Purpose: We examined indications for transcatheter arterial embolization (TAE) in cases sustaining blunt abdominal trauma in rural areas. Methods: Twenty-five trauma cases in which TAE had been performed in our hospital were retrospectively studied. Injured organs, classification of injury, other traumas, embolized vessels, time from arrival to TAE, blood transfusion volume, reaction to volume resuscitation, complications, surgical procedures, assessment by the trauma and injury severity score (TRISS) method, outcome and the survival rates were analyzed. Results: The average injury severity score (ISS) was 32. Twelve patients did not receive a blood transfusion before emergency TAE. Five patients survived offer TAE in eight non-responders. Four of the patients required surgery for hemostasis after TAE. Three patients died, but these three deaths were unpreventable. Conclusions: In hospitals located in rural areas, preparation for blood transfusion takes a long time. TAE is first performed followed by an operation in the treatmeut of unstable blunt abdominal trauma cases.

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Recently, the rapid development of interventional radiology has meant that transcatheter arterial embolization (TAE) of visceral or UGI hemorrhage can be performed safely and effectively. The advent of newer coaxial catheterization techniques has, in particular, greatly improved the embolization of small tortuous vessels. TAE has been used to control emergency visceral, or upper gastrointestinal (UGI) hemorrhage. Preoperative angiography has played an important role in facilitating the surgical management with or without TAE. Embolization is useful to decrease blood flow and to stop bleeding temporarily, even if we can embolize only the afferent artery. Less invasive TAE, by which diagnosis and treatment can be performed simultaneously, should be performed for treatment. In this section we explained how to control visceral arterial hemorrhage or UGI hemorrhage with hemobilia.

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The incidence of trauma-related vascular injury is low, and in general, surgeons rarely encounter this type of injury. However, vascular injury may result in a fatal outcome if surgery is not performed promptly enough. The presence of vascular injury should therefore always be considered in treating trauma patients in the condition of shock. Vascular injuries in the portal system are classified into those in the portal vein alone and those as a complication of traumatic abdominal organ injury. In Japan, the percentage of sharp injuries is low, and that of vascular injury as a complication injury is high. Recently, injury as a complication of traumatic abdominal organ injury has been treated with TAE even when the organ injury is severe. However, surgery is indicated in patients showing unstable hemodynamics with injury in a major vessel in the portal system as a complication. For surgery, rapid exposure of the injured site and hemostasis with accurate repair are important. Portal vein injury is repaired by a simple suturing, patch plasty, end-to-end anastomosis, graft replacement, or ligation according to the degree and the status of injury. The technique must be selected based on the morphology and grade of vascular injury, concomitant injury of other organs, grade of contamination, and the patient's general condition. To achieve this, general surgeons also should learn vascular surgical procedures.

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The aim of this study was to investigate the features of intraoperative massive bleeding during procedures in the pelvic space. We studied 322 consecutive patients from 1998 to 2002 who sustained massive blood loss (>500ml) during abdominal surgery. The patient group consisted of 175 cases of digestive or gynecological malignancy, 35 of injury, 30 of aortic aneurysm, 17 of hepatic/pancreatic malignancy, 11 of perforated peptic ulcer, 10 of cholecystitis, 9 of bowel obstruction, 9 of benign colonic tumor, 4 of perforated acute appendicitis and 22 of other diseases. Seventy-eight (24.2%) of these patients underwent surgery in the pelvic space. The operative maneuvers related to the bleeding included lymph node dissection for cancer in 34 patients, presacral dissection in 18, adhesiotomy in 12, resection of advanced cancer in 10, dissection of the adjacent plexus to the prostate/vagina in 4 and others in 10. All the patients who sustained massive bleeding from the presacral plexus had rectal/sigmoid colonic cancer. In terms of correlation between the blood loss and operation time, the presacral bleeding is almost identical to the bleeding caused by other dissecting maneuvers in the pelvic space. Our results suggested that lymph node dissection could also be another major cause of massive intraoperative bleeding in addition to presacral dissection.

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Although their incidence is rare, successful management of injuries to the abdominal aorta and its main branches is a challenge to both trauma surgeons and vascular surgeons. Early diagnosis is extremely important and surgical exploration should be performed without delay. A thorough knowledge of the abdominal vascular anatomy and techniques of vascular repair are indispensable together with the concept of damage control surgery, the principle of abbreviated laparotomy with planned reoperation. The primary goal in the management of these patients should be hemorrhage control rather than maintenance of blood flow to save their lives.

