrosis therapy), comprising the highest percentage. Staphylococcus epidermidius was detected in 8. Communication with the bile duct was observed in 8 and th with the duodenum, large intestine, or bronchus in 1 each. We discuss the clinical features of liver abscess and US-guided drainage as a strategy for liver abscess, its indications and procedures.

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Obstructive jaundice occurs in relatively mild disease and severe disease such as acute obstructive suppurative cholangitis. Since the mortality of severe cholangitis is very high, we studied approaches such as emergency biliary-tract drainage case by case. The 1 general approaches to alleviate jaundice are percutaneous transhepatic biliary drainage (PTBD) which is percutaneous transhepatic, and endoscopic nasal biliary drainage (ENBD), which is through the papilla of Vater. The choice depends on the case. We conventionally used PTBD as the treatment of choice for obstructive jaundice. With the introduction of stable endoscopy in May 1988, however, we began using biliary-tract drainage with 5Fr ENBD without using endoscopic sphincterotomy (EST), particularly for obstructive jaundice due to incarcerated common bile duct stones. The approach with 5Fr ENBD in obstructive jaundice due to choledocholithiasis incarceration is nearly as effective as PTBD, and is safe and not associated with serious complications. Since drain insertion for ENBD is difficult in some cases, however drainage should be determined case by case.

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Acute pancreatitis with pancreatic and peripancreatic necrosis involves a poor clinical course, although pathogenetic advances have improved prognosis. In sterile pancreatic necrosis, intensive nonoperative treatment including the administration of prophylactic antibiotics is essential. Patients with infected necrosis, however, require surgical intervention, which consists of necrosectomy and postoperative management entailing resection of remnant necrotic tissue and drainage. We discess the surgical management of infected pancreatic necrosis, including controversies regarding the surgical indication and timing and the choice of drainage, e.g., conventional drainage, open drainage, and closed lavage. No general consensus exists regarding surgical technique, largely because the distinction between infected necrosis and pancreatic abscess, the determination of severity, and the timing of surgery vary widely. Large prospective studies are thus required to determine optimal surgery for necrotizing pancreatitis.

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A 65-year-old man with liver cirrhosis underwent high anterior resection for sigmoid colon cancer. On postoperative day 9, he developed a high-grade fever with severe chills, and Enterobacter aerogenes was detected in a peripheral blood specimen. Because there was no evidence of leakage peritonitis, bacterial translocation (BT) was highly suspected as the cause of the bacteremia. After treatment by selective digestive decontamination (SDD) plus systemic antibiotics, the patient's condition improved and he was discharged on postoperative day 21. He was re-admitted because of adhesion ileus one month after the operation, and was treated conservatively. One day after admission, he developed a high-grade fever, and Enterobacter cloacae was detected in both peripheral blood and small intestinal fluid specimens. BT was strongly suspected, and SDD was performed again, resulting in a good, prompt response. Our case suggests that patients with cirrhosis are susceptible to BT and that SDD may be a useful therapeutic strategy against BT.

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A 91-year-old woman came to our hospital complaining of abdominal pain and distention. Abdominal US revealed marked gastric distention, and the laboratory data showed a high level of myoglobin (2, 303ng/ml) and severe metabolic acidosis (BE: -17.1mmol/l). A preoperstive diagnosis of intestinal necrosis was made, and emergency laparotomy was performed. Laparotomy revealed extensive necrosis of the stomach, and total gastrectomy was performed. The pathologiy examination showed transmural necrosis in the fundus and upper body of the stomach, and venous congestion was also observed. we conduded that the etiology in this case was venoustasis secondary to acute gastric dilatation.

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We report a case of stricture of the rectum and ureter secondary to pelvic peritonitis. An intrauterine contraceptive device (IUD) had been in place for 8 years in a 40-year-old women admitted for right lower abdominal pain. Computed tomography (CT) confirmed right hydronephritis, and severe inflammation was found around the right ovary. Colonoscopy revealed complete stricture of the rectum about 25cm above the dentate line, but the rectal mucosa was smooth. A diagnosis of stricture of the rectum and ureter secondary to pelvic peritonitis was made, and surgery was performed. At laparotomy, the pelvic mass was found to consist of an infected ovarian mass that had resulted in dense fibrosis between the right fallopian tubes, ovary, rectum, ureter, and appendix. Right salpingo-oophorectomy and appendectomy were performed and the patient made an uneventful recovery. Although there have been few reports of stricture of the rectum and ureter caused by pelvic peritonitis, pelvic inflammatory disease is more likely to occur in patients with a history insertian of an IUD.

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A 75-year-old man was referred to the department of surgery because of progressive epigastric pain with muscle guarding. He had no previous history of surgery. The preoperative diagnosis was strangulated ileus secondary to internal hernia and we performed an exploratory laparotomy. At surgery, the small intestine was found to have prolapsed through a hiatus in the omentum and to have become strangulated. Incarcerated intestine about 1 m long was resected, and the abnormal hiatus was closed. We should be alert to the possibility of strangulation because transepiploic hernias often progress rapidly to fatal necrosis of the small intestine.

