This study was performed to clarify the usefulness of the Acute Physiology and Chronic Health EvaluationII (APACHEII) score, the Sequential Organ Failure Assessment (SOFA) score and the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) score for postoperative risk assessment in emergency surgery for patients with colorectal perforations. In 35 patients who underwent emergency surgery for a colorectal perforation between September 2001 and October 2007, the mortality rates were compared using the APACHEII, SOFA and POSSUM. As the result, the postoperative mortality was 22.6% (n=8). There was no statistically significant difference in the patients' backgrounds and surgical methods between non-survivors and survivors, however, the POSSUM score was the significant predictor of postoperative mortality in the patients with perforation of sigmoid colon and rectum (non-survivors/survivors : 64.4±11.4/52.7±8.2, p=0.041). In the evaluation by the cut off value, the accuracy of SOFA (accuracy : 88.4%) and POSSUM (accuracy : 76.9%) were significantly excellent evaluation methods in the patients with perforation of sigmoid colon and rectum. It is concluded that the SOFA and POSSUM score are better predictors of postoperative mortality and useful as indicators for the risk assessment in patients with perforation of sigmoid colon and rectum.

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Background : We examined the effectiveness of Systemic Inflammatory Response Syndrome (SIRS) to describe patients with strangulation ileus. Methods : The subjects consisted of 72 patients given a diagnosis of ileus who underwent surgery during the period from January 2001 to December 2007. On the basis of the surgical findings, they were classified into two groups : the strangulation group, consisting of 27 patients, and the control group, consisting of 45 patients with simple ileus. The background factors, SIRS, blood test findings before treatment, and vital signs were compared between these two groups in a retrospective study. Results : A univariate analysis revealed statistical significant differences between the two groups in SIRS, white blood cell count, Platelet, CRP, CPK, PaCO2, BE, PF ratio, MAP, pulse rate, and GCS. The SIRS, CRP, PF ratio, and BE were significant independent factors in the multivariate analysis. Conclusions : SIRS was proved to be highly effective as a diagnostic method for strangulation ileus.

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Immunosuppression after surgical stress frequently leads to death in critically ill patients, which is the critical problem to be resolved to improve the mortality rate in such patients. The present study reviews, pertinent publications relating to regulatory T cells (Treg) with emphasis on their clinical and pathophysiological importance in sepsis. In addition, a summary of the author's own experimental data from this field was set in the context of current knowledge regarding Treg. Treg, which is a small population characterized by CD4+CD25+Foxp3+T cells, is known to play a major role in suppressing immune reactivity. Sepsis increases Treg in the peripheral blood of septic patients and in the spleen of septic animals, suggesting that enhanced Treg may contribute to immunosuppression during sepsis. Both anti-IL-10 and anti-TGF-&bata; antibodies suppressed the increase of Treg observed in septic animals, and administration of the anti-TGF-&bata; antibody improved survival following polymicrobial sepsis. Thus, the regulation of Treg may be a novel therapeutic approach against the immunosuppression associated with sepsis.

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Septicemia refers to a condition in which infection and the related inflammation spread to involve the entire body. Blood coagulation and inflammatory responses, as part of the innate host defense mechanism, are inter-related. New scientific advances have led to the current understanding that coagulation factors such as tissue factor (TF), Factor VII, Factor X and thrombin (II), are important players in inflammation, neovascularization, angiogenesis, and tumorigenesis. Furthermore, non-specific proteases, eg. leukocyte elastase, have also been implicated in the pathogenesis of septicemia. Secondary deficiency of the von Willebrand factor (vWF) -cleaving proteinase, ADAMTS13, which is possibly cleaved by leukocyte elastase, is found in sepsis, and this may contribute to the development of renal failure. HMGB-1 is a protein that plays a role as a late mediator of lethal systemic inflammation in sepsis. In sepsis, HMGB-1 causes DIC and multiple organ failure. HMGB1 release can possibly be controlled by Thrombomodulin (TM), and recombinant thrombomodulin (rTM). It is thought that concomitant treatment of both the inflammation and the closely related coagulopathy in patients with sepsis may be associated with reduced mortality. The overall aim of this review was to summarize our current understanding about blood coagulation and inflammation.

