PURPOSE: We determined the prognostic outcome of patients with gangrenous ischemic colitis, compar ing patients with segmental disease and those with total colonic ischemia. METHODS: Patients with gangrenous ischemic colitis were investigated and reviewed for demographics, symptoms, diagnosis, treat ment, and prognosis, with data taken from cases documented over the last 10 years in Japan. RESULTS: We identified 119 patients and subclassified them into those with segmental ischemic colitis and total colonic ischemia. Mean age was 70.1 years; 50 of the 113 were men. Ischemic colitis developed during the hospital-ization of 26 of 119 during admission for an unrelated illness. Diagnosis of ischemic colitis was made preoperatively in 24 and in the operating room in the remainder. Total mortality was 31.1%. Ninety four of the 119 patients had segmental colitis, with a mortality of 17.9%, and 25 total colonic ischemia, with a mortality of 72.0%, (p<0.001, X² test). CONCLUSION: Although the prognosis for gangrenous ischemic colitis has improved slightly in the last decade, high mortality remains the hallmark in total colonic ischemia, which carries a worse prognosis than segmental colonic ischemia.

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We report herein a review of our 19 patients with spontaneous rupture of the esophagus, which include 14 of the extra-mediastinal rupture type and 5 of the intra-mediastinal rupture type. We clinically analyzed the cases in reference to the diagnosis and the treatment. Most patients complained of chest pain after vomiting, which required an early appropriate diagnosis. Emergency operations for the extra-mediastinal rupture type and conservative treatment for the intra-mediastinal rupture type achieved satisfactory results. The procedure consisted of closure of the perforation site with left thoracotomy and gastric fundic patch via the transhiatal approach. To prevent post-operative empyema and mediastinal abscess formation, insertion of a conventional thoracic drainage tube and another fixed drainage tube from the posterior diaphragm to the lateral border of the vertebral column along the thoracic descending aorta seemed effective. The patients underwent continuous irrigation and suction via these drainage tubes.

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We studied the usefulness of administering neutrophil elastase inhibitor following radical esophagectomy for cancer, examining interleukin-6 (IL-6), neutrophil elastase, C-reactive protein (CRP), and the PaO₂/FiO₂ (P/F) ratio, an indicator of respiratory dysfunction. The steroid-only (5) group included 11 patients, the steroid-plus-neutrophil elastase inhibitor (SE) group 11, and the untreated control (N) group 9. Clinicopathologic factors, operative time, and intraoperative blood loss did not differ between groups. The N group showed higher IL-6, neutrophil elastase, and CRP than other groups, while all groups showed similar changes in leukocyte count, aspartate aminotransferase, and alanine aminotransferase. The P/F ratio was higher in the SE group than in other groups from day 1 to 5 after surgery, with no difference between the N and S groups. Preoperative steroid administration thus controls cytokines and neutrophil elastase after esophagectomy for esophageal cancer, while concomitant administration of neutrophil elastase inhibitor may improve postoperative respiratory function.

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Colonoscopy is mostly performed for the diagnosis and treatment of colonic bleeding. However, in urgent colonoscopy, the preparation before colonoscopy and invasiveness for the patients must be taken into consideration, amongst other factors. The usefulness of many kinds of procedures such as thermal contact probes, monopolar electrocautery, laser, argon plasma coagulation, injection therapy, hemoclip and ligation using an O-ring has been reported. When endoscopic hemostasis fails, interventional radiology (IVR) with arterial embolization using microcoils could be performed. Furthermore, the usefulness of barium impaction therapy for colonic diverticular bleeding has also been reported. However, surgical treatment should be considered if these treatments are ineffective. There are no reports of any meta-analysis between those therapeutic procedures for colonic bleeding, therefore, further analysis for a more safe and reliable diagnostic procedure and treatment for colonic bleeding should be performed.

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Free perforation rarely occurs in patients with Crohn's disease. We studied the clinico-pathological findings in patients with free perforation due to Crohn's disease. Free perforation was seen in 6 (4.9%) of 123 patients with surgically treated Crohn's disease from 1985 through 2002 in our institute. All 6 patients were male with average age of 30.2 years, ranging from 20 to 42 years. Crohn's disease was ileocolitis in all patients. The mean duration from the onset of Crohn's disease to occurrence of the perforation was 8.5 years, ranging from 0 to 18 years. One patient was diagnosed as having Crohn's disease during an operation for free perforation in the abdominal cavity. Free perforation was identified at the time of the first operation in all patients. The site of perforation was the ileum in 5 patients and the transeverse colon in one patient. Fistulization near the site of perforation was seen in 3 patients. Operative procedures were resection and diversion in 4 patients, resection and anastomosis in one patient, and only diversion in one patient. Two of the 6 patients (33.3%) had postoperative complications. One had an anastomotic breakdown and the other had an intraabdominal abscess. All 6 patients survived. Of the 5 patients with diversion, only 2 patients (40.0%) underwent delayed reconstruction.

