【Purpose】 We examined the correlation between the serum albumin (Alb) level before surgery for digestive tract perforation and the incidence of surgical-site infection (SSI). 【Subjects and Methods】 The subjects were 39 patients who underwent surgery for digestive tract perforation in our department between April 2006 and March 2008, in whom the levels of Alb were measured. We divided the patients into two groups (SSI group, n=16 ; non-SSI group, n=23) and compared the patient background factors and serum Alb levels between the two groups : 16 patients with SSI (SSI group) and 23 without SSI (non-SSI group). 【Results】 Of the total, 41% of the subjects developed SSI. The volume of blood loss was significantly greater (p=0.04) and the serum Alb level was significantly lower (p<0.05) in the SSI group than in the non-SSI group. The incidence of SSI was significantly higher (59.1%) in the patients with serum Alb levels of 3.4mg/dL or more.Conclusion : The risk of SSI in patients undergoing emergency surgery for digestive tract perforation was correlated with the serum Alb level, suggesting that this parameter could be used as a predictor of SSI.
Abdominal trauma involves several organs non-anatomically and non-systematically and is often complicated with involvement of some organs in other parts of the body. A team approach involving not only full-time generalist staff in the emergency or traumatology department but also some special surgical staff and intensivists is necessary to manage patients with abdominal trauma. Although our critical care and emergency center is one of the special sections in the university hospital, it is not an independent and isolated department but a central section comprising several specialists from different departments, in which we have aimed for a team approach, harmony and integrity in clinical practice. In the initial resuscitation care in the emergency room, 4 or 5 specialists use the team approach for patients with severe and complex abdominal trauma. All staff can perform tracheal intubation and surgical airway management, catheterization into a central vein, tube thoracotomy, and open heart massage as a minimum requirement for generalists in the emergency room, and each specialist belonging to our center performs other specific techniques. After the initial resuscitation care, each specialist group manages patients and other specialist groups support the in-charge-specialist group, in which fashion we can achieve the team approach and combined intensive care management.
Cases of emergency abdominal medicine usually tend to be characterized by both a high grade of severity and a high degree of urgency. They require not just the treatment of the underlying disease, but also early detection of changes in the clinical condition, and the provision of safe medical care. Team-based medical care involving professionals from various fields makes it possible to provide safe and elaborate treatment drawing from the separate perspectives of the different professions. The clinical engineering technologist (CE) is a professional whose job involves the safe and effective use and maintenance of medical equipment. CEs play a particularly important role in the field of emergency abdominal medicine, where a number of invasive medical devices including artificial life support systems are used. A CE can do much for the medical team by playing a proactive part in managing and ensuring the safe use of medical equipment. The smooth functioning of the medical team makes it possible to provide safe and high-quality medical care for abdominal emergency patients.
It is difficult for doctors in separate departments of tertiary emergency centers in Japan to comprehensively treat emergency patients due to the complex conditions of the majority of such patients. Patients with severe multiple trauma require treatment for not only each injured organ but also for respiratory and circulatory conditions, necessitating the involvement of doctors from multiple departments. This interdepartmental cooperation and organic teamwork results in superior treatment performance and role definition simultaneously reduces medical errors. At our institute, doctors in the emergency center cooperate from primary examination to intensive care with doctors from other departments to treat patients with abdominal trauma complicated with multiple injuries. The emergency center doctor assumes the role of team leader, recruiting the assistance of doctors from other departments and coordinating their various opinions. Thus, we are aiming to develop organic teamwork in our medicinal practice. Doctors from the emergency center and other departments regularly convene clinical conferences with the goal of advancing team performance to verify whether team medicine is functioning successfully. In Japan, it is difficult for many different specialists to be positioned in a single emergency center ; therefore, it is important for emergency doctors to cooperate with specialists in other departments to advance medical performance.
Surgical intervention for oncologic emergencies in patients with unresectable advanced/recurrent gastric cancer is controversial. Planned and careful surgery for each individual patient with gastric outlet obstruction (GOO) or malignant bowel obstruction (MBO) must be of clinical significance. However, it may be hard for such patients with GOO or MBO to decide to undergo palliative surgery without any hope of cure. Gastrointestinal surgeons must try for safe operations to allow oral intake, as an initial goal, after obtaining sufficient informed consent. In addition, the integrated treatments by several expert teams before and after surgery may be mandatory to obtain successful intervention allowing oral intake and continued further chemotherapy. The integration of expert care strategies with responsibilities, particularly for psychological management, will play a vital role in a high standard of palliative medicine as well as emergency medicine. The Japanese, hopefully, should reach a consensus on the integrated team treatment by experts who will be responsible for their specialized fields. In contrast, the medical staff including surgeons are asked to acquire humanity and the spirit of cooperation to achieve better team treatment for patients.
