An emergency endoscopic procedure is recommended for acute biliary pancreatitis in cases with biliary obstruction by stones or cholangitis following the guidelines for medical care in acute pancreatitis in Japan. However, there are differences in the therapeutic timing and methods used among different hospitals. We examined 25 cases of acute biliary pancreatitis admitted to Showa university hospital in whom endoscopic retrograde cholangiopancreatography (ERCP) was performed within 72 hours after admission. The ages of the patients ranged from 30 to 89 years. Fourteen patients were male and 11 were female. Eleven patients had mild or moderate acute pancreatitis and 14 patients had severe acute pancreatitis according to the former clinical criteria adopted until September 2008 for severity of acute pancreatitis proposed by the research group of the Ministry of Health, Welfare, and Labour of Japan. The clinical condition of acute biliary pancreatitis was ameliorated by early endoscopic treatment, but there were no significant differences in total hospital stays, removal rates of bile duct stones and rates of endoscopic incidents between the endoscopic biliary drainage (EBD) group and the EBD with endoscopic sphincterotomy (EST) group, and between patients who underwent EBD with removal of bile duct stones and EBD prior to removal of bile duct stones. The results suggest that early ERCP is preferable for acute biliary pancreatitis with biliary obstruction by stones or cholangitis, however we have to be careful to avoid hemorrhage after EST and cholecystitis after EBD. More through investigations are required to evaluate whether EBD with EST or EBD without EST is more useful and whether EBD with stone removal or EBD prior to stone removal is more beneficial for patients.

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Thirty-seven cases of acute abdomen in elderly patients over 80 years of age treated surgically from January 2000 to December 2007 were studied. The mean age was 84.8 yr and the male to female ratio was 16 to 21. Twenty-three patients (62.2%) had concomitant medical disease. Overall, 13 (35.1%) patients had morbidity of some kind. Five patients died due to sepsis in 3, and cancer and suffocation in 1 each. Those patients combined with morbidity had a higher APACHE2 score compared with the patients without morbidity. On the other hand, patients who died after their operation had a lower mean BP on admission, higher serum creatinine and APACHE2 score and POSSUM score compared with those who survived.

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A nationwide survey was performed to clarify the epidemiologic picture of fulminant hepatitis and late onset hepatic failure between 2004 and 2006 in Japan. One hundred and sixteen, 106 and 14 patients, respectively, with acute and subacute types of fulminant hepatitis and LOHF were analyzed. The age of the patients was significantly higher in the subacute type and LOHF than in the acute type. The etiology of fulminant hepatitis was viral infection in 65% of the acute type and 29% in the subacute type. The main causative agent was hepatitis B virus(HBV). The etiology was unknown in 16% and 39% of the acute type and subacute type, respectively. Autoimmune hepatitis and drug allergy-induced liver injury were found in 15 and 17%, respectively, of the subacute type. The survival rates of the patients without liver transplantation were 55%, 24% and 100% in the acute type, subacute type and LOHF, respectively. The prognosis was especially poor in HBV carriers. In contrast, the total survival rate of those who underwent liver transplantation was 77%. The incidence of HBV reactivation is higher mainly in HBs Ag negative patients after chemotherapy and is associated with a high mortality rate.

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To clarify the outcome of Japanese children with acute liver failure (severe acute liver failure and fulminant liver failure), a retrospective multicenter case study was performed from 1995 to 2005. One hundred and thirty five children were enrolled. Thirty cases were categorized into severe acute liver failure and fulminant liver failure accounted for 105 cases. The cause of acute liver failure included metabolic disease (25%), viral infection (22%), drug-related hepatotoxicity (8%), autoimmune liver disease (2%) ; and indeterminate in 43%. The survival rate has been improved from 30.7% to 69% for those who underwent liver transplantation. Even after undergoing liver transplantation, the outcome of children under one year of age was still not good. The high percentage of indeterminate cases should provide a good incentive for investigation throughout Japan.