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Although injuries to the inferior vena cava (IVC) are relatively rare in Japan, emergency abdominal surgery pertaining to these injuries is justifiably considered as one of the most difficult and challenging areas of surgery. IVC injures often cause massive bleeding followed by hypovolemic shock, and are almost always associated with multiple organ injuries such as the liver, small and large intestines, pancreas and kidney. IVC injuries and associated lesions have been divided into the suprahepatic, retrohepatic, suprarenal, renal and infrarenal segments. One half to one third of IVC injuries occur in the infrarenal segment. Retrohepatic vena cava injury is rare but the most lethal among IVC injuries since it is associated with high-grade liver injury. In this article, we review the clinical features of IVC injuries in the Japanese literature, and discuss the concepts and procedures pertaining to surgical repair for injuries including use of occlusive clamping methods, atriocaval shunts, Pringle's maneuver, autologous blood recovery systems, aortic balloon occlusive catheters, supraceliac aortic cross-clamping and extracorporeal circulation. In addition, we present a case of a ruptured infected infrarenal abdominal aortic aneurysm, where the patient underwent IVC replacement with an E-PTFE graft concomitant with aortic aneurysmal repair.

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We report a case of delayed multiple penetration of the sigmoid colon by a transanal foreign body. A 39-year-old man with abdominal pain was referred to our hospital due to the presence of a transanal foreign body. Physical examination revealed a palpable abdominal tumor with tenderness, but no muscular rigidity. Abdominal CT showed a foreign body in the pelvic cavity, without free air. Emergency laparotomy demonstrated purulent ascites and a shaped foreign body in the sigmoid colon. Multiple penetration due to pressure necrosis by the foreign body was observed in the sigmoid colon. Partial resection of the colon with covering colostomy was performed. The postoperative course was uneventful.

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We report an extremely rare case of ventral hernia caused by abdominal blunt trauma. An 18-year-old male was hit directly in the abdomen by the bucket of a power shovel during construction work and was brought to our hospital by ambulance in December 2000. Muscular defense was recognized in the entire abdominal region. A distension, the size of a fist, in the right upper flank was confirmed, and at the same site a 4-fingerbreadth hernia opening was recognized. The colon was palpable under the skin. An abdominal CT scan revealed a defect of the rectus muscle of the abdomen, prolapsed transverse colon under the skin, edema and swelling of the small intestine and extensive retroperitoneal hemorrhage. The patient underwent surgery under a diagnosis of ventral hernia. A median skin incision was performed to evaluate the intraabdominal injury. After suturing the lacerations of the ascending and transverse colon, rupture of the posterior sheath of the rectus muscle of the abdomen and peritoneum were repaired from the internal side of the abdominal wall. An 8-cm skin incision was then performed just above the hernia and the anterior sheath of the rectus muscle of the abdomen was sutured. The possibility of late injury of intestine had to be taken into consideration therefore prosthetic mesh was not used to avoid infection. The patient suffered paralytic ileus and pancreatitis but was discharged on the 41st postoperative day. At 2 years of follow-up, the patient has no complaints and there have been no signs of recurrence.

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Small bowel obstruction due to blunt abdominal trauma is rare. A 75-year-old male, who had undergone a total gastrectomy for gastric cancer eight years previously, received blunt trauma to his left lateral abdomen during an accident. Five days after injury, he consulted our hospital for abdominal pain and a left hypochondrial tumor. Abdominal CT examination revealed an intra-mesenteric hematoma and reverse rotation of the mesenteric artery and vein. As all other data such as blood analysis and abdominal plain films showed normal findings and the clinical symptom was slight, conservative treatment was performed. His symptom, however, persisted. Diagnostic laparoscopy showed torsion of the small intestine around the jejuno-abdominal adhesion, and laparoscopic manipulation of torsion and lysis of the adhesion were performed. Abdominal CT examination is useful for diagnosis, and instead of open laparotomy, laparoscopy can be used safely and effectively for the diagnosis and treatment of traumatic abdominal injury.

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A 74 year-old woman came to our hospital with a chief complaint of severe abdominal pain. An abdominal X-ray revealed a free air shadow at the subphrenic space. She was diagnosed as having perforative peritonitis and was admitted as an emergency. Upper gastrointestinal endoscopy revealed a gastric ulcer with perforation in the upper body of the stomach. We performed an emergency operation under the diagnosis of perforation of a gastric ulcer. The wall of the stomach was thick and hard. The perforation, 3 mm in diameter, was seen in the body of the stomach and peritoneal dissemination was noted in the mesenterium. The final diagnosis was Borrmann type 4 cancer of the stomach with perforation and a total gastrectomy and drainage was performed. Poorly differentiated adenocarcinoma was recognized histologically in the resected specimen. The patient was discharged from hospital 40 days after the operation but died 2 months after the operation with the recurrence of peritoneal dissemination. Borrmann type 4 gastric cancer with perforation is rarely seen, and its prognosis is extremely poor. We believe that the type of surgical procedure should be determined on the basis of the patient's overall physical condition, the degree of progression of the cancer, and the severity of the peritonitis.

