Abdominal visceral artery aneurysms are relative rare conditions demanding quick and precise treatment. We herein report on 19 cases of abdominal visceral artery aneurysm in 18 patients experienced during the past 10 years, concentrating particularly on the localization of the aneurysms, the therapeutic methods selected and the outcome of the management. The location of the lesions comprised 8 cases of splenic artery, 4 cases of superior mesenteric artery, 2 cases each of hepatic and pancreaticoduodenal artery, and 1 case each of gastroduodenal artery, celiac artery, and a celio-mesenteric anomaly. The therapeutic methods introduced were coil embolization in 11 cases, open laparotomy surgery in 6 cases and laparoscopic surgery in 1 case. The results were satisfactory enough with no severe perioperative complications or operative death. Moreover, no aneurysm was seen to recur during the course of an observation period ranging from 4 months to 8 years and 9 months (mean; 6 years and 5 months). In conclusion, a less invasive procedure such as endovascular surgery should be recommended wherever possible and appropriate, however open laparotomy surgery is also indicated in some cases according to the localization and the type of aneurysm. On the other hand, laparoscopic surgery is the approach of choice for the saccular type aneurysm, because the blood supply can be preserved.

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It appears that a conservative therapy should be tried initially for post-operative adhesive intestinal obstruction and we reviewed our results of htper baric oxygenation (HBO) therapy in our institution. We retrospectively evaluated 92 patients with post-operative adhesive intestinal obstruction treated with HBO between January 1998 and December 2003. They consisted of 65 men and 27 women, with a mean age of 63. 1 years. All of them underwent HBO, associated with a short or long tube, as necessary. Intestinal obstruction improved in 78 patients (84.8%), including 55 patients treated with HBO only and 23 treated with HBO combined with a short or long tube. HBO failed in 9 patients (9.8%), including 7 patients who required surgery and 2 patients who were successfully treated with a long tube. HBO were interrupted in 5 patients due to earache. Complication occurred in 32 patients, the most common being mild earache. In conclusion, HBO therapy combined with a short or long tube is safe and effective for patients with post-operative adhesive intestinal obstruction.

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The utility of preoperative gastrofiberscopy for determining the indications for laparoscopic omental patch repair for perforated peptic ulcers were reviewed. Treatment outcome (rate of conversion to open procedures, incidence of postoperative complications, outcome) was retrospectively reviewed according to the indications for laparoscopic surgery (hemodynamic stability, no organ dysfunction, and the presence of a duodenal ulcer without stenosis confirmed by preoperative gastrofiberscopy) among patients who underwent laparoscopic surgery for the treatment of perforated peptic ulcers between 1992 and 2002. The rate of conversion to open procedures was relatively low and postoperative complications were minimized by the performance of preoperative gastrofiberscopy. Thus, preoperative gastrofiberscopy appears to be a useful method for determining the optimal surgical method for treating perforated peptic ulcers.

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We report the validity and effectiveness of conservative treatment for perforated gastric and duodenal ulcers (PGU and PDU). We retrospectively analyzed 152 cases of PGU and PDU treated between 1995 and 2005. Of the 47 and 105 patients with PGU and PDU, 13 and 17 underwent emergent operations (early operation group), while 34 and 88 were treated conservatively. Although 28 and 77 patients with PGU and PDU were successfully treated (conservative group), 6 and 11 subsequently had to undergo surgery (delayed operation group) because of progression of peritonitis. Among patients over the age of 65 years, 11 patients were classified in the early operation group, 19 were classified in the conservative group, and 6 were classified in the delayed operation group. The patients in the conservative group were significantly younger than those in the delayed operation group. No significant differences in the duration after the onset of perforation, the amount of ascites, or and the diameter of the perforation were observed between the two groups. In the delayed operation group, body temperature and the WBC count had gradually worsened by the third day. The mean hospital stay in the conservative group (11. 2 days) was significantly shorter than that (22. 8 days) in the delayed operation group. The overall curability was 87% in the early operation group, and 97% in the conservative group.