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Of 117 patients who had undergone surgery for the treatment of Crohn's disease in our hospital as of March 2003, twelve patients complicated with abscess formation were studied according to the region of the abcess and causal intestine. Regarding the abscess region, there were five ventral wall cases, two pelvis cases, two iliopsoas muscle cases, one paracolitic case, and one case involving both the abdominal wall and iliopsoas muscle. Conservative treatment was performed in those cases where the abscess was localized in the ventral wall only ; surgery was performed only after reduction of the abscess. Cases involving abscess in the pelvis and/or iliopsoas muscle, on the other hand, showed resistance towards conservative treatment, and required pre-surgical puncture drainage or fecal diversion. Examination of the relevant intestinal tract found that there were eight and four cases in the right and left colon, respectively. Conservative treatment was not applicable for the left colon cases. These findings suggest that there is a need to consider the suitability of conservative treatment and surgical timing, taking into account the abscess region and causal intestine, and that conservative treatment-resistant cases require early drainage including fecal diversion.

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We assessed long-term (greater than 2 years) results of Seton drainage on anal fistulas in patients with Crohn's disease. Methods: Between September 1990 and September 1999, 32 patients with Crohn's disease underwent Seton drainage for complex anal fistulas. Median follow-up was 62 months (range: 25-133 months). In 10 patients (31.3%), recurrent perineal abscesses occurred with inlying Seton dainage, and these were drained by reinsertion of the Seton device. A Malecot catheter was also inserted in 8 patients with recurrence. Results: The overall sucess of long-term Seton usage was 87.5%. The subsequent associated procedure was simple Seton removal (n=9), secondary core-out fistulectomy (n=7), or lay-open fistulotomy (n=4). Eleven patients still had the Seton in place. Recurrence developed in 3 patients (33%) who underwent simple Seton removal and in 2 (18.2%) who underwent secondary core-out or fistulotomy. At the last follow-up examination, continence had not changed in 28 (87.5%) of the 32. No change in continence was experienced by 10 of the 11 who underwent secondary fistulotomy or core-out. Conclusions: Long-term Seton drainage for complex anal fistula in Crohn's disease is efficacious both in treating sepsis and preserving anal sphincter function. A relatively good result was was achieved by secondary core-out or fistulotomy at Seton removal.

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We reviewed the effectiveness of leukocytic cell removal therapy for severe ulcerative colitis. Leukocytic cell removal therapy was performed for 16 patients with severe ulcerative colitis, leukocytapheresis (LCAP) was performed for 8 and granulocytapheresis (GCAP) was performed for 8. No patients had complete effects, 3 patients (19%) had some clinical effects, 12 patients (75%) had no effects, and 1 patient (6%) deteriorated. Three patients who had some clinical effects improved in the first week, and the deep ulcer disappeared. Twelve of thirteen patients in whom the therapy had no effects or were seen to deteriorated needed an operation. Macroscopic examination of the resected specimens revealed that all of them had extensive (3.75 areas) deep ulcers. The transverse colon and the descending colon had many more deep ulcers (75% of patients) than other areas. The effective rate of leukocytic cell removal therapy for severe ulcerative colitis was low (19%), so an operation should be performed in there patients with extensive deep ulcers or which do not improve in at an early stage.

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The incidence of ulcerative colitis (UC) has increased. Conservative medical treatment is the first step in treatment. While many difficulties may arise in attempting to treat this disease, every effort should be made to introduce surgical management. The underlying principle of surgical management is total removal of the colon and rectal mucosa. Indications for emergency surgery in UC are a sudden turn for the worse in general, acute peritonitis (colon perforation), toxic mega colon, and copious bleeding. The crucial points in management are early recognition, aggressive medical therapy, and regular review by a joint medical and surgical team. Bloody motions, together with systemic signs, including fever and abdominal pain, characterize severe acute symptoms of this colitis. It is important to detemine surgery to prevent worsening the condition of UC patients.