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【Background【We developed an equation to determining the likelihood of development of hepatic encephalopathy (HE) in patients with acute hepatic injury (AHI). The cutoff point of P20 was set as the criterion for transferring a patient to a major liver center. 【Objective【 To verify the prediction equation criteria. 【Design【A prospective, multicenter, community-based case-cohort study. 【Setting【 Thirty-nine hospitals in the vicinity of Iwate Medical University Hospital in Japan. 【Patients【 Patients with AHI having a prothrombin time of less than 80%, but without gradeII or worse HE. 【Outcome measures【 Development of gradeII or worse HE. 【Data collection and analyses【 The patients were prospectively observed according to the above-described criterion. The difference in the rate of development of HE between the patients who fulfilled the criterion and those who did not was analyzed. 【esults【 A total of 147 patients were enrolled from August 2004 to December 2007. During prospective follow-up, 55 patients fulfilled the P20 criteria, and 8 of these 55 patients (15%) developed HE. None of the patients not meeting the criterion developed HE. 【Conclusion【 Our prediction formula is therefore considered to be reliable for predicting the determining the likelihood of development of HE in patients with AHI.

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In order to improve the survival of patients with severe hepatitis, Yoshiba, et al. have postulated early intervention therapy based on a prediction score for progression to fulminant hepatitis. However, it has been pointed out that the positive predictive value for the prediction score may not be satisfactory. We have initiated combined anti-viral (interferon, nucleotide analogues) and immunosuppressive (corticosteroid pulse, cyclosporin) therapies in 18 severe hepatitis patients, when they had positive scores in Yoshiba's score for prediction of fulminant hepatitis. We compared the survival of these patients with that of 6 fulminant hepatitis patients. We have evaluated the efficacy of early intervention by decision analysis. Eighty three percent (15 of 18) of our patients with severe hepatitis survived following early anti-viral/immunosuppressive therapy. This was significantly higher than the survival rate (33%) in fulminant hepatitis patients (P<0.05). Decision analysis revealed that the early intervention based on Yoshiba's score provided better survival than late intervention, even considering the positive predictive value of the score. We also evaluated the efficacy of nucleotide analogues (lamivudine, entecavir) for preventing the occurrence of severe hepatitis in 19 hepatitis B virus (HBV) carriers receiving chemotherapy or corticosteroid therapy. None of the 19 HBV carriers, who were pretreated with lamivudine or entecavir, experienced liver injury after undergoing chemotherapy or corticosteroid therapy. We conclude that fulminant hepatitis, especially in its subacute form, can be effectively prevented by early initiation of anti-viral/immunosuppressive therapies and that Yoshiba's score can be the rationale for such early intervention.

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Fulminant hepatitis is an intractable disease caused by various etiological agents. Artificial liver support (ALS) is a symptomatic treatment to control the bleeding tendency, hepatic coma and brain edema. Several attempted ALS treatments have not been sufficient for the patients to regain consciousness, and randomized control trials (RCTs) have failed to show any beneficial effect on the patient survival rate. Plasma exchange has been the prevailing ALS method in Japan since the mid 1980's. It can supply an adequate amount of coagulation factors, however its capability to remove water-soluble substances with a large distribution volume is poor. We thus tried to combine plasma exchange with hemodiafiltration to compensate for the faults of plasma exchange. Plasma exchange in combination with hemodiafiltration using a high-volume buffer and high performance membrane can remove water-soluble toxic substances with a large distribution volume such as glutamine, resulting in a recovery rate of more than 90% from hepatic coma. This combination It can also sustain favorable conditions in patients with severe fulminant hepatic failure (FHF) with favorable comparison to an ahepatic state. ALS is a symptomatic treatment ; therefore the recovery rate from hepatic coma is a suitable primary endpoint of any clinical trial that evaluates the efficacy of ALS. This combination ALS has become a reliable and standard method for Japanese clinicians, although its efficacy has not been ascertained by an RCT.

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Hepatocyte growth factor (HGF) is a promising agent for the treatment of fulminant hepatic failure (FHF) because of its mitogenic and anti-apoptotic effects. We started a phase I/II clinical trial of recombinant human HGF (rh-HGF) in patients with FHF as an investigator-sponsored ICH-GCP registered trial. Four FHF patients, who required liver transplantation, but who could not undergo the procedure for various reasons, such as the lack of an appropriate donor, were enrolled in this clinical trial. Although intravenous injections of rh-HGF moderately decreased patient blood pressure, administration of rh-HGF for 12-14 days did not induce severe side effects. In two patients, hepatic failure gradually progressed, and they died 66 and 29 days, respectively, after encephalopathy occurred. The other two patients survived.

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We developed a novel cell therapy (ABMi therapy) using autologous bone marrow cells for liver cirrhosis patients. Our study depends on the findings from basic studies using GFP/CCl4 models. In November 2003, we started clinical trials of ABMi therapy and found it to be safe and effective for liver cirrhosis patients. Multicenter trials in Japan and Korea have also shown the effectiveness of ABMi therapy for liver cirrhosis patients. Cell therapy using bone marrow cells appears to be a prospective and promising new therapy for liver failure patients.