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duodenal ulcer. Based on a retrospective review of nonsurgical treatments for perforated duodenal ulcer performed at our institution between 1987 and 1995, we defined the following criteria for treating patients nonsurgically: (1) diagnosis confirmed by endoscopic examination, (2) no severe underlying disease, (3) general condition undisturbed, (4) limited physical signs of generalized peritonitis, (5) no or small amounts of ascitic fluid collection determined by ultrasonography or computed tomography, and (6) within 12 hours of perforation. These criteria were prospectively applied in 74 consecutive cases with perforated duodenal ulcers between 1996 and 2004. Sixty-five of the 74 patients (87.8%) met the criteria and were treated nonsurgically. Nonsurgical treatment included resuscitation with intravenous fluids, nasogastric suction, and the intravenous administration of antibiotics and an H2 blocker or PPI. Fifty-eight patients (89.2%) were successfully treated. Delayed emergency operations were performed in seven patients (10.8%). We concluded that nonsurgical treatment was effective for the majority of patients with perforated duodenal ulcers who met the abovementioned criteria and were carefully observed.

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Conservative treatment for acute perforated gastric or duodenal ulcers was evaluated using a clinical pathway (CP). Fifteen days was set as the admission period for our CP, with the first three days under intensive care unit (ICU) management. This CP was applied to a total of 34 patients between October 2000 to June 2006 with the following results: 29 patients were treated successfully without variance, yielding a completion rate of 85.3% (29/34); the treatment of 5 patients deviated from the CP; two cases developed intra-abdominal abscesses, two cases were diagnosed as having of malignant gastric disease as a result of endoscopic examinations performed on the 7th admission day, and one case was diagnosed as having an unclosed perforated duodenal ulcer as a result of an endoscopic examination performed on the 7th admission day, resulting in conversion treatment to surgical treatment. Based on the previously mentioned results, we set the entry criteria for the CP as follows: 1) an age less than 65 years; 2) no evidence of psychiatric diseases; 3) no or only a small amount of ascitic fluid collection; 4) no apparent history of cancer or severe underlying disease and a generally stable condition. We concluded that conservative treatment for acute perforated gastric or duodenal ulcer using our CP was effective from both a medical and an economic viewpoint in the majority of patients who met the entry criteria.

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Conservative treatment for perforated duodenal ulcer (PDU) is a useful and safe treatment. We have been proactively performing conservative treatment for PDU since 1989, and performed proactively. The following criteria are used for the selection of conservative treatment: (1) a generally stable condition; (2) no or only slight localized fluid collection observed by ultrasonography or computed tomography; and (3) less than 20mm of gastrografin leakage during an upper gastroduodenography (UGI). These criteria increased completion rate of the conservative treatment to 96% and reduced the number of abdominal abscess complications. In conclusion, conservative treatment is effective for patients with PDU who meet the above-mentioned criteria. Reprint requests: Kazuo Chijiiwa, Department ofSurgery 1, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki-gun, 889-1692 Japan

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Seventeen cases of gastric perforation and thirty-six cases of perforated duodenal ulcers treated with laparoscopic surgery accrued over the last thirteen years were studied. The etiologies of the gastric perforations were peptic ulcers in 14 patients, gastric cancer in 2 patients, and malignant lymphoma in 1 patient. Laparoscopic omental patch repair (LOPR) was performed in 12 of the 17 (70.6%) patients with gastric perforations. The mean operating time and hospital stay among these cases were 78 minutes and 16 days, respectively. Five other patients who could not be treated with LOPR underwent conversion to open surgery that included a distal gastrectomy in 1 patient and omenal patch repair in 4 patients. On the other hand, 32 of the 36 (88.9%) patients with perforated duodenal ulcers were treated using LOPR. The mean operating time and hospital stay of these patients were 61 minutes and 14.8 days, respectively. In conclusion, laparoscopic surgery may be effective, especially for the treatment of perforated duodenal ulcers because peritonitis caused by perforation can be sufficiently treated using this minimally invasive procedure. Since conservative treatment for upper GI tract perforation is also effective with restricted indications, treatment should be selected based on the physical condition of the patient.

