For the evaluation of emergent ileus surgery for strangulation in pediatric patients, we conducted a study of 19 cases at our department over a 7-year period. The results were as follows: (1) The 19 pediatric ileus cases included 6 neonates (0∼30days), 6 infants (1∼12months), 3 children (1∼5years), 3 school children (6∼12 years), 1 student (13∼15years). (2) The male-to- female ratio was 10:9. The mortality rate was 15.8%. (3) The most frequent cause of the disease was congenital (8 cases: 42.1%), followed by intussusception, strangulation of external inguinal hernia. (4) The pH and base excess in the death group were less than those in the surviving group. The interval from the appearance of symptoms to operation in the death group was shorter than that in the surviving group. (5) For improvement of the survival rate, it is very important to detect symptoms early and make an early decision on laparotomy.

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We evaluated palliative treatment for unresectable malignant gastric outlet obstruction (MGOO) using a covered self-expandable metallic stent (SEMS). Seventy-eight patients (gastropyloric obstruction in 36 cases, duodenal stenosis in 42 cases) underwent palliative treatment with a covered Ultraflex stent. Since SEMS for MGOO has not been launched in the market in Japan, we used the covered esophageal SEMS as a substitute. The covered SEMS was successfully retained in the target region in 77 patients. The patients became able to ingest orally after a mean of 2.3 days, and 91% of the patients (70/77) became able to eat solid or semi-solid diets subsequently. The covered SEMS did not get obstructed by tumor ingrowth or hyperplasia, and was, therefore, maintenance-free. In regard to the problems associated with the use of the covered SEMS for the duodenum, there is the concern about possible blockage of the papilla. However, the problem was resolved with the use of a biliary SEMS. We concluded that the covered SEMS is useful as palliative treatment for unresectable MGOO.

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Self-Expandable Metallic Stent (EMS) treatment has recently been employed for colorectal obstruction caused by various diseases. There has been a relative delay in the use of EMS for colorectal obstructions as compared with that for other organs. Recently, however, there have been many reports of the use of EMS for colorectal diseases, mainly from the West. EMS is generally used as a palliative treatment for malignant strictures of the colon and rectum and as a bridging measure before surgery for obstructing colorectal cancers. Some investigators have reported on the usefulness of EMS for strictures associated with benign diseases. The indications for EMS treatment must be considered carefully because of the lack of long-term results of a foreign body placed permanently within the human body. EMS treatment can eliminate the need for unnecessary palliative and temporary colostomies in patients with colorectal obstruction. EMS may be expected to become the standard treatment for colorectal strictures when exclusive colorectal EMS and delivery kits are developed.

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The treatment of colorectal obstruction caused by unresectable malignancies usually requires a stoma creation. However, these patients are debilitated from advanced malignancy and have limited life expectancy. Moreover, the quality of life is usually adversely affected by the presence of a stoma. In such patients, we attempted stent placement to avoid stoma creation. This treatment may be less invasive as compared with stoma creation, and provide an improvement in the quality of life of patients with unresectable malignant obstruction of the colon and rectum.

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Rapid and safe biliary decompression is essential for the treatment of acute disease of the biliary tract. Endoscopic nasobiliary drainage (ENBD) is the conventionally used maneuver. Because we have encountered several instances of trouble, including displacement, with the use of drainage tubes, we have come to prefer another endoscopic method, namely, placement of plastic biliary stents. The present study discusses the usefulness of stent placement as compared with that of ENBD in patients with acute biliary disease. We retrospectively examined 32 patients treated by ENBD and 37 patients treated by stent placement at our center between January 2002 and December 2005. We investigated the patient backgrounds, outcomes of the drainage, complications and prognosis. The results revealed no significant differences in the patient backgrounds (the mean age, underlying diseases, etiology and pathology) of the two groups. ENBD and stent placement were equally effective, because the serum level of total bilirubin and CRP decreased almost equally in both the groups after 3 days of drainage. Tube failure occurred significantly frequently in patients treated by ENBD (31.3%) as compared to that in those treated by stent placement (2.7%). There was no difference in the prognosis between the two groups. Since endoscopic biliary stent placement is the same as ENBD in terms of effectiveness and more advantageous with regard to safety, we conclude that it may be considered as the first choice for emergency biliary drainage.

