Background : Some patients develop adhesive small bowel obstruction (ASBO) recurrences after receiving conservative treatment. The aim of this study was to evaluate the parameters predicting the recurrence of ASBO. Methods : Of the 234 patients with ASBO who were admitted between April 1998 and September 2002, 91 patients who received conservative treatment after long tube placement were enrolled in this study. We followed the patients for 5 years and then divided them into 2 groups : a recurrence group and a non-recurrence group. We then examined the baseline and long tube management characteristics between the two groups and determined the cumulative recurrence rate. Results : A significant difference was found in the number of previous admissions for the treatment of ASBO, the duration of the long tube placement (77 hours vs. 43 hours), the Gastrogratin follow-through study and the location of the long tube's tip. In a multivariate analysis, the duration of long tube placement was an independent parameter predicting the recurrence of ASBO. Conclusions : The present results suggest that the duration of long tube placement might serve as a predictor of the recurrence of ASBO.

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We retrospectively evaluated the usefulness and validity of imaging diagnosis for acute abdomens. Sixty-one patients who had complained of acute abdominal pain upon hospital admittance were and divided into four groups according to the diagnostic imaging modalities that were used : X-ray alone (X-P group, n=11), ultrasonography (US group, n=12), computed tomography (CT group, n=14), and both ultrasonography and CT (US/CT group, n=24). The diagnosis made at the time of admission was also evaluated, and the patients were divided into three groups and analyzed statistically : bowel obstructions (bowel obstruction group, n=20), acute appendicitis or other diseases necessitating a differential diagnosis (appendicitis group, n=35), and perforations of the digestive tract (perforation group, n=6). X-ray and CT examinations were useful for making a diagnosis in the bowel obstruction and perforation groups. Ultrasonography was regarded as important in the appendicitis group. The accuracy of the diagnosis made upon admission was 95.0% in the bowel obstruction group, 88.6% in the appendicitis group, and 100% in the perforation group. Although a prospective evaluation is necessary, CT appears to be useful for diagnosing bowel obstructions and perforations of the digestive tract. Although ultrasonography is useful for diagnosing acute appendicitis, CT is recommended in patients in whom a differential diagnosis is difficult to obtain.

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During conventional management of patients with an open abdomen, many patients with large ventral hernias require a period where granulated abdominal contents are covered by only a skin graft, carrying a high risk of enterocutaneous fistula formation and ultimately requiring late-stage abdominal wall reconstruction. Early abdominal wall reconstruction in patients who are not candidates for standard fascial closure has received little consideration. We used bilateral anterior rectus abdominis sheath turnover flaps for early fascial closure. Bilateral anterior rectus abdominis sheath turnover flaps were created by longitudinal incisions along the lateral edge of the anterior rectus sheath, which was then mobilized medially and approximated. The skin was then closed. Anterior rectus sheath turnover flaps were used in 11 patients who were not candidates for standard fascial closure because of prolonged visceral edema. No fistulas occurred, but 4 patients developed wound infections. Although midabdominal bulging was observed in 7 patients, no abdominal wall hernias requiring secondary reconstruction had developed after 70 months of follow-up. Early fascial closure using an anterior rectus abdominis sheath turnover flap may reduce the need for skin grafting and late abdominal wall reconstruction, and should be considered in the early management of patients with open abdomens.

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Since sepsis remains a leading cause of morbidity and mortality in ICU patients, the control of this burden pathophysiology remains an important issue. Here, we describe a practical strategy for the management of sepsis-related organ failure. In septic patients, standard practices, such as searching for an infection focus, obtaining culture material before the administration of antibacterial drugs, and the proper use of antibacterial drugs, should be done. Empirical antibiotics should be chosen depending on the causative bacteria and their drug susceptibility at that particular institution and de-escalated after sensitivity tests. Polyclonal immunoglobulin may also be used for the treatment of septic patients. To avoid a secondary infection, a semi-recumbent position, enteral nutrition, etc. should be utilized. At the same time, both systematic and organ-specific support should be done. These interventions include support for respiratory, circulatory, renal, hepatic, coagulation-fibrinolytic, neurological, and nutritional systems. The practical management of such organ support is discussed based on high-quality evidence. In the near future, gene polymorphisms related to susceptibility, the outcome of sepsis, and drug response will provide very useful information. To obtain reliable evidence, a large-scale, multi-center survey is needed in Japan.

