From January 2000 to September 2008 we analyzed the clinical features of 68 patients attending our hospital who had undergone surgery for small intestinal perforations. The nature of the rupture in 51 patients was endogenous, and endogenous in the other 17. Endogenous ruptures included ileus in 16 cases, tumors in 7 cases, of unknown origin in 5 cases, and blunt trauma in 23 cases. Exogenous rupture included iatrogenic in 5, foreign body digestion in 5, and penetrating trauma in 7. Postoperative complications occurred significantly more in the endogenous rupture cases than in the exogenous ones. There were 4 hospital deaths, which were in all endogenous cases. The high complication rate and a certain proportion of poor prognosis in cases of endogenous rupture necessitate imminent treatment as soon as an endogenous perforation is suspected.

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Splenectomy via emergency laparotomy has been a common procedure for traumatic splenic injury. With the recent improvements of imaging methods together with advances in angiography and IVR, non-operative management is being performed more frequently. The choice of non-operative management, however, causes morbidity more frequently than in the case of operative therapy. A retrospective review of 75 trauma patients with splenic injury admitted between January 1998 and December 2007 was performed. In the initial treatment, 42 patients (56%) were treated with non-operative management, and 33 patients (44%) underwent emergency laparotomy. No difference in mortality was recognized in either management method. No guidelines exist for non-operative management, so operative management or non-operative management should be selected based on the definite criteria of each medical center.

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In March 2009, an academic committee was founded within the Japanese Society of Abdominal Emergency Medicine to design educational courses for young members. Over half of Japanese medical students choose courses to become physicians of the functional medicines, such as orthopedics, ophthalmology and so on, where there is not usually any life-threatening conditions demanding life-saving procedures, for the sake of avoiding legal issues and an unstable daily life. It is necessary to establish training systems to develop and encourage clinicians to enter such fields as emergency primary care and emergency radiology. Furthermore, socio-economic recognition is necessary.

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The basics of the surgical training in the field of abdominal emergency have not changed for Ba long time and this remains true even today. However, learning endoscopic surgery is presently indispensable. Training in general surgery is essential to nurture first-class experts in acute abdominal surgery, and hospitals have to prepare the environment for severe and simultaneous training of both open and endoscopic surgery. Early exposure as a primary surgeon is effective in the development of an expert surgeon. The surgical training system in the Kameda Medical Center is reported in this paper.

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Since the Japanese emergency medical service is in danger of collapse as a result of changes in social conditions and medical reforms, drastic reform and restructuring of the emergency care system are necessary. One of the roles of the Advanced Emergency and Critical Care Center in abdominal emergency practice is the careful training of acute care surgeons, who are emergency care specialists, and of surgical emergency physicians. The training curriculum for the acute care surgeon aims at accomplishing a total care concept from the initial treatment to definitive care and intensive care. In addition, determining the degree of emergencies and the severity of patients appropriately at the pre-hospital scene is crucial, and assigning patients to an appropriate method of transport to the most appropriate hospital is essential. In order to achieve this, we need to introduce the helicopter and car emergency medical service system and the emergency medical supporting intelligent system. As a result, acute treatment surgeons can experience many cases, which is useful as a means of improving their skills and knowledge. This system is also beneficial to patients, because it makes it possible to provide the best medical care in the most suitable institution.

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The organization of medical office personnel is changing considerably as a result of the introduction of an initial clinical training system and a decrease in the number of post-graduate residents. Regarding changes in the organization of departmental personnel, the total number of personnel at our institution has decreased by three despite an increase in the number of surgical procedures by about 100 procedures annually. This situation places a greater burden on third-year to fifth-year post-graduate physicians and young physicians, and education and instruction in abdominal emergency medicine is occurring within this environment. At work groups for personnel attending initial training courses, problems such as 65% of the attendants being overworked and 35% complaining of a shortage of manpower have been noted. Thus, the quantitative and qualitative burdens on attendants are considerable. Education and training in the field of abdominal emergency medicine are characterized by the provision of education and training while providing appropriate treatment in the midst of various restrictions. Examinations and treatments performed during ordinary operating hours frequently have adequate manpower and equipment available, and education and training can be implemented smoothly. However, accommodations and training performed outside of ordinary operating hours present greater difficulties. Young physicians must be exposed to and experience as many cases as possible during the course of their education. Attendants are required to provide advice and guidance so that initial treatments are provided without overlooking diseases that may determine the subsequent prognosis. It is therefore important to implement education while providing the best care. It is also necessary for attendants to enthusiastically train their younger subordinates with compassion and understanding, and the attendants themselves should also be evaluated. Attendants must be able to provide guidance and counseling to younger physicians regarding diseases that must not be overlooked during the course of abdominal emergency medicine.

