To evaluate one-stage resection following decompression for obstructive colorectal carcinoma. Patients: Seven patients with obstructive colorectal carcinoma underwent resection following decompression were enrolled in this study. Preoperative intestinal decompression was performed with a transanal tube. Results: Curative elective one-stage resection was achieved in 7 patients. The frequency of lymph node metastase was 57.1%. No leakage occurred in any of the patients who underwent one-stage anastomosis following decompression. One Patient had local recurrence. Conclusion: Decompression with a transanal tube may be useful for one-stage resection in patients with obstructive colorectal carcinoma.

View full abstract

Early diagnosis is crucial to determine the need for surgical intervention in patients with strangulation ileus associated with passage or ischemic disturbances. To evaluate the usefulness of the combination of ultrasonography (US) and computed tomography (CT) imaging for the diagnosis of this condition, the clinical history and outcome of 37 patients with strangulation ileus were reviewed. Patients were classified into two groups: patients who received both US and CT examinations, and patients who received either US or CT, examinations or did not no receive either US or CT examinations. In patients who preoperatively received both US and CT examinations, the time until operation, and the period of hospitalization were shorter, and a smaller proportion of the bowel was resected. CT findings were useful for identifying the site of ileus strangulation, but the US findings were superior to the was better than CT findings for estimating the extent of strangulation. The combination of US and CT imaging is likely to be useful for the early diagnosis of strangulation ileus.

View full abstract

Although the preoperative diagnosis of strangulating bowel obstruction is not always easy, recent advances in and widespread use of diagnostic imaging such as abdominal ultrasound, CT, and MRI have markedly improved the preoperative diagnostic accuracy. In particular, abdominal ultrasound has the following advantages: 1) technical simplicity with no need for preparation, 2) noninvasive, 3) can be performed repeatedly, 4) provides real-time information on the intestinal tract (the wall, contents, and peristaltic movement) and the abdominal cavity (presence or absence of ascitic fluid), and 5) allows observation of the desired cross-section. In particular, acquisition of real-time information is extremely useful for the differential diagnosis between of strangulating bowel obstruction and simple bowel obstruction. Abdominal ultrasound diagnostic findings in strangulating bowel obstruction include thickened intestinal wall, absent peristalsis, high-echoic intestinal contents, ascites, intestinal intramural gas, and the pseudotumor sign. However, the amount of information obtained depends greatly on the skills of the examiner and the volume of intestinal gas. It is naturally important to comprehensively evaluate ultrasound findings in combination with physical and other imaging findings, including CT findings, for a more accurate diagnosis. In addition, the importance of ultrasound examination and the accumulation of experience should be emphasized.

View full abstract

The accuracy of ultrasonography for the diagnosis of patients with right lower quadrant (RLQ) pain was evaluated. MATERIALS AND METHODS: The diagnoses of 148 patients referred to our hospital with RLQ pain and who underwent an ultrasonography were retrospectively analyzed. Specifically, the diagnostic accuracy of ultrasonography for patients thought to have acute appendicitis, the dependence of the visualization rate on the inflammation grade, the dependence of the visualization rate on the anatomical positions of the appendix, and the diagnostic accuracy of ultrasonography in patients with RLQ pain were evaluated. RESULTS: The sensitivity and overall accuracy of the initial ultrasonography studies in patients thought to have acute appendicitis were 74.3% and 81.8%, respectively. The sensitivity and overall accuracy increased to 90.5% and to 89.9%, respectively, after a second ultrasonography study and an abdominal computed tomography (CT) scan were performed. The sensitivity and accuracy of the ultrasonography studies in patients with RLQ pain were 74.5% and 81.8%, respectively. CONCLUSIONS: Ultrasonography was a useful aid for differentiating RLQ pain. Furthermore, performing a second ultrasono-graphy study and an abdominal CT scan improved the accuracy of acute appendicitis diagnoses.

View full abstract

Hypertropic pyloric stenosis is the most common abdominal abnormality requiring surgery in infants. We compared the clinical symptoms of recent patients (47 cases from 1992 to 2001) diagnosed using ultrasonography with those of previous patients (39 cases from 1982 to 1991) diagnosed using barium upper gastrointestinal studies. The serum chloride and base excess levels of the two groups were statistically different. Ultrasonographic assessment of hypertrophic pyloric stenosis has become the main radiological method for diagnosing this disease.

