Endoscopic IVR surgery is defined as endoscopic surgery that is assisted by interventional radiology (IVR). We evaluated the effectiveness of endoscopic IVR surgery for the treatment of biliary emergencies. Between November 1996 and August 2005, we treated 62 patients with cholecystocholedocholithiasis complicated by cholangitis using a laparoscopic cholecystectomy (LC) after percutaneous papillary balloon dilatation (PPBD) and 56 patients with acute cholecystitis using an LC after percutaneous transhepatic gallbladder drainage (PTGBD) In 17 patients, PPD after percutaneous transhepatic biliary drainage was performed 2 to 7 days prior to the LC in the remaining 45 patients, PPBD was performed with the use of a muscle relaxant during the same session as the LC while the patient was under a general anesthesia. The bile duct stones were successfully pushed into the duodenum in 61 patients. The conversion rate to open surgery, the mean operative time, and the average postoperative hospital stay were 2%, 84 minutes, and 11 days, respectively. PTGBD was performed 1 to 7 days prior to the LC. The success rate of intraoperative cholangiography through the PTGBD tube, the conversion rate to open surgery, the mean operative time, and the mean postoperative hospital stay were 98%, 5%, 92 minutes, and 9 days, respectively. We concluded that endoscopic IVR surgery is effective for the treatment of cholecystocholedocholithiasis complicated by cholangitis and for the treatment of acute cholecystitis.

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The use of laparoscopic appendectomy (LA) for the treatment of appendicitis with perforation or abscess formation has not yet been fully established, although the procedure is frequently used. LA is commonly thought to be associated with less wound contamination during operation and to enable good visualization during peritoneal lavage, compared with conventional open procedures. We have been using LA for the treatment of appendicitis with perforation or abscess formation since January 2002. The present study reviewed our experience in using LA for the treatment of appendicitis with perforation or abscess formation and compared our results with those obtained using a conventional open appendectomy prior to January 2002. We evaluated the operation time, frequency of analgesic use, start of oral intake, day of recovery*, length of postoperative hospitalization, complications and costs. No significant difference in operation time was seen between the two groups. For the other items, however, significantly better results were seen in the LA group, and the postoperative recovery was significantly quicker in the LA group. Therefore, we recommend that LA be used for the treatment of appendicitis with perforation or abscess formation.

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We reviewed the medical records of 35 patients with perforated appendicitis who had undergone either a laparoscopic appendectomy or an open appendectomy during the past 8 years. Operation time, start of oral food intake, duration of SIRS (Systemic Inflammatory Response Syndrome), complications, postoperative hospital stay, and treatment cost were then compared between the laparoscopic and the open appendectomy groups. The postoperative hospital stay was significantly shorter in the laparoscopic group (15.3 days vs. 24.8 days, P<01). The incidence of postoperative wound infection was also significantly lower in the laparoscopic group (0% vs. 29.4%, P<05) Thus, laparoscopic appendectomy may be useful for the treatment of patients with perforated appendicitis.

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It has been reported in recent years that laparoscopic surgery for acute abdominal conditions is minimally invasive and useful. The usefulness of laparoscopic surgery for intestinal adhesions became widely recognized because minimal invasiveness. However, no standardized operation technique has been established due to variations in previous performed operation and the degree of adhesion, therefore converted laparotomy and recurrence have noted to occur. Surgeons have to understand the indications and limitations of laparoscopy, and should make treatment plans based on sufficient preoperative evaluation

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Based on 3 years of experience performing laparoscope-assisted colectomies (LAC), we expanded the indications for performing this precedure to include patients with acute abdomen as of April 2002. Among the 241 patients who underwent LAC over a period of 6 years and 7 months, 23 patients were treated because of an acute abdomen, including 20 cases of intestinal obstruction and 3 cases of peritonitis. The indications for LAC in patients with acute abdomen were regarded as localized peritonitis or intestinal obstruction that had been sufficiently decompressed before operation to provide a working space for the LAC. The patients who underwent an emergency LAC were retrospectively compared with 51 cases of colonic acute abdomen treated using open surgery and 217 cases of elective LAC. The proportion of patients who received a colostomy, the amount of intraoperative bleeding, and the number of postoperative complications were significantly lower in the emergency LAC group than in the open surgery group. Though 19 complications occurred in the open surgery group, mild wound infection was seen in only one case and no operative mortalities occurred in the emergency LAC group. The conversion rate to open surgery and the incidence of complications after emergency LAC were similar to the rates for elective LAC. Patients with colon cancers were included in the emergency LAC group all the patients survived without recurrence during a median postoperative period of 22 months. LAC is useful in select cases of acute abdomen.

