Recently, tubes for retrograde decompression of the ileus have seen increased use at some institutions in the preoperative management of patients with obstructive colorectal cancer. We examined long-term survival following this treatment. In 131 patients over the past 14 years with obstructive colorectal cancer insertion of a retrograde decompression tube was performed in 75 cases, achieving decompression in 59. Emergency surgery was avoided in all 59 patients, instead all underwent primary curative resection with anastomosis. Furthermore, the rate of curative resection was 83.1% in these patients, significantly higher than the 67.6% rate in patients treated by other means such as emergency surgery or use of an antegrade decompression tube. With retrograde decompression, the 5-year survival rate with respect to the original disease was 43.2%, higher than the 33.9% survival rate seen in patients treated otherwise. In conclusion, retrograde decompression enabled us to improve patients' general condition operatively, increasing the rate of primary curative resection with anastomosis, decreasing the rate of complications such as anastomotic leakage, and improving the 5-year survival rate.

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We examined the diagnosis and treatment for gastrointestinal bleeding in children. In the past 24 years, 83 patients were treated in our department and an operation was performed in 49 patients. The records of 14 patients with hematoemesis and 68 patients with rectal bleeding were analyzed retrospectively. Six children with small intestinal intussusception received an operation during 3 rectal bleeding episodes. Propranolol and octreotide for prophylaxis of variceral bleeding and sclerothrapy might be the preferred modalities in portal hypertension. Abdominal scintigraphy with pertechnetate was useful in Meckel' s diverticulum, in which a laparoscopic procedure was performed. Doppler ultrasonography was useful in diagnosis of the neonatal midgut volvulus, followed by an emergency operation. Aggressive treatment for children based on the frequency of the age-related cases of gastrointestinal bleeding is warranted.

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From 1991 to 2003, the cases of infant gastrointestinal bleeding handled endoscopicically in our facilities consisted of 20 in the upper digestive tract, and 23 in the lower digestive tract. There were 10 cases with varices in bleeding of the upper gastrointestinal, with only 3 cases involving ulcer hemorrhage. Enteritis accounted for more than half of the lower digestive tract hemorrhages, and there were 4 cases of colon polyps, a comparatively large number. Congenital biliary atresia was also found, and congenital diseases such as the obstruction of the extrahepatic part of the portal vein and a case of chromosomal aberration together with the primary disease of gastrointestinal bleeding. We performed sclerotherapy for the varices, endoscope hemostasis was carried out for the hemorrhagic ulcer, and the colon polyps were removed with a polypectomy. There were no deaths as a result of the endoscope treatment, which was a good result. Patients were carefully followed up, and any cases of recurrence were treated as required.

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Causes of gastrointestinal bleeding are age-specific in children. Massive gastrointestinal bleeding is uncommon and can easily cause hypovolemic shock in neonates and infants. Initial management of massive bleeding consists of fluid and blood replacement, intubation with a nasogastric tube, and medical treatment. Vitamin K should be given intravenously, and oxygen should be administered as needed. If intravenous access is difficult to establish in volumecontracted infants, a central line, cutdown or intraosseous line should be established. Some patients need an emergency operation for the surgical disease. NEC, malrotation with midgut volvulus, and gastric rupture may cause massive bleeding in neonates. Intussusception, Meckel's diverticulum, and variceal rupture are frequent causes in infants and preschool children. Intestinal hemangiomas are rarely present in children, and angiography may be useful. The diagnosis and treatment of neonates and infants with massive gastrointestinal bleeding are discussed.

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Endoscopic therapies in 15 patients with esophageal varices due to biliary atresia (10 cases, 22 times), extrahepatic portal hypertension (3 cases, 17 times), Alagille syndrome (1 case, 2 times) and Wilson's disease (1 case, 2 times) are reviewed. Twenty-one endoscopic injection sclerotherapies (EIS) were performed using 1% Aethoxysklerol (AS). Fifteen endoscopic variceal ligations (EVL) were performed using a flexible fiberscope and a Stiegmann-Goff endoscopic ligator. A combination of EIS and EVL was performed six times. Emergency endoscopic therapies were needed in 2 cases of biliary atresia (2 times) and 3 cases of extrahepatic portal hypertension (6 times). In 1993, we changed our treatment strategy from EIS to EVL for children. The recent availability of living related liver transplantation has added another treatment option for biliary atresia. Cases of extrahepatic portal hypertension required endoscopic therapies more frequently than cases of biliary atresia. Due to the increased number of adult patients, cooperation and collaboration are essential between endoscopists with experience in adults and pediatric surgeons.

