Although central venous catheter placement from the femoral veins is recognized as a relatively safe approach, retroperitoneal hemorrhage, a serious complication, can occur when the catheter tip is misplaced into the ascending lumbar veins. In particular, misplacement into the left ascending lumbar vein is more common than into the right because of its anatomical features. It is difficult to determine any misplacement by abdominal radiography, because the locations of the ascending lumbar veins, which run along with the vertebrae, resemble that of the inferior vena cava. The present study revealed the radiographic features of misplacement into the ascending lumbar veins. The catheter tips were located at a lower level than usual, and deviated to the right side in cases of misplacement into the right ascending lumbar vein on frontal abdominal radiographs. They were located at the left side from the midline of the vertebrae on frontal abdominal radiographs, and deviated to the dorsal side from the midline of the vertebrae on lateral abdominal radiographs. To recognize these radiological features is crucial to prevent serious complications from femoral central venous catheter misplacement into the ascending lumbar veins.

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The “Guideline on the Diagnosis and Treatment of Acute Cholangitis and Cholecystitis Based on Scientific Evidence” was issued in 2005. From the viewpoint of the endoscopist, the guideline has led to uniform treatment of diseases, since it stipulates diagnostic standards, severity evaluations and treatment methods based on scientific evidence. Since the guideline also defines the criteria for transporting patients with these diseases, it is anticipated that patients who need to will be transported from one hospital to another in the earlier stages of their disease, allowing for better treatment. For acute cholangitis, endoscopic bile duct drainage is the treatment of first choice, and for acute cholecystitis, we perform percutaneous drainage (PTGBD) with the aim of early operation, although we do not proceed to emergency operation under the present system at our center. Endoscopic naso-gall bladder drainage (ENGBD) has been increasingly performed; this is a useful treatment method for cases where percutaneous drainage is difficult, such as patients with a bleeding tendency or ascites, and those with suspected gallbladder cancer.

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Current JPN guidelines for the management of acute cholangitis and acute cholecystitis represent the clinical standards for the diagnostic criteria, severity assessment and treatment of acute cholangitis and acute cholecystitis. The severity of acute cholangitis is classified into three grades, mild, moderate, and severe. In the practical clinical setting, it is important to identify patients with moderate cholangitis who should receive biliary drainage as soon as possible. However, the criteria of moderate cholangitis contain jaundice (T. Bil > 2.0 mg ⁄dl) that is one of the diagnostic criteria for acute cholangitis itself. Therefore, there difficulties can arise when attempting to distinguishing moderate from mild cholangitis. The principal management of acute cholecystitis is early or urgent cholecystectomy. On the other hand, percutaneous transhepatic gallbladder drainage (PTGBD) is recommended for patients with moderate or severe disease and with surgical risk. In practice, treatment of acute cholecystitis has been regarded as treatment for cholelithiasis with symptoms of cholecystitis. PTGBD may be of value for patients with acalculous cholecystitis or cholecystitis but without detectable gallstone at the time of diagnosis. In addition, it may be useful for the treatment of choledocholithiasis with acute cholecystitis.

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A postal questionnaire was sent to the Councilors of the Japanese Society of Abdominal Emergency Medicine in order to ascertain their current management of patients with acute cholecystitis (AC). A policy of early cholecystectomy for AC was adopted in 41.7% of the responding surgeons before establishment of the Guidelines, but this increased to 57.3% after establishment of the Guidelines. The adaptation rate of laparoscopic cholecystectomy amongst surgeons was 79.1% before establishment of the Guidelines, which increased to 87.3% after their establishment. Therefore, it would appear that laparoscopic cholecystectomy was the first surgical procedure of choice for AC. The utilization rate of the Guidelines in the treatment of AC was 84.7%. This high value of the clinical use of the Guidelines indicated that the Guidelines played an important role in the standardization of treatment for AC.

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While various therapeutic methods have been adopted for choledocholithiasis, it may safely be said that at present, the standard treatment is endoscopic treatment. “ Medical care and treatment guidelines for acute cholangitis and cholecystitis ” have been published for the first time in Japan. According to these guidelines, endoscopic biliary drainage for acute cholangitis is recommended based on evidence level “ A ”. However, interventional endoscopy (IVE) is often very difficult, because it (IVE) requires skill. In some acute cholangitis patients in whom treatment by IVE, particularly insertion of the IVE into the papilla of Vater, was difficult, we used the Rendezvous technique, which combinesinterventional radiology ([IVR], PTCD, and percutaneous transhepatic biliary drainage [PTBD]) with IVE, to conduct successful lithectomy (of the calculi). The purposes of use of the Rendezvous technique for the treatment of acute cholangitis caused by bile duct calculi is to improve the patients' general condition using only one procedure, using a therapeutic method appropriate for the conditions and circumstances available at the facility. The use of this technique allowed noninvasive lithectomy and increased the procedural range of lithectomy. It was considered that the technique contributed to improvement of the patients' quality of life (QOL).