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A novel criterion for selection of patients with fulminant hepatitis for liver transplantation has been proposed recently by the Intractable Liver Disease Study Group of Japan. The simplified scoring system is based on six clinical components at the onset of hepatic encephalopathy. Duration of onset to encephalopathy : 0=0～5days ; 1=6～10days ; 2=11days. Prothrombin time : 0=20.1%> ; 1=5.1%～20.0%; 2=<5.0%. Total bilirubin : 0=<10.0mg/dL ; 1=10.1～15.0 mg/dL ; 2=15.1mg/dL> ; Ratio of direct bilirubin to total bilirubin : 0=0.7> ; 1=0.5～0.69 ; 2=<0.5. Platelet count (/mm³) : 0=10.1>; 1=5.1～10.0 ; 2=<5.0. and Liver atrophy : 0=none; 1=atrophy. Liver transplantation was indicated in patients who scored more than 5 points. The sensitivity was 0.80, specificity 0.76, positive predictive value 0.84, and negative predictive value 0.70. This scoring system had high sensitivity, specificity, and predictability.

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In our hospital, critical care was performed for patients with fulminant hepatic failure (FHF) who were under consideration for living donor liver transplantation (LDLT). We therefore investigated the timing of artificial liver support (ALS), the indication for LDLT, the outcome in 28 patients with FHF, the timing of LDLT, postoperative complications, and the outcome in 7 patients who underwent LDLT. They 28 patients comprised 13 men and 15 women ; age range, 0 to 82 years, mean age, 42.4 years. The causes of FHF were hepatitis B in 9, drug-induced in 7 and unknown in 12. The types of hepatitis were 9 in acute type and 19 sub acute type. The grades of encephalopathy were 2 at gradeI, 17 at gradeII, and 9 at gradeIIIorIV. After performing ALS on these patients, 7 patients were treated with LRLT and 4 patients survived. Thirteen patients died without LRLT, and 8 patients survived without LRLT. The survival rate of all patients was 42.9%. The survival rate of patients without LRLT was only 38.1%, and the rate of patient who underwent LRLT was 57.1%. The significant points in critical care for FHF were considered an adequate ALS and the appropriate timing of LRLT.

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Aim : The aim of this study was to investigate the safety of living donor liver transplantation (LDLT) for fulminant hepatic failure (FHF) patients. Methods : We reviewed the clinical indications, operative procedures and prognosis of LDLT performed in patients with FHF at the University of Tokyo. From January 1996 to December 2008, 108 patients were referred to our department due to severe acute hepatitis or FHF. Of these, 37 underwent LDLT and were the subjects of this study. Of the 37 patients that underwent LDLT, 33 were over 18 years old. The etiologies of FHF included non-A, non-B hepatitis in 24, and hepatitis B virus in 11, Wilson's disease in 1, and auto-immune hepatitis in 1. Graft type included right liver in 19, left liver in 16, and right paramedian sector in 2. Results : Patient and graft survival rate at 5 years were 87% and 82%, respectively. Twenty-three patients had postoperative complications; acute cellular rejection in 12, biliary stricture in 8, bile leakage in 6, peritoneal hemorrhage in 6, and hepatic arterial thrombosis in 4. Conclusion : The LDLT procedure provided satisfactory survival rates for FHF patients.

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Since 1995, our institute has performed 131 cases of live-related liver transplantations, 26 recipients (10 pediatrics) among which were due to acute liver failure. The causes of the acute liver failure were HBV hepatitis (3 cases), Wilson's disease (2 cases), autoimmune hepatitis (4 cases), drug-related (1 case), and unknown (16 cases). Twenty of these 26 recipients survived the transplantation, with 4 of the 6 deaths being pediatric recipients. When we focused on the adult recipients, the survival rate was 87.5% and the average hospitalization period was 70.2 days, which was significantly better when compared to our chronic liver failure recipients (76.4% and 89.0 days, respectively). Based on our experience, we consider that those patients who have come to the limit without surgical intervention are a good indication for the liver transplantation. Furthermore, we have concluded that patients with positive HBV-DNA and patients with only ABO incompatible donors may also be eligible for transplantation, due to the recent improvement in antiviral treatment and perioperative management.