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A 62-year-old male was admitted at our hospital with vomiting and abdominal pain, 4 months after an aorto-bifemoral bypass. A long tube was inserted because of the physiologic and radiologic evidence of intestinal obstruction. Spike fever and tachycardia developed on the 9th day of admission, together with increase of aqueous discharge through the long tube up to about 3, 000ml/day. Because the patients condition did not improve and paralytic ileus developed despite the fact that the tube reached the obstructing point of the intestine, laparotomy was performed on the 20^th day of admission. A fibrous adhesion, which created the point of caliber change of the intestine, at 80cm oral to the ileal end was released. Because MRSA was isolated from the discharge through the long tube, the patient was started on vancomycin and recovered. MRSA enterocolitis associated with adhesional ileus is rare, but it is necessary to pay attention to the properties of the discharge from long tube. If MRSA enterocolitis is suspected, appropriate treatment should be promptly instituted before a bacteriological diagnosis is made.

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A 74-year old female was urgently admitted to our hospital based on a diagnosis of ileus with the chief complaints of lower abdominal pain and nausea. She had swallowed “TAMA-KONNYAKU” (a paste made from the arum root) without chewing, two days before the symptoms developed. Abdominal X-ray examination and a CT scan revealed a generally expanded small intestine, filled with juice and gas. At first, conservative treatment with a naso-gastric tube was performed, followed by long-tube drainage on the fourth day. Emergency laparotomy was performed on the fifth day because ileal obstruction caused by the “TAMA-KONNYAKU” was diagnosed with small intestinal fluoroscopy. Minimally invasive surgery via a 5 cm mini-laparotomy was performed under spinal and epidural anesthesia in this patient as she had concomitant bronchial asthma. Furthermore, the pre-operative examination revealed that the intestinal obstruction was localized in the lower abdomen. During the operation, a bolus of “TAMA-KONNYAKU” measuring about 4×3×2cm was found causing the obstruction 10 cm proximal to Bauhin's valve, and was removed to resolve the ileus. The patient was discharged from the hospital on post-operative day 23. We report a case of food-induced ileus by the swallowing of “TAMA-KONNYAKU” diagnosed preoperatively and treated by minimally invasive surgery with a clinical study on food-induced ileus in the literature.

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We herein describe a rare case of a 60-year-old man with a foreign body embedded in the gastric wall, caused by ingesting a toothpick. The toothpick was easily removed endoscopically within twelve hours after it was swallowed. The post endoscopic course was uncomplicated. Though the diagnosis of ingestion of a translucent foreign body is very difficult with X-ray images, if it is suspected, an early endoscopic examination and treatment should be done.

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A 72-year-old man with abdominal pain in the upper right quadrant was admitted to our hospital. Blood tests revealed anemia, inflammation and liver dysfunction with a pattern of biliary damage. Enhanced abdominal CT scan showed arterial hemorrhage from the wall of the gallbladder. An emergency operation revealed a perforated gallbladder with cholelithiasis. We diagnosed this case as hemorrhage-induced cholecystitis and a perforated gallbladder because of the short clinical course, and an arterial aneurysm was suspected at the gallbladder. Multiple arterial aneurysms were found in different sites.

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We examined a case of obstructive colitis caused by an incarcerated sigmoid colon in an inguinal hernia. A 72-year-old man was admitted to the hospital because of vomiting and abdominal pain. We observed that the abdominal wall muscles were rigid and that there was a reddish swelling and discolored skin in the left inguinal region. Computed tomography (CT) showed that there was a significant amount of colon gas and that the sigmoid colon was incarcerated in the left inguinal ring. An emergency operation was carried out, during which we found the incarcerated sigmoid colon in the left inguinal fossa and 40-cm long obstructive colitis at the oral side. Therefore, a left hemicolectomy and stoma creation were performed. Incarcerated sigmoid colon in an inguinal hernia is an uncommon condition ; furthermore, obstructive colitis caused by an incarcerated sigmoid colon in an inguinal hernia is very rare.

