From January 1990 to June 2000 the imagery from 26 patients with small bowel perforations following blunt abdominal trauma was retrospectively reviewed regarding the appearance of the free air detected by computed tomography (CT). CT did not always demonstrate free air in the early phase after blunt abdominal trauma. In 19 cases, 21 CT scans were performed. In 6 of the 19 cases (32%), free air was detected by CT. Detection of free air by CT was seen to be related to the time interval after injury. Free air was detected by CT in 13% within 4 hours, 75% between 4 and 12 hours, and 100% over 24 hours. As for the outcome, most of the patients who underwent laparotomy in the early phase after blunt abdominal trauma died due to hemorrhagic shock, but not small bowel perforations. The time interval between the injury and surgery was not correlated with the outcome. In addition to the primary survey, we strongly recommend careful observation from12 hours to 24 hours after injury and appropriate re-evaluation with CT.

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An early decision regarding the treatment strategy for acute cholecystitis is extremely important, as patients are often elderly and have other diseases and complications. The aim of this study is to compare the efficacy and usefulness of percutaneous transhepatic gallbladder drainage (PTGBD) and percutaneous transhepatic gallbladder aspiration (PTGBA) as the initial treatment for patients with acute cholecystitis. (Patients and methods): From January 2000 to August 2003, 19 patients with acute cholecystitis for whom drainage was needed were treated with PTGBD, and 16 patients with PTGBA. We compared the efficacy, usefulness, and side effects of those two procedures. (Results): Patients became asymptomatic, and their objective findings and laboratory data improved remarkably after the first procedure in all cases of PTGBA. The ease of procedure was an advantage, and patients could safely proceed to the next step, such as a scheduled operation or conservative treatment. On the other hand, although PTGBD is more reliable than PTGBA, it limits the patients' activity. It is also often painful, and there is a possibility of dislocation of the PTGBD tubes. These are great disadvantages, especially for elderly patients. (Conclusion) The short term efficacy of PTGBA and PTGBD is the same. However PTGBA is safer than PTGBD. It should be the initial treatment of choice for patients with acute cholecystitis, especially for the elderly.

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The surgical outcome of bile duct stones in very elderly patients (90 years of age or older) is associated with a high risk. On the other hand, endoscopic sphincterotomy (ES) is a safe and effective treatment for bile duct stones in very elderly patients in addition to younger patients. The incidences of early and late complications are acceptable for very elderly patients. For very elderly patients with acute cholangitis, nasobiliary drainage without ES is advisable, particularly when the patient is critically ill. Definitive treatment of bile duct stones using ES should be deferred until the acute cholangitis resolves. Biliary stenting is a reasonable alternative for difficult bile duct stones. Very elderly patients who have undergone ES for bile duct stones are expected to have a survival rate as long as that of the general population. ES is useful for treating very elderly patients with choledocholithiasis.

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Common duct bile stones (CBD) stones can often be fatal, and treatment for this disorder is mandatory, even in the case of the very elderly patient. We evaluated the usefulness of endoscopic treatment for elderly patients with CBD stones. A total of 701 patients with CBD stones were studied. We classified patients into three groups according to age: more than 85 years old (super senior patient); 75-84 years old (senior patient); and less than 75 years old (non-senior patient). We compared clinical features, outcomes of the endoscopic treatment, and complications among each group. In all 3 groups, about 90% of patients were successfully treated with EPBD or EST. We found no significant difference in the occurrence of complica-tions among the three groups. In the super senior patient and senior patient groups, however, we found in -hospital death. Endoscopic treatment for the elderly patients with CBD stones was useful, but should carefully performed. Other treatment options should be considered in patients at high risk of complications.

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The strategy of first choice at this hospital for emergency treatment of gallstones in the extremely elderly, that is, cases 80 years old or older, is endoscopic nasobiliary drainage (ENBD) with EST for cholangitis, and percutaneous transhepatic gallbladder drainage (PTGBD) for cholecystitis. Bile duct stones are treated by endoscopic sphincterotomy (EST) and lithotomy. There are also instances in which asymptomatic gallstones in the gallbladder are allowed to remain after choledocholithotomy. We conducted an analysis of the results of therapeutic endoscopy for cholangitis in the extremely elderly, that is, patients 80 years old or older out of the 899 cases in which therapeutic endoscopy was performed over the last 20 years, 140 sessions of the procedure were performed in 135 emergency cases over the age of 80. There were 3 deaths all the 3 were serious cases already suffering from MOF, and were among the early cases when ENBD was placed without EST. There have been no deaths since 1992, when the treatment policy was changed to ENBD with EST, with the goal of providing definitive drainage, and in regard to complications, 1 case of post-EST bleeding and 5 cases of aspiration pneumonia were noted. Thus, therapeutic endoscopy for cholangitis has minimal complications and is a safe and useful procedure even for the elderly. Concomitant use of ENBD with EST is useful for obtaining definitive drainage, and EST with its small incision is useful in terms of preservation of the papillary function as well as safety.

