We have been studying the influence of surgical stress by investigating cytokine. The place producing cytokines after surgical insult is still unclear. We thought that the clarification of this point might develop the selection of surgical procedure as well as perioperative management. We investigated the production of cytokines from the liver, lung, and peritoneum during and after surgery. These studies were performed in patients undergone hepatectomy, esophagectomy, laparoscopic surgery, and open surgery. As a result, the lung and peritoneum produce high levels of cytokines, but not liver. In particular, a patient having ARDS, the cytokine production form lung tissue obtained after intrathoracic procedure was extremely high compared with other patients. Furthermore, cytokine production from the peritoneum in patients undergone laparoscopic surgery was lower than that in patients having open surgery. These results suggest that the control of cytokine levels after surgery may prevent ARDS and laparoscopic surgery may be associated with lower degree of surgical stress. We also investigated the influence of moderate hypothermia on acute pancreatitis using a rat model. Moderate hypothermia inhibit the elevation of cytokine levels as well as pancreatic enzyme. Moderate hypothermia therefore may be clinically applicable for reducing the severity of acute pancreatitis.

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To evaluate the usefulness of computed tomography (CT) in differential diagnosis and decisions for operative indications in patients with acute appendicitis, CT was done in 45 patients diagnosed with acute appendicitis. CT was retrospectively analyzed for the following findings: enlarged appendix, hazy periappendiceal density, increased enhancement of the appendiceal wall, deficiency of the appendiceal wall, appendiceal stones, abscess, and ascites. Surgery was conducted 28 patients, of whom 25 were pathologically diagnosed with gangrenous or phlegmonous appendicitis. Seventeen improved without surgery, i. e., 9 with acute appendicitis, 7 with diverticulitis of the colon, and 1 with pelvic peritonitis. Except for 3 with severe abscess, enlarged appendix, hazy periappendiceal density, and increased enhancement of the appendiceal wall were observed in 22 with phlegmonous or gangrenous appendicitis. In 25 with phlegmonous or gangrenous appendicitis, appendiceal stones were observed in 32% and abscess or ascites in 60%. Sensitivity, specificity, and accuracy in CT diagnosis images were 100%, 80%, and 96%. CT findings thus provide useful information in differential diagnosis and decisions on operative indication in patients with acute appendicitis.

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Hypercytokinemia, an important cause of systemic inflammatory response syndrome is considered to result from local production of inflammatory cytokines at the inflammation site. We used a rat experimental peritonitis model to test whether locally produced cytokines could be eliminated by peritoneal dialysis using a polymyxin-B immobilized fiber column (PMX-F). The experimental peritonitis model in rats was produced by cecal ligation and puncture, and animals were assigned to 2 experimental groups i. e., 1 group undergoing peritoneal dialysis with PMX-F (PMX-F groups) and 1 without PMX-F (controls) 3 h after peritonitis induction. The concentration of IL-6 and IL-10 in ascitic fluid in rats with peritonitis in the PMX-F group was significantly lower than in controls. In addition to the fact that locally produced inflammatory cytokines induced apoptosis of neutrophils indirectly prevents tissue injury, the elimination of cytokines can prevent the inflammatory response that occurred in peritonitis and prevent ultimate progression into multiple organ dysfunction syndrome. These results suggest that peritoneal dialysis with the PMX-F column in early septic insult may help prevent hypercytokinemia and resultant SIRS / MODS.

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To evaluate bridge therapy to living donor liver transplantation (LRLT) in fulminant hepatic failure (FHF), we examined 12 patients with FHF undergoing different treatment, judgment of guidelines for liver transplantation of the Japanese Acute Hepatic Failure Study Group, grade of encefphalopathy, grade of hepatic atropy, and outcomes. Subjects were 5 men and 7 women aged 0 to 60 years (mean: 32.7 years). The cause of FHF was hepatitis B in 4, unknown in 8. Hepatitis involved 5 acute and 7 subacute. Encephalopathy was grade II in 7, grade III in 3, and grade IV in 1. Prothrombin time in 4 was 10%. After ALS, 4 were treated with living-related liver transplantation (LRLT) and 3 survived. Five died without LRLT and only 3 survived without LRLT. The significance of bridge therapy for FLF is thus considered adequate ALS and appropriate timing of LRLT.

