Kanehiro Takaki (1849~1920) was born in Hyuga Province (Miyazaki Prefecture) . He joined the Imperial Japanese Navy as a medical officer in 1872. From 1875 to 1880, he studied at St Thomas'Hospital Medical School in London, UK. As soon as he returned to Japan, he and his colleagues founded the Seikai Medical School, now the Jikei University School of Medicine, and a training school for nursing, the first school of nursing in Japan. At this time, the disease beriberi was endemic in the Japanese armed forces, and Takaki proved that poor diet was the prime factor in beriberi. The disease was soon eliminated from the Imperial Japanese Navy by improving the quality of meals, comprising a mixture of foods including barley rather than white rice. Although he clearly showed that the incidence of the disease was due to nutritional issues, in particular thiamine deficiency, this conflicted with the prevailing idea among medical scientists that beriberi was an infectious disease. In 1905, Takaki was ennobled with the title of baron for his contribution to the elimination of beriberi from the Imperial Japanese Navy, and was later affectionately nicknamed the “Barley Baron”. He was a true man of the Meiji Era (1868~1912) and was multifaceted, being at once a doctor, soldier, teacher and statesman.
Surgery is often performed in the acute stages of an appendiceal abscess, but in such instances bowel resection or post-operative complications may be encountered. In order to avoid these problems, we performed laparoscopic interval appendectomy (lapIA), a form of laparoscopic appendectomy, about 3 months after conservative treatment in 12 cases of appendiceal abscesses. In 5 cases, percutaneous abscess drainage was also used. The mean operating time for lapIA was 91.3 min. and mean blood loss was 18.8 g. Analgesics were used postoperatively twice on average, and the total hospital stay was 23.8 days. These results were no different from those with single-stage surgery. However, lapIA had a significantly lower percentage of postoperative complications, 0%, in contrast to the 50% seen with single-stage surgery. Thus, lapIA is an effective means of treatment of appendiceal abscesses.
The aim of this study was to evaluate preoperative predictive factors for conversion from laparoscopic to open interval cholecystectomy in acute cholecystitis. The data from 109 consecutive patients undergoing elective laparoscopic cholecystectomy from January 2002 to December 2005 in our hospital were analyzed. The demographics and preoperative data of patients who required conversion to laparotomy were compared with those with successful laparoscopic cholecystectomy. The predictive factors for conversion from laparoscopic to open cholecystectomy in acute cholecystitis patient were significantly associated with stones incarcerated in the cystic duct, cystic duct negative with preoperative radiography and Mirizzi's syndrome. Our results strongly suggest that laparoscopic cholecystectomy with these factors could be associated with an increased conversion rate to open surgery.
The development of liver dysfunction or liver failure must be prevented after liver injury, including liver surgery. We describe the usefulness of apolipoprotein A-1 (ApoA-1) for assessment of the liver function after treatment of liver injury. Our previous studies showed that the serum ApoA-1 level decreased on postoperative day (POD) 7 and then recovered on POD 14 after hepatectomy. This change in ApoA-1 seems to reflect the hepatic protein synthetic ability. When patients developed liver failure, ApoA-1 dramatically decreased, and the serum level was usually under 5mg/dL. This decrease of ApoA-1 was recognized in the relatively early phase of liver failure. Recent studies have shown that ApoA-1 has the ability to bind with and protect against lipopolysaccharides and that it is the major contributor to anti-endotoxin function. When ApoA-1 decreases to an extremely low level, the patient will be at high risk to infection or sepsis. ApoA-1 must be measured for the prevention of postoperative infection in patients with liver injury. In the liver failure patients, we experienced improvement of liver function following oral intake of Valine, an amino acid. This selective amino acid therapy may be effective in the treatment of liver failure.