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Procalcitonin (PCT) has been reported to be a useful diagnostic marker in general bacterial infection and sepsis. In 45 sepsis patients PCT levels were measured, and the subjects were divided into the PCT negative group (PCT<2.0ng/mL ; n=14) and the PCT positive group (PCT≥2.0ng/mL ; n=31). The SOFA score and Goris score were significantly higher in the PCT positive group, and they had significantly poorer cardiovascular, respiratory, liver, coagulation and renal functions than the PCT negative group. Most patients in the PCT positive group underwent PMX-DHP. All patients of the PCT negative group were rescued without PMX-DHP. The PCT level was correlated with degree of sepsis and multiple organ failure. This study indicated that the PCT level is useful for the diagnosis and the evaluation of sepsis and the severity of sepsis. Furthermore, it is useful for decision-making whether to use PMX-DHP for treatment guidance.

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【Background【 We started direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) within three hours of surgical treatment for panperitonitis anaphase patients with Acute Physiology and Chronic Health Evaluation (APACHE) II scores of over 20, based on the results of our previous study in which good outcomes were obtained in panperitonitis prophase patients treated by DHP-PMX within three hours of surgery. 【Material and Methods【 We compared the outcomes in prophase and anaphase patients of panperitonitis with APACHE II scores of over 20. The anaphase patients were analyzed in two groups based on the outcome, and the serum levels of high mobility group box-1 (HMGB-1), N-arachidonoylethanolamine (AEA), 2-arachidonoyl glycerol (2-AG), interleukin-6 (IL-6), plasminogen activator inhibitor-1 (PAI-1) and protein C were measured before the start of the DHP-PMX. 【Results【 The actual mortality rate in the prophase group was 54.5%, which was similar to the expected mortality rate of about 53.5% calculated using an APACHE II score of 25.5. On the other hand, the actual mortality rate in the anaphase group was 30.8%, lower than the expected mortality rate of about 66.5% calculated using an APACHE II score of 28.4. The serum HMGB-1 and PAI-1 levels were higher and the protein C levels lower in the patients who eventually died as compared with those in the survivors. 【Conclusion【 We propose that, in panperitonitis patients undergoing surgical treatment, DHP-PMX should be initiated within three hours of the operation ; in addition, we suggest, based on our results, that the serum levels of HMGB-1, PAI-1 and protein c may be predictors of the mortality.

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Severe sepsis and septic shock are considered to be among the most critical of problems in the field of critical care medicine. We studied the safety and effectiveness of a newly developed cytokyne adsorption column for the treatment of sepsis. The newly developed column contains microporous cellulose beads with hexadecyl alkyl chains as the ligands. Eighteen patients with early septic shock or septic organ dysfunction were enrolled. Nine of the 18 patients were randomized to direct hemoperfusion (DHP). All patients received intensive supportive care, and those who were randomized to the DHP group underwent direct hemoperfusion between two and 14 times, for 4 hours each, over a period of 14 days. We measured the plasma concentrations of interleukin 6, 8, 1-beta, and tumor necrosis factor alpha in the patients. The APACHEII score was evaluated in each patient on day 1, 7 and 14 after the start of treatment, in the morning, prior to the start of the treatment session. The decrease of the APACHEII score on day 7, relative to the pretreatment level, was significantly larger in the treatment group than in the control group (p=0.0189 ; Mann-Whitney test). No serious adsorption column-related adverse events were observed in the DHP group. The plasma concentrations of interleukin 6 and interleukin 8 decreased significantly from the pretreatment level in the DHP group (p=0.0464 for both; Wilcoxon's test). The newly developed direct hemoperfusion column produced greater improvement in septic shock patients than the ordinary intensive supportive care.

