We reviewed patients with left colorectal obstruction or perforation to evaluate the efficacy of primary anastomosis and laparoscopic surgery. From July 2001 to March 2003, 18 patients with left colorectal obstruction or perforation underwent surgery involving 7 emergency operations and 11 semiemergency operations (emergency operations after preoperative decompression). Based on informed consent, 11 underwent primary anastomosis and 7 endocolostomy. No significant difference was seen between anastomosis and colostomy groups in lesion sites or preoperative risk factors, although age was significantly higher in the colostomy group. Two postoperative complications in the anastomosis group involved 1 small intestinal necrosis and 1 anastomotic leak. One wound infection occurred in the colostomy group. Laparoscopic surgery was done in 5 patients who recovered from ileus by preoperative decompression and gave informed consent for laparoscopic surgery. Although conversion to conventional open surgery was necessary in 1 patient, complications due to laparoscopic manipulation were not observed in the laparoscopic group. In conclusion, primary anastomosis is safe and effective in patients with left colorectal obstruction or perforation. When preoperative decompression of the intestine is successful, laparoscopic surgery leads to a minimally invasive strategy.

View full abstract

Background and objective: Emergency open surgery has conventionally been indicated in large-bowel obstructions due to colorectal cancer. The use of transanal tubes to decompress obstrucions has enabled us to avoid emergency open surgery and use subsequent laparoscopic surgery, so we make it our primary strategy in treating obstructive colorectal cancer to try transanal decompression first, followed by laparoscopic surgery. We examined the validity of this strategy. Methods: Colorectal cancer decompressed with transanal tubes was reviewed retrospectively to compare laparoscopic (n=9) and open (n=7) surgery results. Result: Mean operative time for laparoscopic surgery was longer than in open surgery but blood loss tended to be less and the duration of pain significantly shorter. No complications specific to laparoscopic surgery occurred. Conclusion: Our series shows that laparoscopic surgery is less invasive and provides equivalent or better morbidity compared to open surgery even in large-bowel obstruction, as long as transanal decompression is successful. Although the long-term outcome of laparoscopic surgery remains to be clarified, the combination of transanal decompression and laparoscopic surgery is minimally invasive for treating obstructive colorectal cancer.

View full abstract

We reviewed 101 acute abdominal surgery patients randomly extracted from among those treated in the last 5 years. Of these, 9 were identified with deep candida infection. Risk factors associated with deep candida infection identified were indwelling IVH catheter, artificial ventilatory assistance, administration of more than 5 antibiotics, MRSA infection, and long fasting. All patients of deep candida in fection were found in a compromised state. Five of the 9 had serious infection with intestinal leakage, esophageal perforation, or colon perforation, and 1 had an abdominal emergency with pancreatic cancer, while another was suffered severe malnutrition. Candida colonization commonly is preceded by candidemia. Oral or enteral feeding combined with several antifungal agents produced significant, rapid recovery from candidemia in 8 of the 9 patients. Predisposing factors for deep candida infection in acute abdominal surgical patients are considered to involve microbial translocation of patients with compromised perioperative status.

View full abstract

Identification of minute quantities of microbe-specific DNA has been made possible by using polymerase chain reaction (PCR). PCR assay is widely used to analyte very small quantities of bacteria and virus and cancer genes. PCR assay could be used to greater advantage, however, in the field of surgery. Highly sensitive assays are essential for detecting fungi in the blood of patients, since their blood samples are rarely culture-positive. We detected Candida DNA in the blood of patients with surgical infection, and analyzed its sensitivity and specificity, and its usefulness for clinical application, compared to bacteria culture and fl-D-glucan levels. We found that PCR assay is more sensitive than blood culture for detecting fungi in the blood of septic patients. Candida DNA is well detected from blood in patients with gastric ulcer perforation, ulcerative colitis, enteritis due to radiology, and postoperative suture deficiency. PCR assay requires little blood and results are obtained quickly, making this technique useful for detecting fungi in patients with surgical infection.

