The therapeutic management of severe acute pancreatitis was generally introduced according to the JPN Guideline for the management of Acute Pancreatitis. Continuous Regional Arterial Infusion of an antibiotics and protease inhibitor (CRAI) has been frequently employed in Japan, and the aforementioned guideline now gives CRAI the status of a therapeutic option. CRAI has been thought of as to be a potent therapy because of the nature of the treatment, in which highly concentrated antibiotics and protease inhibitor are delivered by way of local intra-arterial infusion. However, it seems warranted that more evidence on the clinical usefulness of CRAI should be acquired, before it can be recognized as the treatment of choice.

View full abstract

When severe acute pancreatitis, particularly necrotizing pancreatitis, develops into the infected pancreatic necrosis, the only effective treatment approach is only surgery, but, nonetheless, the mortality rate remains high. In this report, we demonstrate indications for and treatment methods of continuous regional arterial infusion (CRAI). We divided cases of necrotizing pancreatitis into two groups, those with and without CRAI therapy, and reviewed the outcome (rate of organ failure, rate of infected pancreatic necrosis, rate of operation, period from the onset to operation, mortality rate according to Stage, and the cause of death) of both groups, in addition to analyzing the prognostic factors in laboratory data on admission in both groups. CRAI therapy inhibited the development into infected pancreatic necrosis against Stage 3 & 4 necrotizing pancreatitis. CRAI therapy prevented surgery or extended the period from the onset to operation, and thereby reduced the mortality rate. GPT, GOT and T-Bil were prognostic factors in cases with CRAI therapy, suggesting that liver function may be the determinant in the effects of CRAI therapy.

View full abstract

The secondary pancreatic infection rate and mortality of 62 patients with severe acute pancreatitis (median severity score, 11; infection rate, 24.2%; mortality, 16.0%) who did or did not receive continuous regional arterial injection therapy (CRAI) with nafamostat mesilate and, in some cases, imipenem were compared according to disease severity. We also compared these groups according to the start day, duration, and catheter location of CRAI. The infection rate of stage 2 patients who received CRAI was 25.0%, while that of stage 2 patients who did not receive CRAI was 0.0%. In stage 3-4 patients, the infection rate/mortality was 50.0/66.7% in the patients who did not receive CRAI, whereas these values significantly improved to 28.1/18.8% in the patients who received CRAI. If imipenem was added to the treatment, the infections rate/mortality was 17.1/12.2%; if treatment was started within 7 days, these values were 12.5%42.5%. Longer catheter placement (>5days) did not improve the results. No significant differences existed between patients with different catheter locations (celiac artery vs. SMA). Two cases with catheters placed in the celiac artery developed splenic infarction (3.2%). Although the major cause of the splenic infarctions was thought to be spasms in the arteries caused by the pancreatitis itself, the catheters should be placed at the most proximal site possible. No complications, such as intestinal ischemia, occurred in the SMA cases. In conclusion, CRAI is safe and may improve the outcome of patients with severe acute pancreatitis. However, a randomized controlled study is needed to confirm the efficacy of CRAI.

View full abstract

It is usually recommended that arterial infusion therapy for severe pancreatitis should be performed for 5 to 7 days. However, arterial infusion therapy sometimes requires more than 7 days in some patients. In our hospital, 15 patients with severe pancreatitis received arterial infusion therapy between January 1999 and September 2003. Long-term arterial infusion therapy was performed in of 15 patients, and 5 survived. There were no complications related to long-term arterial infusion therapy. These results suggest long-term arterial infusion therapy is useful and may be the treatment of choice for patients with severe pancreatitis.

View full abstract

Continuous regional arterial infusion therapy (CRAI) of protease inhibitors and antibiotics is one of the useful and specific therapies for severe acute pancreatitis. In the past, surgical therapy mainly consisting of pancreatic mobilization and drainage of the pancreas was the treatment of choice. Since 1994, however, we have been actively performing CRAI. The therapeutic results of 90 cases of severe acute pancreatitis treated in our institution were investigated. The severity of acute pancreatitis was judged according to the appropriate evaluation standard provided by the Japanese Ministry of Health, Labor and Welfare. CRAI was indicated for severe cases with computed tomography (CT) grade over IV on admission. In addition, the type and detention site of the arterial catheter were devised for effective drug infusion into pancreatic lesions. Comparing the mortality of CRAI cases with that of operative cases (4 of 57 vs. 4 of 13, P<0.05), CRAI was seen to give more successful therapeutic results. Our CRAI is useful for severe acute pancreatitis with a CT grade over IV.

