Increasing experiences and technical progress in laparoscopic surgery have led surgeons to perform laparoscopic cholecystectomy (LC) even for acute cholecystitis. Since 1995, our first choice for the treatment of acute cholecystitis has been early laparoscopic surgery. A total of 115 patients have undergone LC for acute cholecystitis in our department over the last 10 years. The number of days that had elapsed since the onset of symptoms until to surgery were within 4 days in 84 patients, 5 to 7 days in 11 patients, 8 to 14 days in 5 patients, 15 to 28 days in 11 patients, and more than 28 days in 4 patients. The conversion rate to open surgery was 18.3% in all the patients, and 13.8% of the patients underwent early LC (within 7 days). The main reason for the conversion were technical difficulties during the dissection at Calot's triangle in 7 patients and extensive inflammatory adhesions around the gallbladder in 5 patients. Two patients with advanced gallbladder cancer and one with a bile duct injury required open surgery. An elevated WBC count and serum CRP levels seemed to be risk factors during early LC. Although two patients with advanced gallbladder cancer died of cancer after their discharge from hospital, late complications did not occur in the other patients. Early LC for acute cholecystitis is a safe and feasible procedure, but a high rate of conversion to open surgery must be expected.

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Damage control (DC) has recently been emphasized in the management of severely injured patients and is a priority for the exsanguination of hepatic trauma. A thorough knowledge of the evolution of DC techniques is needed to prevent misapplication. The present article provides an in-depth analysis of advances in operative techniques by reviewing 221 papers reported over the past 100 years to clarify the status of DC in trauma management. Numerous surgical procedures, including the Pringle maneuver, hepatorrhapy, anatomical resection, resectional debridement, and hepatic artery ligation, and several techniques for repairing major venous injuries are described. At present, transcatheter arterial embolization is extremely important for the management of arterial hemorrhage. Trauma surgeons must have a broad knowledge of many kinds of surgical and interventional techniques and should know when it is appropriate to employ DC. Surgeons must be able to immediately select and apply the most appropriate technique according to the pattern of injury. To this end, surgery should be performed by surgeons with considerable experience in trauma care.

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Damage Control Surgery (DCS) is one of several new treatment strategies for trauma surgery. However, the physiological indications for DCS have not been established. In 1995, we proposed new criteria (core temperature<34°C, base excess<-13 mmol/L and PT>17 seconds) for the selection of DCS; these criteria were determined by calculating the probability of a 50 % mortality rate in hepatectomy patients with severe hepatic injuries. In the present study, we analyzed whether the criteria were useful for deciding when DCS should be performed by comparing the outcomes of DCS in patients with severe hepatic injuries before and after the establishment of the selection criteria. The survival rate after the establishment of the DCS criteria was 60%; this rate was superior to the survival rate (22.2%) before the establishment of the selection criteria (p<0.05). Furthermore, our selection criteria are similar to those reported in the United States. These findings suggest that our selection criteria for performing DCS are useful.

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Phase 1 surgery that was limited to gauze packing around the liver and a phase 2 procedure-in which hemostasis was confirmed and the wound was closed while preserving the lesion-were conducted on 6 consecutive cases with acute hepatic injuries [AAST-OIS grade IV and V, IIIb and Mb complicated with parahepatic venous injuries, according to the classification by the Japanese Association for the Surgery of Trauma (JAST)] encountered since August 2003. All patients survived the injuries and were successful in resuming social activities. The surgical procedures applied and postoperative complications are introduced below. Gauze packing is effective not only for the management of the right hepatic lobe but also for hemostasis of the injuries found around the hepatic vein. Postoperative biloma was noted in allpatients but it underwent spontaneous attrition in 4; and 2 progressed to infective biloma that eventually required elective hepatic lobectomy. The procedure introduced here is intended not only for a limited number of highly skilled surgeons: it is also intended for many emergency physicians who may face hepatic injuries and want to produce the favorable results described here.

