Superior mesenteric artery (SMA) embolisms are often difficult to diagnose and the treatment results have to date not been favorable, however some cases are occasionally seen in which surgical operations could be avoided. We examined the diagnosis and the treatments regarding the SMA embolism cases which we experienced at our institution. The subjects were six cases of SMA embolism which we had experienced over the past 10 years. Surgical intervention was indicated in five cases and resection of the intestinal tract for four cases. All four cases suffered from short-bowel syndrome but three cases from the four were discharged from hospital by concurrently undergoing home parenteral nutrition (HPN). The non-surgical case underwent angiography two hours after the onset, and the embolytic therapy was effective. SMA is a disease which is difficult to diagnose, and a surgical operation requires a large amount of resection of the intestinal tract, which has resulted in the short-bowel syndrome. However, there is a possibility of avoiding a surgical operation depending on the individual case and the time which has elapsed between onset and treatment.

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(Purpose) We clinically reviewed patients with obturator hernia who were treated in our hospital. (Subjects) The subjects were 11 patients who underwent surgery in our hospital between January 2006 and July 2009. (Results) The mean age was 82.5 years, and all patients were females. The mean body mass index was 19.1, and the mean frequency of delivery was 2.6. The Howship-Romberg sign was present in 6 of the 11 patients. All patients with an obturator hernia had the correct diagnosis with preoperative computed tomography. All patients underwent emergency operations, and 6 of the 11 patients underwent partial resection of the small intestine because of necrosis of the intestinal wall. All the patients were discharged or transferred to another hospital. (Conclusion) Almost all the patients with obturator hernia were slender females. A pelvic CT scan should be performed early, because their prognosis was affected by the time to diagnosis and critical treatment.

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【Purpose】 We report on our evaluation in twelve cases of obturator hernia in our hospital. 【Subjects and Methods】 The subjects were twelve patients who underwent an operation for obturator hernia in our hospital between April 2001 and August 2009. We divided these patients into two groups, namely the intestinal resection group and the non-intestinal resection group, and evaluated both groups for duration from onset, radiographic findings and so on. 【Result】 The average age of the patients was 83.5 years (73～93yr), and all patients were women. The average BMI was 17.6kg/m². The majority of the chief complaints was vomiting (7 cases 58.3%). The Howship-Romberg sign was observed in only three patients (25%). Preoperative CT scan revealed obturator hernia in nine patients. Preoperative duration from onset was 5～528hr (average 120hr). Emergency surgery was performed in all cases, and we tried the open method for eleven cases and the laparoscopic method for one case. The hernia hilus in four cases was closed with simple closure, and with mesh in eight cases. 【Conclusion】 Recently, early diagnosis and treatment of obturator hernia has become feasible. Therefore, minimally invasive surgery such as laparoscopic surgery might be desirable as the first choice of surgical treatment for obturator hernia in the future.

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Colorectal cancer obstruction is an oncologic emergency that had been treated with emergency surgery. However, decompression through the anus including a colonic stent (Expandable Metallic Stent : EMS) changed the conventional practice. Instead of a conventional ileus tube, through nose with poor effectiveness, the transanal decompression method (colonic EMS) has improved the treatment approach by avoiding emergency operations. It has given better operative results, improved the patients' QOL (quality of life) as well as allowing a higher QOL for the doctors and co-medical staff. It has been reported that colonic EMS has obtained a high clinical success rate of approximately 90% and minimal complication rate of approximately 5%. On the other hand we should note that there has been approximately 10% of migration and 10% of re-obstruction in the long term follow up. In the future, colonic EMS is considered to be the first choice in the treatment of obstructive colorectal cancer in Japan.

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The treatment for acute obstruction caused by left-sided colorectal carcinoma remains controversial in comparison with that for the right side. Several approaches have been performed to remove the colonic obstruction, including emergency surgery with intra-operative colonic lavage, elective surgery followed by preoperative intestinal decompression using a transanal drainage tube or metallic stent. However, emergency surgery is reported to be associated with a higher risk of mortality and morbidity, and the emergency operation without preoperative intestinal decompression should be avoided as much as possible. Although many surgeons have showed some effectiveness of preoperative intestinal decompression by transanal drainage tube before colonic resection, some severe complications such as ulcer formation or colonic perforation could occur while detaining placing the drainage tube. Control of the drainage tube with an appropriate procedure is necessary. New strategies, such as laparoscopic surgery followed by preoperative intestinal decompression, or an investigation of the oral side of the colon using CT-colonoscopy, are required and should be developed.