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We experienced a case of anisakiasis of the small intestine, which caused ileus and forced an emergency operation. A 57-year-old woman suffered from serious abdominal pain one night after eating raw fish (mackerel). A plain X-ray and computed tomography of the abdomen indicated an ileus. Since the abdominal pain failed to improve after conservative treatment with a decompression tube, the patient underwent an emergency operation the next day. The obstruction was caused by a 15 cm swollen ileum located a distance of 50 cm from the cecum, and about 20 cm of the ileum was resected. Postsurgical pathology demonstrated parasitic invasion of the ileal mucosa, identified as an Anisakis larva type I. Anisakiasis of the small intestine is rarely seen, and it is often so difficult to diagnose that surgical treatment is frequently necessary. It is important to consider anisakiasis as a cause of an ileus, if the patient has eaten raw fish.

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The patient was a 40-year-old woman. On May 12, 2003, she developed epigastric pain, which was gradually confined to the right hypogastric area. On May 16, she consulted a nearby clinic, and was referred to our department on the same day. During the first examination at our department, her abdomen was flat and soft, and tenderness and rebound tenderness were noted in the right hypogastric area. A quail egg-sized mass was palpable in the deeper area below the tender point. Her last menstruation had begun on May 18. Hematologically, elevation in WBC (9800/mm³) and CRP (7.6mg/dl) was noted, but the other parameters were normal. On the basis of these findings, the woman was diagnosed as having acute appendicitis. She was hospitalized and underwent emergency surgery on the day of admission. When the abdomen was opened, it was found that the appendix had become fused to the ileocecal segment of the intestine, accompanied by marked inflammatory hypertrophy. Therefore, resection of the ilecocecum was performed. Histologically, the wall of the resected ileocecal segment of the intestine showed scattered distribution of a considerable amount of endometrial tissue, suggesting endometriosis. Although endometriosis is defined as the presence of functioning ectopic endometrial tissue, appendiceal endometriosis is rare in Japan, with only 12 cases reported to date. One such rare case is reported in this paper.

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A 19-year-old female visited our hospital, complaining of abdominal pain. This patient had suffered from intermittent abdominal pain for two years, and the cause had not been investigated during the progress of the symptom. The peritoneal irritation sign was seen on her abdomen. A CT scan of the abdomen revealed intestinal intussusception and multiple pedunculated tumors in the small intestine. An emergency operation was performed. The intussusceptum, 15cm in diameter, was resected and the intestinal lumen was explored endoscopically during the operation. Five tumors were resected. The pathological diagnosis of the tumors was polyps of the Peutz-Jeghers type. After the operation one gastric polyp and three colon polyps were resected endoscopically. The patient was diagnosed as having Peutz-Jeghers syndrome with abnormal mucocutaneal pigmentation, although the hereditary factors were unclear.

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Afferent loop obstruction is a complication following gastrectomy, and we experienced one such case, which was successfully treated with emergency surgery. A 52-year-old man suffering from duodenal stenosis due to a duodenal ulcer underwent a distal gastrectomy reconstructed with the antecolic Billroth-II method with a Braun anastomosis. The patient complained of epigastric pain on the 23rd day after surgery, and on the 25th day he had signs of peritonitis. An emergency operation was performed under the preoperative diagnosis of afferent loop obstruction. Upon laparotomy, the afferent loop was remarkably dilated by a retained pool of intestinal juice. The afferent loop was twisted by an adhesive lesion between the Treitz ligament and the Braun anastomosis. The duodenal stump was perforated. The twisted afferent loop was straightened again and the duodenal stump perforation was directly sutured. A drainage tube was inserted from the efferent loop to the duodenal stump via the Braun anastomosis. The patient had an uneventful postoperative course and was discharged from our hospital on the 38th day after the 2nd operation.

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Gunshot wound victims have been rarely seen in Japan due to the strict laws against owning guns, and the lack of related crimes. Therefore, the treatment strategy for patients with gunshot injuries has not fully been established. Considering the increase in gun-related homicides and an unstable international situation leading to war and terrorism, emergency surgeons should be trained to try and prevent a ‘preventable death’ as a result of gunshot injuries. As part of this, surgeons should be familiar with ballistics, practical gunshot wound management, and the possibility of delayed lead poisoning associated with residual bullets. A 53-year-old man was brought into the hospital by ambulance because he was accidentally hit in the left side of his abdomen by a shotgun blast while he was hunting. On admission, abdominal X-ray films and CT revealed a bullet and its fragments in the left lower abdominal wall. We performed local debridement, irrigation of the entrance, and removement of the bullet and its fragments as well as diagnostic laparotomy. The patient was discharged from our hospital on the 9th postoperative day and his postoperative course was uneventful. In the management of abdominal gunshot injuries, prompt diagnosis and evaluation of organ injuries in minimum invasive procedure are mandatory, and removal of the bullet should be performed as soon as possible when considering the possibility of delayed lead poisoning.

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