We retrospectively reviewed 58 patients who had undergone surgery at our institute for small intestinal and mesenteric injuries caused by abdominal trauma between January 1997 and December 2007. 47 men and 11 women were examined, ranging in age from 18 to 81 years (average 51 yrs). Shock on admission was present in 39.7% of the patients and generalized abdominal tenderness in 60.3%. Abdominal ultrasonography was positive for fluid in 46/58 cases (79.3%). Computed tomography was positive for fluid in 46/57 cases (80.7%), and for free air in 20/47 cases (35.1%). It has been suggested that small intestinal and mesenteric injuries were difficult to diagnose, however in our study, computed tomography was helpful to diagnose small intestinal and mesenteric injuries. In some studies, a delay in the diagnosis of small intestinal and mesenteric injuries resulted in clinical increases in hospital stay and ICU length of stay, morbidity and mortality. Our univariate analysis concluded that early diagnosis was not associated with morbidity and mortality. We suggested that low platelet counts was one of the predictive indicators regarding the mortality rate of small intestinal and mesenteric injuries.

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[Methods] We analyzed DPC data provided by 144 hospitals, and included patients with acute cholecystitis who were discharged from those hospitals between April 2004 and September 2009. We examined patient characteristics (age, sex, and complications), process of care during hospitalization (choice and timing of surgery), patient outcome (mortality rate), and medical resource utilization (length of hospital stay and medical charges). ICD-10 codes were used to identify patients in the database who received hospital treatment for acute cholecystitis. We identified all hospital treatments for any patients with multiple hospitalizations, as well as the types and timing of surgeries (cholecystectomy and percutaneous drainage). To examine changes in medical care over time, patients were divided into 3 groups based on the time of discharge from the last hospitalization : (i) from April, 2004 to March, 2006, (ii) from April, 2006 to March, 2008, and (iii) from April, 2008 to September, 2009. Patient characteristics, choice and timing of surgery, whether or not drainage was performed, and mortality rates were compared across the three groups. [Results and Discussion] The mean age of patients was 66 years, and slightly over half of them were male. More than 80% of patients with acute cholecystitis had a single hospitalization for medical treatment, and approximately 30% of them did not undergo surgical treatment. Thirty to 40% of surgical cases underwent cholecystectomy within two days of hospitalization, while half of them received cholecystectomy 5 or more days after hospitalization. The mortality rate for surgical cases was low (0.2～0.5%), yet the overall mortality rate increased over time, reaching 2.0% between 2008 and 2009. Patient age, comorbidity scores, and coexisting biliary tract malignancies increased over time. However, when adjusted for hospitals, no changes were observed in the mortality rate. The frequency of laparoscopic surgery and surgery performed within 2 days of the initial hospitalization increased over time. No significant changes were observed in the frequency of those who underwent percutaneous drainage prior to surgery. The number of cases with a single hospitalization significantly increased while those with two hospitalizations decreased. No changes were observed in the mortality rate for surgery cases or in total medical charges over time, but the total length of hospital stay for surgical cases between 2008 and 2009 shortened by approximately 2 days compared to the period between 2006 and 2007. Careful consideration is needed to define whether these results are in fact a result of the implementation of the Guidelines. Using administrative data facilitates relatively easy monitoring of treatment patterns and an examination of patient outcome such as mortality rate and readmission rate, and medical resource consumption such as length of stay and medical charges. Future studies which combine and analyze this type of data with detailed clinical data such as disease severity could be applied to monitor the quality of medical care.

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We retrospectively investigated the effects of guidelines when treating acute cholecystitis and cholangitis, by comparing results before and after the guidelines were established. Between October 2002 and September, 2008, 125 patients with acute cholangitis or/and cholecystitis underwent treatment in our institution. In patients with acute cholecystitis, a decrease in the number of days could be seen in the following : period from drainage to operation (11→2 days, P= 0.00015), period for referral from physician to surgeon (23→2 days, P=0.019), period from onset to operation (14→4 days, P=0.00078), postoperative hospital stay (10→6.5 days, P=0.00078), total hospital stay (25→9.5 days, P=0.0044), in addition to an increase in the early cholecystectomy rate (15→50%, P=0.00061). In patients with acute cholangitis, an increase in drainage rate (44→89%, P=0.0044) was found, and cases successfully treated endoscopically resulted in a shorter hospital stay (41→15.5 days, P=0.045). Suitable therapies were promptly performed according to the guidelines, which shortened the hospital stay for patients with acute cholangitis and cholecystitis.