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Deceased donor liver transplantation is considered to be one of the important treatment options for acute liver failure. Thus, Japan needs to implement various imperative measures to increase the rate of organ donation. Although it is believed that the most critical factor for the organ shortage is the lack of a well-established in-hospital system to convert potential donors into actual donors, no previous studies have attempted to analyze the problem from the perspective of the intrinsic motivation level of in-hospital coordinators. Thus, we conducted a questionnaire survey in Europe and Japan to identify the characteristics of in-hospital coordinators who play crucial roles in organ donation. We compared the job satisfaction levels, job core dimensions based on the Hackman and Oldham's Job Characteristics Model, and job responsibilities between European and Japanese coordinators. Our results demonstrated that the European coordinators had higher skill variety, task identity, task significance, autonomy, and feedback in relation to their job characteristics, which led to higher job satisfaction and higher job performance than that of their Japanese counterparts. This finding implies that these coordinators in Japan need to be stimulated to improve the process of motivating potential donors to become actual donors. We suggest that redesigning of the job responsibilities of organ donor coordinators in Japan would increase the organ donation rate in Japan.

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We encountered a case of gallbladder injury which was successfully treated with conservative treatment without complications. An 8-year-old boy bruised his right hypochondrium when he fell from an iron fence surrounding a swing park. Abdominal sonography and CT revealed bleeding and hematoma formation in the gallbladder and its surrounding area. The patient was diagnosed as having gall bladder injury accompanied by gallbladder avulsion from the hepatic bed. His clinical symptoms and vital signs were stable; therefore, conservative treatment was selected. Only 4 cases (including the present one) with gallbladder injury treated conservatively without complications have been reported in the literature. In cases of gallbladder injury accompanied by gallbladder avulsion from the bed, emergency open surgery is usually indicated. However, in the present case, the patient was successfully treated conservatively without developing complications, such as the aggravation of abdominal bleeding, hemorrhagic shock, or cholecystitis.

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A 62-year-old healthy woman developed sudden onset right flank pain while preparing dinner and was brought to our hospital by ambulance with a cold sweat and lightheadedness. On arrival she was in profuse diaphoresis with a blood pressure of 88/50 mmHg. Physical examination revealed right upper quadrant and flank tenderness. Computed tomography (CT) scan of the abdomen demonstrated a round-shaped structure of 5 cm in diameter with eggshell calcification and fluid collection in the right pararenal space. Since a ruptured renal artery aneurysm was suspected and the patient was in a state of shock, an emergency laparotomy was performed. The right retroperitoneum was dissected and the ruptured capsule of the cystic lesion was disclosed in the upper pole of the right kidney around which a large hematoma was seen, and a right nephrectomy was performed. The pathological findings confirmed the diagnosis of a ruptured renal artery aneurysm. The patient's postoperative course was uneventful and she was discharged. The renal artery aneurysm is a relatively uncommon disease, which is usually discovered incidentally on imaging studies or found following rupture as seen in our case. We report on the case of a ruptured renal artery aneurysm presenting with flank pain and shock, with successful surgical treatment following a tentative diagnosis based on the CT scan findings.

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This case involves an 80-year-old man who visited the hospital in June 2007 mainly because of abdominal pain and vomiting. He was hospitalized for small bowel obstruction. Following ileus tube scanning and abdominal computed tomography, a small intestinal intussusception was identified and a laparotomy was performed. During the operation, a small intestinal tumor with a diameter of 7.5 cm was found causing the intussusception at a distance of 40 cm from the Triez ligament. Histopathological examination revealed a gastrointestinal stromal tumor of the jejunum that was positive for c-kit but negative for CD34. We did not administer any chemotherapy after the surgery. No recurrence has been observed for up to 1 year after the surgery.

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A 21-year-old man was transferred to our hospital following a traffic accident. He complained of right upper abdominal pain. There were no signs of peritoneal irritation. An abdominal CT scan showed no abnormal findings. Sixteen hours later, the abdominal CT scan on the second examination showed a edematous change in of the duodenal wall and retroperitoneal air. We started conservative treatment under a diagnosis of duodenal perforation to the retroperitoneal space. Thirty hours later, the patient's his abdominal pain had increased. The abdominal CT scan on the third examination showed retroperitoneal fluid, and an emergency laparotomy was performed. Intraoperative findings revealed that the duodenum had been perforated at the second potion. Simple closure, an omental patch and abdominal drainage were performed. The diagnosis of duodenal perforation to the retroperitoneal space is difficult in some cases, and may require sequential CT scans.