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Abdominal injuries in children are generally classified into blunt and penetrating. We divided blunt abdominal injury into Group A, abdominal injury caused by linear force horizontally across the abdomen and Group B, abdominal trauma caused by other than linear force. Traumatic injury in group A involved the pancreas and luminal organs such as the duodenum, and in group B, involved parenchymatous organs such as the liver, spleen, and kidney. In group A, many cases had only intraabdominal organ injury and had no other injury except to the abdomen. In group B, many cases had multiorgan injuries in abdomen and other parts. This classification is useful for pediatric patients with blunt abdominal trauma in identifying injured organs and starting prompt, appropriate therapy.

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Ten patients who had been receiving long-term glucocorticoid treatment underwent emergency abdominal surgery at our hospital between 1994 and 2002. Glucocorticoids had been administered for the treatment of rheumatic arthritis (n=5), allergic angiitis (n=2), ulcerative colitis (n=1), and blood diseases (n=2). The mean daily glucocorticoid dosage was 24 mg. Serum levels of ACTH and cortisol were low, but within normal limits. Emergency operations were performed because of an acute abdomen: 4 peptic ulcer perforations, 2 small bowel perforations, 1 ileus, 1 steroid-ineffective ulcerative colitis, and 2 colon perforations. The operative procedures consisted of a gastrectomy, 3 omental patches, 2 small bowel resections, 2 colostomies and a total colectomy. Perioperative steroid cover was performed in 9 patients. The morbidity rate was 70%. The complications consisted of surgical site infections (n=2), sepsis (n=4), abdominal ruptures (n=2), and peptic ulcer bleedings (n=2). The mortality rate was 30%. Because the general condition of patients receiving glucocorticoids sometimes worsens in spite of unclear symptoms, treatment indications for acute abdomen should be decided as soon as possible.

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Sabjects were 18 patients receiving glucocorticoids to treat rheumatic arthritis (7), progressive systemic sclerosis and dermatomyositis, systemic lupus erythematosus, malignant lymphoma (2), blood disease (3), ulcerative colitis (2), acute respirocirculatory failure, and intracranial hypertension after neurosurgery undergoing emergency abdominal surgery between 1992 and 2002. The mean daily glucocorticoid dosage was 54.5 mg for 41.9 months. Emergency surgery was done due to acute abdomen accompanying 7 infections (4 of cytomegalovirus, 2 of neutropenic enterocolitis, and 1 of tuberculosis 1), 8 worsening of the original disease (4 of ischemia of the intestinal tract were included), 2 peptic ulcer perforations, and 1 sigmoid colon diverticulum perforation. Perioperative steroid supplementation was done in 14 patients. Morbidity was 77.8%. The 35 complications involved wound infection, anastomotic failure, multiple organ failure, etc., and were observed in 14 patients. Mortality was 33.3% (6 cases). Due to high morbidity and mortality in patients taking glucocorticoids, the activity of the original disease must be evaluated prior to treatment of acute abdomen.

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Thirty-two patients who had been on steroids for extended periods and undergone emergency abdominal surgery during the past 14 years were compared against 207 patients who had also undergone emergency abdominal surgery but had not been on steroids. The disease entities for which the use of steroid administration was indicated were: Inflammatory bowel diseases (10 cases); collagen diseases (9); hematologic diseases (6); cancer (4); and others (3). Among the diseases that required emergency surgery, the incidences of perforating peritonitis and gastrointestinal hemorrhage were high in those who had been on steroids (21 cases or 65.7% and 8 cases or 25.0%, respectively). For the surgical procedures that required anastomoses of the organs of the digestive tract, one-stage anastomotic procedures were normally avoided. Intestinal fistulization with the aid of a tube or stoma creation were more likely choices for those who had been treated with steroids. Among those who were judged during surgery that one-stage anastomosis was possible, suture failure occurred in only one case. Postoperative complications occurred at a higher frequency among those who had been treated with steroids. The higher incidence of surgical wound infection in this group can also be explained by the more frequent occurrence of perforating peritonitis. The incidence of complications and their prognosis differed by the identity of the primary disease that required the use of steroids. It was believed that active treatment of the primary disease is necessary even after emergency surgery.