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The Japanese Evidence-based Guidelines for Acute Cholangitis and Cholecystitis recommend early laparoscopic cholecystectomy (LC). Emergency cholecystectomy cases for 11 years (from 1998 January to 2008 December) were reviewed retrospectively and were divided into the early part (from 1998 January to 2005 December) and the latter part (from 2006 January to 2008 December). The total number of urgent cholecystectomy cases was 85 cases, 4.6 cases on average in a year in the early part and 16 cases on average in a year in the latter part. The duration from the onset to operation was shortened (early, 2.5 to latter, 2.0 days), the complication rate decreased (early, 10.8% to latter, 8.3%), the conversion rate of LC decreased (early, 21.4% to latter, 6.9%). There were significant differences concerning blood loss and postoperative hospital stay. Blood loss decreased, 46 g for LC from 246 g for open cholecystectomy (OC) in the latter part (p<0.0001). The postoperative hospital stay was shortened to 6.8 days with of LC from 11.7 days with OC (p<0.0001). There was no significant difference about blood loss, operating time and postoperative hospital stay for the comparison between emergency and delayed LCs in the latter part. Consequently, we propose recommending that early LC should be performed as much as possible for acute cholecystitis..

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In the clinical guidelines for the management of acute cholangitis and cholecystitis issued in 2005 and 2007, emergency cholecystectomy, preferably laparoscopic, is recommended for cases of acute cholecystitis which do not improve with primary care or which are estimated as medium stage or above. In our department, cholecystectomy was undertaken for 55 cases from January 2006 to December 2008. In this series, no open surgery, conversion to open, or preoperative biliary drainage was found. The retrospective inspection of our clinical data from operative treatment for acute cholecystitis revealed that laparoscopic cholecystectomy undertaken from the 5th to the 10th day results in a good clinical course, as well as within 4 days after onset of acute cholecystitis. In spite of, and in addition to the recommendation in the guidelines that cholecystectomy should be performed within 72 to 96 hours after the onset of acute cholecystitis, surgery over 96 hours can also result in a good clinical course.

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The aim of this retrospective study was to evaluate the influence on the management of patients with acute cholecystitis by the Japanese guidelines. One hundred and sixteen records of patients admitted due to acute calculus cholecystitis and had undergone laparoscopic cholecystectomy (LC) were collected between January 2003 and September 2009. After the issue of the guidelines, the strategies for the management of acute cholecystitis were changed from elective LC to early LC in our institution. The mean length of hospital stay before LC became shorter (16.8 days in 2003~2004 VS 5.0 days in 2008~2009). Of the 116 patients, 23 (19.8%) underwent early LC and 96 (80.1%) underwent delayed LC. There was no significant difference in the conversion rates (early, 0% VS delayed, 3.2%), or postoperative complications (early, 4.3% VS delayed, 5.3%). However, the early group had a shorter hospital stay. Despite these advantages, early LC is not the most common treatment for acute cholecystitis in clinical practice.

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There are many differences between the Japanese Evidenced-Based Guidelines for acute cholangitis and cholecystitis and the International clinical guidelines for acute cholangitis and cholecystitis (‘Tokyo Guidelines’). The present study examines the differences of utility of both guidelines based on actual cases. The clinical records of 60 patients having a final clinical diagnosis of acute cholangitis and 80 patients having a final clinical diagnosis of acute cholecystitis before publication of the guidelines were retrospectively examined. On the acute cholangitis, the Japanese Guideline's diagnostic criteria were met by 91.7% patients above the suspected diagnosis. On the other hand, under the Tokyo Guideline's diagnostic criteria 75.0% met the criteria to be above the suspected diagnosis. Regarding the severity index, 9.1% of the patients were classed as mild, 87.3% as moderate, and 3.6% as severe based on the Japanese guideline. Based on the Tokyo Guidelines, 80.0% of the patients were classed as mild, 4.4% as moderate, and 15.6% as severe. For acute cholecystitis, under the Japanese Guideline's 87.5% of patients met the diagnostic criteria above the suspected diagnosis, compared with 85% who met the diagnostic criteria above the definite diagnosis under the Tokyo Guidelines. As for the severity index, 28.6% of the patients were classed as mild, 48.6% as moderate, and 22.8% as severe based on the Japanese guideline. Based on the Tokyo Guidelines, 48.5% of patients were classed as mild, 39.7% as moderate, and 11.8% as severe.