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Various humoral mediators are involved in the pathophysiology of septic shock and septic multiple organ failure (MOF) following severe sepsis. An immediate mediator, endogenous cannabinoid, causes septic shock and adjusts the production of other early mediators. Early mediators, especially cytokines, play a key role in the pathophysiology of septic MOF. Cytokine balance, the ratio of inflammatory cytokines and anti-inflammatory cytokines, reflects the biological response to severe sepsis. A late mediator of lethality, HMGB-1, is released by the stimulation of endotoxin and/or cytokines. Direct hemoperfusion with polymyxin B immobilized fiber (PMX-DHP) modulates these humoral mediators and brings about an improvement in circulatory and respiratory conditions in septic MOF. Hence, PMX-DHP is an efficient therapy for patients with septic shock and septic MOF when PMX-DHP is performed immediately after the removal of causative lesions.

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Intestine exposed to ischemia/reperfusion produces a variety of inflammatory mediators. These mediators enter into the systemic circulation through the mesenteric lymph duct, leading to multiple organ dysfunction syndrome (MODS). Recent studies have demonstrated that mesenteric lymph includes pro-inflammatory mediators, such as cytokines and biologically active lipids, and activates neutrophil/vascular endothelial cells. Therefore, mesenteric lymph is indispensable to elucidating the mechanism of MODS. While stored blood is the only resuscitative fluid with an oxygen carrying capacity for severe shock, many adverse effects to recipients have been reported. A blood substitute may avoid this clinical dilemma. Our results suggest that resuscitation using a blood substitute may reduce the risk of acute lung injury by attenuating mesenteric lymph-induced neutrophil activation, and thus may be a useful strategy for the treatment of MODS.

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Leukocytoapheresis (LCAP) is a treatment that reduces the production of cytokines by removing activated leukocytes from both peripheral blood and local inflamed lesions. LCAP has been reported to be is effective for the treatment of inflammatory bowel diseases and rheumatoid arthritis. We treated four patients with LCAP who were suffering from multiple organ failure as a result of sepsis. LCAP improved their pulmonary function and circulation status, but did not contribute to saving their lives. To prevent a second attack on major organs and to save patients with multiple organ failure, LCAP may be used during early sepsis.

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A 57-year-old man had undergone a total pelvic exenteration with an ileal conduit followed by ureteral stenting for the treatment of advanced rectal cancer. One month after the operation, gross hematuria occurred from the ileal conduit. An arteriography showed a connection between the left external iliac artery and the ureter, suggesting an ureteroarterial fistula. The patient was received endovascular treatment using an intraarterial covered stent-graft through the left external iliac artery. The hematuria disappeared after the endovascular correction of the ureteroarterial fistula. However, a persistent infection of the intraarterial stent graft was recognized thereafter. Therefore, femorofemoral crossover arterial bypass surgery with en bloc resection of the ureteroarterial fistula was performed. The postoperative course was uneventful, and the patient was discharged two months after the bypass surgery. Ureteroarterial fistula following urinary diversion can occur in association with the prolonged insertion of a ureteral stent ; thus, caution regarding the possible development of a ureteroarterial fistula is necessary in cases with the prolonged insertion of ureteral stents for ileal conduit.

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A 15-year-old girl was admitted to the Department of Orthopedics of our hospital because of a high fever, coughing, and left hip pain in September 2004. She was diagnosed as having diabetes mellitus after admission. Initially, the cause of the fever could not be determined, even after a lumbar vertebral MRI examination. Gallium scintigraphy detected a hot spot on the left side of the pelvic space, and the patient was diagnosed as having an abscess in the pelvic space based on abdominal CT and MRI findings. The patient was transferred to a different department, and percutaneous drainage of the abscess was performed ; Salmonella was isolated from cultures of the fluid taken from the abscess. The patient's symptoms disappeared, and she was discharged on post-drainage day 23. Since the patient's chief complaint was a left hip pain and digestive tract symptoms were not present, the abscess in the present case was difficult to diagnose. When investigating the cause of a fever of unknown origin, a whole-body examination may be necessary to rule out the possibility of a pelvic infection caused by Salmonella. Regarding the treatment strategy used in this case, low invasive percutaneous drainage of the abscess was useful.

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We report an intestinal perforation caused by the ingestion of a press through package (PTP). A 57-year-old man with chronic renal failure had been visiting our hospital to receive hemodialysis (HD) for 24 years. He visited our emergency room (ER) after possibly swallowing a piece of PTP that had been prescribed as part of his HD treatment. Since no abnormal findings were found during a physical examination or on an abdominal X-ray, he was allowed to go home. The next day, he suddenly developed a sharp abdominal pain after eating lunch. He was brought to our ER. A CT scan revealed free air in his peritoneal cavity and a foreign body in his small bowel. Since the unique image of the foreign body coincided with the median section of a PTP, he was diagnosed as having an intestinal perforation caused by the ingestion of a PTP. An emergency laparotomy was performed. The penetrated PTP was found in the jejunum, 75 cm from the Treitz ligament. A partial resection of the jejunum, including the PTP, was performed. His postoperative course was satisfactory. Recently, the number of reports of ingested PTP are increasing. Although patients should be cautioned not to swallow PTPs, it is more important to improve the actual PTPs.