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We assessed the appropriateness of the surgical strategies adopted by our hospital for the treatment of severe hepatic injuries with unstable circulatory dynamics, specifically the aggressive use of anatomical formal hepatectomy instead of relying on damage control surgery. Among patients who underwent surgery for type Mb hepatic injuries during the past decade, 15 patients with unstable circulatory dynamics at the time of initial treatment were enrolled in the present retrospective study. The patients were divided into two groups: six patients had undergone damage control surgery (3 deaths) and nine patients had undergone hepatectomies (1 death). The trauma triad of death (abnormal body temperature, pH and blood coagulation), complicating injuries, intraoperative findings, outcome, and treatment complications were then compared between the two groups. Our results suggested that an anatomical formal hepatectomy was as safe as damage control surgery among cases with the trauma triad of death, particularly among those with either a slightly low body temperature or acidosis. Furthermore, the life-saving rate after damage control surgery wasonly 50% among hepatic injury patients who developed a blood coagulation disorder associated with a clinical tendency to bleed or who were in extreme shock from other injuries, such as a pelvic fracture, suggesting that the combined use of interventional radiology should also be considered.

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The response of trauma patients to initial fluid resuscitation, while not a quantitative measure, is used to determine appropriate therapeutic strategies according to the Japan Advanced Trauma Evaluation and Care (JATEC) guidelines. The charts of 52 patients with liver or spleen injuries who underwent emergency hemostasis between January 2000 and April 2005 were retrospectively reviewed. The patients were divided into two groups: an emergency laparotomy group (group A) and an emergency transcatheter arterial embolization (TAE) group (group B). The severity scores, outcome and presence of criteria for initial fluid resuscitation were then compared between the two groups. Differences between a damage control surgery (DCS) group and a non-DCS group of patients with Japan Association for the Surgery of Trauma (JAST) type IIIb liver injuries were also compared. All the stable or responsive patients in group B survived and achieved effective hemostasis. However, transiently responsive patients in group B required an additional laparotomy. All the non-responsive patients required an emergency laparotomy. The severity of type Mb liver injuries in the DCS group was significantly greater than that in the non-DCS group, and the general condition of the TAE group clearly differed from that of the DCS group. Our criteria for deciding therapeutic strategies based on the response to initial fluid resuscitation seem to be useful from the viewpoint of hemostasis in patients with liver or spleen injuries.

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Abdominal compartment syndrome is a known complication of damage control (DC), a strategy for abdominopelvic trauma with uncontrollable massive bleeding and severe peritonitis and retroperitonitis with septic shock. Although the therapeutic procedure consists of a decompression laparotomy, the protection of intraperitoneal organs and temporary abdominal closure should be considered. A sealed vacuum-assisted continuous high pressure aspiration system (SCHPA) makes it possible to collect infectious exudate and blood from an open abdomen completely, to prevent the spread of infectious exudate and blood around the a patient's bed and room, and to estimate an accurate in-out balance. Among the patients who underwent vacuum-assisted small bag aspiration at our center in 2001, the mean volume of aspirated exudate and blood was 350±460g/hour, the mean volume of exudate and blood soakage in the dressing gauze was 123±154g/day, and the frequency of dressing changes was 1.1±0.5/day. Among the cases that underwent S-CHPA, on the other hand, the mean volume of aspirated material, the mean volume of soakage in the dressing gauze, and the frequency of dressing changes was 247±269g/hour, 6±16g/day, and 0/day, respectively. We concluded that S-CHPA is a useful procedure for temporary abdominal closure after DC based on its ability to remove infectious exudate and blood from open abdomens, minimize dressing changes, and provide an accurate estimation of the in-out balance.

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Spontaneous esophageal rupture is often lethal and requires early diagnosis and appropriate treatment. Here, we present a spontaneous esophageal rupture that was conservatively cured by effective drainage and washing. A 56-year-old male presented with dorsolumbar pain after vomiting because of excessive alcohol consumption. Mediastinal emphysema was seen on a chest X-ray and CT image, and a diagnosis of spontaneous esophageal rupture was made. About six hours from onset was required to make a definite diagnosis. Although a nasogastric tube was inserted and antibiotics were administered, left pleural effusion was observed on the third hospital day so the thoracic cavity was drained. Subsequentl continuous irrigation using a trocar, doses of antibiotics and nutritional administration via high-calorie transfusion were performed, and fistula closure was eventually visualized on the 42nd hospital day. The patient was discharged from the hospital on 89th hospital day.