View full abstract

The Candida gene is detected 2 ways: by DNA assay and by RNA assay. Reverse transcription PCR is used to detect Candida RNA in patients suspected of having deep mycotic infection (DMI). Real-time PCR assay for Candida is done by optical automatic processing, without agarose electrophoresis. The sensitivity and specificity of this assay were higher than results for blood culture. Since a definitive diagnosis of DMI is difficult, however, PCR assay is meaningfut diagnostically in auxiliary diagnosis. The British Society for Antimicrobial Chemotherapy working party published recommendations and proposed a number of clear indications for initiating antifungal therapy. The Infectious Diseases Society of America summarizes current knowledge and recommends treatment for multiple forms of candidiasis. The 4th Mycosis Forum published Japanese guidelines for DMI. In terms of surgery, DMI is classified into proven, clinically documented, and possible. In terms of critical care, however, no steadfast diagnostic method is recognited.

View full abstract

Surgery for advanced biliary tract malignancy, such as extended hepatectomy or pancreatoduodenectomy, may cause the patient excessive surgical stress resulting in an immunocompromised state facilitating mild pathogenic bacterial and fungal infection. We recognized the fungus in half of our postoperative patients. This fungus might be a cause of refractory infection. Of patients who had more than a 7-day period of systemic inflammatory response syndrome (SIRS), 5 evidenced fungal infection by positive culture and/or a serum beta D-glucan level of 20 pg/ml/ or more. Four of the 5 developed acute hepatic failure. Three of the 5 were treated by fluconazole and all were negative for culture and serum beta Dglucan, and 2 recovered from SIRS. These results suggest that early presumptive therapy for fungal infection may prevent postoperative acute hepatic failure. Monitoring culture and serum beta D-glucan is thas useful in managing postoperative fungal infection.

View full abstract

A review of fungal infection after living and cadaveric donor liver transplantation found that invasive fungal infection caused high mortality in liver transplant recipients. Several specimens, including pharyngeal swabs, nasal swabs, urine, and feces were cultured before liver transplantation and if a fungus was isolated, it was treated by fluconazole. Routine preoperative bowel preparation was done orally by fluconazole and kanamycin for 3days before surgery and by amphotericin B gargle. Fluconazole was given intravenously for fungal prophylaxis for the first week after surgery. From the second week, fluconazole was given orally for another 1 or 2weeks. Recipients with suspected fungal infection underwent chest or abdominal computed tomography when appropriate and fundoscopy for Candida endophthalmitis, and suspected sites of infection were cultured. Invasive fungal infections identified included βD glucan, Candida, Aspergillus, and Cryptococcus antigens, and were treated with an initial dose of fluconazole (200-400mg/day), amphotericin B (0.2-0.3mg/kg/day), miconazole (10-15mg/kg/day), or micafungin (100-150mg/day). More than half of invasive fungal infections were caused by Candida organisms. Meningitis caused by Aspergillus had high mortality. To manage fungal infection in liver transplantation, it is therefore important to determine the preoperative care and postoperative role of prophylaxis, empiric, and preemptive therapy.

View full abstract

Surveillance culture of Candida and serodiagnostic testing are useful diagnostic tools for starting empiric therapy for suspected cadidiasis in surgical patients. A cutoff value for β-D-glucan for false positive reactions to the plasma concentration of β-D-glucan has been discussed. We administered fluconazole to 64 postoperative patients with Candida colonization who had risk factors for candidemia and reported persistent fever despite prolonged antifungal therapy. We then analyzed clinical outcome. Sucess was 28%. When the cutoff value was 20pg/ml, the positive predictive value was 47%, the negative predictive value 91%, efficiency 69%, the φ coefficient 0.42, and the odds ratio 13. When the cutoff value was 40pg/ml, the positive predictive value was 72%, the negative predictive value 89%, efficiency 84%, the φ coefficient 0.61, and the odds ratio 21. Further investigation thus is needed to determine a more accurate cutoff value for β-D-glucan plasma concentration.