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Forty-four patients (26 neonates and 18 infants or older children) with primary gastroduodenal hemorrhagic diseases were reviewed retrospectively. All of the neonatal cases required emergency surgery for gastroduodenal perforation or rupture during the early postnatal period. Most cases were delivered at full-term with normal birth weight. In contrast, most of the older cases had ulcerative diseases, and half of those were cured by conservative therapy. The backgrounds of the ulcerative diseases included psychological stress, Helicobacter Pylon infection and others, but are, however, unidentifiable in most cases. Some “carry-over” cases, in which gastroduodenal bleeding developed, caused by relatively rare secondary diseases such as sclerosing peritonitis, are also presented in the current paper in relation to the differential diagnosis. The present study indicates that pediatric gastroduodenal bleeding may be characterized by the wide variation of the patients' backgrounds and age specificity of their clinical features.

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Gastrointestinal bleeding occurring in children is usually noticed as rectal bleeding. Since the introduction of prophylactic treatment for esophageal varices, we have rarely experienced hematemesis. On the other hand, the incidence of melena/hematochezia tends to increase year by year. It is particularly important to rapidly identify and to adequately manage life-threatening rectal bleeding because it requires emergency intervention. A total of 605 cases with diseases accompanied by rectal bleedind admitted by our department in the period of the last 30 years since 1974 were reviewed with respect to the characteristics of each main disease, the frequency of melena/hematochezia, sex, age-related incidence, diagnostic methods, and treatments. The 605 cases were found to range in age from zero days to 15 years of age, with a mean of 3.55 years. The male to female ratio was 1.7: 1.0. Of the diseases noted, those requiring emergency intervention included intussusception, malrotation, strangulation of the ileus, intestinal perforation, NEC, Meckel's diverticulum, UC, AGML, acute appendicitis with pelvic sepsis, and gastric hemorrhage post polypectomy. Death occurred in two cases of midgut volvulus and NEC.

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A case of Intussuscepted primary malignant lymphoma is reported, preoperatively confirmed by colonoscopic biopsy and treated with laparoscopic ileocecal resection. A 75-year-old male was admitted to our hospital complaining of abdominal pain and distention. Abdominal ultrasonography revealed the multiple-concentric-ring sign with a hypoe - choic area in the center. Abdominal computed tomography showed an ileo-colon type intussusception with the tumor in the lead. Colonoscopic examination revealed a tumor 4 cm in diameter in the ileum, about 20cm proximal to Bauhin's valve. The tumor was diagnosed as a malignant lymphoma by biopsy and surgery was performed. The histopathological findings showed that the tumor was a malignant lymphoma of the diffuse large cell type. CHOP therapy was added after the operation, and the patient is alive 20months postoperatively. We reviewed 114 cases of primary ileal lymphoma complicated by intussusception reported in Japan, and analyzed the cases.

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We have encountered a case of an incarcerated adult umbilical hernia that developed consequent to drainage of voluminous ascites via paracentesis, and herein we report the details. The patient was a 51-year-old woman. One month previously she had felt abdominal distension and noticed bulging of her abdomen. She consulted a neighboring doctor who diagnosed the case as stagnant ascites due to liver cirrhosis. About six liters of ascitic fluid were drained, but on the following day a swelling appeared in the umbilical region, she felt abdominal pain and was thus transferred to our hospital. By means of abdominal ultrasonography and computerized tomography scanning, we diagnosed her as having strangulation of the ileus due to impaction of intestinal loops inside the sac of an umbilical hernia, and consequently an emergency operation was performed. Although the ileum was incarcerated, an improvement in the blood flow to the ileum was noticed upon loosening the hernial orifice, and hence resection of the ileum was considered unnecessary. We think that in our present case, the umbilical hernia developed due to the sudden decrease in the ascitic fluid, which was induced by drainage of voluminous ascites on the preceding day.