In order to evaluate the usefulness of and the problems associated with early enteral nutrition (EEN) in the patients with ulcerative colitis (UC), we performed a randomized controlled trial comparing EEN versus total parenteral nutrition (TPN). UC patients who underwent a total proctocolectomy and ileal pouch anal anastomosis with ileostomy or subtotal colectomy with ileostomy were randomized to receive EEN or TPN. Both types of nutritional therapy were continued till postoperative day (POD) 6. Although TPN could be completed with no side effect in all patients, EEN could not be continued till POD 6 in 46% of patients because of abdominal pain and nausea. The administered calories from POD 4 to POD 6 were significantly lower in the EEN not-completed group than in the EEN completed group and TPN group. The serum transthyretin level at POD 7 was also significantly lower in the EEN not-completed group. Although there was no significant difference in the frequency of postoperative complications between the two groups, the incidence of ileus was lower in the EEN group. In conclusion, it is essential for early postoperative recovery of rapid turnover protein to administer a sufficient amount of calories. The combination of low-dose EEN and TPN may be suitable for the postoperative nutritional therapy of UC patients.
The nutritional management of severe acute pancreatitis (SAP) is difficult because of the patient's alimentary function deficiency. We therefore examined the role of the nutrition support team (NST) and the effects of early enteral nutrition with synbiotics (S-EN) in the treatment of SAP. We used antibiotics-resistant Lactobacillus, L-glutamine, oligosaccharide and a dietary fiber as synbiotics. After the establishment of the NST in our hospital in September 2005, those patients with a poor nutritional status were screened by subjective global assessment and objective data analysis, and we continued rounds once weekly until the nutritional problem was completely solved. The pancreatic infection and mortality rates of S-EN group were better than those of the control group. After establishment of the NST, the pancreatic infection and mortality rates of even the most serious SAP patients were better than those of the controls. In conclusion, S-EN and the NST are effective in nutritional management of abdominal emergencies, including SAP.
【Purpose】The usefulness of enteral nutrition for various morbid conditions has been recognized. However, few clinical studies have investigated the validity of selection of enteral trophotherapy after operation for peritonitis. Central venous nutrition is frequently used with oral intake with the aim of replacing the increased caloric requirement in these patients even after the start of oral intake. We designed a randomized comparative trial to assess the duration of hospitalization, costs, adverse effects, and feasibility of enteral trophotherapy during the process of withdrawal from the acute stage after operation for peritonitis. 【Methods】Patients in whom oral intake is possible within 3~7 days after operation for diffuse peritonitis are considered eligible for enrollment in this study. After obtaining IC, the patients are randomly allocated to a group assigned to oral intake with total parenteral nutrition (Group TPN) and a group assigned to oral intake with enteral nutrition (Group EN). Racol is used as the enteral nutritional supplement, and oral or tubal (per tubam) administration is selected as the administration route according to individual patients' conditions. Neoparen is used as the total parenteral transfusion supplement. In both groups, the target caloric administration is 25~35kcal/kg/day, which includes the oral intake of calories. Both groups are instructed to conform to the protocol for at least 1 week. Judging from the urinary volume, etc., the use of any preparation containing at least 7.5% of carbohydrate and any preparation containing amino acid is avoided when the free water and electrolyte balances are corrected transvenously. 【Results】Until date, 15 patients each have been enrolled in Groups TPN and EN. There have been no differences between the two groups with respect to the age, operation time, or volume of blood loss. Oral intake was initiated (the day of entry) on about 5.8±1.7 (mean±SD) days after the operation in Group TPN and 6.1±1.1 days after the operation in Group EN. The APACHE II score at the time of enrollment was 13.7±4.1 in Group TPN and 12.6±4.6 in Group EN. The target caloric administration and the protocol could be adhered to in all the patients, except that 1 patient from Group TPN had to be withdrawn because of catheter infection. There have been no differences between the groups in regard to indices such as the serum levels of albumin, retinol-binding protein, urinary level of 3-methylhistidine, urinary creatinine, ω3/ω6 ratio, cholesterol, TG, or free fatty acid. As adverse events, abdominal symptoms were observed in 5 and 4 patients, respectively, of Groups TPN and EN, and infectious complications were observed in 6 patients of Group TPN alone. Although the difference between the two groups was not statistically significant, the oral intake tended to be higher in Group EN. The medical costs per day have been lower in Group EN. 【Discussion and Conclusion】 The results of our present study indicate the safety and usefulness of enteral nutrition during the process of introduction of oral intake after operation for peritoniti
Current recommendations in the management of the critically ill patient suggest starting enteral nutrition as soon as possible whenever the gastrointestinal tract is functioning. Many patients are usually taking enteral together with parenteral nutrition, however, because, some difficulties exist in finding feeding routes to the gastrointestinal tract for patients with diseases of the abdomen. The positions of the feeding catheters are decided by the tube insertion point, the point of penetration of the gastrointestinal wall, and the position of the catheter tips. Furthermore, the timing of the start of food administration is decided by the patient's general condition. Therefore, a better prognosis would possibly result from enteral nutrition instead of making the easier choice of parenteral nutrition. The nutrition support team is additionally expected to participate in the decision making process regarding the routes for enteral nutrition.