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We report one case of a rare perforative early gastric cancer. A 63-year-old man had been suffering from left hypochondralgia since mid-December 2005 and had been taking an anodyne. The left hypochondralgia had become stronger a few days after, and the patient came our hospital emergency room at night. An emergency operation was performed under a diagnosis of peritonitis due to upper gastrointestinal perforation. A 5 mm perforation was observed on the anterior wall of the angle of the stomach, and the stomach was swollen as if there was a tumor inside. Because there was no denying that the perforation was due to gastric cancer, a distal gastrectomy with Dl+No.7, 8a lymph node dissection was performed. Histopathological examination showed that early gastric cancer (III+IIc, sm) had perforated and No.3, 4d, 5, 6, 7, 8a lymph nodes were metastatic lymph nodes. The patient is currently taking oral S-1 and undergoing drip infusion CDDP for adjuvant chemotherapy.

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An unusual case is described in which a perforation of the colon was caused by compressed air injury. A 33-yearold man presented to the emergency room with severe abdominal pain and abdominal distention after a colleague blew compressed air into his anus as a joke. Abdominal X-rays demonstrated a pneumoperitoneum and perforation of the colon was diagnosed. An emergency laparotomy was undertaken and a 25-cm laceration was noted on the taenia libera of the sigmoid colon and rectum. A Hartmann procedure was performed with resection of the injured rectosigmoid and formation of a colostomy. Mucosal damage in the resected intestinal tissues was circumferential and severe. The patient was transferred to another hospital on the 25th postoperative day.

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A 25-year-old woman presented at our hospital with abdominal pain and diarrhea, was diagnosed as infective colitis and was given by antibiotics for 7 days. Seventeen days after discharge, she presented again to our hospital complaining of lower abdominal pain, diarrhea, bloody stools, and purpura of the limbs. She was hospitalized for further treatment. Abdominal CT imagery showed slight ascites and edema from the ileum to the entire colon. Colonoscopy showed scattered aphtha in the rectosigmoid colon. A kidney biopsy was performed to assess marked proteinuria. The pathological examination revealed findings suggestive of purpuric nephropathy. Taken together, these observations indicated a diagnosis of adult onset Schoenlein-Henoch purpura. She was treated with 30 mg/day of prednisolone, resulting in improvement of the colitis, and she was discharged on the 83rd hospital day. Although an acute abdomen accompanied by Schoenlein-Henoch purpura is extremely rare in adults, it is important to consider this disorder in the differential diagnosis of idiopathic colitis associated with characteristic purpura or proteinuria.

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We report a rare case of childhood gallbladder torsion. A nine-year-old boy with severe upper abdominal pain and vomiting was admitted to our hospital. Ultrasonography and CT imagery revealed enlargement of the gallbladder in general, thickening of the wall and a tumor in the neck. Color Doppler sonography showed absence of blood flow within the gallbladder wall. Magnetic resonance cholangio-pancreatography (MRCP) showed that the gallbladder deviated internally, and the cystic duct was obscure. Gallbladder torsion was suspected and an emergency operation was performed. On laparotomy, the gallbladder was twisted 540° counterclockwise around the neck, and necrosis was present. A cholecystectomy was performed. No postoperative complications occurred and the patient was discharged on the 7th day after the operation. Torsion of gallbladder which occurs in childhood is rare. Only 29 children younger than 10 years have been reported in Japan. Most previous reports have described that making a preoperative diagnosis is difficult. In this case, the correct diagnosis was made preoperatively. MRCP and Color Doppler sonography, as well as US and CT scan, were particularly beneficial.

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A 62-year-old man with severe abdominal pain consulted our hospital. His medical history included a gastrectomy 4 years earlier. Physical examination showed severe tenderness and abdominal distension. Muscle guarding and symptoms of abdominal irritation were observed on abdominal palpation. Laboratory findings showed leukocytosis, and a high level of CPK. A simple abdominal X-ray examination and CT scan both showed an expanded small intestine, filled with fluid and gas. The patient was diagnosed as having a strangulated ileus based on the abdominal findings, and underwent emergency surgery. Intraoperatively, a bolus of “itokonnyaku” was found to be causing an obstruction about 100 cm proximal to terminal ileum, and was removed to resolve the ileus. Among patients with food-induced intestinal obstruction who show severe abdominal findings, some cases may be difficult to differentiate from strangulated ileus. Preoperatively, it could be important to perform detailed questioning regarding the dietary habits of the patient.