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In this review, we mention the process for establishing the severity assessment of acute cholangitis and also indicate the dilemma about the severity assessment. The criteria for severity assessment of acute cholangitis consist of poor prognostic factors and the factors associated with vital-organ dysfunction. Those are the bodies of evidence that have already been reported in the literature, and are also the factors as a consensus formed by experts in agreement. Acute pulmonary dysfunction is known as acute lung injury (ALI) and adult respiratory distress syndrome (ARDS), which are associated with high mortality in SIRS and severe sepsis patients. They are frequently accompanied with acute cholangitis, however, the incidence and the mortality of acute cholangitis patients who are complicated with ALI/ARDS have not been well elucidated. We previously reported that dysfunctions of the liver, kidneys, and lungs were significantly correlated with mortality, and that the number of dysfunctional organs had a strong correlation with mortality in acute cholangitis patients in a critically ill condition. From such a situation, although acute pulmonary dysfunction has not been adopted as one of the criteria for the severity assessment, we imply that it can be a factor which should be included.

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This report presents a case of the enteric fistulas in the open abdomen. An 18-year-old male was admitted to the emergency room following a traffic accident. Computed tomography showed abdominal free air and the rupture of the rectus abdominis muscle. He was diagnosed as having a perforation of the sigmoid colon, and Hartman's operation was therefore performed. The wound became an open abdomen on postoperative day (POD) 20. The open abdomen developed an enteric fistula on POD 28. Vacuum Assisted Closure (VAC) was initiated on POD 35. VAC was markedly effective, and oral ingestion could be administered with the stomal care on POD 70. The fistula was resected and the colostomy was closed on POD 214. VAC has been useful for the conservative treatment of the open abdomen and the open abdomen with an enteric fistula.

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A 63-year-old female was taken to a neighboring hospital by ambulance due to severe abdominal pain. As her abdominal computed tomography revealed free air and ascites, she was soon transferred to our hospital with the diagnosis of diffuse peritonitis. Emergency laparotomy showed obstruction of the upper jejunum due to invasion of the pancreatic body cancer and rupture of the posterior wall of the stomach. There were multiple small nodules on the peritoneum, suggesting carcinomatous peritonitis due to advanced pancreatic cancer. As one of the possible causes of gastric rupture, increased intragastric pressure due to invasion of the pancreatic cancer to the upper jejunum was suspected. The exact cause, however, was not determined. This type of gastric rupture is very rare, and we report herein on the case with some discussion.

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We report herein on three cases of cecal volvulus. In case 1, a 57-year-old woman who was confined to bed with epilepsy was admitted for abdominal distension. Abdominal CT showed dilated cecum, suggesting cecal volvulus. On laparotomy, the cecum was rotated 360 degrees clockwise. Cecopexy between the cecum and parietal peritoneum was performed following detorsion of the volvulus. In case 2, a 79-year-old woman who was confined to bed with cerebral infarction was admitted for vomiting. Abdominal CT showed dilated intestine and sudden loss of the ascending colon, suggesting cecal volvulus. On laparotomy, the cecum was rotated 360 degrees counterclockwise. Cecopexy between the cecum and parietal peritoneum was performed following detorsion of the volvulus. In case 3, a 35-year-old woman was admitted for vomiting. A few weeks previously, she had been involved in a traffic accident. An abdominal X-ray showed a dilated colon. A diagnosis of strangulated ileus was made and an emergency operation was performed. On laparotomy, the cecum was rotated 540 degrees clockwise. Hemorrhagic necrosis was present, extending from the ileal end to the ascending colon. An ileocecal resection was performed. Cecal volvulus is relatively uncommon. If cecal volvulus is suspected, it is important to perform surgical treatment as soon as possible.