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We investigated a treatment strategy and follow-up for the patients with bowel perforation caused by obstructive colorectal cancer. The prognosis of these patients was compared with that of patients with bowel perforation caused by other diseases. From September 2001 to October 2008, an emergency operation for colorectal perforation was performed in 35 cases ; 8 cases were caused by obstructive colorectal cancer and 27 cases were associated with other diseases. In all the patients with cancer, a concomitant radical operation with lymph node dissection including resection of the perforated lesion was performed. There was no significant difference in the short-term mortality between two groups (25.0% in cancer cases and 22.2% in non-cancer related patients, p=0.87). In all 6 survivors among the cancer patients, chemotherapy was performed postoperatively. One patient with synchronous liver metastases died of disease progression 7 months postoperatively. Among the 5 patients who received adjuvant chemotherapy, 3 are alive free from recurrence of the disease, 1 died of brain/liver metastases, and 1 died of liver/lung metastases. No patients developed local or peritoneal recurrences. In durable cases, a radical operation with lymph node dissection and an adequate postoperative chemotherapy regimen should be considered in patients with bowel perforation caused by obstructive colorectal cancer.

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Pathophysiological characteristics and problems with treatment were analyzed in 30 cases of perforated colorectal cancer encountered during the past 18-year period. The age of patients ranged from 46 to 96 years (mean: 73.2 years). Twelve patients (40%) were elderly (over the age of 80). There was no bias in distribution of male and female patients, except for cases with specific features. The site of perforation in patients with colorectal cancer was the cancer-affected area in 12 cases and the area proximal to the cancer-affected area in 16 cases. In 4 of the latter 16 cases, perforation occurred in the distant colonic segment (a finding deserving close attention). There were 2 cases of iatrogenic perforation, associated with transanal ileus tube insertion in 1 case and with colorectal endoscopy in the other case. There were 2 cases with specific features: one case showing formation of a fistula contiguous to the cancer-affected area and the other case having a fistula contiguous to the urinary bladder. The size of the perforation was below 1 cm in most cases of perforation of the cancer-affected area, while it was larger (over 1 cm) in cases of perforation proximal to the cancer-affected area. Most of the latter cases had fecal peritonitis. Many of the cases complicated by fecal peritonitis died. When dealing with perforated colorectal cancer, it is advisable to select an operative procedure with primary emphasis laid on saving the life of the patient in an oncologic emergency, while taking into account the site of perforation, the degree of contamination, age, etc., and to take appropriate measures for control of infection (adequate washing, appropriate drainage, treatment with antibiotics, and so on), recovery from shock and stabilization of respiration and circulation.

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Colorectal perforation usually causes severe bacterial peritonitis, septic shock and life-threatening complications and perforation influences the prognosis of colorectal cancer. From January 1995 to December 2008, 45 patients with colorectal perforation underwent emergency surgery in our hospital. Subjects were retrospectively divided by tumor location, C to D (Group A : n=18) and S to Ra (Group B : n=27). We studied the clinicopathological background, postoperative complication, and prognosis in patients with colorectal perforation. The male-to-female ratio was 30 : 15 and the mean age was 69.6±11.6 years (range 45～94 years). In 51.1% of patients, perforation was due to sigmoid colon cancer. Perforation was observed at the oral end of the lesion in 14 patients and at the tumor in 31. Free perforation occurred in 62.2% (28/45). The white blood cell count of the patients who died during hospitalization after the surgery was lower than 4,000mm