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A 87-year-old woman was admitted to our hospital because of sudden abdominal pain and vomiting. The patient complained of right lower abdominal pain and tenderness. On physical examination, an a elastic hard mass of 5 cm in diameter was palpable in the right lower quadrant. Abdominal computed tomography (CT) imaging showed that a medially-deviated ascending colon had been encapsulated by the thickened wall of the intestine. An emergency operation was performed under the diagnosis of an internal hernia. A laparotomy revealed that a 10 cm portion of the ileum, 160cm orally from Bauhin's valve, had become incarcerated into the retrocecal cavity. Reduction of the incarcerated loop was followed by obliteration of the hernia orifice. Retrocecal hernia is a rare type of internal hernia and correct preoperative diagnosis is difficult to make. We suggest that the CT finding helped to make a correct diagnosis.

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A 60-year-old female was hospitalized with a high temperature and in a state of shock. After further examination, we performed an operation under the diagnosis of a gastrointestinal stromal tumor of the mesenterium of the small intestine. This tumor originated from the mesenterium of the upper jejunum, and the size exceeded 15 cm in diameter. Fistula formation was confirmed in the jejunum contiguous with the tumor. Therefore, the inside of the tumor and the jejunum communicated, and gastrointestinal bleeding and sepsis were recognized. The postoperative course was uneventful. Because their clinical coarse and findings were very interesting, we reported adding consideration with the literature. We have reported this case, together with a review on the literature, because both the clinical cause and other findings are of potential interest.

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A 43-year-old woman, who was diagnosed as having a retroperitoneal tumor, underwent a resection of the tumor, but the intraoperative findings proved resection to be impossible. As a result, only gauze packing was placed in the tumor region in order to stop the massive intraoperative bleeding which had occurred. The patient was thereafter referred to our hospital. After she had sufficiently recovered from the initial surgery, we planned to perform a secondary operation. However, at 5 days after admission, iliac vein thrombus and a pulmonary embolism occurred due to the pressure induced by both the gauze packing and the large size of the tumor. We therefore performed an emergency pulmonary thrombus absorption, and inserted a filter in the inferior vena cava. On the 12^th hospital day, we then performed a secondary operation. First of all, we performed anastomosis of the left subclavian artery to an artificial vessel during urgent PCPS. The gauze and the tumor were resected as quickly as possible. After the operation, the quantity of perioperative bleeding was 4367 ml and, as a result, neither an MAP 8 unit blood transfusion nor PCPS was performed. The size of the resected tumor was 19×12×8cm, while its weight was 1099g. The tumor was diagnosed as a solitary fibrous tumor based on the immunohistochemical study results. The patient's postoperative condition has proven to be excellent, and she has survived in a disease-free condition for over 12 months.

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The subject was a 20-year-old male whose major symptoms were abdominal pains and loose stools. Since the FOM and antiflatulent that we prescribed for him did not improve his condition, he visited us again on the following day. A tumor in his right lower quadrant was identified with palpation, and localized muscular guarding was also present in the same region. In addition, an abdominal ultrasound test presented images similar to target signs and an abdominal CT scan revealed significant thickening of the ascending colon wall. Upon examination of the stool, O157 surface antigens turned out to be positive, and VT1 and VT2-producing Escherichia coli were found on the cultured stool sample. We therefore diagnosed his condition as an O157-induced infectious enteritis. In conclusion, we realized that it might be necessary to carry out examinations and treatments considering the possibility of O157-induced infectious enteritis when an imaging test finds significant localized thickening of the intestinal wall, even if no digestive symptoms such as frequent diarrhea and bloody stools are detected.