View full abstract

We report 2 cases of food-induced ileus caused by rice cakes. Case 1: A 66-year-old woman admitted for abdominal pain and vomiting presented with tenderness, muscle guarding and peritoneal irritation in the abdomen. Computed tomography revealed dilatation of the small intestine and a high density “tumor” in the small intestine. The patient, whose blood pressure was 74/36mmHg, was diagnosed with ileus accompanied by shock, necessitating emergency surgery. White solid foreign matter was found in the ileum about 30cm on the oral side of the ileum end. The intestine was incised and rice cakes were removed. Case 2: A 76-year-old woman admitted for right hypochondrial pain and diagnosed with obstruction of the small intestine was found in CT on admission to have high-density “tumors” in the stomach and small intestine. Rice cakes detected in endoscopy yielded a diagnosis of food-induced ileus caused by rice cakes. CT on the day after addmission showed that rice cakes in the stomach had moved to duodenum and those in the small intestine also moved. Conservative treatment eliminated the symptom. In patients with food-induced ileus caused by rice cakes, rice cakes appear as high-density “tumors” in the intestine in CT, which is useful in diagnosing this problem.

View full abstract

A 34-year-old woman admitted with abdominal pain and vomiting a day before parturition at 38 weeks pregnancy was found in plain abdominal X-ray, abdominal CT, and contrast radiography of the small intestine to have possible strangulated ileus. During surgery, stenosis of the ileum was noted at 50cm proximal to the ileocecal valve due to the torsion of Meckel's diverticulum 4.5×4cm at the site. Meckel's diverticulum was twisted about 360°clockwise at the neck and necrotic. Torsion is a rare complication of Meckel's diverticulum. Distal ampulla and the prelum of the gravid uterus may have led to torsion in this case.

View full abstract

A76-year-old woman admitted with severe anemia and general fatigue had undergone aortic valve replacement due to aortic valve stenosis 18 years earlier and had been receiving warfarin as an outpatient. A gastric ulcer was revealed in upper GI examination and an antiulcer drug begun and warfarin stopped. Anemia gradually progressed, requiring blood transfusion. SMA angiography showed no extravasation, but the wall of the distant ileum was strongly stained and early venous return observed. Hemorrhage scintigraphy showed ^99mTc-labeled RBC accumulation in the terminal ileum 6 hours later, necessitating surgery on hospital days 30. Under cautious examination by intraoperative endoscopy, a tiny blood oozing point was detected at the jejunum 60cm from the Treitz ligament and the small intestine was partially resected. Macroscopically, no abnormal finding was detected in the resected specimen. Histological examination showed thin-walled dilated tortuous vessels spread in the submucosal layer. These findings were consistent with a diagnosis of angiodysplasia. The patient is now on aspirin and no-bleeding has recurred.

View full abstract

A 29-year-old man with blunt abdominal trauma due to a traffic accident referred to our hospital was diagnosed with hepatic and pancreatic contusions. He was hemodynamically stable, so conservative treatment was attempted, but abdominal pain developing on the fourth day, necessitated enhanced CT. It showed increased intraabdominal fluid, suggesting complete transection of the pancreas. We immediately drained the peritoneal cavity and omental bursa. Pancreatic fistula developing postoperatively did not improve with conservative therapy, including fasting, subcutaneous administration of a somatostatin analog, protease inhibitor, and fibrin-stabilizing factor, necessitating fistulojejunostomy 7 months after initial surgery. Minor leakage at the anastomotic site improved conservatively. He was discharged 2 months after the second surgery and has been followed up as an outpatient. Given 2 alternatives in surgical choice, we chose fistulojejunostomy rather than distal pancreatectomy because the patient was young and was important to preserve pancreatic function.