Patients who are admitted to the Department of Emergency and Critical Care Medicine are often referred to multiple diagnosis and treatment departments right from the start. Such patients also tend to be in a severe medical condition and in need of urgent medical treatment. For this reason, the Department of Emergency needs a medical team capable of prompt decisions and action in response to critical, life-threatening physiological abnormalities. Such a team, consisting of doctors, nurses, pharmacists, clinical engineers, etc., must be able to function in a smooth and concerted manner unobstructed by command lines or hierarchies. The team leader should carry the major responsibility of sharing information with the team and suitably and clearly communicating the treatment plans and procedures to be carried out, and the team as a whole would be evaluated on the medical care provided. Like all other forms of team-based medical care, the initial treatment provided at emergency and critical center of the Department of Emergency requires for the team members to enjoy mutual respect, share equal authority, and preserve a patient-centric system and attitude of cooperation.
The patient was an 87-year-old female who had a history of severe constipation and rectal prolapse. She was referred to our hospital because of sudden lower abdominal pain and protrusion of the small intestine through the anus after an evacuation. Her body temperature was 36.5℃. Although she had tenderness in the infraumbilical region, peritonitis signs were not observed. There were no abnormalities in the results of laboratory studies except for the presence of mild inflammatory changes. Although the abdominal X-ray showed no intra-abdominal free air, the patient was diagnosed as having small bowel evisceration through the anus related to a colonic perforation. The laparotomy revealed a 40mm perforation in the rectosigmoid colon ; however, contamination was not observed in the abdominal cavity. There was some reddening, and an edematous small intestine had invaded the rectum and the anus through the perforation. Resection of the eviscerated small intestine (150cm in length), simple closure of the perforation, irrigation of the peritoneal cavity with 5,000mL of saline solution, and drainage were carried out. Although the patient did not develop anastomotic insufficiency or surgical site infection, she did develop a mild cerebral infarction on postoperative day 20. After conservative treatment for the cerebral infarction, the patient was discharged from the hospital 56 days after the operation. Spontaneous colonic perforation remains a critical injury with high morbidity and mortality. Among cases of spontaneous colonic perforation, cases of small bowel evisceration through the anus have been very rare. We present here a case of successful surgery of a small bowel evisceration through the anus that was caused by rectosigmoid colonic perforation, and a review of 12 cases including 11 cases reported in the literature.
A 65-year-old male was admitted to our hospital with high fever and right lower abdominal pain. An abdominal CT scan revealed only slight inflammatory changes in an ileocecal lesion. Antibiotics were then immediately administered, however, the patient thereafter developed sepsis. A laparotomy and drainage were performed on day 5, but the high fever persisted. A blood culture revealed actinomyces on day 11, and antibiotics comprising large quantities of PCG were then administered at a dosage of 24 million units/day which was divided into 6 separate doses. The patient's condition thereafter soon recovered, and the PCG dosage was then gradually reduced. Generally, a preoperative diagnosis of an actinomycosis infection is very difficult because its detection rate by either a bacteriological culture or histological examinations is not very high. In addition, the occurrence of sepsis due to abdominal actinomycosis is also so rare that selecting the optimal treatment was very difficult. However, the appropriate usage of antibiotics eventually proved to be effective in this case.
A 67-year-old man was admitted to hospital with right lower abdominal pain and fever. He had tenderness and muscle guarding in the right lower quadrant of the abdomen and a high grade fever. The white blood cell count was 17,100/μL and C-reactive protein level was 19.3mg/dL. Abdominal CT showed severe inflammatory changes in the ileocecal region and a mass of about 8cm in the ileocecal mesentery. Our diagnosis was an intramesenteric abscess due to acute appendicitis or colon diverticulitis, and a right hemicolectomy was performed. The resected specimen contained a mesenteric abscess of the ileocecal region, as well as a fistula about 5cm proximal to the ileum end which communicated with the abscess. The pathological diagnosis was mesenteric abscess caused by a penetrated diverticulum of the ileum. The postoperative course was uneventful and the patient was discharged from the hospital on the 13th postoperative day.