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We report the case of an 85-year-old man with barium peritonitis caused by gastric ulcer perforation. The patient complained of severe abdominal pain and visited a nearby clinic, where he was admitted for observation. The next day, his condition worsened. After he received an upper gastrointestinal barium study, he was diagnosed as having a perforated gastric ulcer and was brought to our hospital. His abdomen was generally hard, Computed tomography showed free air and barium medium in the abdominal cavity. An emergency laparotomy was performed. The peritoneal cavity was covered with barium medium, and an open ulcer was noted at the antrum portion. As much as possible of the barium coating on the peritoneum was removed, and a surgical procedure including an omental patch was performed with peritoneal lavage. For a considerable number of days after the operation the patient ran a fever and demonstrated an inflammatory reaction. The patient was discharged on the 42nd post-operative day. Barium peritonitis is rare, but it causes a strong inflammatory reactiong, with a severe course. Much attention should be paid to performing barium studies when acute abdominal pain is present.

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A 77-year-old woman underwent an extended left bisegmentectomy for intrahepatic cholangiocarcinoma. The portal vein was resected simultaneously, since the tumor had invaded the hepatic hilus. Reconstruction of the portal vein was achieved by end-to-end anastomosis between the remaining trunk and the right hepatic branch. The patient suddenly developed abdominal discomfort 14 days after surgery. Laboratory examination revealed high concentrations of AST and ALT. Doppler ultrasonography and computed tomography with contrast demonstrated complete lack of blood flow in the portal vein. Portograms obtained via the ileocolic vein detected the complete occlusion of the portal trunk. Thrombolytic therapy using 240, 000 units of urokinase failed to dissolve the thrombus in the portal trunk, although portograms demonstrated the intrahepatic portal pedicles through collateral vessels. A thrombectomy was performed under laparotomy. Although the main portal flow was not restored postoperatively, Doppler ultrasonography detected portal blood flow in the liver. She was discharged 98 days after surgery, and is doing well under warfarin oral anticoagulation 1 year after surgery.

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A 71-year-old man visited our hospital complaining of abdominal distension and pain. He was diagnosed as having an intestinal obstruction. His medical history revealed a total gastrectomy about two years previously. His symptoms improved on fasting, but he had a high fever immediately after having a meal. He was given an antibiotic, but his condition failed to improve and he went into septic shock on the 8th admission day. Physical examination revealed right upper quadrant tenderness. Abdominal computed tomography showed distension of the gallbladder. The patient underwent percutaneous transhepatic gallbladder drainage (PTGBD) under a diagnosis of acute cholecystitis. He was treated with PMX-DHP for the septic shock, and continuous hemodiafiltration for acute renal failure. There were no gallstone and common bile duct stone in contrast imaging of the PTGBD tube. His general condition improved in June and he was discharged in August. Although the occurrence of acute acalculous cholecystitis (AAC) is unusual, its clinical course is rapidly progressive and serious. Therefore, it is important to consider the possibility of AAC, particularly in cases with a postgastrectomy intestinal obstruction.

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The patient was a 72-year-old female with a past medical history of rheumatoid arthritis (RA). She was suffering from appetite loss and lower abdominal pain, and had a fever. When she came for her routine RA examination, she was recommended to have an emergency abdominal CT. She was sent to our department for further treatment. A mass was palpable at the right lower quadrant, and she had rebound tenderness around that region. Her blood chemistry analysis showed severe inflammation and CT imaging revealed a mass of about 8 cm diameter that was continuous to the right iliopsoas muscle. We considered it to be an ileocecal abscess due to acute appendicitis, and decided to perform interval appendectomy in case it needed extended resection because she was under the treatment of RA. The size of the mass decreased dramatically following treatment with antibiotics, and a concomitant improvement was also seen in the laboratory data. The operation was performed 30 days after the initial treatment. The appendix had adhered to the mesenterium and retroperitoneum, but it was possible to dissect it completely off. There was no remnant abscess or tumor and we performed appendectomy alone. Her postoperative course was uneventful and the patient was discharged on the 9^th day after the operation.

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