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Here, we report our experience with emergent surgery for the treatment of inveterate bowel lesions in patients with a history of prolonged steroid therapy. Twelve patients with a mean age of 39.5 years were treated at our hospital. The duration of steroid treatment ranged from six months to nine years, with a median of two years; the preoperative steroid (prednisolone) dosage ranged from 5 mg to 30 mg/day. The underlying diseases in the patients were Behcet disease (n=4), systemic lupus erythematosis (SLE; n=3), ulcerative colitis (n=3), polyarteritis nodosa (PA; n=1), and systemic sclerosis (SSc; n=1). The reasons for surgery were perforation (n=5), bleeding (n=6), and ileus (n=1). We performed 5 anastomoses, including one tube ileostomy, and 7 ileostomies or colostomies. Our postoperative strategy was to minimize the steroid cover dosage used to control the underlying disease, and to pay strict attention to postoperative infections and wound healing. Five bowel anastomoses were successfully performed, while three of the seven ileostomies or colostomies were unsuccessful and required emergent re-operations; one patient died while in the hospital. Ileostomy or colostomy is generally thought to be safe in patients with peritonitis or other deteriorating conditions; however these procedures are not always safe in cases undergoing emergent surgery after prolonged steroid therapy. In such cases, the surgical method and steroid management must be carefully chosen.

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Of the 611 patients having undergone surgery for ulcerative colitis in our department, 131 who required emergency surgery were evaluated for the present study. Their surgical indications were: Severe/fulminant type, 60 cases; massive hemorrhage, 39; perforating type, 17; and toxic megacolon (TMC), 15. The mean duration of their illnesses was 36 months (range, 1 to 336 months). The total amount of steroids administered before surgery was 9, 094.5mg (range, 726.5 to 72, 622.5mg) and the mean pre-operative daily dosage was 60mg (5 to 80mg). Prior to 1997, a 3-stage surgical procedure was the standard format but since 1998 when the Harmonic Scalpel was introduced, a 2-stage procedure has come to dominate the scene. After 2000, even one-stage surgery has been conducted in some selective cases. When focused on early complications for these surgical formats, Total colectomy conducted in 3 stages (n=96) resulted in hemorrhage from the residual rectum in 4 cases and fatalities due to conditions such as septicemia occurred in 5 (including one case with hemorrhage). Among those patients who had undergone the 2-stage procedure (n=26), no fatality was noted during the early period after surgery. Only a few patients (n=4) have undergone the one-stage surgical procedure; two developed early complications related to a surgically created pouch. No early postoperative complications were noted after the following procedures: Total colectomy ileostomy (n=2) and Hartmann's surgery followed by IAA + ileostomy with a stoma closure during the third stage (n=3). Of the 131 patients who were subjected to emergency surgery, the procedures were adequate in preserving the anus in 123 (93.7%). Among the remaining 8 cases, 5 suffered fatal outcomes and 3 underwent reconstruction of enterostoma. It was concluded that if the systemic conditions of the patients are carefully weighed and an optimum surgical procedure is selected, the clinical outcome from emergency surgery for ulcerative colitis is satisfactory.