There have been many reports of idiopathic rectal rupture both in Japan and overseas, but we report herein on a case of rectal rupture associated with small bowel prolapse through the anus, including a discussion based on the literature. The patient was a 69-year-old woman who noticed intestinal prolapse through her anus when she had bowel movements and she was examined by a local physician who referred her to the emergency and critical care center of our hospital for treatment. On arrival at the center, the small bowel was prolapsed through the anus for a distance of about 50cm. The prolapsed intestine appeared slightly dark-red. An emergency laparotomy was performed, and the small bowel was found to have entered the rectum through a longitudinal perforation of the anterior wall of the sigmoid colon and prolapsed outside the body through the anus. Rectal rupture associated with small bowel prolapse is a very rare disease, with only 24 cases ever having been reported from our search of central medical abstracts. In many cases, including this case, there is a disease, such as repeated rectal prolapse, in which traction force is chronically exerted on the sigmoid colon or rectum, and that appears to have caused weakening of the intestinal wall and to have become a factor in the rupture.
A man in his twenties without any significant past medical history and no previous surgery presented at another hospital complaining of an upper abdominal pain lasting for 1 week. He was referred to our hospital from the emergency room for acute upper abdominal pain and frequent vomiting. At the initial examination, slight tenderness was found in the upper abdomen on palpation, without peritoneal signs. A plain abdominal X-ray revealed a small amount of gas in the small intestine. On a CT scan, a cyst-like structure was revealed protruding from the vicinity of the Treitz ligament towards the left anterior pararenal space, which contained a portion of distended intestine. Upper alimentary tract fluoroscopy demonstrated occlusion of the horizontal part of the duodenum. A diagnosis of incarcerated left paraduodenal hernia was made and the patient underwent an emergency operation. Paraduodenal hernias are rare internal hernias that develop near the Treitz ligament by invagination of the intestine into a peritoneal pouch. A cyst-like structure formed by the distended intestine loop on the CT scans is a typical radiological sign of paraduodenal hernia.
A 45-year-old male was referred to our hospital with bloody stools and abdominal pain, and was admitted to the Department of Gastroenterology. Respiratory and circulatory dynamics were stable. Contrast-enhanced abdominal computed tomography (CT) revealed thrombus-related occlusion of the portal and superior mesenteric veins, and the patient was referred to the Department of Surgery. Massive intestinal resection was considered unavoidable. Danaparoid sodium was administered, and follow-up was continued, under the consideration of emergency surgery. Thereafter, the abdominal symptoms subsided and hematological data normalized. However, contrast-enhanced jejunal radiography revealed persistent stenosis. In September, surgery was performed. Adhesion of the greater omentum and a portion of the small intestine was noted. In addition, complete cordlike contraction/necrosis of the jejunum 40 cm from Treitz were observed, with a total length of 40cm. Jejunectomy involving the normal region and one-stage anastomosis were performed. The administration of Danaparoid sodium was again initiated on the first postoperative day (POD 1). On POD 4, the agent was switched to warfarin. The course was favorable. In the present patient, with portal/superior mesenteric venous thrombosis, massive intestinal resection could be avoided by Danaparoid sodium administration.
A 73-year-old man consulted a local clinic complaining of a high fever over 38°C and was treated with antibiotic therapy several times. However, the high fever continued and his serum C-reactive protein concentration rose to 14.8mg/dL. A liver abscess was suspected based on abdominal enhanced CT findings, and he was referred to our hospital. Tenderness and percussion tenderness were noted in the precordial space. Abdominal CT in the clinic revealed an enhanced thick-walled low-density area in the lateral segment of the liver, and abdominal ultrasonography demonstrated a 75mm anechoic lesion with hypoechoic sediment. The lesion was therefore diagnosed as an infected liver cyst, and percutaneous transhepatic liver cyst aspiration was performed under ultrasonic guidance. Milky sticky fluid was obtained from the cyst. Gram's staining for the drainage fluid showed neutrophilic infiltration and no bacteria. The patient's body temperature returned to normal the following day. Inflammation-related laboratory data decreased, and ultrasonography showed a reduction of the cyst. He was discharged on the sixth hospital day. No bacterium was cultured from the drainage fluid. Percutaneous transhepatic drainage using a catheter is generally performed for the infected liver cyst. In our patient, however, percutaneous transhepatic liver cyst aspiration, which was less invasive, was effective.