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Cytokines play pivotal roles in the pathophysiology of septic shock. As a clinical test to monitor hypercytokinemia, in 2000, we introduced into clinical practice a rapid assay system that determines blood levels of IL (interleukin) -6 in approximately 30 min. Since then, blood IL-6 has been routinely measured as a good index of cytokine cascade activation in critically ill patients in our institute. Continuous hemodiafiltration (CHDF) using a polymethylmethacrylate (PMMA) membrane hemofilter (PMMA-CHDF) removed various cytokines from blood continuously and efficiently, mainly through adsorption to the membrane matrix of the hemofilter. Forty-three patients with septic shock were assessed by monitoring their blood IL-6 levels with a rapid assay system and immediately treated with critical care including PMMA-CHDF for cytokine removal. Following initiation of PMMA-CHDF, early improvement of hemodynamics as well as an increase in urine output were noted. PMMA-CHDF treatment improved both hypercytokinemia (assessed by measurement of blood IL-6 level) and dysoxia (assessed by measurement of blood lactate level). The present findings suggest that PMMA-CHDF could be an effective strategy for the treatment of septic shock.

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The Surviving Sepsis Campaign Guidelines (SSC) were published with the aim of improving the outcome of sepsis, but the DIC diagnostic and anticoagulation therapy methods and acute blood purification that are widely performed in Japan are not recommended by the SSC. The subjects were 20 patients with severe sepsis who were managed and treated in the intensive care unit (ICU). We used anticoagulation therapy, primarily with antithrombin preparations, in 15 DIC patients, and various emergency blood purification methods, including continuous hemodiafiltration, endotoxin adsorption therapy, and plasma diafiltration, in 12 patients. The predicted mortality rate of 67.6±19.1% upon entering the ICU was actually 25% (5 patients). Based on these results, it appears possible to adhere to the SSC and increase the survival rate in sepsis even further by combining DIC diagnosis and treatment and appropriate emergency blood purification methods according to the pathology beginning in the early stage.

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A 76 year-old-woman previously attended another hospital for epigastralgia and vomiting, and was then referred to our hospital. The CT examination showed the small intestine escaping to the lesser side of the stomach through the right posterior side of the portal vein. We diagnosed it as hernia incarceration through the foramen of Winslow and performed an emergency operation. Using the laparoscope, we observed a great deal of hemorrhagic ascites. Resection of the intestine was considered necessary, and we performed a laparotomy with an upper median incision. The ileum from 270cm to 340cm from the Treitz ligament was incarcerated through the foramen of Winslow, and we manually drew it out. It was remarkably congested. After unfastening the strangulation, the color improved immediately. We did not resect it and closed the 2-finger wide hernia orifice with 3 sutures. The patient's postoperative course was good and she left the hospital on the twelfth postoperative day. Helical CT examination enabled the precise preoperative diagnosis of where the hernia orifice was.

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A 43-year-old male was admitted to our hospital for vomiting and melena with a hemoglobin level of 12 g/dL. Abdominal enhanced-computed tomography revealed a tumor (8 cm in diameter) in the pelvis that was fed from the left gastroepiploic and superior mesenteric arteries. Esophagogastroduodenoscopy and colonoscopy showed no abnormal findings. We performed a laparotomy for the intrapelvic tumor with melena on the 20th hospital day because the patient passed a large amount of bloody stool again on the 14th hospital day. Intraoperative findings revealed a large jejunal tumor covered by the omentum, and we performed a partial resection of the jejunum. The postoperative course was uneventful. The tumor appeared to be well circumscribed, and the mucosal surface was ulcerated. Pathological findings showed mitotic spindle tumor cells arranged in a palisade pattern making up the tumor between the submucosal and subserosal layers. Immunohistochemical findings showed positive staining for KIT and CD34, and a jejunal gastrointestinal stromal tumor was diagnosed.