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The indications for urgent surgery are toxic megacolon, perforation of the colon, and massive bleeding. The appropriate procedures are colectomy, ileostomy and mucous fistula of the rectal stump. Urgent procedures are predictors of poor outcome, so the indication and optimal timing of surgical intervention require optimal interdisciplinary collaboration between surgeons and gastroenterologists. On the other hand, the outcome of elective surgery has been improved because of the development of surgical procedures including laparoscopic techniques and proctocolectomy with a restorative ileal J pouch-anal anastomosis. Laparoscopic total proctocolectomy in the hands of skilled laparoscopic surgeons is a feasible, safe and effective procedure. It does not have the disadvantage of intra-operative fluid loss, prolonged post-operative ileus, pain and, in younger patients, psychological discomfort associated with a wide scar.

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A two-or three-stage separated operation has been the usual surgical treatment for ulcerative colitis (UC). However, since 1997, we have performed one-stage restorative proctocolectomy for patients with UC. In this report, we demonstrate the outcome of those who underwent this one-stage procedure. Out of84 patients who underwent surgery for UC in our institute, the one-stage procedure was performed in 49patients (58%), who underwent analysis of the efficacy of this procedure. As for postoperative complications, minor anastomotic leakage was observed in 5 patients (10%), all of whom recovered, however, withonly conservative treatment. No significant difference existed between patients who needed an emergencyoperation and others concerning the incidence of the postoperative complication. Moreover, no significantcorrelation was found between the incidence of the complication and the dose of steroid medication priorto the operation. Postoperative bowel function was relatively good, and all of the patients could return totheir normal social life. Despite the fact that further examination is naturally required to decide under whatcircumstances one-stage restorative proctocolectomy can be indicated, this procedure may be useful toavoid multiple separated operations and a long hospital stay for patients with UC.

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Spigelian hernia is rare in all abdominal hernia. We report a case of Spigelian hernia which was broughtabout by straining. A 32-year-old man suffered a severe low back pain when he strained trying to lift a carwhich had gone over the edge of a curb and into the gutter. The pain was soon localized in the right lowerquadrant and a fist-sized bulge was present at the same place. A bulge was recognized when the patient wassitting erect, but was reduced in the supine position. In abdominal CT, no abnormalities could be seen inthe supine position, however in the prone position, intra-abdominal content was seen to protrude from theabdominal wall at the lateral side of the rectus muscle in the right lower quadrant. We operated under thediagnosis of Spigelian hernia, and found a laceration approximately 2cm long on the aponeurosis of theexternal oblique muscle. After division of the aponeurosis the hernia sac was seen, and a defect 3×3cmin size in the aponeurosis of the internal oblique muscle and transverse abdominal muscle was also revealed.The orifice was closed with an interrupted suture, followed by repair using polypropylene mesh. In this case, we considered that high intraabdominal pressure on straining might have caused the hernia.

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A 79-year-old woman was admitted to the hospital complaining of right lower abdominal distension withpain. CT scanning revealed an abscess in the abdominal wall and a contiguous mass in the peritoneal cavity.Immediate drainage was performed under a diagnosis of colonic cancer invading the retroperitoneal wall.About 300ml of pus was discharged from the abscess. After 10 days laparotomy was performed. A tumorof the ascending colon was found fixed to the retroabdominal wall. Right hemicolectomy in combinationwith resection of the abdominal wall was performed. Histological examination of the tumor showed it tobe a well-differentiated adenocarcinoma. To our knowledge, cases of colonic cancer with abdominalabscess are rarely found by chance in Japan. According to reports, the prognosis in such cases is favorable, so aggressive resection after drainage should be performed to further improve the prognosis.

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We have experienced a total of 11 cases of obturator hernia in the past 8 years. All patients were womenof a slim build. They were all elderly patients with ages ranging from 66 to 92 yrs (mean 82 yrs). Ninepatients had previously undergone abdominal surgery. At the first visit all patients presented with intestinalobstruction, and were complaining of nausea or abdominal pain. Only four patients had Howship-Romberg's sign that was characteristic for obturator hernia. All patients were diagnosed by pelviccomputed tomography (CT). The duration from the onset of symptoms to surgery ranged from 1 to 12 days, (mean 4.3 days). Right obturator hernia was found in seven cases, and left in four cases. Incarceratedintestine commonly occurred in the ileum. A Richter type hernia was found in nine cases, and completeherniation of the small intestine was found in two cases. Necrosis of the incarcerated intestine was presentin six cases. Excision of the intestine was required in eight cases. The hernia hilus was closed with directsuture of parietal peritoneum in eight cases, with suture of the pubic periosteum to the obturator fascia in2 cases, and by covering with polypropylene mesh in one case. Ten patients improved and were dischargedfrom the hospital except for one patient who died of subarachnoid hemorrhage. No recurrence has beennoted after surgery. Obturator hernia is common in lean elderly women. In instances in which ileus isconfirmed in such women, CT scan of the pelvic region under the suspicion of obturator hernia is required.