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Among patients with ulcerative colitis undergoing surgery, 18-50% had steroid side effects of osteoporosis, psychosis, myopathy, infection, neuropathy, diabetes, hypertension, thrombosis, avascular necrosis of the femoral head, peptic ulcer, growth retardation, glaucoma, and premature cataract. The incidence of these side effects was significantly higher in patients given more than 10, 000 mg of prednisolone. Avascular necrosis of the femoral head, psychosis, growth retardation, and thrombosis were recognized in patients given less than 7, 000 mg. Surgery should be considered when patients have irreversible side effects or were given more than 10, 000mg of prednisolone. Postoperative steroid-related complications, such as wound infection, intraabdominal abscess, anastomotic leakage, steroid withdrawal syndrome, and wound separation developed in 30% of 297 patients undergoing surgery. Although most were controlled, reoperation was needed in 7.7%. Three (1.0%) died of MRSA infection, pneumocystis carinii infection, or liver dysfunction with ARDS. The incidence of wound infection, intraabdomninal abscess, and general complications (cytomegalovirus infection, candidiasis, pseudomonas aeruginosa infection, MRSA infection, and liver dysfunction with ARDS) was higher in patients with severe colitis, emergency surgery, and given more than 300mg/month of prednisolone. To reduce the incidence of severe postoperative complications, it is important to recognize steroid-related complications preoperatively.

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A rare case of acute pancreatitis accompanied by pancreatic abscess penetrating the colon is reported. A 54-year-old man with severe acute pancreatitis induced by a gallstone was administered intraarterial infusion of Urinastatin, Nafamostat mesilate, and Imipenem/Cilastatin, which improved his general condition but a pancreatic abscess developed. Although the abscess cavity was reduced by hyperbaric oxygenation therapy, oral food intake of aggravated inflammation. No apparent fistula between the abscess cavity and the upper gastrointestinal tract was detectable preoperatively. Surgery showed a retroperitoneal abscess at the pancreas tail extending to the transverse mesocolon. The abscess was drained a large amount of feces was drained on the fifth post operative day on postoperative day 5, Relaparotomy showed a fistula between the abscess cavity and the transverse colon near the splenic flexure. Partial resection of the transverse colon and abscess drainage wase done. Pancreatic abscess penetrating the colon may occur as a complication of severe acute pancreatitis.

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We report a case of small cecal cancer with symptoms suggesting acute appendicitis. An 82-year-old woman with pain in the right lower abdomin in April 2003 was diagnosed with appendicitis. Based on physical and CT findings, appendicitis with abscess formation around the cecum was confirmed, and emergency surgery done. The operative diagnosis was a perforated appendicitis. The root where the perforation had occurred was disconnected during the operative procedure and required ileocecal resection since it was impossible to directly suture the defect. Pathological study showed local peritonitis due to cecal cancer perforation at the orifice of the appendix. The tumor was 15×10mm and histological by diaguosed as well-differentiated adenocarcinoma with serosal invasion. Cecal cancers accompanied by symptoms suggesting acute appendicitis are rare, i.e., 0.1%, and are reported after reaching an advanced stage. Accordingly, it is important to consider the existence of malignant neoplasms in such cases, especially in older patients. The incidence of advanced colon cancer with a diameter 2cm or less is 0.5%.

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A 64-year-old man who tried to commit a suicide by stabbing himself in the abdomen with a chopstick and hurling himself against a wall while jailed has found to be conscious level and to have stable vital signs. The abdomen was soft and flat. The complexion was not pale. The chopstick was fixed in the umbilical region. Abdominal CT showed it had penetrated the inferior vena cava and stuck in the lumbar vertebral body. There was no obvious abdominal bleeding or free air. We diagnosed inferior vena cava injury from chopstick impalement and conducted emergency surgery. The chopstick had penetrated the jejunum about 30 cm distally to Treitz's ligament and the inferior vena cava about 2 cm cephalically from the common iliac vein. We sutured the hole at the inferior vena cava and jejunum. We conducted another investigation though the abdominal cavity but found no other injury. The clinical course was uneventful and he discharged on postoperative day 16. When a penetration wound stabilizeds and vital signs are stable, CT is very useful in diagnosing injury in an abdominal stab wound.