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The numbers of surgeons are decreasing especially in rural areas in Japan, and this has become a serious problem. As a result, abdominal emergencies have all been directed to the core hospitals, including University Hospitals, which is threatening the accomplishment of advanced or sophisticated operations in these hospitals. Surgeons must receive patients with abdominal emergencies during daily surgical practices. Even should surgeons with some specialties like that of The Japanese Society of Gastroenterological Surgery or Cardiovascular Surgery be integrated to high volume centers, some fixed numbers of general surgeons are necessary in individual general hospitals in rural areas. For this purpose the numbers of certified general surgeons by Japan Surgical Society is supposed to be optimum at present, however, allocation should be designed. Establishment of the training system for surgeons is another important issue. To keep the quality and the safety of surgery, not only the numbers of operations experienced but the training process should be strictly programmed just as is the case in the training system for airline pilots. Essential reasons for the decrease in candidates for surgeons are the low income in relation to the degree of overwork and the associated high risk. Above all, most important matter is the deep appreciation of affected patients since emergencies are a dramatic way to raise young surgeons' morale.

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Making an accurate and prompt diagnosis for patients presenting with acute abdomen needs not only knowledge but adequate experience. To provide practice with an appropriate degree of quality for patients is important, but such practice in the case of young doctors under training may include some degree of intrinsic risk. On the other hand, if the risk is always avoided by these young doctors being fully under the control of experienced and well-trained doctors, the problematic condition arises whereby the young doctors may lose the correct condition of self-assessment and become overconfident in their own ability. In the present article the authors suggest a system and method of instruction which we believe could be optimum to train young doctors based on our experience in training medical staff regarding the acute abdomen.

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A 63-year-old woman with no previous relevant history was seen in the emergency room because of left lower abdominal pain and vomiting. Abdominal CT showed a small amount of ascites, dilatation of the sigmoid colon and small intestine, concentration of the mesenterium, and a closed loop of the small intestine with thickened wall. We suspected a strangulated ileus, and performed an emergency operation. On laparotomy, an ileosigmoid knot was found to have formed, resulting in strangulation of the small intestine. Subsequently, the knot was carefully released, followed by resection of the necrotic small intestine. The postoperative clinical course was uneventful. The ileosigmoid knot is a relatively rare condition, and the preoperative diagnosis is difficult. When we examined the MDCT images retrospectively, they showed the characteristic finding that the knot itself was described. MDCT may be useful for the preoperative diagnosis of this difficult to diagnose condition.

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A 91-year-old woman was admitted for pneumonia and heart failure to a local hospital and was transferred to our hospital because of vomiting. Computed tomography (CT) showed a high-density lesion in the right lower abdomen. Based on a diagnosis of pit-induced ileus, we started to treat the patient with an ileus tube. Three days later, abdominal CT showed a plum pit at almost the same site. After recovery from the ileus, we operated and found a tumor 40 cm oral from the ileocecal valve, containing a plum pit. We resected the small intestine along with the hard atrophied appendix. Pathological examination revealed that both the ileal tumor and the appendix were carcinoid. This is the first case of a foreign body-induced ileus occurring with an ileal carcinoid tumor.

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We experienced three cases of sigmoid volvulus. Case 1 : A 66-year-old man was admitted with a chief complaint of abdominal pain. According to findings of the abdominal computed tomography, the diagnosis of sigmoid volvulus and strangulated ileus was made. An emergency sigmoidectomy and colostomy were performed. Case 2 : A 75-year-old man was referred to our department for a diagnosis of ileus. On further examination, the diagnosis of sigmoid volvulus was made. The colon might not have been strangulated. An endoscopic volvulus detortion was performed successfully. Case 3 : A 66-year-old woman was referred to our department for a diagnosis of the recurrent sigmoid volvulus. She had undergone successful treatment with endoscopy. Therefore, as volvulus had recurred three times in the short term, an elective sigmoidectomy was performed. Management of the method of treatment in each case of sigmoid volvulus is very significant. Even when the initial non-operative detortion can be successfully accomplished, an elective operation may be the most effective for those cases with a mechanical factor or recurrence.

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A 63-year-old woman visited our hospital with upper abdominal pain and jaundice. Abdominal CT examination revealed a gallstone, cholecystitis and a thrombus in the left branch of the portal vein, which had most probably been induced by cholecystitis. Therefore, to remove the focus of infection, an emergency laparoscopic cholecystectomy was performed one day after hospitalization. Anticoagulant therapy was administered immediately after surgery, and the extension of the thrombus was not observed. Heparin 5,000U/day) was given intravenously from the day of surgery for three days. Warfarin (2mg/day) was also administered after surgery. Patient's postoperative course was uneventful, and the patient was discharged on the 9th day after surgery. It is considered that both controlling the focus of infection and administering anticoagulant therapy are important in the treatment of portal vein thrombosis associated with biliary tract infection.