View full abstract

Background and purpose; “Evidence-based medical care guidelines for acute pancreatitis” was published in 2003, outlining a treatment strategy for severe acute pancreatitis. Based on these guidelines, we performed intensive care, mainly intra-arterial infusion therapy, for the treatment of severe acute pancreatitis and obtained good results. Using CT images, we examined the improvements in pancreatic perfusion and the outcome of intra-arterial infusion therapy using nafamostat mesilate and imipenem (FUT+IPM). Cases and Methods; Seventy-two cases with a lowdensity area (LDA) >30% on their CT image taken at the time of admission and treated with intra-arterial infusion therapy were included in the study. The morphologic changes (improvement rate) in the pancreatic LDA were then examined after intra-arterial infusion therapy. Results ; The improvement rate of patients with a baseline LDA of 30-50% was 71%, while that of patients with a baseline LDA of>50% was 64%. Regarding the LDA spread, the improvement rate tended to decrease. Discussion and Conclusion ; Early intra-arterial infusion therapy may improve pancreatic perfusion and decrease the incidence of complications, such as infectious pancreatic necrosis, thereby improving patient outcome.

View full abstract

An 87-year-old woman was admitted to the hospital because of ileus. Abdominal computed tomography showed an abscess and marked calcification in the pelvic cavity. The white blood count and C-reactive protein were respectively elevated to 13, 600/μl and 23.9mg/dl. Consciousness showed progressive impairment the second hospital day, when an emergency laparotomy was performed. Intraoperatively, the ileum showed invasion by bladder cancer, with abscess formation at the invasion site. Invasion of the uterus and metastasis to the peritoneum were also seen, and partial resection of the ileum, ileostomy, and peritoneal drainage were carried out. The pathologic diagnosis from examination of the resected intestine and a bladder biopsy specimen was squamous cell carcinoma of the bladder. Although this form of bladder cancer is relatively invasive, it rarely invades the intestine to cause ileus. In an elderly woman with acute abdominal pain and calcification in the pelvic cavity, the possibility of intestinal penetration by invasive bladder cancer should be considered.

View full abstract

On September 2, 2002, a 34-year-old man who had a history of arterial infusion therapy for severe acute pancreatitis about 2 months previously was transferred to our hospital with pyrexia and left upper abdominal pain. CT scans demonstrated an isodense mass extending from the retroperitoneal space to the stomach. Splenic angiography confirmed the existence of a splenic artery pseudoaneurysm, and transcatheter arterial embolization was performed. After 7 days, endoscopy revealed a submucosal tumorlike lesion on the greater curvature associated with a fistula. We made a diagnosis of a splenic artery pseudoaneurysm with rupture into the retroperitoneal space and stomach. An abdominal abscess was suspected because of the persistent fever, so antibiotics were administered, but were ineffective. Therefore, we performed surgical drainage and the patient's postoperative course was uneventful.

View full abstract

A 42-year-old man was admitted because of abdominal pain. Abdominal X-ray photography showed a niveau in the small intestine. On the next day, fever the patient's had mcrcused, the abdominal pain had worsened, the peritoneal irritation sign was seen on palpation, and ascitis developed on abdominal CT. Although laboratory data were normal, an emergency operation was performed under the diagnosis of strangulation ileus. On laparotomy, a diverticulum was found at the ileum. 50cm proximal to the ileum end, and inflammatory adhesion had formed between the apex of the diverticulum and the mesenterium. The proximal ileum was strangulated by the loop. The diverticulum was resected. Because a histological study revealed pancreatic tissue at the apex of the diverticulum, and the final diagnosis was Meckel's diverticulum. Preoperative correct diagnosis of strangulation ileus caused by Meckel's diverticulum is difficult. We should take this disease into consideration and diagnose strangulation ileus in the early stage when we encounter ileus caused by an unknown reason.

View full abstract

A 74-year-old man, who had been diagnosed as having intestinal obstruction and had been treated at a hospital, was transferred to our hospital because of exacerbation of the symptom. An abdominal X-ray film and enhanced CT scan of the abdomen revealed bowel intrusion between the liver and right diaphragm, and air fluid levels in the whole abdomen. These findings established the diagnosis of Chilaiditi's syndrome. A barium enema revealed no abnormal findings, but a small bowel series proved interposition of the small bowel without involvement of the colon. After decreasing the bowel pressure, we performed a laparoscopic-assisted operation. At surgery, fibrous adhesion between liver and right diaphragm was identified, and the small bowel was trapped into the adhesion from the left side. Partial resection of the jejunum with primary anastomosis was performed via a small laparotomy. Chilaiditi's syndrome associated with obstruction of the small intestine is uncommon, and only about twenty cases have been reported in the Japanese literature. This is the first case report of a laparoscopicassisted operation for Chilaiditi's syndrome. For an accurate diagnosis and less invasive surgery, an appropriate combination of preoperative examination and laparoscopic-assisted surgery is worth a trial.

View full abstract

We report two cases of gallstone ileus which were diagnosed correctly and in which a one stage repair was able to be performed after improvement of the general medical condition of the patients. In case 1, the patient was a 79-year-old woman with the chief complaint of vomiting. Upper gastrointestinal endoscopy revealed two stones in the duodenal bulb, and abdominal CT revealed calcified features within the small intestine which was markedly dilatated, and gas within the gallbladder. In case 2, the patient was a 69-year-old woman with the chief complaint of abdominal pain. Abdominal CT revealed ring calcification within the small intestine which was markedly dilatated, and gas within the gallbladder. Long tube examination revealed detected features which were thought to be gallstone within the lower small intestine. Based on these findings, both cases were diagnosed as gallstone ileus. After treating the patients' dehydration and renal dysfunction, we assessed their general medical conditions with the POSSUM score. After POSSUM score had improved, we performed a one stage repair in both cases.