View full abstract

The objective of this study was to determine the accuracy of preoperative ultrasonography for the diagnosis of appendicitis in children. During a 7-year period, 181 children who had been clinically diagnosed as having appendicitis were evaluated using ultrasonography. Of the 181 patients, 151 underwent an appendectomy. The ultrasonography diagnosis was correlated with the postoperative histopathological findings. Overall, 149 of the 151 patients who underwent an appendectomy exhibited histopathologically confirmed acute or perforated appendicitis. Of the 151 patient, two patients did not undergo an appendecto-my. Preoperative ultrasonography is very useful for the correct diagnosis of appendicitis in children.

View full abstract

To evaluate the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of ultrasonography (US) findings for the diagnosis of pediatric appendicitis, we retrospectively reviewed data obtained in 261 consecutive patients with suspected appendicitis. US examinations were performed in 222 patients (85%): 131 patients underwent examinations performed by abdominal US technicians (TE group), and 91 patients underwent examinations performed by emergency room residents (ER group). The sensitivity and NPV of the TE group were higher than those of the ER group (sensitivity, 91% versus 68%; NPV, 86% versus 35%). The ER group, however, had a higher specificity and PPV than the TE group (specificity, 87% versus 56%; PPV, 96% versus 69%). We concluded that US is a valuable tool for the diagnosis of appendicitis, but that clinical examinations remain essential for an accurate diagnosis. Furthermore, the level of technical experience of the operator influences the interpretation of US findings and the diagnostic accuracy in patients with appendicitis.

View full abstract

A case of intrapancreatic complete avulsion of the common bile duct caused by a deceleration injury after a blunt abdominal trauma incurred during a traffic accident is presented. The patient was preoperatively diagnosed using drip infusion cholangiography-three-dimensional computed tomography (DIC-3DCT) and successfully treated using a choledochojejunostomy. The mechanism responsible for this type of trauma is thought to be a sudden deceleration force that pulls the biliary tree out of the liver, duodenum and pancreas, which are fixed to the retroperitoneum. Since this type of injury occasionally requires emergent exploration, an early diagnosis is desirable. In the present case, major gastrointestinal and arterial injuries were excluded using preoperative computed tomography (CT) and angiography studies. Consequently, DIC-3DCT was selected as the diagnostic modality for evaluating potential injuries to the biliary tree. During the emergent operation, the papilla of Vater was confirmed to be intact, so the pancreas head was preserved. A postoper-ative abdominal CT scan did not show any signs of pancreatic duct occlusion or the development of pancreatitis. Although intrapancreatic common bile duct injuries are rare, this condition should be excluded during the evaluation of patients who have experienced a blunt abdominal trauma. Furthermore, the selection of safe treatment procedures is also essential to the management of trauma patients.

View full abstract

A case of gastrointestinal stromal tumor of the stomach with intratumor hemorrhage is reported and discussed in relation to previous medical, literature. A 49-year-old man complaining of a loss of appetite and epigastrial discomfort was admitted to hospital. A solid tumor, 17×10×20cm in size, located in front of the stomach was identified using abdominal computed tomography. After undergoing a blood transfusion, the patient's laboratory data showed progressive anemia, and emergency surgery was performed based on a diagnosis of intratumor hemorrhage. In the resected specimen, the tumor cells were immunohistochemical-ly positive for c-kit and CD34 protein, but negative for α-smooth muscle actin and S-100 protein. The tumor was diagnosed as an uncommitted gastrointestinal stromal tumor (GIST), GIST with intratumor and/or intraabdominal hemorrhage is relatively rare, and all of the cases reported in Japan have tested positive for c-kit and/or CD34 protein.

View full abstract

An 83-year-old man presented with abdominal pain and nausea. On admission, an abdominal radiograph and ultrasonogram showed no remarkable findings, except for a slight swelling of the intestine. A contrast-enhanced computed tomography examination showed fluid collection around the liver. An emergency laparotomy was performed 26 hours after the onset of symptoms, and biliary peritonitis without perforation of either the digestive or biliary tracts was observed. A cholecystectomy with biliary drainage was performed. Although inflammatory changes in the gallbladder were not observed, the wall of the gallbladder was thin and a deep Rokitansky-Aschoff (R-A) sinus was present, especially at the fundus. Biliary transudation from the gallbladder as a result of a thin gallbladder wall and a deep R-A sinus, such as in this case, is quite rare.