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This article discusses and evaluates In this article, we discuss? the clinical significance of the treatment guideline for acute cholangitis and cholecystitis associated with gallstones with reference to? our experience. We believe that the guideline is useful for the diagnosis of acute cholecystitis or cholangitis and for classification of the severity of these biliary inflammations. Early cholecystectomy, especially laparoscopic cholecystectomy, is recommended for the treatment of acute cholecystitis, although acute cholecystitis can be easily controlled in most cases by medical treatment, with occasional cases needing percutaneous gallbladder drainage. It is currently neither a severe nor fatal disease, except when it is complicated by gallbladder perforation with generalized peritonitis or multiple liver abscesses, which have been rare in recent years. Therefore, we should be careful in considering the risk of general anesthesia for surgery and choose either early laparoscopic cholecystectomy or medical treatment. Acute cholangitis is, likewise, mostly controllable by medical treatment. Eleven % of cases with acute cholangitis require biliary drainage, either PTBD or ENBD, because of severe cholangitis or obstructive jaundice. Most of our cases with acute cholangitis are treated by elective laparoscopic management for choledocholithiasis without endoscopic sphincterotomy.

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In this report, we describe the indication and outcome of endoscopic nasogallbladder drainage (ENGBD). ENGBD, recommended in degree C under the Tokyo Guidelines, can be performed in cases with an inaccessible percutaneous approach, and the treatment can show a dramatic effect if it can be intubated. However, the success rate of placement of the ENGBD tube and post-ERCP pancreatitis as an adverse event is a big issue. Therefore, we concluded that ENGBD should be performed in patients with acute cholecystitis in which a percutaneous transhepatic approach is contraindicated or anatomically impossible.

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In September 2005, the world's first evidence-based guidelines for acute cholangitis and cholecystitis were published in Japan. We examine herein correlations between our clinical diagnosis and the guideline-based evaluations. The clinical records of 166 patients having an initial diagnosis of acute cholangitis, cholecystitis, obstructive jaundice or fever of unknown origin that were treated at Nagoya Daini Red Cross Hospital before publication of the guidelines were retrospectively examined. At the initial diagnosis there were 74 cases of acute cholangitis cases and 81 of cholecystitis, Cholangitis: Among the 74 cases in which the initial clinical diagnosis was cholangitis, the rate of definite diagnosis based on the diagnostic criteria was only 37.8%. However, if suspected diagnosis was included, the rate became 81.1%. On the other hand, there were 14 cases that did not meet the diagnostic criteria of acute cholangitis. Among these 14 cases, 4 cases (5.6%) met the criteria of acute cholecystitis. Cholecystitis: Among the 81 cases in which the initial clinical diagnosis was cholecystitis, the rate of definite diagnosis based on the diagnostic criteria was 67.9%. If suspected diagnosis was included, the rate became 82.7%. On the other hand, there were 14 cases that did not meet the diagnostic criteria of acute cholecystitis. Among these 14 cases, 4 cases (4.9%) met the criteria of acute cholangitis.

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A questionnaire was carried out to evaluate the influence on clinical medical treatment of the clinical practice guidelines for the management of acute cholangitis and cholecystitis. From January to February 2007, the questionnaire was carried out with the members of the Japanese Society for Abdominal Emergency Medicine, the Japanese Society of Hepato-Biliary-Pancreatic Surgery, the Japan Biliary Association and the research members of the Japanese Ministry of Health, Labour and Welfare, in total about 8,000 doctors. 1,836 (22.9%) doctors responded. The guidelines contents had been read by 61.3% of them. Of these, the doctors who showed guideline-influenced changes in their medical care Accounted for 58.9%. In addition, about 90% of the guidelines users referred to criteria in the clinic, and many clinical doctors evaluated the guidelines as being useful. At the time of medical care, the doctors who used the guidelines for explanation to a patient and their family accounted for 57%. The guidelines can exert an influence on clinical medical treatment, but the important problems are how the dissemination of these guidelines and promotion of their use is effected.