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A total of 113 patients with inoperable malignant biliary strictures were analyzed retrospectively. Metallic stents (MS ; 81 patients), single Tannenbaum stents (STS ; 9 patients) and double Tannenbaum stents (DTS ; 23 patients) were placed consecutively in our institute between 1995 and 2003. The stent patency period, survival period, effect of chemotherapy on survival, occlusion ratio, and complications were compared among the MS, STS and DTS groups. Significant differences were found in the 50% patency period among the three groups (MS; 172 days, STS; 91 days, DTS; 235 days, Kaplan-Meier method, log-rank test, p<0.05), although when pancreatic cancer patients alone were considered for the analysis, no differences in the patency period were noted (MS; 234 days, DTS; 235 days, p<0.05). The survival period was significantly prolonged with chemotherapy in the DTS group (median survival period; with chemotherapy 375 days, without chemotherapy 103 days), while no survival benefit was obtained in the MS group. The occlusion ratio was significantly higher in the STS group (67%) as compared with that in the MS group (38%) and DTS group (14%). Univariate analysis was performed by the Kaplan-Meier method compared by the log-rank test to determine the risk factors for stent occlusion. Then, variables with a P value of less than 0.05 determined from the univariate analysis were introduced into the Cox proportional hazards model, and the odds ratios, 95% confidence intervals and P-values were calculated. The results revealed STS and gender to be statistically significant risk factors for stent occlusion. The DTS group not only showed a significantly prolonged patency period, but also good survival benefit with chemotherapy for pancreatic cancer as compared with the results in the MS group. Bile drainage through the gap between the two plastic stents (interductal drainage) may have played a key role in the notably improved drainage effect of the plastic stent. DTS could well be a good option for biliary strictures caused by pancreatic cancer.

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We encountered 8 cases of malignant airway stenosis due to advanced esophageal cancer, who were treated with a self-expandable metallic airway stent (SEMS). In all cases, the SEMS was placed successfully. No major complications, such as perforation of the trachea or massive bleeding, occurred. Five of the 8 cases could be discharged from the hospital and 2 were treated by chemoradiotherapy after the placement of the SEMS. The mean survival time after the stent placement was 124 days (9∼362days). Most of the patients with airway stenosis due to end- stage esophageal cancer are in poor general condition and have a poor prognosis, therefore candidates for stent placement should be selected carefully and informed consent must be obtained from the patient and the family. Airway stenting for malignant airway stenosis due to advanced cancer enables not only saving of the patient's life and improving his/her QOL, but also allows addition of further chemoradiotherapy to improve the life expectancy of the patient.

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We report a case of a ruptured gastrointestinal stromal tumor (GIST) of the stomach associated with hemoperitoneum. A 67-year-old man complained of having developed sudden epigastralgia after supper. He was transferred to our hospital on the following day and examination revealed tenderness of the whole abdomen. Because abdominal computed tomography (CT) revealed bleeding in the splenic hilum and the liver surface, the patient was admitted. Angiography revealed staining of a tumor measuring about 5 cm, fed by a short gastric artery, with no extravasation. Enhanced CT revealed continuity of the tumor with the upper stomach. Surgery was undertaken and a diagnosis of gastric GIST was made. During the operation, about 300 ml of bloody ascites and a ruptured tumor measuring 50×60×35 mm in size was noted between the upper of the stomach and spleen. Therefore, partial gastric resection was undertaken, and histopathological examination revealed a diagnosis of GIST of the stomach, with the tumor being positive for KIT. The possibility of intraperitoneal dissemination must be borne in mind in such cases with a ruptured tumor.

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A 44-year-old man was admitted to the hospital because of abdominal pain and abdominal fullness. Barium enema showed proctosigmoid stenosis ; based on the suspicion of ileus caused by colon cancer, we constructed an artificial anus. Postoperatively, the urine became turbid with a fecal smell, and cystography showed a rectovesical fistula. Biopsies of both the rectum and bladder were negative for carcinoma. Since the rectal stenosis did not appear to improve, we performed anterior resection and partial cystectomy. A diagnosis of rectal stenosis with rectal diverticulitis and rectovesical fistula was made based on histopathological examination of the resected specimens. A literature search for rectal stenosis caused by diverticulitis yielded 5 case reports, however, none had an associated rectovesical fistula ; thus, we believe that ours is a rare case worthy of reporting.

