We reviewed the results of the medical treatment and complications of interventional radiology for blunt abdominal trauma and pelvic fracture. In this series, the pelvic fracture cases were associated with a higher mortality rate than the cases without pelvic fracture. We report on two cases. The first case of pelvic fracture was in a man in his 60's as a result of a traffic accident in which several complications developed after transcatheter arterial emboliszaion (TAE). In this case, the patient's colon was perfolated by embolization-related ischemia. In the second case, a man in his 30's fell from an apartment, and sustained abdominal trauma. Bilateral internal iliac artery embolization was performed because of severe hemorrhage shock, and the patient developed gluteal necrosis. It is important to be aware of these significant complications and clear this indication for bilateral iliac artery embolization.

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Non-operative management of blunt hepatic injury has become a mainstream therapy since the broadening of selection criteria after the addition of TAE to conservative management strategies in the mid-1970s. TAE has begun to be employed for the management of type III blunt hepatic injury because of its advantages over operative management, including a reduced need for blood transfusion and a shorter period of hospitalization. Since reports of patient deaths caused by the misapplication of TAE have been made, however, the selection criteria for this procedure need to be firmly established. The management of type III blunt hepatic injury cannot be solely determined by the classification of hepatic injury according to computed tomography (CT) results; the hemodynamics and severity of injuries from complications involving other organs should also be taken into consideration. We established criteria for TAE, conservative management, and operative management based on blood pressure, reaction to transfusion, and CT classification, and obtained favorable results in their application to type III blunt hepatic injuries. Here, we discuss the selection criteria for TAE in type III blunt hepatic injury, including our experiences.

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Superselective embolization of intrarenal arterial branches was performed in 8 patients with severe blunt renal trauma, except in one case with a renal pedicle injury, to enable rapid hemostasis and preserve renal function.Embolization was selected to control bleeding using a minimally invasive procedure. A catheter was selectively inserted from a segmental artery into the ruptured intralobar artery. A metallic coil and GS were successfully used as the embolic materials in all the cases. After embolization, a marked reduction in transfusion was obtained; in particular, 4 cases required no further blood transfusions. The average proportion of preserved renal parenchyma was 86 %, as determined by comparing pre-and post-embolization CT images. Urinoma, a complication of the procedure, was cured with conservative therapy in one case. Abscess formation or nephrectomy did not occur in any of the cases. Though superselective renal embolization was useful in this series, a few concerns remain. For example, superselective embolization, has not been directly compared with previous conservative therapies or nephrectomy. Since patients with severe blunt renal trauma require emergency therapy, a randomized trial cannot be performed. The prediction of ruptured intrarenal arteries is also problematic. Presently, pre-embolization CT images cannot accurately depict ruptured arterise.

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Generally, the major treatment for blunt trauma to the mesentery with shock caused by abdominal bleeding is emergency surgery because of the critical nature of this injury and the possible complications of intestinal injury and ischemia. Since 2000, we have been treating this injury, using transcatheter coil embolization of the mesenteric artery, and a limited number of patients were stabilized after volume resuscitation. To prevent intestinal injury and ischemia, enhanced CT and angiography of the intestine after coil embolization using microcoils for landmarks and DPA (Diagnostic Peritoneal Aspiration) should be performed. Compared with emergency surgery, embolization reduced the amount of transfused blood, the number of hospital days, and the total amount of bleeding during operation, if an operation was needed following embolization. Interventional radiology may be a useful treatment alternative for mesenteric injuries.