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Laparoscopic operation for ulcerative colitis is less invasive but still takes too long compared with laparotomy surgery. We have therefore reported the usefulness of the laparoscopy-assisted small laparotomy operation. From 2001 to 2005, we performed the laparoscopy assisted operation for 36 patients with ulcerative colitis. Ten of them were under emergency operation conditions, consisting of total colectomy and ileostomy. Most of the operative procedures were performed from small a laparotomy incision placed in the hypogastrium. Hepatic flexure, splenic flexure and mesocolon of the transverse colon were treated under hand assisted laparoscopic conditions. The bowel in patients with ulcerative colitis is usually too weak to manipulate firmly with forceps, so the hand-assisted method was useful and safe to treat the bowl in these patients. The mean operating time was 205 minutes and intraoperative blood loss was 87 ml. Most of the patients started ingestion within a few days postoperatively. Ileus occurred in one patient, but it resolved spontaneously without surgical treatment. This operative approach has the characteristics not only of the low invasiveness associated with laparoscopic surgery, but also its inherent safety. Even under emergency operation conditions, laparoscopic assisted surgery was useful in patients who were in good general condition.

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We used the Billroth-1 method and multiple staples to quickly and safely create anastomoses in critical patients with ulcer perforations who required an emergency gastrectomy. One patient with a gastric cancer perforation, 6 patients with gastric ulcer perforations, and 4 patients with duodenal ulcer perforations, for a total of 11 patients, were treated using this minimally invasive method. We did the transection of the duodenum after having put on a purse-string suture device. Furthermore, we fixed an anvil in the duodenum. We did the stomach excision with a linear stapler after having done the gastroduodenostomy with a ring stapler which was inserted on the excised stomach side of the anastomosis. The time to need for the anastomosis and the resection of stomach, by the above, was less than 10 minutes, and the overall operation time averaged. 104 minutes. This method is suitable for high risk cases, because it can be safely completed in a short time and does not require a great deal of experience to perform. This method should be considered as a minimally invasive option when performing emergency gastrectomies.

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We report a case of severe acute pancreatitis that may have been triggered by testosterone treatment. A 32-yearold woman with gender identity disorder was receiving testosterone therapy once a week after having undergone a bilateral mastectomy at another hospital. Early in May 2004, she started to suffer from abdominal distension, followed by sudden cramps, back pain and vomiting. She was brought to our emergency room. An abdominal exam and CT findings suggested acute pancreatitis requiring immediate hospitalization. She was treated with fasting and the continuous infusion of nafamostat mesilate (200mg/day) and meropenem trihydrate (1g/day). An intraperitoneal abscess subsequently developed as a complication of her cordition percutaneous abscess drainage was undertaken, but her symptoms did not improve. An open operation was performed to remove the necrotic tissue and drain the abscess. Symptoms improved with continuous intraperitoneal lavage after the operation, and she was discharged from hospital. The acute pancreatitis recurred after the re-administration of testosterone 6 months later, and she was re-admitted to hospital. Since the re-administration of testosterone induced the recurrence of acute pancreatitis, the testosterone therapy may have caured drug-induced acute pancreatitis.