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A 5-year-old girl admitted after a 2-meters fall had abdominal pain and was in shock due to severeanemia. Abdominal CT showed her right kidney to be transected with a huge hematoma in the pararenalspace. Her left kidney was aplastic. Angiography showed bleeding from the right renal peripheral artery.We conducted transcatherter arterial embolization (TAE) using a micro coil and achieved hemostasis.TAE is thus safe and effective in controlling bleeding following blunt renal injury.

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A 16-year-old male visited his local doctor with the complaint of vomiting. Since investigations suggestedacute circulatory failure and acute renal failure, he was referred to our hospital. Plain X-ray films showedsubcutaneous emphysema extending from the neck to the precordial region, as well as marked dilation ofthe stomach and duodenal bulb. Chest CT showed subcutaneous emphysema of the precordial region andmediastinal emphysema. Abdominal CT showed dilation of the duodenum and stomach, indicating a doublebubble sign in the broad sense. Endoscopy revealed a 3 cm long esophageal perforation extending from themid portion of the esophagus to the left wall of the lower esophagus. An upper gastrointestinal contraststudy revealed dilation and obstruction of the horizontal part of the duodenum. Accordingly, he wasdiagnosed as having an esophageal rupture localized to the mediastinum, which was possibly induced by thesuperior mesenteric artery syndrome. He recovered with conservative therapy. This paper presents thedetails of this patient along with examination of previously reported cases.

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Delayed rectal stenosis following abdominal blunt trauma is extremely rare. A 60-year-old man undergoingblunt force to the abdomen in a traffic accident underwent emergency surgery under a diagnosis of leftlower limb infarction and suspicious bowel ischemia. Since operative findings showed complete occlusionof the left common iliac artery, severe damage in the pancreatic head and stomach wall, and severalmesenteric hematomas, we conducted femoral arterial bypass and pancreaticoduodenectomy. About 1 month later, he reported constipation. Stenosis of the end of the ileum, ascending colon, and rectum wasconfirmed by complete examination and surgical treatment was indicated. We conducted righthemicolectomy and low anterior resection. Histological findings showed scar formation following an ulcerby transient rectal ischemia but no malignancy. Rectal stenosis should thus be considered as a potential siteof constipation in patients having blunt abdominal trauma and it is important that this be differentiallydiagnosed from malignancy before treatment.

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A 51-year-old man was admitted to our hospital complaining of abdominal pain after a traffic accident.A computed tomography examination revealed a collection of fluid in the abdominal cavity. After 12 hours, the second computed tomography detected the presence of free air. Abdominal exploration was carried outunder diagnosis of intestinal perforation. Laparotomy revealed a 7cm laceration at the dome of the bladder.The bladder was repaired with 2-layer sutures. The postoperative course was uneventful. Intraperitonealbladder rupture must be taken into consideration in the differential diagnosis of blunt abdominal trauma.

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We report a case of idiopathic mesenteric hematoma, and review reported cases in the Japanese literature.A 55-year-old man woke up one day with pain throughout his abdomen, and visited the emergencydepartment of our hospital early on the following day. On examination, his entire abdomen appeared to beseverely painful and showed a board-like rigidity. A CT scan of the abdomen revealed intraperitoneal fluidretention, and a mass extending from the retroperitonium to the mesentery. He was admitted under thediagnosis of acute abdomen for further check-up and treatments. After admission, he showed advancedanemia. Ultrasound-guided needle aspiration yielded bloody ascites, and an emergency surgery was subsequentlyperformed. A large amount of bloody ascites was identified in the peritoneal cavity, and hematomaswere seen around the descending portion through the transverse portion of the duodenum, around theperiphery of the superior mesenteric artery, and in the mesentery. No bleeding point could be determined.The patient did not have any history of trauma, and furthermore, neither angiography nor surgery determinedthe source of the bleeding. If there intraperitoneal bleeding of unknown cause is seen in a patient, the presence of idiopathic mesenteric hematoma should be considered as a possible cause, although it is rare.

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The patient was an 80-year-old women with severe abdominal pain and a history of constipation.Abdominal computed tomography revealed free air in the pelvic space. Panperitonitis due to perforation ofthe colon was suspected, and an emergency operation was performed. A perforation was found on the rectalwall. The colon wall around the perforation was necrotic, and the colon proximal to the perforation wasfilled with many solid stools. Partial resection of the rectum and sigmoid colostomy was carried out.Operative findings and pathological findings led to a diagnosis of stercoral perforation of the rectum. Afeature unique to this case of stercoral perforation was that the patient was still capable of defecation.