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We present a case of ischemic colitis of the anastomotic intestine of the anal-side developed approximately two years after laparoscopic sigmoidectomy. A 54 year old woman, who had a history of hyperlipidemia and was on oral drug therapy, presented with the chief complaint of lower abdominal pain and constipation. A tendency toward constipation and difficulty with bowel movement had developed one month previopusly. After the onset of lower abdominal pain, the patient was admitted for a detailed examination and treatment. Colonoscopy revealed an anastomotic site approximately 18cm from the anal verge and circumferential mucosal edema with poor distensibility measuring about 8cm in the anal-side intestine, yielding a diagnosis of ischemic colitis. Following conservative treatment, the patient returned to a normal diet after the endoscopy at eight weeks post admission with improvement in intestinal narrowing, and was discharged on Week 9. For left colon cancer patients with hypertension, diabetes, or hyperlipidemia, among other vascular factors, it is important to monitor any postoperative rise in intestinal pressure associated with any abnormal bowel movement after surgery.

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A 65-year-old male with fever and abdominal pain was diagnosed as having septic shock, disseminated intravascular coagulation and multiple organ failure due to choledocholithiasis and acute obstructive suppurative cholangitis. He was, however successfully treated as the result of intensive treatment. He was transferred to our hospital to undergo therapeutic ERCP which showed the presence of a common bile duct stone, measuring 1.5cm in diameter. Endoscopic sphincterotomy (EST) was performed and the stone was removed using a mechanical lithotripter. On the day after EST, the patient developed fever and abdominal pain with subcutaneous emphysema. CT showed abdominal free air and retroperitoneal emphysema behind the duodenum. An emergency operation was thus performed based on a diagnosis of duodenal perforation and peritonitis after EST. We cut the duodenum open and detected the common bile duct which completely resected to the deep papilla of Vater. We performed a cholecystectomy and choledochojejunostomy. Forceful removal of a bile duct stone using a mechanical lithotripter might cause lower common bile duct injury.

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Transcatheter arterial embolization (TAE) of the bilateral internal iliac arteries is advantageous in controlling retroperitoneal massive hemorrhage associated with pelvic fractures. However, it has recently been reported that TAE of only the bilateral internal iliac arteries occasionally fails to stabilize a patient's hemodynamics. We report the case of a 70-year-old male with pelvic hemorrhage from an irregular sacral artery that was controlled by direct surgical ligation. He was admitted to our hospital following a road accident and was diagnosed as having thoracic abdominal, and sacral injuries. His anemia continued to worsen and hence a CT scan was performed the next day which suggested abdominal hemorrhage. Emergency angiography was performed and it revealed bleeding from the bilateral sacral, left iliopsoas, and median sacral arteries. Bleeding from the bilateral sacral and left iliopsoas arteries was successfully stopped with TAE. However, since the median sacral artery branches from the fifth lumbar artery, it was beyond the reach of the catheter. Therefore, an emergency laparotomy was performed and the injury in the artery was exposed and manually ligated. Hemostasis was obtained and the patient's recovery was excellent. Open surgical hemostasis should be considered in patients with severe pelvic fracture in whom bleeding cannot be controlled with TAE.

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We herein report a rare case of a 42-year-old man with acute necrotizing cholecystitis demonstrating anomalous drainage of the right posterior segmental branch of the bile duct into the gallbladder. The patient was admitted to our hospital with fatigue and pyrexia. Based on the findings of the abdominal CT scan, he was diagnosed as having acute necrotizing cholecystitis and underwent an emergency cholecystectomy. At the time of dissection of the gallbladder from its liver bed, bile leakage was seen from the liver bed. Cholangiography via the site of the bile leakage revealed the presence of the right posterior segmental branch of the bile duct. From these findings, we judged that the bile leakage in this case was associated with an anomalous drainage of the right posterior segmental branch into the gallbladder. Biliary reconstruction was achieved with a Roux-en-Y hepaticojejunostomy after the cholecystectomy. The patient's postoperative course was uneventful and he was discharged on the 21st day after surgery. He was well without clinical signs of cholangitis at a 9-month follow-up. Patients requiring urgent surgical treatment for biliary tract do not always undergo sufficient medical imaging investigations. Intraoperative cholangiography is essential when required to prevent unpredictable morbidity.