View full abstract

A 51-year-old male with a 30-year history of heavy alcohol consumption was admitted to our hospital complaining of melena. Abdominal computed tomography showed a 5cm cyst containing blood and gas in the pancreatic taii. Endoscopic retrograde cholangiopancreatography (ERCP) revealed irregularity of the main pancreatic duct and leakage of contrast-media from the duct into the cyst. A Hypaque v'-enema showed stenosis of the transverse colon and a fistula communicating with the pancreatic pseudocyst. Based on these findings, a diagnosis of pancreatic pseudocyst with fistula to the transverse colon was made, and the pancreatic body and tail, the spleen, and a part of the transverse colon were resected en bloc. The postoperative course was uneventful. Fistula formation between a pancreatic pseudocyst and the transverse colon is very rare, with only six cases, including our own ever having been reported in the Japanese literature.

View full abstract

A 74-year-old man was admitted to hospital complaining of the sudden onset of abdominal pain. Distension and muscle guarding were noted during an abdominal examination. Hepatic portal venous gas was seen on a plain abdominal X-ray and during an abdominal computed tomography examination. A partial filling defect was detected in the branches of the superior mesenteric artery using enhanced computed tomography. An emergency laparotomy was performed under a diagnosis of superior mesenteric arterial occlusion. During the laparotomy, pulsations were not detected in the branch of the jejunal artery or in the ileal artery, and a 200-cm length of necrotic small intestine was resected. The patient was discharged from hospital on the 21st postoperative day. The prognosis of digestive perforation and bowel necrosis with hepatic portal venous gas has been reported to be poor. We conclude that immediate treatment is necessary for abdominal emergencies accompanied by hepatic portal venous gas.

View full abstract

A 77-year-old woman was admitted to hospital because of vomiting and abdominal pain. An abdominal computed tomography examination revealed the presence of ascites in the pelvic cavity. Severe tenderness, muscular defense, and a Blumberg sign were observed throughout the abdomen. The patient was diagnosed as having diffuse peritonitis caused by a perforation of the digestive tract and underwent an emergency operation. During the operation, a hole was found in the uterus body ; consequently, the diagnosis was changed to diffuse peritonitis caused by a pyometra-induced perforation of the uterus. A simple hyster-ectomy was performed. Diffuse peritonitis arising from a pyometra-induced perforation is rare, but this condition should be included in a differential diagnosis of in acute abdomen in elderly woman.

View full abstract

A 41-year-old woman was referred to our hospital because of severe abdominal pain. No signs of peritonitis and no abnormal laboratory data were obtained. The X-ray findings were also normal. An abdominal computed tomography examination revealed a dilatation of the small intestine and a target sign. Since the patient's symptoms did not improve and her laboratory data, including the white blood cell count and creatine kinase level, began to worsen, an emergency operation was performed. At the time of the laparotomy, the small intestine had prolapsed through a hiatus in the omentum into the omental bursa, resulting in the strangulation of the small intestine. The necrotic portion of the small intestine, about 25cm in length, was resected, and the hiatus was closed. The patient's omentum was very brittle and contained many holes with diameters of several millimeters. These holes were sewed or plugged to prevent recurrence. As a preoperative diagnosis of this disease is very difficult, the possibility of an internal hernia should be kept in mind when treating a patients with an acute abdomen.

View full abstract

Small bowel hemorrhages have been reported to account for 2-5% of all cases of gastrointestinal hemorrhage. Although rare, small bowel hemorrhages can lead to death as a result of massive bleeding. The source of the blood loss within the small bowel is generally very difficult to identify using upper and lower gastrointestinal endoscopy. We experienced two cases with small bowel hemorrhages and considered various methods of locating the site of bleeding. In case 1, a hemorrhaging tumor of the small bowel was easily identified. In case 2, however, the presence of several idiopathic ulcers made locating the exact site of bleeding difficult, and a large amount of the small bowel was excised as a result. In these two cases, the difficulty in locating the site of bleeding depended on the presence or absence of a tumor. Abdominal angiography is useful for identifying lesions, especially those that are hemorrhaging, and an immediate angiography is recommended in patients with obscure gastrointestinal bleeding. If a tumor is not present, the vessel responsible for the bleeding should be first embolized with a metallic coil to serve as a landmark for subsequent intraoperative small bowel endoscopy and surgical procedures.