View full abstract

A 15-day-old premature female neonate weighing 712 g (gestation: 28 weeks and 4 days) was diagnosed as having necrotizing enterocolitis based on clinical signs and results of an abdominal X-ray. Because conservative therapy was not effective, surgery was performed when the patient was 18 days old. Approximately 20 cm of necrosis was found near the terminal ileum, and an ileostomy was performed. Since post-operative recovery was normal, the fistulae were closed at 7 months post-birth. However, an ileus developed on day 17 after closure. Diamond anastomosis was then performed to treat the colonic atresia at the descending colon. Six days after the procedure, panperitonitis due to sutural insufficiency developed. Another ileostomy was performed, and the fistulae were closed 6 months later. The patient recovered and was discharged two months later. Currently, only 11 reports regarding colonic atresia after necrotizing enterocolitis exist. It is important to consider the possibility of colonic stricture or atresia at the distal gastrointestinal tract and to perform a thorough study of the intestine before closing fistulae.

View full abstract

A 80-year-old man was admitted to our hospital with right lower abdominal pain and muscle guarding. The patient was operated on under a diagnosis of acute appendicitis. We found biliary ascites and necrotizing “punched-out” lesions in the fundus and body of the gallbladder. A cholecystectomy was performed. No gallstone was found in the resected specimen and no microbes were detected from the biliary ascites. Histologically, necrosis and hemorrhage were found in the gallbladder wall, but no inflammatory change was seen through the specimen. On the basis of the microscopic findings, we considered that this perforation was caused by a micro-infarction in the gallbladder wall. Spontaneous gallbladder perforation is a rare entity, and only about forty patients have been reported in Japan.

View full abstract

A 33-year-old man was presented with lower abdominal pain. He had fallen on his buttocks in a bamboo thicket. A 30cm long bamboo stump had penetrated and lodged in his buttocks. Tenderness and rigidity of the muscles were found in his lower abdominal wall. There was a wound to the right of the anus. Digital examination revealed a penetrating injury to his lower rectum, together with another wound in the upper rectum. Five hours after the accident, an emergency laparotomy was performed under the clinical diagnosis of perforated peritonitis. The laparotomy revealed a blood clot at the bottom of the pelvis. A 25×9mm hole was found in the rectal anterior wall, with a random scattered distribution of bamboo splinters. Primary anastomosis was difficult because of contamination, so we decided to close the hole and perform a colostomy, following saline irrigation. In the recent literature, primary anastomosis has been reportedly useful for rectal trauma. However, the presence and degree of contamination must be taken into account. Primary anastomosis for impalement injuries should thus be indicated with caution.

View full abstract

An 82-year-old male was seen at the hospital because of sudden onset of abdominal pain. Abdominal CT showed a massive amount of hepatic portal venous gas in the liver and superior mesenteric vein. The gas had almost disappeared after 5 hours. Although Blumberg's sign and muscular rigidity were lacking, tenderness was noticed and continued in the abdomen. An emergency operation was thus performed under the diagnosis of suspected intestinal necrosis. On emergency laparotomy, there was no necrotic bowel. Hyperemia was found in a small segment of the small intestinal mesenterium. Angiography of the superior mesenteric artery revealed stenosis without arterial occlusion. Our final diagnosis was nonocculusive mesenteric ischemia (NOMI). Many reports indicate that hepatic portal venous gas is often associated with bowel necrosis and an emergency operation is recommended, however intestinal necrosis is not suggested in some patients like our current case with portal venous gas. The indications for surgery should be carefully evaluated.

View full abstract

Fournier syndrome is a rare and life-threatening infectious disease. We present two cases of Fournier syndrome in which the infectious and necrotizing tissues extended into the pelvic cavity and retroperitoneum. In both cases, the focus of the fulminant infection was a periproctal abscess. CT scans demonstrated extensive gas and inflammatory exudate and abscesses in the ischiosacral space, pelvic cavity and retroperitoneal space. Urgent aggressive surgeries were performed. Under general anesthesia, the pelvic abscesses were drained using an extraperitoneal approach through a lower abdominal skin incision. Necrotizing fascia in the retroperitoneal space or ischiosacral space was resected through a large skin incision. To prevent fecal contamination of the perineal soft tissue defect, a diverting colostomy was constructed in both patients. After surgery, systemic antibiotic administration and wound irrigation were performed. In conclusion, the drainage of intrapelvic abscesses and the resection of retroperitoneal necrotizing fascia, using an extraperitoneal approach through a lower abdominal skin incision is beneficial in patients with Fournier syndrome.

View full abstract