Emergency medicine is characterized by the following, (1) A lack of sufficient time for the physician to give his patient an adequate explanation, (2) Frequent existence of a consciousness disturbance on the part of the patient, (3) The lack of a trusting relationship between the physician and patient. The importance of informed consent need not be reiterated; but what should be regarded as most important in emergency medicine is the “life of the patient.” We must not miss the opportunity to apply the most appropriate therapy for fear of getting involved in a malpractice suit. If the physician is wavering in making a medical decision, he must follow the approach in accordance with current medical standards.

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We studied the efficacy and safety of insertion via external jugular vein for central vein access using a Groshong catheter, and compared complications of the procedure with those of conventional subclavian venous catheters in adult patients. We retrospectively evaluated demographic data, the term of insertion, and catheter-related complications. Subjects were 137 patients (group 1) with 243 argyl catheters and 131 (group 2) with 228 Groshong catheters. The mean term of catheter use was 21.3±20.2 days for group 1 and 15.2±13.7 days for group 2 (NS). Fever occurred in 34.6% (84/243) of patients in group 1 and in 18.9% (43/228) in group 2, (p<0.01). Malposition and pneumothorax occnrred in 15.2% (37/243) and 3.1% (7/228) (p<0.01) and 2.1% (5/243) and 0% (0/228) (p<0.05). Insertion variables and catheter-related infections did not differ significantly between the two groups except for insertion site. Our results suggest that cannulation by Groshong catheters via the external jugular veins is more useful for central venous access in adult patients than cannulation by conventional subclavian venous catheters.

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The purpose of this study was to determine the indications for initial conservative therapy of perforated gastric or duodenal ulcer. The goal is to identify any patient who does not require immediate surgical intervention at the initial medical examination. For our study, patients within SIRS criteria at the first examination must be performed surgical operations immediately. At our institution, patients fulfilling the criteria for SIRS are immediately taken up for surgery. On the other hand, we determined that the presence of two or less of the following criteria would constitute an indication for immediate surgery, whereas the presence of three or more criteria would constitute an indication for medical therapy. (1) medical evaluation within 6 hours after the apparent onset of perforation, (2) full stomach or solid residue in the stomach (as detected by enhanced computed tomography), (3) localized peritonitis (peritoneal signs limited to upper abdomen), (4) ascites limited to upper peritoneum (bilateral subphrenic spaces, Morrison's pouch, or splenorenal boundary), (5) absence of any severe underlying disease and presence of a reasonably stable general condition. On the basis of the new criteria, 23 patients were initially treated by conservative therapy. Of these, 4 patients were eventually taken up for surgery, because the patient developed severe abdominal pain associated with board-like rigidity of the entire abdomen, and a repeat CT revealed increased intraperitoneal ascites. All of the remaining patients (19 patients) were successfully treated by conservative therapy. A total of 52 patients (12 with gastric ulcer and 40 with duodenal ulcer) were treated by surgical therapy. We believe that these criteria are extremely useful, as only non-invasive methods are needed for the evaluation and they allow rapid judgment by the doctor regarding the need or otherwise for surgery.

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Explanation about the conditions of patients is not easy in the emergency medical care setting. We analyzed the status of the explanation provided at our Critical Care Medical Center for 373 cases. There were 141 cases (37.8%) who seemed to understand our explanation on the day of admission. On the other hand, 139 patients (37.3%) with drug poisoning, consciousness disturbances, head injury or alcoholism seemed to understand our explanation several days after the admission. There were 93 patients (24.9%) with consciousness disturbances, head injury, dementia or psychological diseases who could not understand our explanation at any time-point during their hospitalization. The families of the patients visited the hospital on the day of the admission in 293 cases (78.6%). In 39 cases (10.4%) who had no families, or whose families did not visit the hospital, we faced severe difficulty. At the same time, we must also respect the privacy of the patients.

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Pediatric emergencies sometimes include rare diseases and critical conditions. Therefore, initial misjudgment or delay in treatment may result in a high risk to the patients. For risk management in this situation, critical surgical diseases should be considered first, and examinations should be performed promptly for the differential diagnosis. Moreover, repeated observations and consultation with senior doctors are also necessary. Exploratory operations should be considered when critical surgical diseases (ex. strangulation of the intestine) are strongly suspected.

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Credentialing and privileging are common in the US for quality assurance of surgery. Many states have health care credentials and data collection acts that require standard forms to collect credential data commonly requested by health care entities and health care plans for credentialing and recredentialing. The Joint Commission on Accreditation of Health Care Organizations, http://www.jointcommission.org/) (JACAHO) is responsible for updating surgeon privileges in every two years. In Japan, such systems based on peer review have yet to be formed. With increasing risk of malpractice suits, the need for ensuring the quality of surgical management is expanding. At Kyorin University, a credential committee has been formed for granting privileges to surgeons. Surgical procedures were stratified in five categories based on technical difficulty, and estimated blood loss and procedure duration of were standardized. A precautionary system was also formed that enables other surgeons of unexpected difficulty in surgery. This precautary system was designed to run when blood loss or surgical time exceeds twice as much as the standard. We expect this system to help reduce adverse outcomes in surgical procedures involving hospital death, reoperation, and serious complications.