View full abstract

A 67-year-old woman with no history of a laparotomy visited our outpatient clinic complaining of abdominal pain and nausea and was diagnosed as having an intestinal obstruction. The abdominal pain worsened after admission, and peritoneal rigidity signs appeared in the right lower quadrant. An abdominal computed tomography (CT) examination demonstrated a whirl-like sign in the mesentery, and the patient was diagnosed as having a primary volvulus of the small intestine; an emergency operation was performed. Abdominal CT provides useful information and may be essential for an early diagnosis of this disease.

View full abstract

We report a pancreatic injury and delayed large intestinal perforation caused by a seat belt injury. An 18 -year-old woman was admitted to our emergency center after being involved in a traffic accident. She had sustained a type I pancreatic injury, a type Ia hepatic injury, fractures of the 7-9th right ribs, and a fracture of the 12th thoracic vertebra, without any severe abdominal symptoms or related findings. On the 14th day of hospitalization, a tendency towards abdominal distension was noted. Acute peritonitis caused by gastroin-testinal perforation was diagnosed based on an abdominal computed tomography examination and an abdominal cavity exploratory puncture. An emergency surgery was performed, and perforated points with remarkable hyperplasia were found in the wall of the transverse colon. A partial resection of the transverse colon and a colostomy were performed. She did not experience any remarkable postoperative complications and was transferred to an affiliated hospital on the 37th day of hospitalization. The possibility of delayed intestinal perforations must be kept in mind when treating cases with blunt abdominal injuries.

View full abstract

Fournier's gangrene is a severe infectious condition of the perineal region that quickly leads to the necrosis of subcutaneous tissue. We recently encountered three patients with Fournier's gangrene over a 6 -months period. All the patients were male, with a mean age of 73 years. The skin color of the scrotum progressively changed to a dark red, and crepitus developed. Two patients developed septic shock and disseminated intravascular coagulation. Abdominal roentgenograms and computed tomography examina-tions demonstrated widespread gas in the scrotal subcutaneous tissue. One patient had an anal fistula and liver dysfunction, while another had diabetes mellitus. Escherichia coli, Streptococcus Pyogenes, Enterococcus Faecalis, and Bacillus fragilis were detected in cultures of pus from the lesions. About 100 cases of Fournier's gangrene have been reported in Japan, while about 500 cases have been reported in Western countries. Early diagnosis and surgical treatment are essential.

View full abstract

A 51-year-old male was hospitalized because of an abdominal mass and pain. The patient's leukocyte count and C-reactive protein levels were markedly elevated. A computed tomography examination of the abdomen revealed a large amount of gas in the abdominal wall, and the patient he was diagnosed as having necrotizing fasciitis. The necrotic tissues in the abdominal wall were immediately removed, as much as possible, while the patient was under a general anesthesia. Since a gangrenous appendix was found during the surgery, the necrotizing fasciitis was thought to have been caused by the appendicitis. Postoperatively, the inflammation quickly improved with continuous washing of the abdominal wall. A fistula remained in the lower abdominal wall for a long period of time but eventually disappeared after being treated using hyperbaric oxygen therapy at another institution. Early diagnosis, removal of the necrotizing tissue, and effective drainage are crucial for the successful treatment of necrotizing fasciitis.

View full abstract

A 64-year-old woman was referred to our hospital because of sudden abdominal pain and vomiting. A fist -size tumor was palpated in the right lower quadrant. An abdominal computed tomography (CT) examina-tion demonstrated a target-like appearance in the ascending colon, and the presence of a fat-density lesion A colonoscopy revealed the presence of dark red invaginated ileal mucosa in the ascending colon. The patient was diagnosed as having intussusception caused by an ileal lipoma, and an emergency operation was performed. The tumor was located 31cm proximal to the ileocecal valve, and a histological examination confirmed the tumor to be a benign lipoma. We suggest that abdominal CT and colonoscopy are useful procedures for the preoperative diagnosis of adult intussusception.

View full abstract