View full abstract

The splenic or renal artery is a common site for intraabdominal arterial aneurysm. We report a patient with an aneurysm of the accessory middle colic artery who underwent nonemergency surgery. A 49-year-old man with upper abdominal pain and nausea was found in clinical examination to have no anemia but to have a tender mass in the left upper abdomen. Abdominal computed tomography and ultrasound examination showed a mass suspected to be an intraabdominal hematoma. An aneurysm of the accessory middle colic artery was consequently diagnosed by abdominal angiography. Intraoperative findings showed retroperitoneal hematoma on the left side of the transverse mesocolon, causing upper jejunal obstruction, necessitating left colectomy and partial jejunal resection. The postoperative course was uneventful. This is the third case report of an aneurysm of the accessory middle colic artery in the Japanese literature.

View full abstract

The incidence of acute pulmonary embolism (APE) has been increasing in Japan. We report 3 cases of APE after gastrointestinal surgery from January 1999 to December 2002. The latest was treated with compression stockings and intermittent pneumatic compression to prevent APE. One patient suffering from massive brain infarction died of a cerebral hernia. We saved 2 patients, one treated with catheter intervention under percutaneous cardiopulmonary support (PCPS) and another treated with anticoagulation after the insertion of an inferior vena cava filter. Gastrointestinal surgery patients have many clinical risk factors, such as prolonged immobility, cancer, surgery involving the pelvis, and pneumoperitoneum caused by laparoscopic surgery. The diagnosis of pulmonary embolism remains difficult, because its symptoms and clinical findings are not necessarily specific. We must therefore consider APE as a critical complication after gastrointestinal surgery. It is important to introduce PCPS immediately in the seriously ill, and to simultaneously maintain the patients breathing and circulation.

View full abstract

A febrile 61-year-old man admitted for abdominal pain and vomiting was found in physical examination to have right localized lower abdominal tenderness without rebound tenderness and guarding. Abdominal ultrasonography did not show a swollen appendix. On hospital days, abdominal pain increased and his temperature reached 40°C with shaking chills. Preoperative blood cultures were taken. Abdominal CT showed a barium stone and gas in the swollen appendicular lumen, but no ascites. Emergency laparotomy showed an inflamed, nonperforated appendix with hemorrhaging at the tip. Pathologic examination showed a gangrenous appendicitis. Escherichia coli was isolated from both blood and pus in the appendicular lumen. Sepsis associated with nonperforated appendicitis is rare, and we surmise that abdominal ultrasonography failed to detect the swollen appendix because of gas in the lumen.

View full abstract

We report a case of intussusception due to lipoma of the ileum diagnosed by abdominal CT. A 71-yearold man seen for abdominal pain was diagnosed with ileus in abdominal plain X-ray. Abdominal CT showed a concentric circular image of prolapsed small intestine and the presence of a tumor presenting a lowdensity area at a portion suspected to be the head of the prolapse. Intussusception due to the tumor was suspected and emergency surgery done the same day. Laparotomy, showed over 5 cm of the ileum, to be invaginated 340 cm from the Treitz ligament. After the invaginated ileum was reduced manually, the ileum was partially excise due to a 2-cm elevated lesion with a broad peduncle at the head of the prolapsed portion. Histological diagnosis was benign lipoma. The postoperative course was uneventful. Intussusception in adults is relatively rare and accounts for about 5-10% of all cases of intussusception. Small bowel tumor is also relatively rare and may be difficult to diagnose preoperatively. In the diagnosis of this disease, abdominal CT is thus very useful.

View full abstract

A rare case of duplication cyst of the ileum was definitively diagnosed by emergency preoperative imaging at hospitalization for acute abdomen. The 42-year-old man diagnosed elsewhere with acute abdomen was found in preoperative abdominal ultrasonography to have a possible duplication cyst of the ileum. Based on abdominal CT and superior mesenteric angiography, a definitive diagnosis of duplication cyst of the ileum was made. Laparotomy showed an extraintestinal duct that communicated with the adjacent ileum. This duct was lined with small intestinal mucosa and ectopic gastric mucosa. Inflammation was apparently secondary to the accumulation of intestinal contents in the duct-like structure and its walls had become dilated, leading to acute abdomen.