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A 47-year-old woman complaining of coffee-ground-like vomiting visited our acute medicine center. Rebound tenderness was not apparent upon admission. Laboratory tests showed a white blood cell count (WBC) of 22,700/mm³ in addition to severe metabolic acidosis and hyperglycemia. Rebound tenderness eventually appeared and gradually intensified, and the patient was diagnosed as having peritonitis as a result of strangulation ileus. An emergency operation was performed 10 hours after hospitalization. Operative findings showed a transmural necrosis extending from the hepatic flexure of the colon to the descending colon. Therefore, a resection of the transverse colon and a double-barreled colostomy was performed. A histological examination did not reveal any thrombi in the main arteries, so the case was diagnosed as non-occlusive mesenteric ischemia (NOMI). One year later, a cecum-sigmoid colon anastomosis was performed and the stoma was closed. Using Ladd's procedure, the absence of intestinal rotation was confirmed. The patient had an uneventful postoperative course and maintains a good quality of life (QOL).

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We report a case of incarcerated incisional hernia after a previous appendectomy that was repaired using a Composix™ Kugel Patch (CKP). A 76-year-old woman was admitted to our hospital complaining of low abdominal pain. An appendectomy had been performed 64 years earlier. The patient was diagnosed as having an incarcerated incisional hernia based on the results of a physical examination, a blood examination, an abdominal X-ray, and computed tomography (CT) findings. Since the abdominal X-ray and CT findings also showed a dilatation of the small intestine, an ileus tube was inserted before the operation. An emergency operation was then performed. The procedure included a partial ileal resection of the strangulated bowel and repair of the wall defect using a CKP. The postoperative course was uneventful. Hernia recurrence had not occurred as of 5 months after the operation. This case suggests that appropriate repair of incarcerated incisional hernias using CKP is feasible.

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We experienced a case of traumatic abdominal wall hernia and mesenteric injury caused by a cow's horn. The patient was a 46-year-old man, whose cow had thrust him against a wall with her horn stuck against the lower right quadrant of his abdomen. He visited the emergency department of our hospital because of abdominal pain, despite exhibiting minor external injuries. An examination showed abrasion and subcutaneous bleeding in the lower right quadrant of the abdomen, but the skin was intact. An abdominal echography revealed an echo-free space under the surface of the liver and between the kidney and the adjacent liver and spleen, as well as in the right paracolic gutter. We diagnosed the patient as having intraabdominal bleeding, and emergency surgery revealed a traumatic abdominal hernia where the horn had struck and an ileal mesenteric injury. The bleeding was stopped, and the wound was sutured. The postoperative course was uncomplicated, and the patient was discharged on Day 12. An object that is both sharp and blunt, like a cow's horn, may rupture deep-lying tissues and cause organ damage, even if the skin is intact. Therefore, it is important to consider the mechanism of injury before making a diagnosis and treating the injury.

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A 17-year-old man had a prior history of recurrent abdominal pain and vomiting several times a year since childhood. Since a diagnosis could not be established, psychotherapy for nonspecific abdominal symptoms was recommended. The patient was admitted to our hospital because of sudden abdominal pain and vomiting. An abdominal CT demonstrated that the mesentery and intestine had encircled the superior mesenteric artery (whirl-like pattern). The patient was diagnosed as having idiopathic intestinal volvulus, and emergency surgery was performed. The surgical findings demonstrated an attachment of the mesentery from the jejunum to the right colon without the ligament of Treitz. Furthermore, the ligament of Ladd was detected on the proximal portion of the jejunum. Since the ligament of Ladd had twisted the jejunum, the patient underwent a Ladd's procedure. The postoperative course was uneventful.

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Patients 1, 2, and 3 were admitted to our hospital because of abdominal pain. Abdominal CT studies showed ascites and a “whirl sign” in all cases, and sclerosis in the abdominal aorta in case 3. Emergency operations were performed under a diagnosis of strangulated small bowel obstruction, and the small intestine was found to be twisted in each of the cases. The color of the affected portion of the intestine was normalized by repositioning in cases 1 and 2, but in case 3, the distal ileum was strangulated and partial bowel necrosis was found, requiring bowel resection. No anatomical abnormalities capable of inducing the rotations were found in these three cases, and primary small bowel volvulus in adults was diagnosed. No single specific diagnostic clinical sign or abnormal laboratory finding was found, but the presence of a “Whirl sign” in each case was a specific diagnostic radiologic finding. The gangrenous small bowel associated with volvulus may have been caused by the degree of mesenteric artery twisting and arteriolar sclerosis.