A 60-year-old woman driving a car was involved in a traffic accident. She consumed a large amount of food just before the accident. Her car collided with an oncoming car, and she was wearing a seatbelt. On arrival at the emergency room, she was fully conscious and no bruising was evident on any part of her body. CT imaging revealed no evidence of pneumothorax, pulmonary contusion, intraabdominal bleeding, or pneumoperitoneum, and therefore we began conservative management. Three hours after arrival, however, she vomited a small quantity of blood. We therefore conducted a plain abdominal CT. This revealed a region of high absorption in the stomach, and leakage of contrast medium from the lesser curvature of the stomach was suspected. Emergency endoscopy revealed laceration of the mucosa at the lesser curvature, and the torn mucosa was closed with a clip. Gastric rupture due to blunt abdominal trauma is rare. In this case, the rapid deceleration was considered to be one of the causes of the laceration. We report this case with considerations on the mechanism of damage to the gastric mucosa.
The patient was a 63-year-old woman who underwent a pancreatoduodenectomy with reconstruction with the modified Child's method for bile duct cancer in August 2007. She was admitted for melena in September 2008. Laboratory examination showed a hemoglobin level of 6.7g/dL. Abdominal enhanced CT showed severe portal vein stenosis, the mass being located behind the superior mesenteric vein and the portal vein, and a strongly stained bile duct. From these findings, the patient was diagnosed as having recurrence of bile duct cancer, and hepatopetal collaterals resulting from portal hypertension was suspected as the cause of the melena. Gastrointestinal endoscopy revealed small amounts of clotting blood in the jejunum. Through further examination of the jejunum, a small exposed vessel with oozing was detected in the choledochojejunostomy. Since the melena was considered as hemorrhage from choledochojejunostomy varices fed by hepatopetal collaterals, an expandable metallic stent was placed at the portal vein stenotic lesion. Portography after stent placement revealed the disappearance of the collaterals. After the treatment, the patient underwent chemotherapy, and no further episodes of gastrointestinal hemorrhage have occurred.
22 year-old male presented to our emergency department with abdominal pain and nausea. The abdominal CT scan revealed signs of a small bowel obstruction and the diverticulum at the terminal ileum. An emergency operation showed Meckel's diverticulum filled with ingested food, which had caused mechanical obstruction of the small bowel. Partial resection of the small bowel was performed. We could not find the any inflammatory sign in the resected tissue. Conventionally, bowel obstruction caused by Meckel's diverticulum is usually classified as described by Rutherford et al. in 1966. In our case, however, the dietary bowel obstruction caused by Meckel's diverticulum is not listed in this classification. Our cases is therefore a comparatively rare mechanism of bowel obstruction caused by Meckel's diverticulum.
We experienced a case of adult type intussusception induced by advanced type 1 cecal cancer. A 79-year-old man with hydrocephalus was admitted to the department of neurosurgery for a V-P shunt operation and he suddenly had left hypochondrialgia. A movable elastic hard tumor of the size of a fist was palpable on his left hypochondrial abdomen, and the abdominal X-ray examination exhibited a niveau. The abdominal ultrasound and CT examinations revealed that a solid tumor of 6cm in diameter was in the transverse colon with intussusception. We therefore diagnosed the patient as having intussusception with the ileus and carried out an emergency operation. The intraoperative findings showed that the cecum and the ascending colon had invaginated into the transverse colon induced by the intestinal tumor, and the terminal ileum and the ascending colon were resected with the intestinal tumor. Pathological findings finally diagnosed the intestinal tumor as advanced type 1 cecal cancer.
We report on a patient with hemophilia A who was re-admitted with intra-abdominal bleeding on the fifth day after an appendectomy, underwent emergency surgery, and achieved hemostasis. A 27-year-old man was referred from another hospital with a diagnosis of acute appendicitis. He was diagnosed as having abscess-forming appendicitis based on an abdominal CT scan, and was treated conservatively with antibiotics. Two months later, he underwent an elective laparoscopic appendectomy. He received factor VIII products pre-and postoperatively, was discharged with good symptomatic relief on the fifth postoperative day, but was readmitted as an emergency because of right lower abdominal pain on the same day. Since an abdominal CT scan showed massive ascites and the extravascular leakage of contrast medium, we performed an emergency laparotomy, identified arterial bleeding from the mesoappendiceal stump, and stopped the bleeding. He received factor VIII products again before and after surgery, and was discharged with good symptomatic relief. The present case suggests the importance of the choice of surgical procedure and device, taking adequate hemostatic measures, administering appropriate factor VIII products, and following-up patients for a specified period of time in their surgical treatment and postoperative management.