View full abstract

We report successful surgical treatment for a large retroperitoneal tumor with blast crisis in chronic myelocytic leukemia (CML). A 26-year-old man reporting general fatigue and leg pain was found on admission to have hemoglobin of 4.3g/100ml and a WBC count of 564, 100/μl. CT showed marked splenomegaly and hepatomegaly and a large retroperitoneal tumor. Chemotherapy was done based on a diagnosis of blast crisis in CML. After chemotherapy was started, his WBC count decreased marked, but the retroperitoneal tumor showed marked growth, reaching to the pelvic cavity. On day 6 after admission, he suffered multiple organ failure including the lung, kidney, liver, and heart. Under respiratory and cardiovascular failure, splenectomy and resection of the retroperitoneal tumor were done. The postoperative course was uneventful, and he was discharged on postoperative day 26. He has been free from recurrence for 9 months after surgery. This case demonstrates that surgery is an option even in serious blastic crisis of CML.

View full abstract

We report emergency acute appendicitis in a patient with hemophilia A. A 25-year-old man reporting acute lower abdominal pain was diagnosed with acute appendicitis with peritonitis. The dosage of recombinat factor VIII (octocog alfa) was decided based on the formula of Abildgaurd, and an appendectomy with drainage was done. Postoperative factor VIII activity on postoperative day (POD) 1 was maintained at 80-100%. Postoperative factor VIII activity on POD 3 deteriorated to 20% and was less than the theoretical value. Postoperative kinetics examination on POD 3 showed early degradation of blood factor VIII activity, compared to the theoretical half-life of octocog alfa. Factor VIII metabolism thus appeared to be inconsistent perioperatively. This suggests that a kinetics examination is necessary in factor VIII replacement therapy after emergency surgery.

View full abstract

A 68-year-old man admitted for a right chest injury from pruning shears was on admission found to be lucid and alert. Physical examination showed that the intestine was damaged due to the chest injury. A diagnosis of traumatic diaphragmatic hernia necessitated emergency surgery. The right diaphragm was torn near the costal part but other organs, including the liver and right lung, had been damaged beyond two perforations in the small intestine. Directly sutures and partial ilectomy led to completely recovery an uneventful postoperative course.

View full abstract

We report a case of acute superior mesenteric artery (SMA) embolism treated in a second-look procedure after embolectomy. A 69-year-old man with a 10-year history of hypertension and atrial fibrillation admitted for sudden onset of severe abdominal pain was found on admission to have spontaneous pain throughout the abdomen, a weakened intestinal murmur, and tenderness in the upper abdomen. Contrastenhanced CT showed a low-density area in the SMA. SMA angiography showed complete occlusion of the SMA trunk. Transcatheter infusion of urokinase had no effect. Emergency laparotomy was done 8 hours after onset. The moderate segment of the intestine showed cyanotic change, necessitating embolectomy of the SMA. About 24 hours after embolectomy, a second-look procedure showed the small intestine near Treitz's ligament to be necrotic for 220cm, necessitating resecction of the necrotic small intestine with a primary anastomosis. The patient was discharged 1 month after surgery. The second-look procedure is thus recommended in patients with equivocal viability of the bowel after revascularization.

View full abstract

A 77-year-old woman reporting lower abdominal pain was found in computed tomography (CT) to have a large amount of ascites and free air in the pelvic cavity. Perforation of the digestive tract was suspected preoperatively, necessitating emergency laparotomy. There ware no abnormal findings in the alimentary tract. The uterus had a perforation 5 mm in diameter in the fundus, from which purulent fluid flowed. Based on a diagnosis of uterine cancer, we conducted total hysterectomy with bilateral salpingooophorectomy and intraperitoneal drainage. The definitive diagnosis was pyometra by histological examination. There was no evidence of malignancy. The culture of purulent fluid in the uterus showed nonhemolytic streptococcus. Although a ruptured pyometra presenting as pneumoperitoneum is very rare, physicians should consider the presence of perforated pyometra, especially when elderly women report acute abdominal pain.

View full abstract