One hundred and twenty-six septic patients who had severe sepsis or septic shock due to intra-abdominal infections were treated with polymyxin-B direct hemoperfusion (PMX-DHP). These patients were separated into two groups : those who survived for at least 28 days after the start of PMX-DHP therapy (survival : 85 cases) and those who did not (non-survival : 41 cases). Background factors and inflammatory mediators were examined in each group. PMX-DHP was assessed with the changes of clinical parameters (HR, SAP, MAP, PaO2/FIO2) and various cytokines (TNF-α , IL-6, IL-8, IL-1ra, PAI-1). Sepsis was diagnosed according to the criteria of the ACCP/SCCM Consensus Conference Committee. Ninety-one point seven percent of the survival cases were principally treated with a surgical procedure. From the demographic data, Goris's MOF score only showed significant differences between the groups (survival cases : 5.8±2.8, non-survival cases : 8.0±2.6, p<0.05). PCT before PMX-DHP in all patients was 59.1±97.2 ng/mL and tended to decrease 54.7±81.7 ng/mL after PMX-DHP. PCT was 67.3±109.6 ng/mL before PMX-DHP and significantly decreased to 54.7±82.1 ng/mL immediately after PMX-DHP in the survival group, but it did not change significantly in the non survival group. There was a significant correlation between endotoxin and PCT (r=0.527, p<0.001)
Acute appendicitis is the most frequent condition that leads to emergency abdominal surgery. This study is a retrospective analysis of 189 patients who underwent appendectomy at a community medical open hospital. To enter the abdomen, a transverse incision over the McBurney point was performed in 98 patients (51.9%), and a vertical pararectal incision was performed in 91 patients (48.1%). The severity of the inflammation is an important factor in deciding on the treatment of acute appendicitis. The conservative treatment for catarrhal appendicitis is recommended, while surgery is needed for phlegmonous or more advanced appendicitis. With the pathological findings, catarrhal appendicitis was seen in eight patients (4.2%), phlegmonous appendicitis was seen in 99 patients (52.4%), and gangrenous appendicitis was seen in 82 patients (43.4%). A drain was inserted in 54 patients (28.6%). There was no difference in the pathological findings between adults (over 16 years old) and children (under 15 years old). A pararectal incision was, however, performed in six patients (6/44, 13.6%) and three patients (3/44, 6.8%) required the insert of a drainage tube. These results suppest that the indication of appendectomy and the choice of the incision method seen to be almost correct.
【Purpose】The purpose of this paper was to evaluate the safety of transcatheter arterial embolization (TAE) of the intestine with a mixture of N-butyl-2-cyanoacrylate and lipiodol (NBCA-LPD) in an animal model.【Material and Method】The subjects of the study were three swine. TAE was performed on nine branches of the mesenteric arteries and nine branches of the renal arteries. The embolic materials were categorized on the basis of the concentration of NBCA-LPD. The swine were sacrificed and the embolized organs were extracted immediately after TAE (swine A), 24 hours after (swine B) and 72 hours after (swine C). We embolized isolated the mesenteric arterial branch in swine A and swine C, embolized its neighboring branches in swine B. Histologically the extent of the embolic materials was assessed with oil-red staining, and tissue reaction with H-E staining.【Results】There was no necrosis in the intestinal tracts regardless of the concentration except for swine B. All embolized kidneys resulted in necrosis.【Conclusion】TAE with NBCA-LPD for isolated branches of the mesenteric arteries would be feasible even with a low concentration of NBCA-LPD.
Our concept of treatment for blunt hepatic injury consists of urgent management (UM) for exsanguination and planned management (PM) for delayed complications. The strategy was highlighted with the advanced application of urgent arterial embolization (UAE) for hemodynamically unstable patients and duly expedient operative intervention for liver injury-related complication based on consecutively comprehensive monitoring. The survival rate for UAE in cases of high-grade liver injury (grade IV-V) was 91.3% (21 out of 23), and that of hemodynamically unstable patients was 84.6% (11 out of 13). No late death occurred following PM including anatomical liver resection indicating an appropriate approach integral to successfully saving severely injured patients.