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We studied the diagnosis, treatment, postoperative course, prognosis, and in particular the long-term complications in six patients with acute superior mesentric arterial occlusion. Three of the six patients died of multiple organ failure due to cardiac failure, gastric necrosis, or duodenal necrosis 9 to 22 days after the surgery caused by the removal of almost the entire intestine. The other three patients survived over one month after the surgery. One patient, in whom 50 cm of the jejunum and left colon were preserved, survived without any drip infusion therapy with good quality of life. Two patients with preservation of only 15cm and 20cm of the jejunum, respectively, died of malnutrition due to short bowel syndrome one year and three months and four years after the surgery, respectively, with poor quality of life. The intestine should be preserved to the greatest extent possible in surgery for acute superior mesentric arterial occlusion to obtain long-term good quality of life.

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Obturator hernia is a relatively rare pelvic hernia and usually occurs in elderly, thin, multiparous women. Thirteen patients with obturator hernia were treated with surgery at Mitoyo General Hospital between 1992 and 2004. All were elderly females with a mean age of 83.8 years (range: 75-93 years) presenting with small bowel obstruction. The mean body mass index was 16.7 (range: 14.3-23.1) and the mean number of deliveries was 4.1 (range: 0-7). All 13 patients who underwent pelvic CT scanning received correct diagnoses preoperatively. The mean interval from admission to operation was 3.9 days (range: 0-10 days) and the gut resection rate was 69.2%. In one recent case, we performed laparoscopic surgery. The mean hospital stay was 49.1 days (range: 13-172 days) and all patients were cured and discharged. Of the 13 cases, we successfully performed the reduction of the incarcerated hernia with the water pressure method in the 6 most recent cases. In the water pressure method, a Nelaton catheter is inserted along the incarcerated small intestine into the hernia sac, saline is vigorously pumped into the sac, and the incarcerated small intestine is pushed out from the sac by the water pressure. In the 5 most recent cases, reverse and high ligation of the hernia sac was performed because infection of the sac was suspected. We recommend performing the reduction of an incarcerated hernia with the water pressure method, and the repair with reverse and high ligation of the hernia sac, since this procedure is more simple and useful in strangulated cases.

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We describe a relatively rare case of right paraduodenal hernia. The patient, a 77-year-old woman, was admitted to our hospital because of pain in the right side of the abdomen and vomiting. Computed tomography (CT) showed dilation of the small intestine behind the pancreatic head. She was diagnosed as having a right paraduodenal hernia and emergency surgery was performed. Laparotomy revealed a hernia orifice 10cm in diameter in the right side of Treitz' ligament, through which the entire small intestine had migrated into the right retroperitoneal space and become strangulated. The jejunum and ileum were severely congested, but recovered after they had been returned to their normal position. No intestinal resection was therefore performed, and the hernia orifice was closed with sutures. Right paraduodenal hernias are relatively rare, and to our knowledge 68 cases have been reported in the Japanese literature. A diagnosis of paraduodenal hernia was obtained preoperatively in 18 of these cases. The present case illustrates the usefulness of abdominal CT for diagnosis of this acute condition.

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A 74-year-old man with the chief complaint of dysphagia was diagnosed as having esophageal cancer and was admitted to the hospital for surgery. He had a good appetite and no underlying disease. Preoperative hematology and a respiratory function test revealed no abnormality. An esophagectomy and reconstruction using a gastric tube via the posterior mediastinal route was performed with 3-field lymph node dissection. The estimated blood loss amounted to 2, 810ml. Intraoperatively, 1, 200ml of autologous blood and homologous blood (5 units of MAP and 14 units of FFP) were transfused. Immediately after surgery, the WBC count was remarkably low, 1, 600/μl. Administration of G-CSF and anticytokine was immediately started, but hypoxemia occurred on the 2nd day after surgery. Although steroid pulse, high-frequency jet ventilation and NO inhalation therapy were performed, the patient died due to respiratory failure on the 6th day after surgery. On autopsy multiple massive abscess formations with a great volume of pus were identified in the bilateral lungs. We believe that high levels of WBCs accumulated in the lung parenchyma intraoperatively and that accumulation led in this case to serious pneumonia.