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We report on a conservative case of mesenteric panniculitis. A 51-year-old man was seen at our hospital because of left upper abdominal pain. We diagnosed mesenteric panniculitis based on the characteristic features seen on abdominal computed tomography. Conservative therapy was effective, and the patient was discharged from hospital after 7days. Recurrence was not seen up to the time of writing. When abdominal symptoms are accompanied by an abdominal mass seen on abdominal CT, mesenteric panniculitis must be kept in mind.

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We herein report on a patient with traumatic massive bleeding from the middle colic vein and left gastro-epiploic artery who was successfully treated with a combination of damage control surgery and transcatheter arterial embolization (TACE). A 58-year-old male who had fallen from the top of a ladder was admitted to our hospital and was diagnosed with computed tomography as having massive abdominal bleeding. An emergency laparotomy after proper resuscitation revealed a complex injury near the root of superior mesenteric vein which was unable to be repaired completely at the initial operation. Temporary hemostasis was performed with local gauze packing. Three hours after the operation, massive intra-abdominal arterial re-bleeding occurred. Following a emergency conference among surgeons, intensive care specialists and radiologists, the bleeding from the left gastro-epicolic artery was successfully and temporally controlled with TACE by radiologists under systemic management by the intensive care specialists. Thirty six hours later, complete hemostasis was achieved by fixing both the middle colic vein and left gastro-epiploic artery with a surgical maneuver. The patient gradually recovered from renal failure and pneumonia during a 22-day stay in the intensive care unit. Cross-speciality medical care is essential for the treatment of patients with a complex injury.

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A 75-year-old woman underwent an urgent laparotomy for acute-onset panperitonitis, which was found to be caused by a non-tumor-associated rectosigmoid perforation. Hartmann's procedure with resection of the perforated part of the large bowel and creation of colostomy was performed in conjunction with resection of part of the ileum which appeared ischemic. The early postoperative course was complicated by sepsis and systemic inflammatory response syndrome, resulting in cardiorespiratory and renal failure, liver dysfunction with prominent jaundice and disseminated intravascular coagulopathy. Intensive treatments including continuous hemodialysis and filtration and endotoxin absorption therapy attained a successful recovery from multi-organ failure (MOF) at 1 month postoperatively. However, hyperbilirubinemia persisted for approximately 1 year postoperatively, which was suggested to have resulted not from liver failure but from chronic infectious complications including pneumonia, pyothorax, wound infection and unnoticeable persistent fungal infection. Particularly, the recognized activity of fungal infection seemed to correlate well with changes in the degree of jaundice in the late period of the entire clinical course. This case suggests the benefit of hemopurification in recovery from sepsis-induced MOF and the association of postoperative sustained hyperbilirubinemia with chronic infection, particularly fungus-related, in severely ill patients with large bowel perforation.

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We report on a case of Pneumatosis Cystoides Intestinalis (PCI) with gas in the retroperitoneal space. An 86-year-old female was referred to Ogaki Municipal Hospital complaining of abdominal and back pain. She had been taking steroids 5 mg/day for rheumatoid arthritis (RA). Because of the positive peritoneal sign and free air in the retroperitoneal space on abdominal CT, the patient underwent an emergency laparotomy under a tentative diagnosis of intestinal perforation. Emergency laparotomy showed no ascites, nor intestinal perforation, but gas-filled multiple cysts along the 3rd duodenum wall and mesentery. The diagnosis of PCI was made. The patient was discharged from the hospital on the 26th hospital day. There have been no signs of recurrence as of 6 months after the operation.