Recent developments in Interventional Radiology (IVR) have offered a novel non-operative treatment option for more cases of blunt hepatic injury. However, there are currently no obvious guidelines on choosing between emergency surgery and IVR. The basic principle is that in hemodynamically unstable cases, or when Focused Assessment with Sonography for Trauma (FAST) has revealed obvious intraabdominal bleeding, emergency surgery is generally indicated. In those cases who are hemodynamically stable and in whom FAST is negative, contrast-enhanced CT should be used as a secondary survey and the findings evaluated based on the hepatic injury classification proposed by The Japanese Association for The Surgery of Trauma. In type 3 injury, IVR is indicated. A combination of both treatments such as postoperative Transcatheter Arterial Embolization (TAE) or post-TAE surgery should be further investigated as potential options for severe hepatic trauma. We also discuss the current situation of emergency medicine and treatment plans for traumatic liver injury at our institution.
To reassess the current strategy of management of severe blunt hepatic injuries (BHI), JAST type IIIb or AAST grade IV/V, we reviewed all of the BHI patients during the past 16 years in our hospital. Among these, 34 hemodynamically stable patients after fluid resuscitation were managed nonoperatively. Three of the 34 patients required a delayed laparotomy within 15 hours of arrival in the ER, and all surgical indications were related to hemodynamic instability due to hepatic vein injures indicating that these should be managed with surgery. When contrast extravasation or pseudoaneurysm associated with BHI was identified on angiography, transarterial embolization (TAE) was performed in a superselective manner. Thirteen patients who underwent TAE for BHI did not experience recurrent arterial bleeding. During the study period, 24 patients with severe BHI were managed operatively. The survival rate was markedly higher in the patients treated with hepatectomy (94%, 16/17) than in those treated with perihepatic packing (PHP) (14%, 1/7). Logistic regression analysis identified pelvic-ring fractures and severe chest injuries (≥AIS4) as negative independent contributors to survival. Hepatectomy was safe and appropriate for BHI patients without extra-abdominal injuries. However, coagulopathic BHI patients should be managed through a multidisciplinary approach that includes aggressive correction of coagulopathic disorders, PHP with staged laparotomy, and postoperative TAE.
(Background) In our department, classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (DCS) scoring system have been used to determine the efficacy of the treatment strategy in trauma patients. (Cases and Methods) We examined 247 out of 289 hepatic injury patients, excluding cardiopulmonary arrest cases. The present study was undertaken to establish a valid strategy for the treatment of hepatic injury, and further improvement of the survival rate was evaluated based on the incidence of grade IIIb (JAST) hepatic injury necessitating emergency room laparotomy. (Result) Interventional Radiology (IVR) treatment cases were all stable or responder patients and all survived with effective hemostasis. Transient responder or non responder patients that needed hemostasis were treated with emergency laparotomy, and all the cases that eventually expired needed DCS. The mean injury severity score (ISS) was 42.3, the mean probability of survival (Ps) was 0.413, and hemostasis treatment was started within a mean of 39.1 minutes, yielding a survival rate of 42.9 % in the cases with grade IIIb (JAST) liver injury that needed emergency room laparotomy. (Conclusion) Our criteria for deciding on the therapeutic strategy based on the response to the initial fluid resuscitation seemed to be useful from the viewpoint of hemostasis for liver injury. The key to securing quality regional trauma care is to designate a trauma care hospital as a trauma center and to transport severely injured patients to the center as rapidly as possible.