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Perforated colorectal carcinoma usually leads to severe sepsis. Despite improved intensive therapy, it has a high mortality rate. Moreover, the long-term prognosis of survivors despite successful initial therapy was reported to be poor. We analyzed 19 cases who were operated on for perforated colorectal carcinoma complicating generalized peritonitis from 2001 to 2007. The mean age at onset was 63 years old. Seven patients were male and 12 were female. Perforation at the cancer site was observed in ten cases and perforation proximal to the carcinoma was observed in nine cases. Hospital mortality was 16% (three cases). Risk factors of hospital mortality were poor performance status (ECOG), preoperative shock, postoperative DIC and distant metastases. All cases were followed and mean observation period was 40 months. Seven cases with distant metastases at the time of initial operation died of the cancer. Relapse was seen in 8 cases of the remaining 12 cases (67%) without distant metastases at initial operation. Relapse was confirmed at an average of 10 months (5 to 21 months) after the initial operation. Oxaliplatin-based adjuvant chemotherapy, which was reported as effective, may be recommended for survivors of the initial operation, in order to improve this poor prognosis.

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Surgical treatment is an effective approach to improve the quality of life (QOL) of patients with ileus caused by malignant tumor recurrence when they are nonresponsive to other types of treatment. On the other hand, because of the invasive nature and possible postoperative complications of surgery, surgical intervention can be associated with the risk of further deterioration in the QOL and shortened survival time. Therefore, the surgical indications for this type of ileus should be carefully evaluated. We investigated herein factors that affect improvement in the QOL using data from our surgical cases of ileus caused by malignant tumor recurrence, and previously reported cases from the literature. The results showed that the presence of an expanded intestinal tract, patterns of recurrence, and time between the first surgery and the onset of ileus may provide criteria for surgical indications. However, it is difficult to make an appropriate decision based solely on these specified factors. It is important to evaluate on an individual patient basis surgical indications and surgical procedures based on a comprehensive assessment of biochemical blood test results and radiological findings, taking into consideration their changes over time.

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Oncological emergencies are increasing. In cases where the cancer is far-advanced, should we give priority to lifesaving or palliation? To select a therapy, we consider that the prognosis is an important factor. For predicting the prognosis, the Palliative Prognostic Index (PPI) is useful but it is hard for doctors to use unless they are experts in palliative medicine. We developed a simple and easy method, which is a simplified conventional PPI. The new method uses the Performance States (PS) scores of the Eastern Cooperative Oncology Group (ECOG), so we refer to the method as PS-PPI. The purpose of this study is to review the utility of the PS-PPI. The subjects were 55 patients with colorectal cancer. If the PPI or PS-PPI were less than 4, we predicted that the patient would live more than six weeks. PPI had a sensitivity and specificity of 90.2% and 73.3%, respectively. For the PS-PPI the sensitivity and specificity were respectively 86.8% and 66.6%. Our results suggest that the PS-PPI is simpler and easier to apply than the PPI while offering similar usefulness.

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Intractable bleeding from unresectable malignant tumors of the pelvis is potentially life-threatening and impairs the quality of life as it is difficult to control with conservative medical management. We treated ten patients with selective arterial embolization. Embolization was effective in 60% of the cases. Repeated procedures were required in 40% for long-term control. No serious complications were seen. Arterial embolization is a safe and useful treatment for intractable bleeding from unresectable malignant tumors of the pelvis.

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A 22-year-old woman was transported to our emergency room because of blunt trauma following a motorcycle accident. Her systolic blood pressure was 60mmHg on arrival, but it rose up to 120mmHg in response to fluid resuscitation. We diagnosed her as being a transient responder. CT imaging revealed a IIIb type liver injury that extended from the entire right lobe to the hepatic hilum. Transcatheter arterial enbolization (TAE) for the hepatic artery was immediately performed, resulting in successful hemostasis and stabilized circulation. Thoracic cavity drainage was then needed due to lung damage and hemopneumothorax. Although severe respiratory failure had persisted from the day after the injury, the patient gradually recovered from a critically ill condition under intensive care. Percutaneous drainage was also needed several times due to late complications, such as intraabdominal abscess, bile leak and hepatic necrosis formation. We experienced a transient responder with severe liver damage, successfully treated with nonoperative management approaches.