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We report a rare case of small bowel obstruction due to a Richter inguinal hernia and enterolith. A 71 year -old man with no history of abdominal surgery admitted for preshock, abdominal pain, and vomiting evidenced slight tenderness in the upper abdomen but neither muscular defense nor the sign of Blumberg. Abdominal computed tomography (CT) showed the small intestine to be dilated, leading us to suspect an inguinal hernia. Abdominal ultrasonography (US) showed part of the ileal incarcerated in the inguinal hernia orifice and an enterolith with an acoustic shadow. Based on a diagnosis of small bowel obstruction due to a Richter inguinal hernia and enterolith, we conducted emergency surgery. On laparotomy, we released the strangulated hernia and found that a small part of the ileal wall 40 cm oral from the ileum evidenced ischemic change and confirmed the presence of a hard 4 cm enterolith, so we partially resected the ileum and repaired the inguinal hernia. The solidly spongy enterolith was 5×3cm.

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A 64-year-old man diagnosed with schizophrenia at 27 years of age old and admitted to our psychological ward often ate inedible objects (pica), which were spontaneously excreted. In April 2001, he developed fever and was treated with an antipyretic, but fever continued and abdominal pain occurred. He was examined by X-ray and ultrasonography 2 days after onset. Perforated peritonitis due to swallowed batteries was suspected, and he underwent emergency laparotomy. During laparotomy, the ascending colon was found to be perforated by 1 of 2 small batteries. Lodged in the colon wall an ulcer was detected aroude the perforation. Most cases of gastrointestinal perforation by foreign bodies are due to the sharp objects, and this is, to our knowledge, the first report of colon perforation by a small battery.

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The foramen of a Morgagni hernia is a rare form of diaphragmatic hernia. We report laparoscopic repair of Morgagni hernia in a 89-year-old woman with partial colon obstruction. After removing the transverse colon and omentum from the hernia sac, we incorporated a Composix Mesh^R over the defect and fixed it with staples. The patient recovered immediately after hernia repair and has remained free of recurrence and complaints in the 6 months since surgery.

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A 33-year-old married woman who had consulted several doctors, including gynecologists, in a two-week period was admitted for severe abdominal pain. A diagnosis of chlamydeous infection not detected until a blood test it on admission was found. She underwent exploratory laparoscopy, appendectomy, lavage, and drainage, following tentative remission with conservative treatment. Light-yellow clear ascites, a violinstring adhesion between the surface of the liver and peritoneum, and a swollen appendix were identified. The definitive diagnosis was Fitz-Hugh-Curtis syndrome in conjunction with acute and chronic appendicitis. Although it is not a frequently encountered acute abdominal condition, the recognition of this syndrome is crucial for diagnosis. Operative measures are not always needed for the disease. Laparoscopic surgery, however, should be taken into consideration for both diagnosis and treatment, when there is a progressive condition or failure to respond to conservative treatment.

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A 73-year-old woman seen on October 2, 2002, for abdominal pain was found in abdominal CT to have a swollen gallbladder, bladder calculi and air in the gallbladder, and an abscess near the gallbladder. She was diagnosed with acute cholecystitis accompanied by gas-producing anaerobes. She was treated with CZOP and PTGBD, which resulted in drainage of a vile suppurative bile. She developed reduced consciousness and breathing with jaw movement appeared 2 hours after treatment. The patient's blood chemistry data changed suddenly (pH 6.7, Hb 3.2g/dl, and K 7.5mmol/l) and macrohematuria was found, suggesting severe hemolysis. The patient was immediately placed under respiration control, but died 6 hours after PTGBD treatment. The result of a bile culture test revealed C. perfringens. These bacteria contain a hemolytic exotoxin, referred to as a-toxin, that causes severe thrombosis and DIC in microcirculation, followed by multiple organ failure. It was concluded that the level of C. perfringens had increased in the patient's gallbladder and in the hepatic abscess around the gallbladder under ischemic conditions due to acute cholecystitis, and that PTGBD treatment had led to sepsis.