To assess the appropriate management of blunt liver injury and splenic injury, we retrospectively reviewed 29 patients with blunt hepatic injury and 18 patients with splenic injury who were admitted to our university hospital. According to the classification of the Japanese Association for the Surgery of Trauma, the patients with hepatic injury were divided into types Ia (1), Ib (6), II (3), IIIa (4) and IIIb (13) and the patients with splenic injury were divided into types Ia (1), II (4), IIIa (5), IIIb (2), IIIc (4) and IIId (1). Eight patients with hepatic injury (type IIIa and IIIb) were successfully treated with TAE (transcatheter arterial embolization). Ten patients with hepatic injury (type IIIa and IIIb) underwent laparotomy, 1 of whom required damage control surgery at first. TAE was performed in patients with types II and III splenic injury. Twelve patients with type III splenic injury required laparotomy, 1 underwent splenorrhaphy, 2 underwent partial splenectomy and 10 underwent splenectomy. In the initial treatment for hepatic injury and splenic injury, the control of bleeding from the liver or spleen and hemodynamic stabilization were most important. Operative or non-operative management should be selected based on hemodynamic stabilization, the extent of injury to the liver or spleen and the presence of injury to any other organ.
In the past decade, selective splenic angioembolization (SAE) has improved the nonoperative management (NOM) success rate in patients with blunt splenic injury. In this study we assessed the characteristics of these trauma patients to identify factors that could predict the failure of NOM. We also applied the scale of the Japan Trauma Association (JTA) grading of splenic injury as well as the American Association for the Surgery of Trauma (AAST) grading in the present study. A retrospective chart review of 31 trauma patients with blunt injury to the spleen admitted between September 2000 and July 2006 was performed. In the initial treatment, 8 patients (26%) were treated with a surgical operation, nineteen patients (29%) underwent angiography and 16 patients (52%) were treated with SAE. Nonoperative treatment was successful for 13 patients (42%). AAST gradeIIIand higher, JTA gradeIIIc and higher, PRBCs and proximal embolization all correlated with SAE failure. Left renal injuries correlated with a higher grade of splenic injuries.
Splenectomy via emergency laparotomy has been a common procedure for traumatic splenic injury. However, with the recent improvements of imaging methods and advances in IVR, non-operative therapy is being performed more frequently. The guidelines for management at this Center are as follows : (1)Patients with stable hemodynamics or responders are followed, and TAE or surgery is considered when an increase of bleeding or new abdominal findings are observed. (2)For transient responders, TAE is performed when the injury is isolated, but TAE plus treatment of the associated disease is performed when the case is complicated by injuries in other regions. (3)For non-responders, laparotomy should be performed if intra-abdominal injury is their major diagnosis. However, patients with splenic injury frequently also have injuries in other regions, so the treatment priority for those in shock on arrival must be decided rapidly to allow proper diagnosis and treatment on the basis of the managing physician's judgment.
The present study reports on an 18-year-old male motorcyclist who was brought to the emergency department of our hospital due to injuries sustained when he was struck by a car making a left turn. Although a hematoma was observed around the left kidney, the patient was given conservative treatment in the ICU as he was hemodynamically stable. No hemodynamic changes were observed on day 2. However, abdominal CT revealed urinary leakage outside the ureter, and the renal pelvis could not be seen on retrograde ureterography. Therefore, a ureteric injury involving the renal pelvis and calyces was suspected. As the patient's hemodynamics were stable, a ureteral stent was placed. Due to the subsequent onset and gradual exacerbation of peritoneal irritation symptoms, a left nephrectomy was performed on day 3. A section of the resected sample following surgery revealed avulsion of the renal pelvis and calyces from the renal parenchyma. Renal pyelocalyceal avulsions with virtually no injury to the renal parenchyma, such as in the present case, are extremely rare. In cases of ureteric injury, it is necessary to consider cases in which placement of a ureteral stent does not result in improvement, such as the present case.