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The aim of this study was to evaluate IVR therapy for hemorrhage after surgery and rupture of hepatocellular carcinomas (HCCs). Of 14 patients with postoperative hemorrhage after pancreatoduodenectomy (PD) or other operations, 10 patients were treated with IVR, and 4 patients underwent emergency surgery. Of the IVR patients, hemostasis was successful in 4 (40%). Of the 6 patients in whom hemostasis could not be obtained with IVR, subsequent emergency surgical treatments were successful in 5. Of 18 patients with HCC rupture, bleeding was successfully controlled in 14 patients who underwent IVR. Four non-IVR patients died within 1 month. Of the 14 IVR patients, 4 had nonresectable HCCs treated with IVR, and survived 11.5± 2.4 months. The cumulative 5-year survival rate of the patients who had hepatectomy after IVR was 67.5% (n=10). IVR therapy for gastrointestinal or intraperitoneal hemorrhage has proved indispensable to abdominal surgeons, and we should have the flexibility to select IVR or surgical treatment for hemorrhage according to the situations of each individual patient and the hemorrhage.

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Seventeen patients who developed intra-abdominal hemorrhage after undergoing a pancreatoduodenectomy were retrospectively analyzed. TAE, open hemostatic operation with a pancreatostomy, open hemostatic operation, and replacement of an artificial blood vessel with a pancreatostomy were performed in 4, 10, 2, and 1 patients, respectively.Seventy-five percent of the patients who underwent TAE and 90% of the patients who underwent an open hemostatic operation with a pancreatostomy were rescued ; however none of the patients treated with the other procedures were saved. One patient who developed a liver infarction after TAE survived after undergoing a hepatectomy. Bleeding from the superior mesenteric artery was not considered as an indication for TAE because of the fear of mesenteric ischemia.All 4 patients who hemorrhaged from the superior mesenteric artery underwent a second laparotomy, but none survived.

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We encountered 11 cases of ruptured abdominal visceral arteries between 1993 and 2003. The patients (9 men and 2 women) renged in age from 47-68 years old. Their chief complaints were abdominal pain (6 cases), hemorrhagic shock (6 cases) and gastrointestinal bleeding (2 cases). The arterial ruptures were located in the pancreaticoduodenal artery (3 cases), the splenic artery (2 cases), the superior mesenteric artery (2 cases), the left renal artery (1 case), the inferior mesenteric artery (1 case) and the right and left gastric arteries (1 case each). The arterial ruptures were caused by celiac trunk stenosis (2 cases), chronic pancreatitis (2 cases), abdominal operations (2 cases), hypertension (2 cases), liver cirrhosis (1 case) and aortic dissection (1 case). The patients were treated using arterial embolization (9 cases) or surgery (4 cases), and 2 cases died.

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A 77-year-old man was admitted to a local hospital after complaining of melena. No bleeding site was detected during an upper gastrointestinal endoscopy or a total colonoscopy. Angiography of the superior mesenteric artery revealed a tumor. The patient was clinically diagnosed as having a small intestinal tumor and was referred to our hospital for surgery. Laparoscope-assisted surgery was performed, and a tumor was found 320 cm distal to the Treitz'ligament; a partial resection of the small intestine was thus performed. The histological diagnosis was gastrointestinal stromal tumor (GIST) of the small intestine. The patient's postoperative course was uneventful, and he was discharged on the llth postoperative day. GIST of the small intestine is a relatively rare disease but should be considered as a potential source of melena when a bleeding site is not detected by endoscopy.

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We report four cases of small intestine and mesenteric injuries associated with seat belt use in traffic accidents. Two involved perforation of the small intestines, and two mesenteric tears. Three patients were driver, and the fourth was a front-seat passenger. Two cases of intestine perforation were diagnosed in follow-up after hospitalization and we conducted simple closure. We conducted emergency resection of the small intestine and anastomosis for mesenteric tears immediately after admission. In one case, the wound became infected postoperatively, lrut no other complications were seen. All patients were discharged from the hospital in healthy condition. of Perforation of the small intestine, is difficult to diagnose immediately after a traffic accident, so it is important that careful observation be made of the patieut's condition.