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The best approach to the treatment of bile duct stones in the extremely elderly is still under debate. Since 1992, we have been performing laparoscopic choledocholithotomy as the standard treatment procedure for bile duct stones, and during these past 13 years, we have performed the procedure in a total of 271 cases. For this study, the patients were divided into two groups according to age (≥80 years of age, 30 patients and≤79 years of age, 241 patients), and the clinical features, risk factors, mean surgery time, mean hospital stay, and postoperative complications were compared between the two groups. The results were almost similar in both the groups. It was concluded that the laparoscopic operation is safe and effective for the treatment of choledocholithiasis even in the extremely elderly.

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In recent years, the possibility of medical treatment with little stress and short hospital stay and early social rehabilitation has increased. For example, the treatment of cholelithiasis has changed greatly with the spread of laparoscopic cholecystectomy (LC). From January 1988 to March 2003, we treated a total of 2, 383 cases of gallbladder and common bile duct stones, consisting of 795 cases (75.3%) of gallbladder stones and 588 cases (24.7%) of common bile duct stones. When the cases were classified according to the age group, there were 134 cases in the super-elderly age group, that is, 80 years of age or older, including 118 cases in their 80's and 16 cases in their 90's. The surgical treatment procedure adopted in these 134 patients included open laparotomy in 69 cases (open cholecystectomy in 26 and common bile duct explora-tion in 43), a laparoscopic procedure in 16 cases (LC in eight and common bile duct exploration in eight), EPBD in 17 cases, ESWL in nine cases, PTPBD in six cases, EST in four cases, PTCSL in three cases, and ten drainage tube retention in 10 cases (PTGBD in five and PTBD in five). There were seven hospital deaths, which tended to occur in elderly subjects with serious underlying disease or complications; four of the seven patients had heart failure, two had CRF and one had pneumonia.

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Three cases of adult intussusception with a malignant tumor are reported. Case 1: An 81 year-old man was admitted to the hospital because of right lower quadrant pain. Ascending colon cancer was confirmed by CT and colonofiberscopy. A curative operation consisting of a right hemicolectomy was performed. Case 2: A 63 year-old man, who had undergone a left upper lobectomy for left lung cancer 7 months previously, was diagnosed as having small intestinal metastasis from the original lung cancer, and palliative partial resection of ileum was performed. Case 3: A 59 year-old woman was admitted to the hospital because of melena. A rectal mass was confirmed by digital rectal examination, CT and colonofiberscopy were performed, which revealed intussusception associated with colon cancer. A Hartomann procedure was carried out since manual reduction was difficult. Making a preoperative diagnosis of intussusception has recently become easier through the development of diagnostic modalites. As most of cases of adult intussusception are associated with malignancy, however, and it demonstrates a variety of extensions, the most appropriate surgical procedure must be chosen on a case-by-case basis.

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We report a case of Pneumatosis cystoides intestinalis of the ascending colon associated with portal vein gases following acute drug intoxication. A 19-year-old woman was admitted to our hospital because of acute sleeping drug intoxication and was given medication. We then started a detailed investigation of her severe abdominal pain. Laboratory data showed leukocytosis, and Pneumatosis intestinalis of the ascending colon associated with portal vein gases was observed on the abdominal CT scan. An operation was performed under the diagnosis of suspected panperitonitis. The intraoperative findings showed that the ascending colon was partially congested, and a pneumatosis-like lesion was also observed at the same part of the colon. A right hemicolectomy was performed and the resected specimen microscopically exhibited severe inflammation, congestion and severe edema, and necrotic changes in the submucosal area and numerous gram-positive rods were also present around the pneumatosis. These features are highly suggestive of gas-producing bacterial infection due to ischemic colitis.

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An 80-year-old man was admitted to our hospital with vomiting. On admission, his abdomen was distended, but he had no abdominal pain or tenderness. He had a history of gallstones and generalized contractures of unknown etiology. Plain abdominal X-ray films showed massive gaseous dilatation of the small bowel in the upper abdomen. Upper gastrointestinal endoscopy showed a depressed lesion resembling a diverticulum in the anterior wall of the duodenal bulb. Abdominal CT revealed a segment of the small intestine compressed by a round calcified mass (20mm in diameter), marked intestinal distension, pneumobilia, and thickening of the gallbladder wall. These findings suggested a gallstone ileus. ESWL was applied following conservative therapy because of the high-risk status of the patient. After 8 sessions of ESWL, the ileus resolved.