Spontaneous esophageal rupture is an emergency disease with lethal consequences from mediastinitis. We report a case of spontaneous esophageal rupture complicating with pneumo-nectasia successfully treated with primary suturing via the transabdominal approach. A 53-year-old male was admitted to our hospital with chest and abdominal pain after vomiting. Enhanced abdominal CT revealed fluid and emphysema in the lower mediastinum. An esopagogram revealed leakage of contrast medium from the left side of the low-er esophageal wall to the mediastinum. He was diagnosed as having a spontaneous esophageal rupture. Initially conservative treatment was selected. After 40 hours, the inflammation and mediastinal emphysema progressed, and a surgical procedure was therefore performed. The transabdominal approach was chosen because of the patient's poor pulmonary function. The perforated site of the esophagus could be identified clearly through the incision of the esophageal hiatus. Primary suturing of the perforated site and a pedicled omental covering procedure were carried out. The transabdominal approach is a possible procedure in cases of spontaneous esophageal rupture when the esophageal hiatus is localized within the lower esophagus. This approach is also useful for poor risk cases or those with pulmonary dysfunction.
A 58-year-old man presented to our hospital with an abdominal gunshot wound from point-blank range, and was admitted after 2.5 hours of being injured. He appeared pale, but conscious. Also, there were no signs of shock (blood pressure, 130/70 mmHg; pulse rate, 66 beats/min). There was a 40-mm diameter gunshot entry wound on the left side of the waist and four exit wounds on the right side of the abdominal area. Also, there were two bullets in the subcutaneous tissues on the right side of the abdominal area. He was paralyzed from the waist down. Computed tomography (CT) showed a wound track from the left waist to the right abdominal quadrant through the lumbar spine, resulting in a comminuted fracture. In addition, CT showed ascites and free air in the abdominal cavity. Eighty minutes after his arrival, he underwent surgery. We found a 1-point perforation of the duodenum, a 5-point perforation of the ileum, and amputation of the ileocolic artery. Fortunately, his major blood vessels were not injured. We performed an ileocecal resection along with simple closure of the duodenum and a gastrojejunostomy, followed by abdominal drainage. In addition, we removed the bullets from the right abdominal subcutaneous region. After irrigation, we closed the waist wound. Thereafter, on the 34th postoperative day he was referred to the orthopedic department of our hospital.
An 89-year-old woman was referred to our hospital for abdominal pain. Her past history included abdominoperineal resection for rectal cancer 40 years previously, and she had been conscious of flatulence at the parastomal site for a long time. On physical examination, she was diagnosed as having an incarcerated parastomal hernia, which was confirmed on CT images, and underwent emergency surgery. After about 50 cm of necrotic small intestine had been removed and reconstructed, fascial repair of the parastomal defect was carried out using absorbable sutures. The patient's post-operative course was uneventful, and she was discharged from the hospital on the 11th post-operative day.
Omental torsion is a rare condition due to an ischemic change of the omentum as a result of twisting. A 53-year-old Japanese male suffered from a right abdominal dull pain, which gradually increased over 4 days. He had a history of hepatitis B for 11 years. Abdominal ultrasonography and computed tomography showed that the right side of the omentum was twisted and swollen. Abdominal laparoscopy revealed that part of the omentum was adherent to the abdominal wall and bowels. Under a laparoscopic procedure, an adhesiotomy revealed Meckel's diverticulum and both the twisted omentum and diverticulum were resected. Pathological findings revealed inflammatory changes and hemorrhagic necrosis in the resected omentum. On the other hand, the inflammation in Meckel's diverticulum was on the serosal surface only. Based on these findings, we concluded that the diagnosis was omental torsion secondary to Meckel's diverticulitis. To the best of our knowledge, this is the first report of such a case in the literature.
A 51-year-old male with chronic alcoholic pancreatitis had been admitted several times due to acute exacerbations for several months. At the end of 2003, a pancreatic stent was placed for stenosis of the main pancreatic duct in the head of the pancreas, with stent exchange being performed every 2-4 months. In 2005 an endoscopic examination was carried out for the stent exchange and migration of the stent was found. At first we tried to remove the stent endoscopically but failed, so the pancreatic stent was removed operatively and a pancreatojejunal anastomosis was performed. The postoperative course has been uneventful for 2 years. Endoscopic pancreatic stenting is minimally invasive and effective for stenosis of the main pancreatic duct, but some complications may occur including the necessity of stent exchange within a short period. Pancreatojejunal anastomosis seems to be effective in some cases of chronic pancreatitis associated with pancreatic duct stenosis.