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We report on a case of incarcerated femoral hernia complicated with abdominal compartment syndrome (ACS). A-83-year-old woman underwent an emergency operation for an incarcerated femoral hernia. The small intestine was not necrotic, but some parts of it were remarkably edematous and multiple lacerated wounds were found on the serosal side. The sections of the lacerated intestine were resected and sutured. During operation, the patient's systolic blood pressure dropped to 30 mmHg due to supraventicular arrhythmia. Cardiopulmonary resuscitation was performed for 30 seconds. Noradrenalin, Vasopressin and Ladiolol were given and the systolic blood pressure went up to more than 100 mmHg. When closure of the abdominal wall was started after completion of the hernia repair, the blood pressure dropped to 75/45 mmHg. Because ACS was suspected and we were afraid of worsening of multiple lacerated wounds of the small intestine, closure of the abdominal wall was stopped and a Silo-closure was performed. Six days later, following resolution of edema of the intestine and improvement of the patient's general condition, we were able to close the abdominal wall with a staged operation. The patient was transferred to another hospital for rehabilitation three months after the first operation. We should keep ACS in mind and consider a staged operation for ACS.

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We herein report on a rare case of sigmoid colon perforation induced by a press-through package (PTP). A 68-year-old woman was admitted to our hospital due to lower abdominal pain with a suspected diagnosis of perforated peritonitis. She was referred to our hospital. The presence of ascites and free air was detected on abdominal CT. Retrograde colonography with gastrografin demonstrated a leakage and a linear filling defect in the sigmoid colon. Emergency surgery was performed with the diagnosis of perforation of the sigmoid colon caused by a foreign body. The operative findings revealed that the sigmoid colon perforation was due to the presence of a PTP. Partial resection of the sigmoid colon with sigmoid colostomy was performed. The patient was not aware that she had taken the PTP, hence the preoperative diagnosis was difficult. Because the number of cases of PTP ingestion is increasing, redesign of PTPs and better patient education may be necessary.

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An 89-year-old man complained of vomiting frequently after eating sweets which had been left at room temperature for three days, so he visited our hospital and was admitted. He had tenderness throughout the abdomen. His abdominal symptoms were worsening and an abdominal CT scan showed intraperitoneal free air. An emergency operation was performed with a diagnosis of perforation of the intestine. Following the laparotomy a perforation was found in the jejunum located 50 cm from the Treitz ligament. A partial small intestinal resection including the perforated lesion was performed. We could not specify the cause of the perforation from the pathological findings. He was diagnosed as having idiopathic perforation of small intestine.

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A case of small gastrointestinal stromal tumor (GIST) of the stomach with gastric hemorrhage is reported. A 48-year-old man had undergone laparoscopic distal gastrectomy for early gastric cancer 3 years previously. Follow up gastrointestinal endoscopy one year later revealed a 10×10mm gastric submucosal tumor in the gastric cardia. After one year the diameter of the tumor had increased to 20mm. One year after that he presented with a GI hemorrhage due to the tumor and we performed a total resection of the remnant stomach. The postoperative histologic examination revealed a 25×20mm GIST of the stomach with 12 mitoses per 50 HPF and was classified under the high-risk category according to the National Institute of Health (NIH) consensus. Although GI hemorrhage from a small GIST is not frequent, this case clearly showed that closer observation is mandatory even in smaller GISTs.

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Non-occlusive mesenteric infarction (NOMI) indicates intestinal ischemia or necrosis in the absence of an arterial occlusion and has an unfavorable prognosis. Its incidence is low and the number of reports on this disease are few, making preoperative diagnosis and treatment difficult. We experienced a patient who suffered from this disease after comminuted lumbar vertebral fracture, massive hemorrhage-related shock, and sepsis treatment, who had a successful outcome. Etiological factors for NOMI included heart failure, shock, arrhythmia, and a decrease in the cardiac output. However, irritative peritoneal symptoms were less marked, and repeated exacerbation/remission made preoperative diagnosis difficult. Recently, as the incidence of obesity/smoking-related ischemic heart disease has increased, that of NOMI may also increase. In acute abdomen patients with less marked irritative peritoneal symptoms, as was the present case, contrast-enhanced CT should be performed, bearing the possibility of NOMI in mind. For the early detection of NOMI it is important to confirm the presence or absence of occlusion of the principal artery.

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