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A 73-year-old female visited a local clinic with chief complaints of abdominal pain, bloating and anorexia. Abdominal X-rays showed free air. She visited our hospital with a suspected intestinal perforation. Her history revealed drugs prescribed for diabetes mellitus and a psychological illness related to traumatic subarachnoid hemorrhage (SAH). Abdominal computed tomography showed intra-abdominal free air and cystic emphysema. An emergency operation was performed because of the aggravating abdominal pain and the suspicion of intestinal perforation. No recognizable perforation was observed in the gut. Multiple emphysematous changes were apparent in the subserous structure of the small intestine and ascending colon. We diagnosed pneumatosisi cystoideas intestinalis (PCI). The postoperative course was uneventful and the patient was discharged on the postoperative day 2. She was conscious of abdominal distention a month after the operation. The abdominal X-ray again showed free air. The recurrence of PCI was diagnosed. She was admitted. Her condition improved with conservative therapy, which included fasting and oxygen inhalation. Few reports in the relevant literature describe PCI accompanied by intraperitoneal free air in patients with psychological disorders. However, it is prone to recurrence, and it is therefore necessary to adopt a good wait-and-see approach. We report the details of this case of PCI with intra-abdominal free air in a patient with psychological illness and discuss the case in light of the related literature.

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A 67-year-old man complaining of severe diarrhea and abdominal pain was admitted to our hospital. He had a history of undergoing a distal gastrectomy ten years previously. An operation was performed under the diagnosis of large bowel perforation, and a perforation of the sigmoid colon was intraoperatively found. Despite intensive care, he died of sepsis and type A Clostridium perfringens was detected from his blood and the perforated colon. C. perfringens infection accompanied by gastrointestinal perforation is extremely rare. The type A C. perfringens has sometimes caused sitotoxism but its prognosis is usually good. On the other hand, C. perfringens septicemia is fatal and causes severe hemolysis and disseminated intravascular coagulation. C. perfringens infection should be considered in the case of acute abdomen with severe diarrhea for the early initiation of active treatment and for the prevention of C. perfringens-mediated septicemia.

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A 72-year-old woman was admitted to the hospital because of vomiting and abdominal pain. She had been diagnosed as having gallstones 20 years earlier. Plain abdominal X-ray images showed dilatation of the small intestine, and abdominal computed tomography (CT) showed a stone in the small intestine and pneumobilia. Upper gastrointestinal endoscopy revealed a fistula in the anterior wall of the duodenal bulb. We diagnosed it as a gallstone ileus and a cholecystoduodenal fistula. We tried conservative management in expectation of excretion of the gallstone, but the abdominal pain became worse. Laparoscopy-assisted simple enterolithotomy was performed on the day after the admission.

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Non-occlusive mesenteric ischemia (NOMI) due to hemorrhagic shock caused by trauma is a rare condition. We report herein on a case of necrotic intestinal perforation in a 69-year-old woman following a traffic accident. We performed emergency laparotomy because of hemorrhagic shock due to injury of the right kidney and inferior vena cava, extracted the kidney and restored the inferior vena cava. The patient was in profound shock and manual blockade of the abdominal aorta was conducted to control the bleeding. During this surgery, we confirmed that the intestine and mesenterium were undamaged. We then performed transcatheter arterial embolization for the bleeding of the lumbar vertebrae bone fracture, after which the patient recovered well. On postoperative day 9 we performed a re-operation because the solution in the bowels was flowing out from an abdominal drain. We found intestinal perforation and resected the terminal ileum and ascending colon which was necrotized, and performed anastomosis. Pathologically, evidence was seen of ischemic intestinal necrosis without vascular occlusion. It seemed that the enteric avascular necrosis had been caused by the perioperative profound shock.