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We report a case of a ruptured aneurysm of the anterior inferior pancreaticoduodenal artery. A 70-year-old man was referred to our hospital because of loss of consciousness. Plain computed tomography (CT) revealed no lesions in the head, and the patient returned home. Five hours later, he visited our hospital again complaining of increasing abdominal pain, and was admitted with a diagnosis of acute peritonitis. Enhanced abdominal CT showed a retroperitoneal hematoma, 15×12×5cm in size, with an extravasation around the head of the pancreas. As the patient had developed circulatory shock, emergency angiography was performed, revealing a ruptured aneurysm of the anterior inferior pancreaticoduodenal artery. He was successfully treated with transcatheter arterial embolization using platinum micro -coils.

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An 81-year-old woman was seen at the hospital because of abdominal pain and nausea on 19 September 2003. On physical examination, lower abdominal tenderness and distension were noted. An abdominal CT scan showed distension of the small intestine and a calcigerous mass. The patient underwent conservative therapy upon admission. Despite conservative treatment, peritoneal irritation developed and an emergency laparotomy was performed. Intraoperatively, the laparotomy revealed many adhesions and the distended small intestine adhered to the calcigerous mass at its center giving it a cloverleaf-like appearance. The adhesive intestine was resected. Pathological examination revealed the fiber-like substance to be gauze fibers. We report the rare case of a retained surgical sponge in a patient who presented with intestinal obstruction-like symptoms about 50 years postsurgically.

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A 77-year-old woman came to our hospital complaining of left lateral abdominal pain with marked eosinophilia and anemia, following bronchial asthma. Abdominal ultrasonography and computed tomography revealed ascites around the spleen and rectouterine pouch. Culdocentesis yielded bloody fluid. We diagnosed intra-abdominal bleeding due to Churg-Strauss syndrome (CSS) and immediately initiated treatment with hydrocortisone IV at a dosage of 500mg. Steroid therapy was decreased gradually to a daily dose of 40mg of prednisolone. After the steroid treatment, the patient was in good condition without any signs of arteritis. We believe that this was a very rare case of CSS, with acute abdominal pain due to intra-abdominal bleeding.

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Here we report a case of a 79-year-old male patient suffering from abdominal pain who was referred to our hospital to be checked for acute appendicitis. The hematological test showed inflammation, and an abdominal CT scan revealed a mass in the right lower abdomen. Emergency surgery was conducted based on the diagnosis of acute appendicitis and ileocecal abscess. Laparotomy found mucinous cystadenoma of the appendix with expansion of the saccular appendix from the root. We conducted an appendectomy, and for the past twelve months since the surgery, the clinical course has been good and there have been no signs of reoccurrence. Typical image findings of mucocele of the appendix enable pre-surgery diagnosis in many cases however, diagnosis is difficult in cases involving acute abdominal pain. This particular patient developed inflammation of the cyst, which could not be distinguished from the appendicitis. Since it is difficult to distinguish between benign and malignant mucoceles of the appendix, every case should be considered suspect of malignancy. We report the case with discussion and a review of the appropriate literature.

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An 87-year old female with dementia unintentionally ingested the contents of a calcium oxide packet found in a cookie container. Upon initial consultation, she presented with epigastric pain and vomiting. After admission, gastrointestinal endoscopy revealed strong adherence of calcium oxide particles along the gastric mucosa, which was subsequently treated with endoscopic gastric lavage. On the second day, follow-up endoscopy revealed a gastric ulcer (stage Al) in the lesser curvature of the stomach. The patient was diagnosed as having a corrosive gastric ulcer based on the ingestion of calcium oxide and she was treated with a proton pump inhibitor. The patient was then discharged from the hospital. However, one month later, the patient suddenly complained of reoccurring abdominal pain. Abdominal computed tomography showed free air in the peri-hepatic area. Emergency endoscopy of the upper gastrointestinal tract revealed a perforation in the lesser gastric curvature. An emergency laparotomy (omental implantation) was performed. The patient was then discharged on the 68th day without any further events. This case report describes an accidental ingestion of desiccant material with subsequent development of a gastric ulcer and perforation, the first report of its kind in adults.

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We report a case of successful endoscopic drainage of an ileocecal abscess. A-73-year-old male had an abscess of unknown origin. On admission, Pelvic CT scan revealed a heterogenous mass in the ileocecal lesion and colonoscopy showed that pus was discharged from the vermiform appendix. The patient was on warfarin postoperatively following an artificial valve replacement for aortic regurgitation, and thus had the tendency to bleed extensively, ruling out an emergency operation. For the confirmation of an invaginated abscess, a contrasting ERCP tube was inserted into the appendix and the mass was fully contrasted. After insertion of a guide wire, an ERBD tube was inserted and a large quantity of white matter flowed out and was drained off. After the patient had achieved a generally stable condition, appendectomy was performed. From the pathological findings, perforation of the vermiform appendix diverticulum was believed to be the major cause of the abscess.