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An 85-year-old man who had been treated with radiotherapy for brain metastases that occurred after lung cancer surgery, developed abdominal pain and was hospitalized. On admission, a fist-sized mass was palpable in the lower right abdomen. A gastrografin enema and abdominal CT study identified two intussusceptions and ileus in the cecum and transverse colon. The intussusception in the transverse colon was removed using an enema. However, removal of the intussusception in the cecum required emergency surgery. During the operation, multiple neoplastic lesions were noted between the cecum and the transverse colon. An extended right hemicolectomy was performed at two sites to remove the ileus caused by the tumors. Histological examination revealed that the tumors were pleomorphic carcinomas of the lung that had metastasized to the colon.

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An 86-year-old man was seen at our hospital because of nausea and vomiting. An abdominal plain X-ray film showed an intestinal loop and dilated intestinal loop and ileus. (?) Abdominal enhanced-CT revealed a markedly dilated small intestine and with an enhanced solid mass (8 cm in diameter). The ileus did not improve, so an emergency operation was performed. During the laparotomy, a tumor was observed at a point 240 cm anal from the Treitz ligament ; the tumor had an extraluminal stalk on the opposite side of the mesenterium. The small intestine was not necrosed, so a partial resection of the small intestine was performed. Immunohistochemical examination showed that the tumor was strongly positive for c-kit protein, partially positive for CD34, positive for S-100 protein, and negative for α-SMA and NSE. Thus, the histological diagnosis was gastrointestinal stromal tumor (GIST) of the small intestine. Here, we report this rare case of an extraluminally growing GIST causing strangulation ileus and review the relevant medical literature.

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The patient was an 81-year-old woman. She consulted a local clinic complaining of acute lower abdominal pain and was referred to our hospital after being diagnosed as having ileus. Upon examination, rebound tenderness was noted in the lower abdomen but muscle guarding was not observed. A plain abdominal X-ray showed the absence of gas. Contrast-enhanced computed tomography (CT) of the abdomen revealed marked retention of ascites and dilatation of the small intestine with the concentrated mesentery in the lower abdomen. These findings suggested strangulation ileus, and an emergency surgery was performed 15 hours after onset. A laparotomy revealed an oval defect 5 cm in diameter in the sigmoid mesocolon. Approximately 60 cm of the small intestine had herniated through the defect at a point 100 cm distant from Treitz's ligament and had been strangulated. Under a diagnosis of transmesosigmoid hernia-related strangulation ileus, the necrotic intestine was resected and the oval defect was closed. Transmesosigmoid hernia is rare and may be difficult to diagnose prior to surgery. However, this disease should be considered when ileus of unknown cause is encountered so that strangulation ileus can be diagnosed at an early stage.

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A 37-year-old-man with chronic alcoholic pancreatitis and a pseudopancreatic cyst was followed at another hospital. In July 2004, he was admitted to that hospital after complaining of abdominal pain with fever as a result of an infectious pseudopancreatic cyst. The patient was transferred to our hospital for percutaneous drainage of the cyst. Imaging of the cyst revealed the communication of the pancreatic cyst with the main pancreatic duct and stenosis of the main pancreatic duct in the head of the pancreas. Obstructive jaundice developed as a result of the pancreatitis, so endoscopic biliary tube stenting was performed. A laparotomy was performed in our hospital when the infectious pseudopancreatic cyst did not improve. Since an intraoperative examination revealed severe adherence of the pancreas and pseudocyst to the surrounding tissues, we resected the pseudocyst by performing a distal pancreatectomy with splenectomy, as well as a reconstruction of the distal pancreatogastrostomy. The patient's abdominal pain was reduced postoperatively and he was discharged without a drainage catheter. At present, he is doing well and his blood sugar is well controlled with the treatment of 20 units of insulin per day at the previous hospital.

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Inflammatory fibroid polyp (IFP) of the small intestine is relatively rare. This case report documents an IFP of the ileum that presented with intussusception and perforation. An 86-year-old woman was admitted to our hospital complaining of severe lower abdominal pain. An abdominal CT showed free air on the surface of the liver and a tumor in the intestine. She was diagnosed as having peritonitis caused by a perforation of the gastrointestinal tract, and an emergency laparotomy was performed. During the surgery, an intestine-intestine type invagination of the small intestine was observed at a point 60 cm oral from Bauhin's valve. Part of the intestine was also perforated at this location. A partial resection of the ileum, including the tumor and the perforation site, was performed. The tumor was 3×3×3 cm in size, round-shaped with a stalk, and lacking a mucosa on the superior surface of the tumor. The cut surface of the firm tumor was yellowish-white. Histological findings showed the proliferation of fibrous connective tissues and small vessels. Inflammatory cells containing eosinophils had mainly infiltrated the submucosa. Immunohistochemical studies were positive for vimentin. But negative for either c-kit or CD34. The pathological diagnosis of the tumor was IFP.

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