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A 55-year-old female outpatient with type 1 diabetes was admitted to the hospital due to impaired consciousness as she had discontinued insulin injection by herself 3 days earlier. Her blood test revealed that she had diabetic ketoacidosis, and treatment was initiated. Urgent CT scanning was conducted due to a fever of 38°C and abdominal distension on the day following hospitalization. Ascites, portal venous gas, and extensive intestinal emphysema were observed ; she was diagnosed as having acute peritonitis because of intestinal tract necrosis, which later required emergency surgery. During laparotomy, segmental necrosis was observed at about 200 cm of the terminal ileum, and the sigmoid colon was in an ischemic condition, having turned into dark purple in color. The patient's pulsation was palpable in the superior mesenteric artery and inferior mesenteric artery from the stem through the distal part. For that reason, she was diagnosed as having nonocclusive mesenteric ischemia (NOMI) ; the necrotized intestinal tract was resected and a colostomy was performed in the descending colon. NOMI, despite demonstrating no organic occlusion in the major artery, is a disease with a poor prognosis inducing ischemia or necrosis in the intestinal tract. In our case, it can be considered that marked dehydration and hyperosmosis-caused hyperglycemia were the precipitating factors leading to the occurrence of NOMI.

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Rectal foreign bodies occur mainly due to sexual preference or accidents. A 50-year-old man was admitted for a broken glass bottle in his rectum. Abdominal X-ray examination showed the a broken bottle in the pelvic space and 3D computed tomography indicated the detailed situation of the broken parts of the bottle. glass. We conducted an emergency laparotomy because removal by the anal approach was difficult. The broken bottle was removed using an automatic anastomotic device by retrogression from the Rectosigmoid When we try to remove a rectal foreign body, we should confirm its form and broken pattern using some imaging examinations and should choose the most appropriate method.

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The lymphangioma is the proliferation of lymph vessels in a limited part of the body. Most of these occur in the cervix of the infant and very few in the intestinal tract of the adult. A 72-year-old man was admitted to our hospital because of his lower abdominal pain, flatulence and dysuria in July 2008. An abdominal CT examination revealed a 97×78 cm multi-cystic tumor inside his pelvis, which was pressing on his ileum. MRI showed that a fluid-fluid level had formed inside. We diagnosed the condition as ileus caused by an ileal mesenteric tumor, and performed a resection on his small intestine. Later, our pathological examination revealed that the tumor was a lymphangioma. We report herein on this unusual case, adding a review of the relevant literature.

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A 67-year-old male was treated with chemotherapy and radiation therapy for lung small cell carcinoma and was under follow-up on an outpatient basis in the Internal Medicine department of our hospital. He reported right lower abdominal mass and was admitted to our hospital. Abdominal CT and FDG-PET was performed and acute appendicitis due to appendicular metastasis was suggested because of high FDG accumulation in the appendix and an operation was thus carried out. The tip of the appendix was perforated. Histopathologically, the appendicular metastasis had occurred from the lung small cell carcinoma. Acute appendicitis due to appendicular metastasis is characterized by difficulty in the preoperative differential diagnosis and rapid progression of inflammation, suggesting the need to rapidly decide on surgery. FDG-PET may be helpful for making the diagnosis and deciding on the operative indication for this disease.

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A 62-year-old male was hospitalized with a diagnosis of intestinal obstruction. No abnormalities were observed in endoscopic examinations of the upper and lower gastrointestinal tracts. An ileus tube was inserted to reduce the pressure in the intestinal tract and a contrast study was conducted. An image of stenosis was observed in the ileum, leading to a diagnosis of stenosis of the small intestine, and laparoscopic surgery was performed. In the perioperative findings, cord-like fibrous adhesions had formed between the small intestine and the pelvic and abdominal walls, and parts of the small intestine had adhered to each other in a loop at a section approximately 50 cm from the terminal ileum. After separating the adhesion from the abdominal wall, the skin incision in the umbilical region was extended to 3 cm and the looped adhesion of the small intestine was exposed outside the abdominal cavity, resected and anastomosed. A histopathological examination revealed multinucleate giant cells in penetrating the ulcer tissues but no other distinct pathological findings were observed and the patient was diagnosed as having a simple ulcer of the small intestine. A simple ulcer of the small intestine is a rare disease and diagnosis is often difficult. It was believed that in cases in which an intestinal obstruction or a disease of the small intestine of unknown cause is suspected, laparoscopic surgery is an extremely useful method for both obtaining a diagnosis and providing appropriate treatment.

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