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A 76-year-old woman admitted for femoral pain had suffered from recurrent monthly pain for 4 years. Intervals between attack became shorter. Pelvic CT scan revealed an incarcerated small intestine between the right pectineus muscle and the internal obturator muscle. Symptom disappeared in 30 minutes. A second pelvic CT scan showed no incarcerated intestine. From these findings, the hernia was thought to have been reduced spontaneously. The patient underwent elective surgery. The hernia hilum was covered with a Teflon mesh plug. Spontaneous reduction in obturator hernia is not known widely, and such patients may have been inaccurately diagnosed. Emergency pelvic CT was useful in definitive diagnosis, which is why health care professionals in all departments should be made awave of this condition.

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A 81-year-old man who had undergone a loop colostomy in the right upper abdomen for colonic obstruction 2 years before, was referred for severe colostomy prolapse and signs of intestinal obstruction. The prolapse, which was difficult to reduce, was about 30 cm, and marked discoloration of the bowel wall was observed. An emergency laparotomy through a midline incision found a protruded mass composed of a prolapsed sigmoid colon and an incarcerated intestinal loop 50 cm long. Resection of the strangulated small intestine and primary anastomosis was done, and the elongated, partly gangrenous sigmoid colon resected and a new double-barreled colostomy constructed at the new site (left lower abdomen). The incidence of colostomy prolapse is 7-25%. To prevent severe complication, staff should ensure careful postoperative observation and adequate treatment.

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We report a case of mesenteric rupture due to air bag injury in a traffic accident. A 44-year-old man driving a compact car and using a safety belt crashed, at which time the air bag was activated. Although he had slight lower abdominal pain on admission, he reported severe pain about 24h later. Abdominal CT showed fluid in the lower abdominal cavity, suggesting perforation of the small intestine. Surgery showed regional necrosis of the small intestine 40cm long. We have treated 2 other cases of mesenteric rupture due to air bag injury in traffic accidents, and cannot over emphisite the importance of close observations of these patients for physical findings and blood and imaging examinations to evaluate intraabdominal injury and enable adequate and immediate interventions.

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There is a high incidence of leakage after surgery for duodenal injury because the repair site is exposed to activated pancreatic juices and bile. Current surgical procedures cannot prevent anastomosis selfdigestion. We encountered duodenal injury during right nephrectomy for renal cell carcinoma, so, we conducted complete pancreatic drainage with a pancreatic tube placed through the papilla of Vater and biliary drainage with a tube placed in the bile duct through a cystic duct. These drainage methods are more straightforward than current procedures for duodenal injury. In this case, we conducted this procedure for intraoperative duodenal injury, but we believe this technique could be applied to traumatic duodenal injury.

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A 77-year-old man admitted for right hypochondralgia, vomiting, and jaundice has a medical history of duodenal ulcer, hypertension, and diabetes mellitus. Blood laboratory studies evidenced severe inflammatory response with jaundice and liver dysfunction. Results of plain abdominal X-ray, ultrasonography, and computed tomography showed intestinal gas, air in the gallbladder, and intrahepatic bile duct. The patient was diagnosed with emphysematous cholecystitis and ileus resulting from panperitonitis, necessitating cholecystectomy and abdominal drainage. The gallbladder was surrounded by gangrenous pus but not perforated. Cultivation of the bile juice detected Clostridium species. The postoperative course was uneventful, and the patient was discharged on postoperative day 17. There is a high risk of gallbladder necrosis and perforation with emphysematous cholecystitis, necessitating early diagnosis and appropriate treatment. This report presents a case study of emphysematous cholecystitis with ileus.

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A case of surgical resection for ruptured large hepatocellular carcinoma with acute abdominal pain is reported. A 75-year-old woman seen for sudden abdominal pain was found in abdominal ultrasonography to have a huge mass in the liver and she was slated for surgery. Abdominal computed tomography detected a nodule in the liver 20 cm in diameter, together with shight ascites. She underwent central bisegmentectomy using an anterior approach after transfusion for anemia, since her vital signs were stable on admission except for anemia. She was discharged on postoperative day 34. She has been followed up as an outpatient with no recurrence during these 6 months. We report this case with some literary discussion about the treatment of ruptures involving large hepatocellular carcinoma tumors.

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