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Determining the competency of a practitioner to provide high-quality and safe patient care is one of the most crucial issues in a hospital. We have, therefore, established credentialing and privileging standards at our hospital. The categorization for the privileging was based on operative experience and specialty board requirements. The credentialing and privileging process for the surgical staff was based on general competencies, such as licensure, relevant training, and experience. We have also started to use look into operative and discharge notes to improve the quality and safety of patient care and to provide the necessary feedback for establishing the credentialing and privileging standards. We believe that the establishment of credentialing and privileging standards is useful for not only the provision of high-quality and safe patient care, but also to remove the distrust of the general public in medical practice.

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The merits and demerits of electronic medical records for risk management in the treatment of emergency abdominal diseases are discussed. Prompt uploading of the results of investigations, such as of blood tests, urinalysis and radiography into the computer enables prompt and accurate diagnosis by the attending doctor. Thus, the system could contribute to the prevention of medical accidents. Sharing of information about the patients through the use of electronic medical records can save time for both the patients' families and the medical staff. Concerning informed consent, a prescribed form containing just enough information can be easily prepared and printed out by the use of a fiberoptic communication system. This could also avoid patients' misunderstanding about the situation that could be caused by hasty writing. Furthermore, precise patient information can be provided to both anesthetists and nurses prior to emergency surgery. These findings indicate that electronic medical records are useful tools for risk management in the treatment of emergency abdominal diseases.

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Most small intestinal injuries are caused by blunt abdominal trauma during traffic accidents. Clinical presentation is often vague, and free air may not be detected early after injury. On the other hand, surgical delays can aggravate many cases. Here, we report six cases of traumatic small bowel perforation that were treated at our hospital over a 5-year period between 2000 and 2005. The time from presentation to surgery was less than 12 hours in four cases and longer than 12 hours in two cases. Computed tomography (CT) findings showed free air in the peritoneum in five cases, and all the cases exhibited intraperitoneal fluid at the time of the final diagnosis. The initial CT scan could not detect any signs of intestinal perforation in the two cases whose surgeries were delayed for more than 12 hours. These two patients were discharged after an eventful (What happened?) postoperative course, while the other patients were discharged without complications. Multiple CT examinations over time are the most appropriate means of investigating suspected small bowel perforation; changes in vital signs and physical examinations are also useful for diagnosing this condition.

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Objective: We retrospectively studied the effects of neutrophil elastase inhibitor on postoperative respiratory management in patients with acute abdomen. Methods: Seven patients received neutrophil elastase inhibitor for postoperative respiratory management under artificial ventilation after emergency surgery between August 2004 and March 2005. We compared the outcomes of these seven patients with those of six patients who were managed without neutrophil elastase inhibitor during postoperative artificial ventilation after emergency surgery between April 2002 and July 2004. Adjustment standards for neutrophil elastase inhibitor (Pa_O2/Fi_O2 200mmHg, bilateral permeation shadow observed on X rays, heart failure not seen) and extubation (oxygen status, blood circulation, expiration effort, state of consciousness) were established. Results: In patients who were managed with neutrophil elastase inhibitor, the average artificial ventilation period was 64.4±22.6 hours; the average artificial ventilation period of the patients who were managed without neutrophil elastase inhibitor was 138.3±50.8 hours. Statistically, the patients who received neutrophil elastase inhibitor tended to be extubated earlier than the patients who were managed without neutrophil elastase inhibitor (P=0.0051). Conclusion: The administration of neutrophil elastase inhibitor is useful for postoperative respiratory management under artificial ventilation in patients with acute abdomen.

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A 72-year-old man was referred and admitted to our hospital because of anal bleeding. He had experienced transienthypotension (BP 60/40) as a result of acute alcohol poisoning one day before the symptom had appeared. A colonoscopyshowed an ulcerative lesion with mucosal necrosis and bleeding in the lower rectum. Computed tomography and abarium enema demonstrated a mucosal irregularity and a 6-cm stenotic segment in the lower rectum. A pathologicalstudy of the biopsied specimen showed no evidence of malignancy, ulcerative colitis, or Crohn's disease, although apositron emission tomography (PET) scan showed the strong accumulation of 2-fluoro-2-deoxy-D-glucose (FDG) inthe rectum. A subsequent colonoscopy showed morphological changes in the ulcer despite a lack of treatment, otherthan avoiding oral intake, and the inflamed mucosa improved gradually. During the 10-month period after the patient'shospital discharge, he experienced no symptoms, such as anal bleeding or abdominal pain, and the rectal ulcer healedwith no signs of stenosis. We concluded that the ischemic rectal ulcer had been caused by the transient shock state thatthe patient had experienced prior to the onset of rectal bleeding.