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A 74-year-old female who had been diagnosed with rheumatoid arthritis at the age of 72 and had been treated with oral predonisolone (10mg/day) since February 2004 suddenly developed abdominal pain on May, 2004, and was admitted to hospital on the same day. After admission, free air and the retention of ascites were noted on an abdominal CT image, and a plate-like hardness was palpated mainly in the lower abdominal region. A diagnosis of diffuse peritonitis associated with a gastrointestinal perforation was made, and the patient underwent emergency surger. During the laparotomy, the retention of turbid ascites and two ileal perforations about 10cm from the end of the ileum were found. An ileocecal resection was performed. In the excised specimen, many deep ulcers perforating the terminal region of the ileum were discovered. A histopathological examination showed no signs of specific inflammation, angitis, vascular occlusion, or amyloid deposition. A very rare case of a perforating ileal ulcer as a complication of rheumatoid arthritis that was successfully treated using an ileocecal resection is reported, along with a review of the relevant medical literature.

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Duodenal injury in abdominal trauma is relatively rare. Early diagnosis is difficult, compared to other gastrointestinal tract injuries, because the duodenum is located in the retroperitoneum. When this condition is not diagnosed early, serious complications like suture failure may occur postoperatively because of the effects of bile or pancreatic juice. A 45-year old man was admitted for blunt abdominal trauma. An abdominal CT scan did not reveal the presence of air or fluid collection in the retroperitoneal cavity around the duodenum one hour after, the blunt abdominal injury. During an emergency laparotomy for the treatment of other injured organs, a slight hematoma around the Treitz ligament in the retroperitoneum was found. We mobilized the duodenum and found a perforation in the 4^th portion of the duodenum. A duodenorrhaphy was subsequently performed. No serious complications occurred during the postoperative course.

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Endometriosis is a disease in which endometrial tissues grow in locations outside the uterus. Of such ectopic sites, the ileum is very rare. In this paper, we report a case of endometriosis of the ileum that presented as an ileal obstruction. A 41-year-old woman was referred to our hospital because of abdominal pain and vomiting. She had undergone a left adnexectomy for the removal of a chocolate cyst of the left ovary 9 years earlier. Laboratory data showed an elevated WBC count and an elevated CRP level. X-ray and CT images showed a dilated ileum and small amount of ascites. An emergency operation was performed under a diagnosis of ileal obstruction and strangulation. During the operation, two points of the ileum, located 10 and 20cm proximal to the ileocecal junction, were found to have adhered to the back side of the uterus. The ileum between the two points formed a loop and was not strangulated. Because the two points were stenotic and obstructive, we performed a partial resection of the ileum. Histopathologial examination showed endometriosis of the ileum. We report a rare case of ileus caused by endometriosis of the ileum.

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Perforative gastric cancer is relatively rare. Between 1991 and 2003, we treated 4 cases of perforative gastric cancer. These cases accounted for 7.8% of the 51 cases with perforations of the upper digestive tract and 30.8% of the 13 cases with gastric perforations treated during the same period. These findings suggest the need to consider the possibility of malignancy when gastric perforations are encountered. Three patients were over 79 years old. Tumors were located in the L region in 3 cases and in the M region in one case. The perforation was located on the anterior wall in all cases. Distal gastrectomies were performed in all cases. The gross tumor appearance was type 0 (III+IIc) in one case, type 2 in one case and type 3 in 2 cases. A pathological study showed signet-ring cell carcinoma in one case, mucinous adenocarcinoma in 2 cases, and moderately differentiated tubular adenocarcinoma in one case. A preoperative diagnosis was made in 2 cases, an intraoperative diagnosis was made in one case, and a postoperative diagnosis was made in one case of early perforative gastric cancer. A radical gastrectomy, if indicated by the patient's overall physical condition, should be performed in cases with perforative gastric cancer even in elderly patients. We recommend a two-step approach: omental coverage followed by radical surgery only if the overall physical condition is poor or a fiberscopy reveals gastric malignancy after the omental coverage.

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A 90-year-old woman was admitted to our hospital because of bloody stools and upper abdominal pain. Though laboratory examinations indicated relatively non-severe conditions, limited peritoneal signs in the left upper quadrant were observed. The segmental wall thickness of the left part of the transverse colon and ascites storage revealed by CT scan suggested mesenteric ischemia, and emergency surgery was performed. The transverse colon had atrophied over a region of about 20cm, although the corresponding mesenterium, including the blood vessels, appeared normal. These findings were judged irreversible, and a Hartmann's operation was recommended. Pathological examination showed mucosal necrosis and ischemic changes in the wall, but no thrombi in the main arteries of the mesenteric specimen were observed. Treatment was successful thanks to the early diagnosis and surgical treatment, and the patient was discharged on postoperative day 40.