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We report a case of ascending colon diverticula diagnosed by abdominal enhanced CT. A 71-year-old man was brought to hospital ambulance because of massive melena and dizziness. When he arrived, his blood pressure was 62/40mm Hg, his heart rate was 100 beats/min, and his abdomen was not tender. We performed an abdominal enhanced CT examination. The abdominal CT scan revealed the leakage of contrast medium into the ascending colon, so bleeding from ascending colon diverticula was suspected. The melena persisted, so an emergency operation was performed. At the time of surgery, multiple diverticula were seen in the ascending colon, and a right hemicolectomy was performed. A colonoscopic survey and endoscopic treatment is the treatment of choice for cases with bleeding in the lower gastrointestinal tract, but this strategy has a few problems. An abdominal enhanced CT examination can be helpful for determining the point of bleeding and planning and treatment.

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A 47-year-old unconscious man suspected of having gastrointestinal bleeding arising from the duodenal invasion of a tumor of the pancreas head was referred to our department by a nearby hospital. After admission to the previous hospital, he experienced hypovolemic shock and was brought to our hospital by ambulance. We suspected that the gastrointestinal bleeding could not be treated by endoscopic therapy, and an angiography was performed. A common hepatic angiography revealed an extravasation from the cystic artery. After embolization of the right hepatic artery, his general condition improved. An endoscopic examination performed two days later showed an anterior duodenal ulcer without bleeding, and an abdominal computed tomography examination performed five days later showed no mass in the pancreatic head. In conclusion, we diagnosed this patient as having suffered hypovolemic shock from the penetration of a duodenal ulcer. We successfully treated the arterial bleeding from the duodenal ulcer without surgery.

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A 60-year-old man presented at our hospital with a right lower quadrant abdominal pain. A physical examination showed tenderness, rebound tenderness, and muscle guarding across the entire abdomen, centered on the right lower quadrant. Based on the findings of an abdominal computed tomography examination showing free air around the ascending colon, we diagnosed the patient has having perforative peritonitis and performed emergency surgery. Apparent inflammation of the ascending colon was observed, and a right-hemicolectomy was performed. A perforation was subsequently found in the terminal ileum, 1 cm proximal to the ileocecal valve. The pathological diagnosis was perforative peritonitis caused by a diverticulum of the terminal ileum.

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We herein report the very rare case of a 68-year-old Japanese man with Fournier gangrene caused by a retroperitoneal soft tissue infection resulting from perforated gangrenous appendicitis. He was admitted to our hospital with perforated ascending colon diverticulitis. A contrast enhanced CT of the abdomen showed retroperitoneal abnormal gas and an ileocecal mesenterial fatty tissue infection. The patient was preoperatively diagnosed as having perforated acute appendicitis with panperitonitis. The operative findings showed perforated gangrenous appendicitis with a retroperitoneal abscess. On the second postoperative day, he complained of pain and swelling in his right scrotum. He was subsequently diagnosed as having Fourneir gangrene caused by acute appendicitis. On the fourth postoperative day, we debrided the and drained the area of necrotizing fascitis (Fournier gangrene). The complications of perforated gangrenous appendicitis are also discussed.