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Superior mesenteric artery (SMA) occlusion causes ischemic changes in the intestine resulting in large-segment necrosis, and the survival prognosis in such cases is dismal. We report a case of SMA occlusion occurring 20 years after a total gastrectomy. Aortic angiography in an 80-year-old woman admitted for sudden onset of severe abdominal pain revealed an embolus completely occluding the SMA trunk. Twelve hours after onset, we conducted an emergency laparotomy. We found that a large segment of the small intestine and part of the transverse colon had undergone ischemic changes. The preserved small intestine was only 30cm from the Treitz ligament. Bowel resection of the large segment and a partial colectomy were done and oral ingestion cleared. The woman died 89 days after surgery of heart failure. SMA occlusion after total gastrectomy is rare, and this is only the third case report.

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A 38-year-old male came into contact with a 33, 000 volts electrode while working in the factory, and sustained electrical injury of the abdominal wall, both hands, and the right lower limb. The center of the abdominal wound was perforated, and an emergency laparotomy was performed. The burned portion of the small intestine was resected, the superficially burned area of the transverse colon was covered with omentum, and the necrotic and perforated area of the abdominal wall was resected. Continuous hemodiafiltration was started immediately after the operation to remove myoglobin and to prevent acute renal failure. Subsequently, the necrotic right lower limb was amputated above the knee and the necrotic right upper limb was amputated below the elbow. Moreover, late onset perforation of the transverse colon and remarkable expansion of the necrotic area of the abdominal wall occurred in the course of time, so irrigation of the large intestine through a tube cecostomy and irrigation of the opened abdominal wall were carried out to control infection. On hospital day 18, a right hemicolectomy and reconstruction of the abdominal wall were performed, and the patient's course after this operation was uneventful. He recovered and was discharged on hospital day 159, and was referred to another hospital in his home town for rehabilitation of the affected limbs.

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The patient was a 36-year-old male with ulcerative colitis, which was treated with by subtotal colectomy, singlebarrel ileostomy and sigmoidostomy. At postoperative day 6, abdominal pain and nausea appeared. On the following day, an abdominal X-ray revealed the presence of the niveau sign. The diagnosis of intestinal obstruction was made and followed by insertion of an ileus tube, but without any improvement. An emergency laparotomy was thus performed on the same day, and the cause of the intestinal obstruction was identified as a torsion of aberrant intestine present laterally to the elevated distal ileum. The torsion was removed, the retroperitoneum and peritoneum in the proximal part of ileostomy sutured, and the gap closed to prevent the recurrence of the intestinal aberration. In addition, to prevent the aberration due to the fixed intestine, fibrin glue was sprayed intraperitoneally and the abdominal cavity closed. The postoperative outcome was favorable, without any complication due to the recurrence of intestinal obstruction, and the patient was discharged on postoperative day 31. An ileostomy is one of the possible causes of intestinal obstruction in ulcerative colitis patients and therefore plays an important role in diagnosis, therapy and prevention of recurrence in these patients.

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We report a case of intramesenteric perforation of obstructive colitis due to rectal cancer with liver metastasis. A73-year-old-man visited our hospital complaining of lower abdominal pain. On physical examination, there was tenderness in his lower abdomen, but without muscular defence. Abdominal computed tomography revealed a liver tumor and an abscess-like tumor along the sigmoid colon. A Gastrographin®-enema showed the applecore sign of the rectum and a leakage of contrast medium at the oral portion of the tumor. An emergency operation was performed 53 hours after the onset of symptoms. A Laparotomy showed rectal cancer with liver metastasis and perforation of the sigmoid colon to the mesocolon. An anterior resection of the rectum together with the sigmoid colon was performed. The resected specimen revealed type 2 carcinoma and a punched-out perforation, 3.0×2.5cm in size, at about 6cm oral from the tumor. Histopathologically, there was normal mucosa about 6cm in length with submucosal edema between the carcinoma and the perforation site.

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