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A 76-year-old woman visited our hospital complaining of an abscess in her left groin, which had been unsuccessfully treated with an antibiotic by her family doctor. Her left groin region was reddish and swollen with skin defects on the surface of the abscess. A purulent discharge from the skin defects was noted. A fistulography through the skin defect showed a fistula connected to the ileum. Computed tomography revealed a perforation of the small intestine at the site of an incarcerated femoral hernia, causing a subcutaneous abscess of the left groin. During operation, one-fourth of the ileal wall's circumference, at about 40cm from the Bauhin's valve, was found to be incarcerated into the left femoral canal. The incarcerated part of the ileum, was necrotic and perforated, which was resected with sufficient margins and anastomosed. The femoral canal was simply approximated. The patient's postoperative course was uneventful.

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We report two cases of mesenteric hiatus hernia. Casel: A 79-year-old woman was admitted to our hospital because of abdominal pain after about a month's hospital stay for the treatment of a right femoral neck fracture. She had undergone an appendectomy when she was thirty years old. Under a diagnosis of adhesion ileus, an emergency operation was carried out. An oval defect about 8cm in diameter was present in the mesentery of the transverse colon. The small intestine was invaginated through the defect. Case 2: A 77-year-old man consulted our department complaining of abdominal distension and vomiting. Under a diagnosis of internal hernia, an emergency operation was carried out. A small defect was found in the mesentery of the transverse colon. A short segment of the small intestine located 40cm from the ileocecal valve was invaginated through the defect. In both cases, the small intestine was returned to its normal position and the defect was closed by suturing. The postoperative courses of the two cases were uneventful. The possibility of internal hernia, including mesenteric hiatus hernia, must be carefully considered in elderly patients with intermittent abdominal discomfort of unknown origin.

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A 49-year-old man presented with abdominal pain and diarrhea in August, 2003. Twelve days later, he developed rectal bleeding and a high fever and was admitted to a local hospital with a diagnosis of intestinal obstruction. He was transferred to our department after showing no improvement for 19 days since the onset of his symptoms. During an anal digital examination performed at admission, a large amount of liquid stool mixed with necrotic tissue and pus was discharged. A colonoscopy revealed extensive mucosal necrosis from the rectum to the sigmoid colon. An emergency operation was performed under a diagnosis of generalized peritonitis caused by necrosis of the rectosigmoid. During a laparotomy, purulent ascites with an offensive odor weve noted, and the cecum as well as the rectosigmoid seemed to be necrotic. The necrotic portion of the colon, descending through the sigmoid colon and the rectum, were resected, and a descending colostomy was constructed. An ileocecal resection was also performed, and a duble-barreled ileostomy and ascending colostomy were constructed. Because the wet blotting paper-like appearance of the resected specimen strongly suggested amebiasis, metronidazole was administered through a nasogastric tube immediately after the surgery. Although a stool culture did not demonstrate trophozoites, amebiasis was confirmed by histological examination of the resected specimen. Postoperatively, he was diagnosed as having an HIV infection with positive HIV-1 antibody and positive HIV-1 using a Western blotting method. Although he recovered temporarily after the surgery, his condition was complicated by disseminated intravascular coagulopathy, hepatic failure and renal failure, and he died on the 51st postoperative day.

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We report a case of unresectable gastric cancer with perforation. A 74-year-old man who had been treated with an anticancer drug, S-1 for unresectable gastric cancer was admitted to hospital complaining of abdominal pain. An abdominal X-ray showed a full stomach, so the stomach was drained using a naso-gastric-tube. Pylorus stenosis as a complication of gastric cancer was suspected, so a gastrograffin upper gastrointestinal examination was performed. The examination showed a perforation in the prepylorus. Muscular defense was not observed, so conservative treatment using a nasal-gastric tube, H2-blocker, antibiotics and antifungal agent was performed. After three weeks, the perforation in the stomach closed, and the palliative treatment was regarded as successful.

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