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A 59-year-old man had been suffering from pain on urination for 4 years. He was admitted to our hospital because of fecaluria and recurrence of cystitis. CT and MRI revealed a mass in the bladder, and colon graphy demonstrated the apple-core sign and multiple diverticula in the sigmoid colon with a fistula to the bladder. A preoperative histological diagnosis could not be obtained through biopsy examination. The operation was performed under the diagnosis of colovesical fistula-related deverticulitis or cancer of the sigmoid colon. Intraoperative findings revealed that the bladder and the sigmoid colon formed a hard lump involving the ureter. We strongly suspected that the mass was an advanced colon cancer, and performed a low anterior resection of the colon with D3 lymph node dissection, total cystectomy, and vesicostomy using the ileum. Pathologically, severe diverticulitis of the sigmoid colon was the cause of the colovesical fistula. Since the operative method of the colovesical fistula depends on the cause and the degree of its inflammation, it is necessary to make a precise diagnose and to select the operative method flexibly.

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The case in the current report was a 27 years old male. He suffered from mental retardation from birth with allotriophagy. He consulted a doctor with chief complaints of anorexia and abdominal distension. CT findings revealed sigmoid wall thickness and a foreign body at the locus, and prominent oral colonic dilation. The patient was admitted as an emergency case under the diagnosis of a foreign body ileus. We performed an abdominal operation and found that a circumferential sigmoid carcinoma and incarceration of a pickled Japanese apricot seed were the cause of the ileus. We performed sigmoidectomy (D2 dissection), and at the same time recovered many various foreign bodies from elsewhere in the a colon. This is the first report in Japan, as far as we know, of colon cancer in a young adult in whom an ileus developed due to incarceration of foreign body.

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We report on a single case of a 55-year-old man with a traumatic duodenal injury caused by a snow shovel. The patient complained of severe abdominal pain and so he was admitted for observation. Next day, abdominal computed tomography (CT) showed retroperitoneal rupture of Bthe duodenum and an emergency operation was performed. A laparotomy revealed double perforation, both anterior and posterior wall, of the duodenum in the third portion and retroperitoneal inflammation. All wounds were closed with Albert-Lembert sutures, and a gastrojejunostomy with Braun's anastomosis, catheter jejunostomy and external biliary drainage were performed for drainage of the duodenal contents. The postoperative course showed no serious complications, such as anastomotic leakage. We considered that the combination of some of the decompression treatments we performed was a simple and useful operation for duodenal rupture.

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A 16 year-old male was admitted to the emergency room in our hospital, complaining of severe abdominal pain and bilious vomiting. He evacuated a strawberry jelly-like stool following a glycerin enema. Abdominal X-ray and CT scan revealed colo-colic intussusception where the presenting part appeared at the transverse colon. We tried to reduce the intussusception with a gastrographin enema, but the contrast medium failed to run into the ileum. Having regarded this treatment as inadequate, we performed an emergency operation. The intussusception was reduced, but many small and soft masses were palpable on the cecum and the ascending colon. Believing that these masses had caused intussusception, we performed an ileocecal resection, Inside of the masses cava could be seen, and a diagnosis of pneumatosis cystoides intestinalis (PCI) was made based on the macroscopic and histopathological findings. PCI is a comparatively rare disease, and it very occasionally causes intussusception. It often happens that PCI is cured by hyperbaric oxygen therapy, therefore the appropriateness of surgery needs to be judged carefully.

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The prognosis of acute superior mesenteric artery occlusion with hepatic-portal venous gas (HPVG) is usually poor. prognosis. A 67-year-old man was admitted to the department of neurosurgery of our hospital with intracranial hemorrhage. He complained of abdominal distension and his blood pressure gradually decreased. An abdominal plain CT scan showed ascites and HPVG. The patient was transferred to our department, and an emergency laparotomy was performed about 12 hours after the onset. Extensive bowel necrosis existed from the jejunum to the hepatic flexure of the colon, and the necrotic bowel tissue was resected, followed by construction of a jejunostomy. The length of the residual jejunum was about 50cm. Survival of this patient was achieved by performing the operation at a relatively early period together with intensive care postoperatively, and he was transferred to the Department of Neurosurgery 43 days after surgery.