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A 69-year-old man with a history of appendicitis surgery at age 7 admitted for right lower abdominal and hip pain lasting 1 week had a temperature of 37.8°C, leukocytosis, and high CRP. Computerized tomography of the abdomen showed abscess-like formations between the right psoas muscle and an ileocecal lesion, indicating a psoas abscess secondary to ileocecal infection. He was initially treated with antibiotics. There was no abnormal finding in the ileocecal lesionon barium enema or colonoscopy. After conservative therapy, he underwent laparotomy, which showed that he had never undergone appendectomy and that he had phlegmonous appendicitis with a psoas abscess. We conducted appendectomy and lavage, and the postoperative course was uneventful. This case shows that we should consider appendicitis as a possible cause of psoas abscess even in patients who supposedly have a history of appendicitis surgery.

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The presence of any association between superior mesenteric artery syndrome (SMAS) and peptic ulcers are relatively rare. We experienced a case of superior mesenteric artery syndrome in a patient with acute perforation of the duodenal ulcer. A 25-year-old man, who had previously undergone an operation for an endoceliac abscess, was admitted to the hospital because of abdominal pain and nausea. Tenderness persisted in the epigastrium. He was diagnosed as having SMAS by an upper gastrointestinal X-ray examination and a computed tomography (CT) examination. The symptoms improved after conservative treatment. An upper endoscopic examination revealed no abnormality. However, twelve days after hospitalization, he experienced stronger abdominal pain and recrudescence of SMAS was suspected by a CT examination. Thirteen days after the hospitalization, he suddenly experienced severe abdominal pain. A CT examination and an upper endoscopic examination were done. He was diagnosed as having a perforated duodenal ulcer with peritonitis and underwent an omental patch repair. During conservative treatment for SMAS, caution should be paid to the possibility of the presence of acute peptic ulcers and their perforation.

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We report a case of neuroleptic malignant syndrome (NMS) after an operation for sigmoid volvulus. A 54-year-old man who had a history of schizophrenia since the age of 18, complained of vomiting and abdominal pain, and was admitted to the hospital for acute peritonitis. Abdominal X-ray examination and abdominal CT revealed a markedly dilated sigmoid colon. General peritonitis was suspected and an emergency laparotomy was performed, which showed volvulus of the sigmoid colon with a 180°C clockwise torsion. Five days after the operation, a high grade fever (over 40°C) persisted despite administration of antibiotics and normalization of white blood cell count. The patient demonstrated extrapyramidal symptoms, and NMS was diagnosed. Although much infusion and systemic cooling was performed, the patient died suddenly five days after the operation. The autopsy showed no significant pathological changes of any tissues, (including brain, muscle, and heart.). NMS must be kept in mind as a differential diagnosis of treatment-resistant patients with high grade fever, if the any antipsychotic agents have been administered to the patient.

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A 17-year-old man was admitted for abdominal distension and was found to have colon gas dilatation or abdominal plain radiography. Based on this, a diagnosis of volvulus of the sigmiod colon was made However, no improvement of the condition could be seen on colonofiberscopy. Under the diagnosis of ileus an emergency operation was performed. On laparotomy, the cecum and the ascending colon were found tc be unattached to the retroperitoneum, and were rotated 360 degrees counterclockwise with strangulation Dilatation and hemorrhagic necrosis were seen to extend from the terminal ileum to the ascending colon and an ileocecal resection was performed. This disease is relatively uncommon and the preoperative diagnosis often presents difficulty. If a strangulated ileus is suspected, we must keep the possibility of thi: disease in mind, and it is most important to perform surgical treatment for this disease.

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A 69-year-old woman who had undergone hemodialysis for chronic renal failure was admitted to the hospital because of abdominal pain and hypotension. On admission, the abdomen was distended with peritoneal signs in the lower abdomen. An abdominal CT scan showed gas in the hepatic portal vein, but no thrombi in the mesenteric arteries and veins. Nonocclusive mesenteric ischemia (NOMI) was suspected and emergency surgery was performed. The operative findings showed bloody ascites, an unfavorable color of the small intestine and tiny air bubbles in the portal vein. Four meters of necrotic intestine was resected. Histopathological examination of the resected specimen showed no thrombi in the main arteries and veins, and NOMI was diagnosed. As NOMI may occur in hemodialysis patients, a sudden onset of severe abdominal pain should be carefully observed and NOMI was considered as the differential diagnosis.

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