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A 16-year-old girl was admitted to our hospital complaining of epigastralgia lasting for two days. A preoperativediagnosis of acute appendicitis was made, and an emergency laparoscopic appendectomy was performed. Gangrenousappendicitis was observed, but no clear signs of perforation were seen. After the operation, the patient developed a feverof more than 38 that lasted for five days. Conservative therapy was effective. On the 16th postoperative day, thepatient complained of fever and a lower abdominal pain and was readmitted to our hospital. An abdominal computedtomography (CT) examination revealed a Douglas abscess, and transanal drainage was performed on the 20th postoperativeday. She subsequently developed another fever of more than 38°C and was readmitted on the 46^th postoperativeday. An abdominal CT showed a lower abdominal abscess, and a laparotomy for abscess drainage was performed onthe 50^th postoperative day. A left oophorectomy was performed to remove the left ovarian abscess. No abdominalabscesses have recurred since the last operation.

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A 74-year old female was admitted to our hospital because of a lower abdominal pain and vomiting. Acutepanperitonitis caused by a gastrointestinal perforation was suspected because of muscular defense throughout her entireabdomen and diffuse pneumoperitoneum findings during a computed tomography examination. An emergency laparotomywas performed based on a preoperative diagnosis of colon perforation, since the patient's laboratory resultsrevealed leukopenia at the time of admission. During the operation, a thumb-sized round perforation with sharp edgeswas found in the sigmoid colon, and several hard stools were scattered in the peritoneal cavity close to the perforationsite. Moreover, the proximal side of the perforation was packed with a large amount of hard stools up to the ascendingcolon. Based on these clinical findings, a diagnosis of stercoral colon perforation was made and a sigmoidectomy withcolostomy was performed. Because the leukopenia persisted after the operation, the patient underwent a polymyxin Bdirect hemoperfusion (PMX-DHP) treatment on the same day. The patient's leukopenia improved on the followingday, and her postoperative course was favorable without any complications, such as respiratory failure or surgical siteinfection. She was discharged from hospital on postoperative day 29. PMX-DHP treatment might be useful forpromoting a favorable postoperative course in patients with colon perforations and preoperative leukopenia.

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Traumatic Rupture of the Gallbladder is a rare form of blunt abdominal trauma because the gallbladder isanatomically protected by the abdominal organs. A 45-year-old man was transferred to our hospital by ambulance asa result of a traffic accident in May 2004. He exhibited peritoneal irritation. Ultrasonography revealed intra-abdominalfree fluid and a heterogeneous echo pattern in the cystic lumen. Enhanced computed tomography (CT) revealed anirregularity of the cystic wall, pericystic fluid collection, and extravasation of the enhancement material into the freeabdominal cavity; these findings indicated a rupture of the gallbladder with intra-abdominal hemorrhage. About 2000mL of blood was found in the intra-abdominal cavity and an 8-cm laceration of the gallbladder was identified. Livercirrhosis and adhesions between the neck of the gallbladder and the bulbs of the duodenum were also observed. Acholecystectomy was performed. The patient recovered uneventfully and was discharged on postoperative day 10.Solitary rupture of the gallbladder with intra-abdominal hemorrhage is very rare.

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Pneumatosis cystoides intestinalis (PCI), a disorder in which gas filled cysts develop within the bowel wall, is a rareentity. We report a case of PCI in a case of bronchial asthma (BA) developing during the administration ofprednisolone, which was recognized by the presence of free air in the abdominal cavity. A 77-year-old female with ahistory of schizophrenia, diabetes melitus, constipation and bronchial asthma, was admitted to our hospital withexacerbation of BA precipitated by infleuenza type A virus infection. She had been taking prednisolone for BA. In thecourse of her treatment, X-ray and CT revealed intestinal pneumatosis and free air in the abdominal cavity, whilephysical examination, revealed no abnormal findings and the WBC count and serum CRP were within normal range. She received conservative treatment for the PCI: that is, prednisolone was withdrawn and she was kept nil by mouth.The intestinal gas cysts and intraabdominal free air disappeared spontaneously. In our case, PCI could have beencaused by the rupture of the pulmonary alveoll secondary to severe BA, by the increased intraluminal pressure of theintestine secondary to constipation, or by the steroid administration itself.