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An 81-year-old man was referred to our hospital with acute abdominal distension in November 2006. He reported the subjective symptom of constipation for a month. The abdominal X ray examination revealed dilatation of the small intestine and colon with niveau formation. Computed tomography revealed enhanced wall thickness with an irregular shape of the sigmoid colon and a foreign body in this lesion. A caliber change was recognized at this point, so we diagnosed colorectal bowel obstruction induced by the sigmoid colon cancer associated with impaction of a botanical seed. The patient underwent temporary transverse colostomy as a emergency operation. Postoperative colonoscopy from the transverse colostomy revealed sigmoid colon cancer and an impacted botanical seed. Radical sigmoid colectomy with lymph node dissection was performed at the 15th post primary operative day. The resected specimen revealed the sigmoid colon cancer with impaction of a Japanese apricot seed. The patient was discharged from our hospital without any complication 28 days after the primary operation. Only 11 cases of bowel obstruction induced by seeds was reported between 1983 and 2006 in the Japanese literature. We experience a rare case of bowel obstruction induced by seeds.

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A 74-year-old man was diagnosed as having systemic lupus erythematosus at 71 years of age and oral steroid treatment had been administered since then. In early August 2002, he felt hot and developed a fever (4°C). In mid-August 2002, he was referred to our hospital. At admission, he had right lower abdominal pain and right back pain. Laboratory examinations revealed inflammation, and a fecal occult blood test was positive (3+). CT scans showed retroperitoneal gas behind the descending colon. Colonoscopy indicated perforations of the descending colon. An emergency laparotomy was performed and showed purulent ascites, a dilated edematous descending colon including partial necrosis with perforation and a large retroperitoneal abscess. Left hemicolectomy, transverse colostomy, abdominal drainage and retroperitoneal drainage were carried out. The resected specimen showed three punched out perforations. Histological findings revealed acute inflammation around the perforations, but no evidence of specific arteritis or vasculitis. The patient ’ s postoperative course was uneventful and oral steroids were administered for the SLE. He was subsequently discharged.

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A 53-year-old man demonstrated a repeatedly recurring localized intra-abdominal abscesses, despite abscess drainage treatment performed several times during the previous year. Because of the unidentified origin of these abscesses, a barium x-ray study of the small intestine was performed and a perforation of the ileum to the abscess cavity was demonstrated, based on which the patient was treated surgically and the perforated portion of the ileum was sutured and closed primarily. The genesis of the ileal perforation, however, was not identified at surgery, because there were no detectable pathological changes such as diverticula, foreign bodies aberration, or inflammatory changes of the intestine. We concluded that in this case, a tiny perforation of the ileum occurred primarily due to an unknown etiology and then secondary intra-abdominal absceses occurred due to that ileal perforation.

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A 90-year-old man with dementia after cerebral infarction underwent partial resection of the small intestine because of an adhesional ileus, and thereafter an enteral diet tube was placed because of his inability to ingest food orally. On the 61st postoperative day, he vomited suddenly, and plain abdominal X-rays showed that the colon in the right lower quadrant of the abdomen was dilated with gas. Abdominal CT of the coronal section revealed that was the gas was located in the cecum, and that the mesocolon was abnormally rotated, consistent with the so-called bird's beak sign and with a whirl-like appearance. Colonoscopy demonstrated ischemic change and dilatation of the cecum. As it was impossible to reduce the cecal volvulus endoscopically, emergency surgery was performed, and this revealed a postoperative fibrous adhesion between the area where the small intestine had been anastomosed and the right wall of the abdomen, into which the mobile cecum had entered and become twisted. We released the twisted cecum and performed cecopexy to the right side. The number of bedridden elderly with dementia is increasing, and cases of cecal volvulus in this population are also thought to be on the rise. In such cases, diagnosis with MPR (coronal section) with multidetector CT (MDCT) would allow Bthe appropriate surgical approach to be selected.

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An 87-year-old woman was seen at our hospital because of abdominal pain nausea and vomiting in March 2006. There was a 3×3cm hard mass with tenderness in the left lower quadrant of the abdomen. Abdominal CT scan showed a prolapsed intestine in the left lower abdominal wall, which was diagnosed as an incarcerated hernia of the abdominal wall. A Spigelian hernia was diagnosed. Manual reduction of the hernia content was impossible, and an emergency operation was therefore performed. The hernia sac was found under the aponeurosis of the external oblique muscles, perforating the lacertus of the transverse abdominal muscles and internal oblique muscles. In conclusion, we made a diagnosis in this case of Spigelian hernia and repaired it with by direct suturing. The patients postoperative course was uneventful, and she was discharged very much improved on the 10th hospital day.

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