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Left-sided colorectal carcinoma often causes intestinal obstruction. Preoperative peroral decompression in these cases frequently yields poor results, necessitating emergency surgery, namely, the construction of a temporary colostomy. We report 4 cases of laparoscopic surgery for left-sided colon cancer after decompression with transanal ileus tubes. Lesions were located in the descending colon in three cases, and in the rectum in one case. The transanal ileus tube insertion was successful for the relief of obstruction in all cases, and all cases underwent a laparoscopic one-stage radical resection. Decompression with the transanal tube may be useful for one-stage laparoscopic resection in patients with obstructive colorectal carcinoma.

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Three patients who underwent fibrin sealing therapy for intractable biliary fistula after hepatectomy are described. The types of hepatectomy were partial resection of the right lobe (Case 1), left lobectomy without caudate lobectomy (Case 2), and incomplete right lobectomy with preservation of the left peripheral side of the anterior segment (Case 3). In all patients, bile leaked from the peripheral side of the interrupted hepatic bile ducts. After confirming that the fistula was aseptic and that the volume of discharge was as ow as 20ml per day, fibrin glue was injected into the fistula. The fistula was closed without any complications in cases 1 and 2, in whom the fistula and hepatic bile ducts were completely sealed with the fibrin glue. However, the fistula did not close in case 3, because the fibrin glue did not reach the hepatic bile ducts. In conclusion, this method of treatment may be safe and useful for closure of biliary fistula from the peripheral side of the interrupted hepatic bile ducts if the fistula and hepatic bile ducts are completely sealed by fibrin glue when the fistula becomes aseptic and the volume of leakage is small.

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Injuries to the portal vein are rare, but are associated with a high mortality. To the best of our knowledge, there are no reports from Japan of successful treatment of extrahepatic portal vein injury (PVI). We present the case of a 71-year-old male with PVI sustained in a car crash while driving driving accident, which was successfully treated. He had a history of undergoing a distal gastrectomy with reconstruction by the Billroth I procedure for gastric cancer eight years previously. When he was transferred to our department, he was in shock. An open fracture was observed in his left knee. Abdominal CT scan revealed pancreatic body laceration, intraabdominal hemorrhage, and an unusual fluid collection in the omental bursa. Emergency laparatomy disclosed partial laceration in the pancreatic body and PVI. Although the massive hemorrhage prevented a direct approach to the PVI, use of the intra-aortic balloon occlusion technique enabled us to clamp the portal vein both proximally and distally. We finally succeeded in repairing the PVI using lateral venorrhaphy, and sutured the pancreatic laceration. His postoperative course was complicated by ileus and splenic vein thrombosis, both of which were treated conservatively. After operative treatment of his femoral fracture on day 26 and subsequent rehabilitation, he was discharged from the hospital on day 117.

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A 60-year-old man was admitted to our hospital with a two-day history of severe abdominal pain and vomiting. He was under regular medication with warfarin and aspirin for cerebral infarction. Physical examination revealed severe left upper abdominal pain and muscle guarding. Standard laboratory tests were unremarkable, except for a Hb of 11.0g/dL, INR (international normalized ratio) >10, and evidence of inadequate regulation of thrombolysis. Abdominal CT confirmed segmental thickening of the jejunal wall and mesenterium, with ascites. An exploratory laparotomy revealed segmental thickening of the jejunal wall and mesenterium for hematoma, also involving the duodenum, with massive bloody ascites. Partial resection of the jejunum was performed. The postoperative course was uneventful. The hematoma appeared to have arisen spontaneously after administration of thrombolytic agents. Conservative therapy is recommended, but laparotomy should be considered if the symptoms do not resolve spontaneously.

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We report a case of billary peritonitis due to gangrenous cholecystitis caused by polyarteritis nodosa. A 36-year-old female was diagnosed to have polyarteritis nodosa and was receiving steroid pulse therapy. During her hospital stay, she developed severe right hypochondralgia and was diagnosed as having noncalculous cholecystitis. Cholecystectomy was performed, based on the diagnosis of billary peritonitis with gangrenous cholecystitis. Pathological examination revealed vasculitis in the perforated gallbladder wall. Postoperatively, several severe complications occurred, such as bile leakage and an intractable fistula, and the symptoms of polyarteritis nodosa also worsened. Surgical operations may cause severe damage of organs if they are performed during the active phase of PN. Therefore, when patients with polyarteritis nodosa present with acute cholecystitis, caution must be exercised during the operation, with surgery conducted only in cases with absolute operative indications. Priority should clearly be given to the treatment of systemic PN with corticosteroids and cyclophosphamide.