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We report a case of penetration of the descending colon by an ingested fish bone diagnosed with computed tomography. An 85-year-old woman was admitted our hospital complaining of severe left lower abdominal pain. On physical examination, tenderness and rebound tenderness were noted in the left lower abdomen. A conventional abdominal X-ray showed no subphrenic free air, but an abdominal CT showed an abscess with gas in the retroperitoneal space and a high density foreign body 3cm in diameter through the thickened wall of the descending colon. On hearing that the patient had eaten cooked sea bream at dinner two days before admission, we diagnosed the problem as a penetration of the descending colon by an ingested fish bone. An emergency operation was performed, and a partial resection of the descending colon and abscess drainage were carried out. The foreign body was a fish bone, 3cm in diameter, and was removed from the thickened descending colon wall. The preoperative diagnosis of a perforation or penetration by a fish bone is very difficult. Our case suggests that hearing the history in detail and examining the computed tomograpy are useful to diagnose cases of fish bone perforation or penetration.

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Spontaneous esophageal rupture is invariably treated via a thoracotomy. We treated a case of a spontaneous esophageal rupture complicated with pyothorax and mediastinitis with a laparotomy via the transhiatal approach, the pedicled omental covering procedure and external esophageal drainage using a T-tube. A 48-year-old man on steroid medication for bronchial asthma was admitted to our hospital because of severe dyspnea and vomiting after drinking. An esophageal rupture was revealed with chest X-ray, esophagography and CT scan, and was treated with right chest drainage. An operation was performed 11 hours after the onset of the symptoms with a laparotomy. We expanded the esophageal hiatus manually and found pus and debris at the right thoracic cavity and left mediastinum, and recognized a 5 cm longitudinal tear in the right anterior wall of the esophagus just above the diaphragm. Through the esophageal hiatus, we irrigated and debrided the right chest cavity and left mediastinum. After lavage, we instituted tran-shiatal drainage of the right cavum thoracis and left mediastinal space. We closed the ruptured esophageal wall, started external esophageal drainage using a T-tube, and applied a pedicled omental flap over the suture site. Oral intake was resumed 14 days postoperatively, and the T-tube was removed 30 days postoperatively.

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We report a case of an abscess in the lateral abdominal wall and an intractable cutaneous fistula due to a gallstone lost in a laparoscopic cholecystectomy (LC) performed two years earlier. A 74-year-old man who had undergone an LC for cholelithiasis and chronic cholecystitis two years previously was seen at the hospital because of a right flank tumor after an uneventful postoperative course. Under the diagnosis of an abscess within the right oblique muscles, debridement and drainage were performed, but purulent discharge persisted from the wound site for more than three months. An abdominal CT scan showed a low density area in the right lateral abdominal wall and on the lateral surface of the right lobe of the liver. A fistulography revealed a fistula extending up to the lateral and inferior surface of the liver and around the radiolucent area denoting a lost gallstone. As the abscess and fistula were considered to be caused by the gallstone dropped during the previous LC, we removed the stone, and performed a fistulotomy and peritoneal drainage. The patient recovered uneventfully and has been free from recurrence for four years after the operation.

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A 77-year-old man consulted another hospital for abdominal pain. Although the serological examination revealed an inflammatory change, the patient was treated with only oral antibiotics because the abdominal findings were not so severe. Four days later, he was admitted to our hospital complaining of abdominal pain. The physical examination and laboratory data indicated acute circulatory and renal failure. Abdominal computed tomography revealed perforated acute emphysematous cholecystitis. After consultation with our department, an emergency laparotomy was performed. About 900ml of yellowish pus existed in the abdomen, and the basis of the gallbladder has been perforated. A cholecystectomy and drainage were performed. No stone existed in the gallbladder. Pathological examination of the surgical specimen revealed acute gangrenous cholecystitis. The ascites culture was positive for Escherichia coli. Artificial ventilation was needed for 5 days, and the course after weaning off the respirator was uneventful. The patient was discharged on the seventeenth postoperative day. Acute emphysematous cholecystitis is a relatively rare disease, but the mortality rate is high. On examination of elderly patients with acute abdominal pain complicated with diabetes mellitus, hypertension, cardiovascular and cerebrovascular diseases, acute emphysematous cholecystitis must be taken into consideration. It is important to perform an early diagnosis based on abdominal CT and to start proper treatment before the condition becomes severe.