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Ruptured gastrointestinal stromal tumor (GIST) of the stomach is a rare condition, and only a few reports have beenmade. Here, we present a surgical case with a ruptured GIST of the stomach. We planned an operation for a 62-year-old man diagnosed as having a submucosal tumor of the stomach based on the results of computed tomography andgastrointestinal endoscopic examinations. Before the operation, he complained of a sudden upper abdominal pain andwas hospitalized. A strong tenderness, progression of anemia and a low systolic blood pressure, compatible with adiagnosis of hypovolemic shock, were noted upon admission. Thereafter, the growth of a tumor with an indistinctborder, suggesting rupture, and fluid collection in the right subdiaphragmatic space were observed using computedtomography. An abdominal puncture examination revealed bloody ascites. The patient was diagnosed as having aruptured gastric submucosal tumor, and an emergency operation was performed. During the operation, about 1, 400 mLof bloody ascites and a ruptured tumor in the middle of the stomach were revealed. We performed a distal gastrectomy.The resected specimen was KIT-positive, and the pathological diagnosis was compatible with a GIST of the stomach.The patient has shown no signs of recurrence for 21 months.

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A 67-year-old man was admitted to hospital because of a right upper abdominal pain. A fist-sized induration withtenderness was noted. Ultrasonography and computed tomography revealed an abscess in the abdominal wall. Percutaneousdrainage was performed, and a fistelography showed an abscess cavity/transverse colon fistula. Endoscopicexamination showed a small ulcer; histological examination revealed no signs of malignancy. An operation wasperformed, and a small induration of the transverse colon fixed to the right upper abdominal wall was observed. Apartial transverse colectomy and partial resection of the abscess wall were subsequently performed. Histologicalexamination showed a simple ulcer of the colon. Most cases of abdominal wall abscesses with digestive tract fistulasrequire surgical treatment. Although rare, the main etiologies of these lesions are malignant disease, such as coloncancer, or inflammatory disease, such as appendicitis. Here, we report a rare case of a simple ulcer in the transversecolon that was complicated by an abdominal wall abscess.

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Primary torsion of the greater omentum is an unusual cause of acute abdomen, and very few reports of this conditionhave been made in children. A 5-year-old girl was admitted to our hospital complaining of a right lower abdominalpain. Her white blood cell count and C-reactive protein (CRP) level were slightly elevated. A computed tomographyexamination showed a low-density fatty mass in the right lower quadrant of the abdominal cavity. A laparotomyshowed a torsion of the greater omentum. We excised the necrotic omentum. The patient's postoperative course wasuneventful. Sato first reported a primary omental torsion in a child; the present case is only the second report of thisunusual disease.

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Two patients with ruptured aneurysms of the pancreaticoduodenal artery are presented. Case 1 was a 74-year-oldwoman who was admitted because of a sudden right abdominal pain. An abdominal computed tomography (CT) scanshowed a retroperitoneal hemorrhage, and an abdominal angiography showed a hemorrhage of the posterosuperiorpancreaticoduodenal artery. Since the insertion of a catheter into the lesion was difficult, we elected not to performtrans-arterial embolization (TAE). Instead, we performed a laparotomy and ligated the feeding arteries. Case 2 wasa 72-year-old man who was admitted to hospital because of a lower abdominal pain. A CT scan of his abdomen showeda retroperitoneal hemorrhage, and an abdominal angiography showed a hemorrhage of the anterioinferior pancreaticoduodenalartery. Since the insertion of a catheter into the lesion was difficult, we elected not to perform TAE.Instead, we performed a laparotomy and ligated the feeding arteries. Postoperative abdominal angiographies in bothcases showed stenosis of the basal portion of the celiac artery and the development of a collateral vessel from thesuperior mesenteric artery. We suspect that this condition caused the aneurysms of the pancreaticoduodenal artery.When a retroperitoneal hemorrhage is seen using abdominal CT, TAE after abdominal angiography is the treatmentof first choice because of its low invasiveness. In cases where cannulation at the point of bleeding is difficult, however, an operation should be performed as soon as possible.

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A patient with an internal hernia through a defect in the broad ligament of the uterus is presented. A 62-year-oldwoman complaining of upper abdominal pain was admitted to our hospital on July 13, 2003. Two days after admission, an abdominal X-ray examination revealed dilated loops of the small intestine and multiplanar reformatted computedtomography (MPR-CT) revealed the strangulation of the small intestine in the left pelvic cavity. The patientunderwent an emergency operation after Blumberg's sign was observed. The operative findings revealed a herniationof the small intestine in the left pelvic cavity, as demonstrated by MPR-CT. She was diagnosed as having an internalhernia originating in an abnormal defect of the broad ligament of the uterus. Internal herniation through a defect inthe broad ligament of the uterus is extremely rare, and a precise diagnosis is difficult. In this case, MPR-CT wasextremely useful for diagnosis because it clearly demonstrated the position of strangulation. MPR-CT may have greatpotential for the diagnosis of ileus.

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