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A 56-year-old woman was admitted to our hospital because of abdominal pain and vomiting. She had been under treatment for systemic lupus erythematosus (SLE) since 8 years previously. Abdominal examination revealed signs of peritonitis and abdominal CT scan showed the presence of free abdominal gas. An emergency surgery was immediately performed under the diagnosis of perforation of the descending colon. A perforation measuring 2 cm in diameter was detected on the mesenteric side of the descending colon. Surgery site infection occurred, however, it could be treated uneventfully. She was transferred to the Department of Internal Medicine on the 19^th postoperative day.

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We report a case of acute diffuse peritonitis due to perforated pseudocyst of a gastric ectopic pancreas. A 15-year-old woman visited our hospital complaining of vomiting and abdominal pain. She had agenesis of the corpus callosum. At first, the patient was diagnosed as having strangulated intestinal obstruction based on the results of physical examination, blood examination, abdominal X-ray, and computed tomographic (CT) findings. During the emergency surgery, a perforated cystic tumor of the stomach was found. A partial resection of the stomach, including the tumor, was performed. The postoperative course was uneventful, and the patient was discharged on Day 17. Pathological examination revealed that the cystic tumor was a perforated pseudocyst of the gastric ectopic pancreas.

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Biliary peritonitis due to bile leakage from the gallbladder not associated with any perforation is very rare. An 89-year-old man was diagnosed to have generalized peritonitis and admitted to our hospital. Abdominal computed tomography revealed the presence of ascites around both the right lobe of the liver and the gallbladder, and a collapsed gallbladder. Ultrasound-guided peritoneal paracentesis indicated biliary ascites. The patient was diagnosed to have biliary peritonitis caused by perforation of the gallbladder, and an emergency laparotomy was performed. A large amount of biliary ascites was found in the right upper portion of the abdomen. Although the gallbladder wall was thinned out at the fundus, no perforation was detectable. No other lesions causing bile leakage were observed. A cholecystectomy and drainage around the gallbladder were performed. An oval mucosal defect, approximately 1.3 cm in size, was observed in the fundus of the gallbladder. Bacterial culture of the bile was negative. Histopathological examination revealed hemorrhage and necrosis throughout the remaining thickness of the wall. The biliary ascites did not recur after the surgery. Although the patient suffered from multiple organ failure postoperatively, he recovered gradually, and was discharged from the hospital on the 35th postoperative day. The cause of biliary peritonitis in this case was considered to be biliary leakage from the necrotic portion of the gallbladder wall. It was suspected that necrosis of the gallbladder was caused by circulatory failure of the bladder due to sclerosis of the arterioles, although no evidence of such lesions was found in this case.

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We recently encountered a case with migration of an intrauterine device (IUD) into the abdominal wall. The patient was a 22-year-old woman from Pakistan, who had lived in Japan since she was 15 years of age. She admitted to a history of suffering from several episodes of left lower abdominal pain during the previous five years. She also gave a history of having had bladder inflammation infection? twice, which was cured by medication on both occasions. She visited our hospital in July 2005, when her symptoms aggravated. Examination revealed tenderness in the area of the pain, and a foreign body could be palpated beneath the abdominal wall, even though no operation scar was noted. A plain x-ray of the abdomen revealed that the object was t-shaped and partially made of metal. The operation for removal of the foreign body was performed in August. The object was located in the abdominal wall, and the bladder was found to be adherent to the abdominal wall in this region. Although we could not confirm any previous record of IUD insertion, from its appearance, the foreign body was determined to be an IUD. This is a case of IUD migration to the abdominal wall.

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A 63-year-old man presented with a 5-day history of fever and jaundice. He was admitted to our hospital with the diagnosis of a common bile duct stone and cholangitis made by plain abdominal CT and laboratory data. ERCP was attempted on the second hospital day but ended in failure due to ampulla of Vater in duodenal diverticulum. Abdominal ultrasonography on the third hospital day revealed absence of blood flow in the left branch and the anterior branch of the portal vein. Contrast-enhanced 3-dimensional CT portography confirmed the diagnosis of portal vein thrombosis. After improvement of the fever and jaundice with conservative therapy, the patient underwent cholecystectomy and choledochotomy on the 15^th hospital day. Examination of the gallbladder revealed severe chronic cholecystitis. Preoperative abdominal contrast-enhanced CT demonstrated partial recanalization of the portal vein. Thus, portal vein thrombosis was associated with cholecystitis and cholangitis in this case. Clinicians should be aware of the possibility of portal vein thrombosis as a complication in cases with severe cholecystitis and cholangitis.

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