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A 34-year-old man with an 11-year history of Crohn's disease was admitted to our hospital because of abdominal pain. The abdominal pain developed suddenly after he underwent balloon bouginage under endoscopic guidance for a narrowed transverse colon segment and contrast media flowed out into the abdominal cavity. Abdominal computed tomography (CT) showed free air and intrahepatic gas and the patient was diagnosed as having a colonic perforation with portal venous gas. Surgery was performed and postoperatively, his clinical course was good. The portal venous gas disappeared on an abdominal CT performed 16 days after the operation. It is possible that increased alimentary canal pressure and mucosal injury during endoscopy caused the portal venous gas in this patient.

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A 69-year-old man, who was suspected of having acute pancreatitis at another hospital, was admitted to our hospital due to a concomitant giant aneurysm of the left common iliac artery (LCIA). Abdominal CT scan and MRI revealed the giant aneurysm of the LCIA, a hemorrhagic pancreatic pseudocyst and a pseudoaneurysm of the splenic artery. Emergency abdominal angiography showed bleeding from a branch of the dorsal pancreatic artery communicating with the pancreatic pseudocyst and subsequently to the major pancreatic duct. He was eventually diagnosed as having hemorrhage from the pancreatic pseudocyst complicated with hemosuccus pancreaticus and with a giant aneurysm of the LCIA. Successful coil embolization was carried out, first of the pseudoaneurysm, followed by the splenic artery. The aneurysm of the LCIA was then embolized with coils, following by a bypass with a femorofemoral artery graft. The authors consider that combinations of various therapeutic methods, including interventional endovascular procedures, can be useful in highly risky cases.

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We performed laparoscopic surgery for foreign body perforative peritonitis due to the incarceration of a swallowed denture in the jejunum. The patient was a 54-year-old man. Although he noticed the loss of his left posterior denture after dinner four days previously, he did not suspect misdeglutition. Occasional abdominal pain had developed since the day before admission. He underwent an emergency medical examination because the abdominal pain became continuous during the evening before admission. Plain radiographic examination of the abdomen found clasps of the denture and a small amount of intestinal gas in the left abdominal region. Although CT examination also showed similar findings, there was no suggestion of perforation. Under a diagnosis of suspected perforative peritonitis due to a foreign body within the small intestine due to the presence of the peritoneal irritation sign in the left hypogastric area and leukocytosis, a partial jejunal excision was performed under the laparoscope and the denture was successful-ly removed on the same day. Although one of the clasps was incarcerated in the jejunum about 60cm from the Treitz's ligament, no perforations were observed. The patient's postoperative course was excellent, and he was discharged from the hospital on the 10th postoperative day.

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We report a rare case of a perforated duodenal diverticulum. An 83-year-old-man was admitted to our hospital complaining of right hypochondralgia. Conservative treatment was performed but the abdominal pain persisted. CT examination showed the presence of abnormal air in the right retroperitoneal space and abdominal cavity. Emergency surgery was performed following a diagnosis of perforation of the digestive tract. An abscess in the retroperitoneal space was removed after duodenal mobilization and a perforated diverticulum with an intestinal stone was detected at the lateral side of the second portion of duodenum. It was resected and the duodenal wall was sutured after insertion of a T-tube. The postoperative course was uneventful and the T-tube was removed 30 days after the surgery and the patient was discharged. This patient had undergone distal gastrectomy reconstructed with the Billroth II method in the past. A review of the relevant literature indicates that the existence of the blind loop may be one of the factors that led to the perforation. Thus, if a duodenal diverticulum is detected during a distal gastrectomy reconstructed with the Billroth II method, it may be beneficial to perform an introversion on the duodenal diverticulum in order to prevent perforation.

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We experienced a patient with a solid pseudopapillary tumor (SPPT) detected incidentally during an examination for abdominal trauma. A 9-year-old boy fell down some stairs at his school and sustained blunt trauma to the abdomen. He showed facial pallor and was brought to our hospital for medical examination. A Focused Assessment with Sonography for Trauma (FAST) revealed retention of at least 800ml of fluid in the abdominal cavity. Abdominal computed tomography (CT) with contrast medium revealed a low density area measuring approximately 10cm in the facies anterior pancreatis. An emergency operation was undertaken for treatment of retroperitoneal hematoma and intraperitoneal hemorrhage. The intraoperative findings showed a tumor containing ruptured hemorrhagic clots in the facies anterior pancreatis. The tumor mass was found to have originated from the pancreas, and was excised by resection of the body and tail of the pancreas. The tumor mass was diagnosed as SPPT by histopathological examination. The postoperative course was favorable, and there was no impairment of glucose tolerance. The patient was discharged on hospital day 15. SPPT, which generally occurs in women in their late teens to the 30s, is a relatively rare pancreatic tumor. There have been fewer than 40 reports of male SPPT cases. In conducting a thorough review of the extensive literature concerning SPPT, we found 20 cases including our present case in which the condition was detected incidentally during a medical examination to assess trauma.

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