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We present two cases of incarcerated umbilical hernias in adults. CASE 1: The patient was a 57-year-old male with liver cirrhosis and an umbilical hernia. He had undergone abdominal paracentesis by a private doctor, yielding 7, 500 ml of ascites. After that, he complained of severe abdominal pain, and he was then transferred to our hospital with the diagnosis of an incarcerated umbilical hernia. An emergency laparotomy was performed which revealed the incarcerat-ed jejunum that was not necrotic, so a bowel resection was not performed. Umbilical hernioplasty was then performed. CASE 2: The patient was a 53-year-old obese female with an umbilical hernia. She complained of abdominal pain for 7-days before admission, and noticed umbilical discharge, suggesting bowel perforation. Abdominal computerized tomography scanning showed impaction of intestinal loops inside the sac of an umbilical hernia, and consequently an emergency laparotomy was performed. Partial resection of the intestine had to be done, because the incarcerated jejunum was necrotic. We believe that the development of an incarcerated umbilical hernia occurred in the first case following massive paracentesis of ascites, and in the second case was due to severe obesity.

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A 44-year-old man underwent distal gastrectomy with Billroth Ireconstruction for gastric carcinoma. A nasogastric tube was inserted into the remnant stomach. The patient's postoperative vital signs were stable, and on the second postoperative day (POD), the nasogastric tube was pulled out. After that the patient had severe abdominal distension and fever, and laboratory data showed increase of WBC count and CRP. On the forth POD, an abdominal CT scan was done. It revealed a large amount of pleural effusion and ascites, and also showed free air. We believed this was due to injury of the gastrointestinal tract by electrocautery or suture insufficiency, so an emergency laparotomy was perfor-med. The intraoperative findings revealed perforation of the remnant stomach probably due to the nasogastric tube, and primary closure of the perforation was performed. Here we present this rare post-gastrectomy case of perforation of the remnant stomach due to a nasogastric tube, together with a review of the literature.

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Obstructive colitis of the cecum accompanying right-side colon cancer is considered comparatively rare. We reported 2 cases with references. Case 1: A 76-year-old man reporting lower right abdominal pain evidenced a tender, rigid lower right abdomen. Abdominal ultrasonography and CT showed an extended right colon and a tumor at the anal side. Bowel obstruction and peritonitis from gastrointestinal perforation with cancer of the ascending colon was suspected. Laparotomy revealed a 4 cm tumor at the hepatic flexure of the colon, with the oral side extended with pin-hole perforations. The resected specimen showed a type 2 tumor at the ascending colon and congestion and necrosis at the cecum. Histopathological findings showed moderately differentiated adenocarcinoma with perforation and peritonitis from obstructive colitis.Case 2: A 62-year-old man with subdural hematoma seen for abdominal distension had initially stable vital signs that rapidly descended into shock. CT showed an extension of the right colon and a tumor at the transverse colon, accompanied by dirty ascites. Peritonitis and septic shock were suspected. Laparotomyrevealed a 10 cm tumor at the transverse colon, with the oral side extended with pin-holes. The resected specimen showed a type 2 tumor in the transverse colon and congestion and necrosis in the cecum. Histopathological findings were the same as for case 1.

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Incarcerated internal hernias are relatively rare and may present as ileus, but have no typical findings. We report a rare case of an intestinal hernia due to a defect in the broad ligament of the uterus. A 77-year-old woman was referred for abdominal pain with the niveau sign in plain abdominal X-ray films and was treated conservatively under the diagnosis of ileus. The next day, she complained of strong rebound tenderness and muscle guarding over the entire abdomen. Though a definitive diagnosis could not be obtained, a laparotomy was conducted under the diagnosis of strangulated ileus. Laparotomy disclosed a fissure in the right broad ligament about 2 cm long and 15 cm of the ileum was incarcerated through this defect. The small intestine was returned to the normal position and the orifice was closed. A part of the incarcerated intestine was necrosed and perforated, necessitating resection. The post operative course was uneventful and the patient was discharged after 14 days.