At our institution, we treat the majority of patients with gastric or duodenal perforation conservatively using criteria established by us. Thus, surgery is performed in only complicated patients, and in these patients, postoperative nutritional support is of great importance. We thus retrospectively reviewed the postoperative nutritional management in patients who underwent surgery for gastric or duodenal perforation at our institution during the last three years. Of the total of 21 patients, 11 were on peripheral parenteral nutrition, 5 were on total parenteral nutrition (TPN) and 5 were on enteral nutrition (EN). In 4 cases, EN was administered through a feeding jejunostomy created intraoperatively. Postoperative complications occurred in 67% of all cases, and anastomotic leak occurred in 4 cases. Oral meals were started on postoperative day 12, on average. Of those with anastomotic leakage, EN was administered in 2 patients who resumed oral intake earlier than the other 2 patients on TPN. Hospital stay was also shorter in the EN group. The majority of the patients are treated conservatively at our institution, the patients who are operated upon have a high postoperative morbidity rate and need prolonged hospitalization. Postoperative nutritional support is essential in these groups of patients and intraoperative feeding jejunostomy placement appears to be a good option for postoperative nutritional support.
Since the start of our nutritional support team activity in April 2002, we have treated 498 cases for a total of 2550 times. As for cases of abdominal emergency, we have treated 38 cases for a total 339 times. The patients comprised 6 cases of gastrointestinal perforation, 5 of suture insufficiency, 2 of abdominal traumatic injury, 4 of rupture of aortic aneurysm. 5 of short bowel syndrome, 4 of serious acute pancreatitis, 2 of hemorrhagic enterocolitis, one of ischemic enterocolitis, 5 of pseudomembranous colitis and 5 of acute hepatitis. Total parenteral nutrition was first employed for cases with shock or sepsis. We made it rule to control blood sugar lower than 150mg/dL with reinforcement insulin therapy. We adopted early enteral nutrition for cases whose intestinal tract was usable. We administered GFO, a functional diet which comprising of glutamine and dietary fiber and oligosaccharide. For patients with renal failure undergoing haemodialysis, we administered a 10% greater quantity of amino acids with conventional composition. We used antiinflammatory nutrients with increased n3 type fatty acids and antioxidants and reduced arginine in a case of respiratory failure and a severe infectious disease. Detection of occult blood and protein using urinalysis tape and searching for Clostridium difficile toxin in watery diarrhea were useful in the diagnosis of enterocolitis. Most patients recovered and could leave the hospital.
In abdominal emergency diseases many patients show gastrointestinal failure including peritonitis and need enteral and parenteral nutritional support. Nutritional management during intensive care was studied in abdominal emergency diseases. Food-intake and applied energy were studied retrospectively in 150 abdominal emergency patients. Twenty-six patients were treated in the Intensive Care Unit and included 8 lower intestinal perforations, 7 small intestine perforations/ileus, 5 anastomotic leakages, 2 upper gastrointestinal perforations, and 4 others. The mortality rate was 35% and mean hospital stay was 37 days. The mean duration of no food intake was 8 days. Parenteral nutrition was performed in 16 patients and enteral nutrition in 7 patients. The serum albumin level was 2.7g/dL on the day after the operation. In some abdominal emergency cases intensive care was necessary and no nutritional support was performed due to severe infectious complications. It is necessary to determine carefully the timing of the start of nutrition support, the route of nutrition, and the amount of energy based on the clinical conditions of the abdominal emergency.
A 62-year-old male arrived at the emergency department of our hospital with injuries to his precordia and upper abdomen after crashing head-on into a tree while driving a light vehicle under the influence of alcohol. The patient exhibited shock on primary survey. Although hemodynamics transiently stabilized following initial fluid therapy, they immediately destabilized. Therefore, the patient underwent emergency laparotomy as a transient responder. Laparotomy revealed that injury to the middle and left hepatic veins was responsible for the bleeding, and that injury to the hepatic parenchyma, including the hepatic artery, was relatively mild. Because the injured area could be easily determined by dorsally elevating the liver, initial surgery involving repair with direct suture was performed without damage control. Severe hepatic injury primarily involving injury to the hepatic vein may be a factor contributing to a transient response. As selection of treatment during the acute phase is of critical importance, establishment of clear fixed standards is necessary in the future.