An 82-year-old male was referred to our hospital because of severe abdominal pain and nausea. A contrast-enhanced computed tomography (CT) scan of the abdomen revealed free air areas not only in the abdominal cavity but also in the gallbladder. Based on these findings, we diagnosed the patient as having the diffuse peritonitis due to the gallbladder perforation, and he underwent an emergency operation. Intraoperative findings showed massive bilious fluid in the abdominal cavity and perforation of the gallbladder. Bile and black gallstones had leaked out through the gallbladder perforation. We performed a cholecystectomy, abdominal lavage and drainage. Preoperative diagnosis of gallbladder perforation is difficult, therefore it is often diagnosed intraoperatively. We report herein on a case of gallbladder perforation which could be diagnosed with a CT scan preoperatively.
The parastomal hernia is well-recognized as a relatively frequent complication of intestinal stomas : impaction, however, is rare. An unusual case of strangulated ileus due to impaction of a parastomal hernia requiring emergency surgery is the subject of this report. An 80-year-old man who had undergone Miles'operation 35 years perviously and a relocation of the colostomy 13 years previously visited our hospital with abdominal pain and nausea. He was diagnosed as having adhesional ileus and was admitted for conservative therapy. His parastomal site gradually became reddish on the 3rd day of hospitalization. Computed tomography showed an impaction of the small intestine into the parastomal space. An emergency operation was performed under the diagnosis of parastomal hernia. The colostomy was located outside of the rectus sheath through the intra-peritoneal route. The orifice of the parastomal hernia was dilated about 2 cm. A part of the small intestine was incarcerated into the parastomal space and had become necrotic. Resection of the necrotic part and an end-to-end anastomosis was performed. The orifice of the parastomal hernia was directly sutured. Surgical cases of strangulated ileus due to parastomal hernia are very rare. Surgeons are forced to perform a simple fascial repair for parastomal hernia in cases of contaminated procedures such as an enterectomy.
A female in her 70s was injured in a traffic accident while wearing a seat belt and was admitted to our hospital with thoracoabdominal pain and dyspnea. Plain chest X-ray showed multiple rib fractures and hemopneumothorax. Computed tomography showed hemopneumothorax, pneumoretroperitoneum, and pneumoperitoneum based on which we diagnosed perforation of the digestive tract. An emergency operation showed two seromuscular tears at the posterior wall of the greater curvature of the stomach but no contamination of the abdominal cavity. We suggested that the origin of the pneumoperitoneum was the thorax, because of increased intrathoracic pressure associated with the blunt thoracoabdominal injury. We need to recognize such a condition, which is called non-surgical pneumoperitoneum. We know that pneumoperitoneum is occasionally caused by positive airway pressure ventilation, bronchial astuma and so on.
We report on two cases of hepatic portal venous gas (HPVG). Case 1 was a 78-year-old male who was referred to our hospital after a fall. Physical examination of the abdomen revealed generalized tenderness, but there was no peritoneal sign. An abdominal computed tomographic (CT) scan showed HPVG and signs of segmental ischemia in the small bowel. We performed an exploratory laparotomy and resected 50 cm of nonviable ileum. The patient's condition deteriorated postoperatively in the intensive care unit (ICU) and he died of multi-organ failure on hospital day 40. Case 2 was a 55 year-old-male who presented at our hospital with appetite loss and abdominal distension. Abdominal X-ray revealed a dilated small bowel. An abdominal CT scan lead to the diagnosis of HPVG and pneumatosis intestinalis (PI). It also demonstrated the presence of gas inside the inferior vena cava (IVC). An exploratory laparotomy showed small bowel volvulus without any sign of necrosis. Although detorsion of the volvulus was successfully performed, the patient's postoperative course was complicated by bacterial pneumonia and he died on hospital day 65. The surgical indication of HPVG still remains unclear. From our literature review, HPVG on abdominal X-ray and HPVG accompanied by PI represent a high risk of bowel ischemia, in which cases surgical intervention should be considered.