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Jejunal transection produced by a blow inflicted by a human is relatively rare. We report a case of jejunal transection following blunt abdominal trauma. The patient was a 69-year-old man with alcohol dependency syndrome who after he had drunk a large guantity of alcohol and quarreled with his 22-year-old daughter was kicked in the abdomen four times with her heel. Although he complained of abdominal pain, there were no signs of peritonitis, no abnormal laboratory data, and no abnormal X-ray or abdominal CT findings. Eight hours later, rebound tenderness was noted in the abdomen, the laboratory data showed evidence of an inflammatory reaction, and abdominal X-ray and CT images revealed intraperitoneal free gas and ascites. A diagnosis of acute peritonitis secondary to gastrointestinal perforation was made, and emergency laparotomy was performed 11 hours after the trauma. The jejunum was found to have been transected 45cm distal to the ligament of Treitz. Other organs were intact. After resecting both stumps of the jejunum, primary end-to-end anastomosis, construction of a tube jejunostomy, and peritoneal lavage with drainage were performed. Although wound infection and dehiscence occurred, the patient was discharged 40 days after surgery. It is important to carefully monitor patients with blunt abdominal trauma who have no signs of peritonitis initially.

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A 58-year-old female with no history of laparotomy referred to us for vomiting, abdominal pain, and diarrhea. When first examined, she had no symptoms, and there were no abnormal laboratory data. An abdominal X-ray film and CT scan revealed mild dilatation of the small intestine, and she was admitted to the hospital for observation. On the 2nd hospital day she complained abdominal pain. Abdominal ultrasonography (US) revealed dilation of the small intestine, and no blood flow was detected by Color-Doppler US. A diagnosis of strangulated ileus was made, and emergency surgery was performed. During the operation the ileum was found to be strangulated and necrosed. Color-Doppler US was helpful in diagnoing strangulated ileus preoperatively.

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A 34-year-old female presented in the outpatient clinic with a chief complaint of abdominal pain and vomiting. A scout film examination of the abdomen and CT scan revealed a markedly expanded small intestine with a full lumen. A diagnosis of strangulated ileus secondary to postoperative adhesion was made, and emergency surgery was performed. A mass was found about 30 cm proxinal to the end of the ileum, and dilatation of the intestinal tract was observed proxinel to the tumor. A small incision in that region revealed a mass of “KINPIRA-GOBO (burdock and carrot) ” measuring about 6×3cm. The mass was considered to be responsible for the ileus and was removed to release the ileus.

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We report the case of 39-year-old male in whom a column canister (145 mm long, 33 mm in diameter) was introduced into rectum, migrated into the descending colon, and was successfully extracted by handassisted laparoscopic surgery (HALS). The patient complained of abdominal pain and diarrhea, and a foreign body in the descending colon was diagnosed based on the abdominal X-ray, computer tomography, and gastrografin enema findings. The foreign body was extracted through an incision in the sigmoid colon, and created a temporary stoma at the site of the incision. The patient was discharged on postoperative day 10. It was concluded that HALS is useful for removing foreign bodies in the distal colon.

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We report a case of hemobilia secondary to rupture of a hepatic artery pseudoaneurysm induced by percutaneous transhepatic cholangio-drainage (PTCD). The patient was a 64-year-old woman, admitted to our hospital complaining of upper abdominal pain and high fever. CT and ultrasonography revealed cholecystitis, and percutaneous transhepatic gallbladder drainage was performed. The cholecystitis improved, but higher total bilirubin values were noted, and MRCP revealed the presence of a stone in the common bile duct. PTCD was performed. When the catheter was inserted, blood drined out of it, but the bleeding stopped within 24 hours. On the 3rd day after PTCD, cholecystectomy and choledocholithotomy were performed. No bleeding was detected during the operation, but hemobilia occurred on the 10th, 64th and 88th days after surgery. On every occasion the bleeding stopped spontaneously. After the 3rd episode of hemobilia, we performed abdominal angiography and detected a pseudoaneurysm. The pseudoaneurysm was no longer seen during the second abdominal angiography examination, and prophylactic embolization was performed with 5 micro-coils. The hemobilia has not recurred since the embolization.

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A 57-year-old man was admitted to our hospital 25 days after a traffic accident in which he was the driver of a car and experienced blunt trauma produced by his seat belt. His chief complaint was vomiting and abdominal pain. Conservative therapy resulted in remission of the symptoms, and he was discharged. On the 48th day after the injury the vomiting and abdominal pain recurred, and he was admitted. Enterography and endoscopy showed pinhole-like stenosis in the ileum about 20cm proximal to Bauchin's valve, and the stenotic region was diagnosed as delayed post-traumatic stricture. The affected small bowel was resected, and examination of the resected specimen revealed an annular ulcer. Histopathological study revealed ulceration and fibrosis in the stenosed segment of the small intestine. This is the first case in which endoscopic findings contributed to making a definite diagnosis of delayed post-traumatic stricture of the small bowel.

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A 21-year-old female with a history of bulimic eating disorder developed acute abdominal fullness and severe pain after consuming a large amount of food and being unable to induce emesis. The physical findings and laboratory values on admission were unremarkable. A plain of the film abdominal and CT scan of the abdomen revealed a markedly distended stomach, and mild pleural effusion and ascites, but did not show free air. An upper G1 series showed no evidence of gastric perforation. Despite adequate nasogastric decompression, her clinical condition deteriorated. Purulent ascitic fluid was obtained by paracentesis, and exploration of the abdomen revealed perforation of a thin and necrotic anterior wall gastric that was tightly adherent to the surface of the liver and abdominal wall. Total gastrectomy and abdominal drainage were performed, and the postoperative course was uneventful. Histopathologic examination showed no underlying gastric pathology, and the perforation was presomed to be secondary to pressure necrosis of the chronically distended gastric wall and increased intragastric pressure caused by the habitually self-induced emesis. The successful outcome of this rare and unusual case of gastric perforation makes early recognition of this unique patient population and prompt surgical management necessary.

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