Cases of transanal rectal foreign bodies are comparatively rare and mostly caused accidentally by the escalation of eroticism. We report on two cases of transanal rectal foreign bodies in middle-aged and elderly men. Case1 : A 71-year-old man was admitted to our hospital complaining of a rectal foreign body inserted by himself. The foreign body was a wooden pestle and removed by manual extraction transanally under spinal anesthesia. Case2 : A 55-year-old man complaining of a rectal foreign body was referred to the hospital. The foreign body was a juice can, and it was removed by the same procedure as in the Case 1. The foreign bodies could not be removed at the outpatient clinic because of anal pain and intestinal edema in both cases, but could be removed transanally by manual extraction under spinal anesthesia. We conclude that manual extraction via the transanal approach under spinal anesthesia is a useful procedure for removing transanal rectal foreign bodies.
A 90-year-old man visited a local clinic with chief complaints of abdominal pain and bloating. Abdominal CT showed intraperitoneal free gas mainly in the upper abdominal cavity, a whirling of the rotated mesentery, small intestinal intramural gas, and intramesenteric gas. These findings led to the diagnosis of digestive tract perforation and pneumatosis cytoides intestinalis (PCI) due to a strangulated ileus, for which surgery was performed. A twisted small intestinal loop had impacted into the aperture formed by a band ; however, since no circulatory disturbance of the small intestine was observed, the band was resected, and the small intestine was reduced. Since our search of the literature failed to identify any previous reports of PCI intestinalis resulting from internal hernia, we report this rare case with a review of the literature.
A 56-year-old man with severe abdominal pain suddenly collapsed in the waiting room of out patient department. Retroperitoneal and intramesenteric hemorrhage due to rupture of the middle colic artery was diagnosed on abdominal computed tomography and angiography. Emergency surgery was immediately performed to improve the patient's state of shock. Middle colic artery injury with intramesenteric hemorrhage was detected intraoperatively and a bleeding point was repaired. Finally, a history of blunt trauma with a hard impact to the buttocks 2 weeks earlier was elicited after the patient's clinical status improved. In terms of vascular injury following blunt abdominal trauma, emergency physicians should consider that the symptoms of injury may appear after a considerable delay.
A 32-year-old woman visited our emergency room with lower abdominal pain. Abdominal CT showed a “whirl sign” and an enhanced solid mass (12 cm in diameter). The pain was not so severe, so it was considered to be caused by transient ischemia of small bowel. An emergency operation was not performed, and additional examinations were done. Abdominal MDCT clearly revealed twisting of the mesenteric arteries of the small bowel. These findings suggested this abdominal pain was due to small bowel volvulus caused by a tumor of the small bowel. Elective surgery was performed. During the surgery, the mesenterium was twisted 360° clockwise at a point 25 cm anally from the Treitz ligament, and its axis was the superior mesenteric artery. The superior mesenteric vein was dilated, but ascites were not found and there was no necrosis of the small bowel. A partial resection of small bowel was performed. Immunohistochemical examination showed that the tumor was positive for c-kit protein. Thus, the histological diagnosis was gastrointestinal stromal tumor of the small bowel.
There are few report on cases of Fournier's gangrene caused by fish bones. 74-year-old woman with a high fever disturbance of consciousness was transferred to a hospital. Computed tomography detected a foreign body in the rectum. A fish bone had pricked the dentate line and was removed. The patient had gangrene in her perineum, and so was diagnosed as having Fournier's gangrene. The patient went into shock an hour after hospitalization, therefore we performed daily drainage and wash-through in the ICU and started PMX-DHP with CHDF in series. Following intensive care, the patient's condition improved and she was released from ICU. A covering stoma was constructed to control perineum dermatitis due to defecation. She was discharged on the 56th hospital day. We conclude that early intensive care, drainage and wash-through are necessary for the treatment of Fournier's gangrene if an aggressive surgical procedure such as radical necrosectomy and debridement can not be chosen.