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An 80-year-old woman with abdominal pain and a sensation of distension feeling saw a doctor after three days from the start of the symptoms. Her previous medical history included an appendectomy. Under the diagnosis of incarceration of an abdominal incisional hernia, she was referred to our hospital for emergency surgery on the 4th day after the start of the symptoms. Contrast enhanced CT demonstrated prolapse of a part of the transverse colon with incarceration from a hernia orifice of 3 cm diameter, and inflammatory findings were confirmed around the area. The patient underwent midline laparotomy the same day. The mid portion of the transverse colon was incarcerated and necrosed within the hernial sac. We therefore performed a right hemicolectomy with debridement of the inside the hernia sac and simple closure of the hernia orifice. An open wound was created with a transverse incision on the right lower quadrant for subcutaneous drainage. In this severely infected case, to manage the patient's condition and the open wound, daily irrigation of the wound was repeatedly applied. The midline incision, however, was infected and disrupted. Therefore, daily irrigation was applied to the incision as well, which closed on the 47th postoperative day. No recurrence has been found in two years.

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Following alkali corrosive alkali ingestion, the stomach is usually protected by its acid content, however ingestion of a very large volume occasionally causes gastric necrosis and perforation. We present herein a 55-year-old female who drank a glass of alkaline detergent by mistake and visited our hospital. Upper gastrointestinal endoscopy revealed a black-colored corrosive change from the lower esophagus to the stomach, leading to a diagnosis of corrosive esophagitis and gastritis. After starting treatment including fasting and the administration of antibiotics and proton-pump inhibitors, the appearance of sudden hematemesis, lowered Hb levels and re-elevated inflammatory reactions were observed on day 11. Because it was difficult to control the bleeding and there was a possibility of a perforation, a laparotomy was performed the following day. Findings from the laparotomy revealed an accumulation of purulent ascites, thinning of a wide range of the stomach wall on the side of the greater curvature of the gastric corpus and a necrotizing lesion : the patient was in a state of impending gastric perforation. A total gastrectomy was performed with jejunal Roux-en-Y reconstruction.

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We report a case of an abdominal abscess caused by a fish bone penetrating the duodenum. A 74-year-old man was admitted to our hospital with upper abdominal pain. Abdominal CT revealed linear high density shadow in the 3rd portion of the duodenum. We considered this high density shadow to be a fish bone. We performed an emergency endoscopic examination and a fish bone was removed, following which we used antibiotics for conservative treatment. Abdominal pain was improved, but a high fever persisted. Repeated abdominal CT revealed an abdominal abscess as a new lesion close to the 3rd portion of the duodenum on the 5th postadmission day. We changed the antibiotics and continued treatment, but the fever persisited. We operated on the 10th day after admission. Intraoperatively we could find only the abscess, but we were unable to identify the penetration lesion of the duodenum. A drainage tube was placed in the abscess cavity, and the postoperative course was uneventful.

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This report presents two cases of hepatic portal venous gas (HPVG) that were successfully treated with conservative management. Case 1. A 36-year-old male was referred to our hospital because he had fallen into a nonketotic hyperglycemic coma. His abdomen was soft, flat and no muscle guarding was observed. Abdominal CT showed HPVG, pneumatosis cystoides intestinalis (PCI) and ascites. Both diagnostic paracentesis and an analysis of ascites analysis were performed to make a diagnosis. The ascites analysis of ascites indicated no risk of bowel necrosis to be present. The patient recovered without surgical intervention. The cause of HPVG was determined to be non-occlusive mesenteric ischemia (NOMI). Case 2. An 85-year-old female was referred to our hospital because of hematochezia. She present with lower abdominal pain. An abdominal CT showed HPVG and rectal tumor necrosis while colonoscopy revealed a rectal tumor. The cause of HPVG was determined to be tumor necrosis. HPVG is not always associated with a poor prognosis if no bowel necrosis is observed. In addition, in some cases of HPVG conservative therapy is also considered to be possible. As a result it is important to carefully consider the causes of HPVG in order to determine the optimal treatment for each individual patient.

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A 58-year-old male with a history of duodenal ulcer underwent pylorus-preserving pancreaticoduodenectomy (PPPD) under the diagnosis of IPMN. On the 27th postoperative day, he vomited a large volume of blood. An urgent upper gastrointestinal endoscopy did not reveal the source of hemorrhage. For identification of the bleeding point, arteriography was performed on an emergent basis. Arteriography via the common hepatic artery revealed extravasation, and super-selective arteriography showed extravasation from a branch of the gastroduodenal artery. Therefore, embolization of the artery was performed with a microcoil, which established hemostasis and restored hemodynamic stability. On the 7th day after arteriography, upper gastrointestinal endoscopy revealed no bleeding, but a part of the coil was exposed in the anterior wall of the bulbus, confirming that the hemorrhage occurred from the duodenal ulcer. As post-PPPD complications, hemorrhage caused mainly by pancreatic fistula, intraabdominal infection or anastomotic ulcer has been reported, while massive hemorrhage from an ulcer in the residual duodenum is rare. In cases undergoing PPPD, the operative procedure and postoperative treatment must be carefully selected, taking into consideration the occurrence of ulcer in the residual duodenum.

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