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We report on a patient who survived nonocclusive mesenteric ischemia (NOMI) with hepatic portal venous gas (HPVG) and pneumatosis cystoides intestinalis (PCI) treated with surgery. The patient was a male in his seventies undergoing enteral nutrition and rehabilitation in our hospital after a cerebral hemorrhage. He complained of increasing abdominal pain and finally lapsed into septic shock. Abdominal muscle guarding was noted. Enhanced abdominal CT showed HPVG in the bilateral lobe of the liver and PCI in the wall of the ileum and ascending colon but no thrombi were seen in the main vessels. After rapid infusion, the patient was operated on under the diagnosis of HPVG and PCI caused by ischemic intestinal disease. Inflammation, necrosis and PCL was seen discontinuousuly and extensively at the small intestine and right colon. The pulsation of the superior mesenteric artery was palpable. At this point we diagnosed NOMI and performed massive resection of the intestine and primary anastomosis. The remnant small intestine was about 1 meter. On pathological studies, NOMI was diagnosed. After operation, the patient was placed in intensive care with endotoxin hemoabsorption. The patient gradually recovered and was transferred to the neurosurgery department for rehabilitation on the 40th postoperative day.

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This report describes a case of retroperitoneal venous malformation. A 38-year-old female was referred to our hospital for abdominal pain. Computed tomography showed a large 20 cm mass up to the right kidney. We suspected an idiopathic adrenal hemorrhage. Angiography did not show any bleeding site, however, inflow blood was detected and embolized. The endocrinological examination was normal. An adrenal tumor could not be ruled out, therefore the patient underwent tumor resection. There was a tight adhesion to the right adrenal gland and kidney. The tumor measured 15×17cm and contained 1,500mL bloody liquid. The pathological diagnosis was a venous malformation.

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An 85-year-old man was admitted to our hospital because of abdominal pain, loss of appetite and vomiting. He had fallen from a bed 2 years previously and had suffered left costal fractures. Based on the CT findings, we diagnosed delayed incarceration of a traumatic diaphragmatic hernia, and performed an emergency operation on the same day. During surgery, a fissure in the left diaphragm about 3 cm in diameter was disclosed and the splenic flexure of colon and the omentum were incarcerated through this defect. We confirmed that the segment of the colon was ischemic and resected it. The defect of the diaphragm was sutured and a colostomy was performed. The patient had an uneventful postoperative course and was discharged from our hospital on the 28th postoperative day. We report on our experience on a rare case of delayed incarceration of a traumatic diaphragmatic hernia and its treatment, together with a review of the literature.

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An 82-year-old woman complaining of abdominal pain and fullness showed dilatation of the intestine with air-fluid level formation on abdominal X-ray film. She was referred to our hospital for investigation of severe constipation at the sigmoid colon volvulus. Our first choice would have been endoscopic release, but the insertion of a fiberscope would have been difficult and dangerous in a patient whose colon was not fixed. An emergency operation was performed under the diagnosis of ischemic change due to sigmoid colon volvulus. A median laparotomy was performed, and the colon volvulus was found at a rotation of 270° counterclockwise of the redundant colon. We released the colon volvulus and revealed that the ascending to descending colon were free from the retroperitoneum, suggesting mesenterium commune. As the ischemic change in the colon did not recover, we decided on resection of the megacolon and performed a colonostomy. The patient was discharged 14 days after the operation and is doing well.

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A 20-year-old man visited the hospital for abdominal pain persisting for five days and vomiting. Abdominal X-ray and CT scan revealed multiple round and radiolucent shapes along the intestinal tract wall and an intussusception with the target sign. The intussusception was reduced with a high pressure Diatrizoate Meglumine enema. Colonoscopy after reducing the intussusception showed multiple elevated lesions in the ascending colo, with a smooth surface, and which looked like submucosal tumors. CT scan after colonoscopy revealed that the tumors were filled with air. From these findings, we diagnosed intussusception associated with pneumatosis cystoids intestinalis (PCI). As the patient's symptoms disappeared after the reduction, we started to treat him with oxygen. A CT scan performed 10 days later verified a decrease in both the number and size of the cysts. smaller. The patient was discharged from hospital 21 days after admission.

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