A 60-year-old man was admitted to our hospital for upper abdominal pain, 8 years after an operation for severe acute pancreatitis (SAP). Continuous intra-arterial infusion therapy was performed for the SAP with necrosis. Although the inflammation of the pancreas was improved, a pancreatic body pseudocyst developed and outgrew. The cyst infiltrated the jejunal mesentery and contained necrotic tissue. Necrosectomy and cystojejunostomy were performed with a drainage tube placed into the cyst through the mesentery for lavaging (internal and external drainage). The postoperative course was uneventful. Pseudocysts developing after the necrotic pancreatitis are known as Organized Pancreatic Necrosis (OPN), and frequently require surgical intervention for preventing infection. Internal and external drainage is considered to be an effective strategy for OPN.
The patient was an 88-year-old female who had been hospitalized with a urethral catheter. She was admitted to our hospital with the chief complaint of abdominal pain and abdominal tenderness. Abdominal CT scan showed ascites and dilatation of the intestinal tract. Gastrointestinal perforation was suggested and an emergency operation was performed on the same day. No apparent perforation was seen in the intestines, but rupture of the bladder was identified. The perforated site in the of bladder was closed with sutures and an indwelling catheter was inserted from the bladder to the bilateral renal pelvis. The postoperative course was uneventful, and the patient was discharged on Day 21. There have been few reports in which chronic cystitis has caused bladder perforation, and the present case is presented with some bibliographical comments.
Ogilvie's syndrome consists of acute large bowel dilatation without mechanical obstruction. An 87-year-old man was admitted to our hospital with abdominal distention. Neither abdominal defence nor rebound tenderness was seen during the physical examination. A plain abdominal X-ray showed dilatation of the colon. The patient underwent a emergency colonoscopy, and intraoperatively, organic obstruction and signs of ischemia were not seen. We diagnosed the condition as Ogilvie's syndrome, and colonic decompression by colonoscopy was effectively performed. When Ogilvie's syndrome is diagnosed early, treatment with decompression is successful. When colonic obstruction is suspected, we should consider the possibility of Ogilvie's syndrome.
Torsion of the gallbladder is an indication for emergency surgery, and it is difficult to make a preoperative diagnosis. Two cases of torsion of the gallbladder in which the diagnosis was made preoperatively by ultrasonography are reported. Case 1 was a 92-year-old female who presented with epigastric pain. Abdominal ultrasonography showed a swollen and thickened wall of the gallbladder. A hyperechoic area in the cervix. and a floating gallbladder were visualized. Based on these findings, a diagnosis of torsion of the gallbladder was made and cholecystectomy was undertaken via a laparotomy. The patient was discharged on the 10th postoperative day. Case 2 was a 73-year-old female who presented with right upper quadrant pain. She was also diagnosed as having torsion of the gallbladder based on the abdominal ultrasonographic findings, and cholecystectomy was undertaken via a laparotomy. The patient was discharged on the 9th postoperative day. In both cases, abdominal ultrasonography revealed a hyperechoic lesion in the cervix and a floating gallbladder, important us findings to make a preoperative diagnosis of torsion of the gallbladder.
A 72-year-old male visited our hospital complaining of intermittent abdominal pain from the early morning, emesis, and diarrhea. The patient's medical history included a partial visceral inversion and a cholecystectomy. He was diagnosed as having infectious enteritis and subileus and was placed under conservative medical management. However, the abdominal pain recurred on the 4th day of the illness, and the patient was diagnosed as having a strangulation ileus and underwent emergency surgery. The ascending colon was not fixed to the retroperitoneum and the patient was diagnosed as having bowel malrotation and incomplete fixation. In addition, torsion from the unfixed ileocecal region to the ascending colon also developed into ischemic necrosis. A 10-mm perforation was found in the center and a resection was performed from the ileocecal region to the ascending colon, followed by an ileostomy. After undergoing surgery, the patient entered septic shock, requiring artificial respiratory management, endotoxin adsorption therapy, and continuous hemodiafiltration. The general conditions thereafter tended to recover, but on the 15th day after surgery, the patient developed acute myocardial infarction and died. We therefore believe it necessary to take bowel malrotation into consideration for cases of ileus in patients with visceral inversion.