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A 48-year-old woman consulted a physician for abdominal pain following constipation for 10 days. She was given enema treatment. The next day, she was admitted with generalized peritonitis and shock. A central venous catheter was inserted via the right femoral vein. Abdominal computed tomography (CT) showed free air and massive ascites centering on the pelvis. Generalized peritonitis due to gastrointestinal perforation was diagnosed and emergency surgery was conducted, revealing an oval 2.0 centimeter perforation in the sigmoid colon with fecal escape. We diagnosed stercoral perforation of the colon and conducted Hartmann's operation. Although the patient suffered from multiple organ failure, she recovered. The central venous catheter was removed on postoperative day 11. There was prolonged high fever, and thrombi in the right external and common iliac vein and inferior vena cava (IVC) were detected on CT on postoperative day 30. Immediately, an IVC filter was inserted, and the patient was treated with thrombolytic and anticoagulation therapy. CT revealed no change in the condition of the thrombi and the patient was discharged on postoperative day 76. She continued anticoagulation therapy with Warfarin, and the IVC thrombus disappeared on the seventh month after surgery. The present case highlights the risk of postoperative venous thrombosis after implantation of a central venous catheter through the inferior vena cava and septic insult.

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We report a case of constrictive pericarditis due to an esophagopericardial fistula occurring after radiation therapy for a germinoma of the thoracic cord. A 31-year-old man was admitted with respiratory distress and general edema. Chest radiography and computed tomography of the chest revealed bilateral pleural effusion and hydropneumopericardium. He underwent an emergency pericardiectomy and drainage under the diagnosis of constrictive pericarditis three days after admission. Postoperatively, his clinical condition improved markedly, but when he started oral intake, food was discharged from the pericardial drainage tube. An esophagogram demonstrated an esophagopericardial fistula just above the esophagogastric junction. Three days later, massive bleeding from the pericardial drain necessitated emergency surgery. Left lateral thoracotomy and laparotomy showed an esophagopericardial fistula just above the esophagogastric junction and bleeding from the inferior vena cava. The fistula was resected and the defect in the esophageal wall was closed with absorbable sutures. An omental pedicle was raised and fixed to the esophageal and venous walls, followed by feeding jejunostomy and drainage gastrostomy. Postoperative recovery was uneventful. One year after the operation, he has no gastrointestinal problems.

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A 31-year-old man was seen at the hospital because of lower abdominal pain and vomiting. The patient was diagnosed as having an intestinal obstruction based on the results of abdominal X-ray examination and abdominal CT scan, and was admitted on the same day. His abdomen was distended and there was no evidence of muscle guarding or Blumberg's sign. Since conservative treatment was ineffective, an emergency laparotomy was performed. Laparoscopic findings showed that Meckel's diverticulum had adhered to the abdominal wall near the umbilicus and was twisted clockwise by approximately 180 degrees. The ileum was obstructed. Meckel's diverticulum was resected. As evidenced by this case, laparoscopy is beneficial for diagnosis and is less invasive than conventional surgery.

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We herein report on a patient with severe acute pancreatitis associated with colonic penetration and melena. A 72-year-old woman complaining of abdominal pain and fever was admitted to another hospital under the diagnosis of gallstone cholecystitis. Subsequent CT showed severe acute gallstone pancreatitis (grade IV), where fluid collection around the pancreas and its extent to the left kidney were observed. Percutaneous fluid drainage was performed, because infection was suspected. Although the common bile duct stone spontaneously disappeared, her symptoms were not relieved and an intraabdominal abscess developed. She was referred to our hospital. While under conservative therapy, she noticed melena, and fistulography demonstrated that the abscess cavity had penetrated the descending colon. Because of these findings and repeated melena, emergency surgery was performed. Since a lot of necrotic tissue in the retroperitoneum and necrosis of the mesocolon were observed, necrosectomy and left colectomy with transverse colostomy were carried out. She was discharged from hospital on postoperative day 77. Six patients with acute pancreatitis penetrating the colon have been reported in the literature. We report on our case together with these six patients.

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