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Here, we report a 28-year-old man with barium diffuse peritonitis caused by a duodenal ulcer perforation. The patient had been taking medications for a gastroduodenal ulcer. He suddenly became sick with severe abdominal pain and visited a general practitioner. He received an upper GI series with barium contrast medium. A deformation of the duodenal bulbous portion was noted. Medications did not relieve the pain, and he was referred to our hospital with a diagnosis of acute abdomen. X-ray examination revealed free air and barium contrast medium in the abdominal cavity. An emergency operation was performed under a diagnosis of diffuse peritonitis. An open ulcer was noted at the duodenal bulbous portion, and the defect was directly sutured. The barium coating on the peritoneum was removed as much as possible. The postoperative course was uneventful, and the patient was discharged on the 13th postoperative day. Only a small number of cases of barium peritonitis have been reported. Barium peritonitis, namely, due to caused by upper GI tract perforation and large intestinal perforation, have both been reported. The An postoperative outcome of the former complication is definitely better than that of the latter. According to the medical literatures, the occurrence of adhesive ileus as a result of barium in the abdominal cavity is high, so, long-term follow-up is needed.

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Primary torsion of the greater omentum is a relatively rare disease. A 19-year-old man was admitted to the hospital because of progressive pain in the epigastrium. An abdominal computed tomography (CT) examination showed a high and irregular fat-dense tumor on the at ventral side of the ascending colon. The patient was observed and treated conservatively, but his pain and laboratory data worsened. An abdominal CT examination performed on the 3rd hospital day showed the progression of the above-mentioned findings. An experienced radiologist diagnosed the case as greater omentum torsion, and an emergency operation was performed. During the laparotomy, the right free portion of the greater omentum was found to be twisted and adhered to epiploic appendices. We resected the necrotic part of the omentum. The patient's post-operative course was uneventful. Primary torsion of the omentum is rare but should be considered in a differential diagnosis of acute abdomen. Abdominal CT is extremely useful for preoperative diagnosis.

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A 34-year-old woman was admitted to our hospital with abdominal pain and pyrexia after labor. An abdominal CT examination revealed bilateral cystic tumors with fatty deposits and calcification in the pelvic region. The left tumor appeared to have collapsed, and perforation of the tumor capsule was suspected. Ascites and a thickened peritoneum, suggesting peritonitis, were also noted. In addition, an MRI examination revealed a fatty component located next to the left tumor. The sebaceous material that had spilled out of the tumor was considered. The patient was subsequently diagnosed as having chemical peritonitis caused by the rupture of a left ovarian teratoma. Enucleation and saline lavage was performed, and the patient recovered. Since teratoma is characterized by a well-formed, sturdy capsule, ruptures are rare. However, tumor rupture constitutes a medical and surgical emergency and has been associated with a high mortality, particularly in cases with acute rupture. We report a case in which typical CT and MRI findings enabled an accurate diagnosis.

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Spontaneous perforation is a very rare complication of pyometra. We report herein an 84-year-old woman who presented with muscular rigidity and free air around the liver on abdominal X-ray films and abdominal computed tomography images. Perforation of the gastrointestinal tract was suspected, and an emergency laparotomy was performed. The uterus was markedly enlarged with a necrotic area on the uterine fundus, which was perforated. A total hysterectomy with bilateral salpingo-oophorectomy and drainage was carried out under a diagnosis of generalized peritonitis caused by the spontaneous perforation of pyometra. A histological examination revealed pyometra with changes in the myometrium and no evidence of malignancy. The patient was discharged without any major complications. The most common cause of pneumoperitoneum is perforation of the gastrointestinal tract. However, other possible causes should be considered. Although rare, perforated pyometra should be considered when elderly women present with acute abdominal pain.

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The ingestion of caustic chemical agents produces a wide range of injuries, from the esophagus to the stomach. A 68-year-old woman mistakenly ingested a chloride agent by mistake and was admitted to hospital because of difficulty in swallowing. An upper GI showed a stricture of the upper and lower esophagus and a stenosis of the pylorus and gastric antrum. The patient was conservatively treated several times using dilated bougies, but severe stenosis of the stomach was confirmed by a gastroendoscopy, so a gastro-jejunostomy and a jejunostomy were performed. Since the guidewire for the bougie used to dilate the esophageal stricture was difficult to insert orally, the guide wire was inserted via the jejunal fistula. After several treatments via this fistula, the esophageal stricture improved and the patient was once again able to consume food orally.

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