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A 78-year-old male was referred to our hospital with anal pain due to severe constipation. The patient presented with urinary retention and fecal incontinence. A pelvic CT scan revealed severe rectal dilatation and perirectal inflammation, leading to the diagnosis of imminent rupture of the rectum. After admission, the urinary and fecal disorders recovered following conservative therapy for a week, following which the patient was discharged. However the patient was admitted again because of relapse of the symptoms brought about by his own decision to stop taking laxatives. An idiopathic megarectum due to fecal impaction sometimes becomes serious with rectal perforation. In cases of severe constipation with anal pain, urinary retention and fecal incontinence, imminent rupture of the rectum should be considered.

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A woman in her 60's, who was in shock, was referred to our hospital after involvement in a traffic accident. Computed tomography examination revealed a contusion of the pancreatic head, potential injury of the portal vein and rupture of right renal. A laparotomy was performed, during which, hematomas were noted in the ligamentum hepatoduodenale and retroperitoneally but the portal vein was not injured. The damage to the pancreatic head was observed to be so severe that the damaged pancreatic duct could not be identified, so strict drainage from the pancreatic head region was performed. A pancreatic fistula was seen on the seventh day after the surgery. We diagnosed type IIIb pancreatic injury, stenosed intrapancreatic biliary tract and stenosed duodenum. The patient was followed for a month, but the pancreatic fistula did not improve. We performed a pancreatoduodenectomy and the patient's postoperative course was uneventful. The authors once again realized the importance of pancreatic fluid drainage. In the case where pancreatic duct damage could not be indentified, careful follow-up is deemed necessary with inspection repeated at regular intervals.

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We have experienced some pediatric cases with acute appendicitis in whom masses in the vermiform appendix have not been recognized on ultrasonographic examination (US) as fecaliths without high-echoic signal as compared to the wall of the vermiform appendix, but which were detected in plain computed tomography (CT). To resolve this question, the correlation between CT values and ultrasonographic findings was investigated in seven pediatric cases with fecaliths. The range of the CT value was between 63.5 and 231.0 Hounsfield units (H.U.). A fecalith in two cases with HU values of 147.4 and 231.0 was observed as an atypical pattern, iso-low-echoic signal without acoustic shadow (AC), with 5MHz US. On the other hand, three cases with HU values from 63.5H.U. to 108.5H.U. showed the typical pattern of a high-echoic signal with AC by the same method. The cases with H.U. values of 147.4 and 231.0 demonstrated the typical pattern with 9MHz US. In conclusion, it is important to use high frequency US for detection of fecalith, and that CT imaging with soft-tissue window settings (window width, 250-300 ; window level, +30) should be performed to detect fecaliths, high density of fat-tissue, and ascites only in suspected cases of acute appendicitis.

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A 22-year-old man who suddenly complained of a severe right hypogastric pain during muscle training was admitted to our hospital. Physical examination indicated muscle defense and a palpable and tender mass 10cm in size. Abdominal enhanced CT showed a hematoma in the right rectus sheath with extravasated contrasting agent, and a downward extension of this hematoma into the lower abdominal wall and pelvis. His vital signs were stable and conservative therapy was started. Because there was gradual worsening of the abdominal pain and a simultaneous increase in intra-abdominal fluid collection, the patient underwent an emergency operation. The right rectus muscle was lacerated and the inferior epigastric artery was found to be ruptured ; the latter was repaired with ligation. The hematoma appeared to spread into the median umbilical fold forming a large mass extending to the bilateral paracolic gutters. A moderate amount of hemorrhagic ascites was found, but no bleeding lesion was detected. The patient was discharged and his postoperative course was satisfactory.

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Asymptomatic cholecystolithasis was discovered in a 34-year-old pregnant woman during a medical check-up. Thereafter she visited a clinic with sudden abdominal pain on the 10th week of pregnancy. With a diagnosis of acute cholecystitis, she was referred to the Department of Gastroenterology at our hospital Her symptoms recovered following fasting and intravenous administration of antibiotics, and a laparoscopic cholecystectomy was electively performed on the 20th week of pregnancy. Because the fundus of her uterus extended 3cm above the navel, a first trocar was placed 5cm cranially from the navel. The gallbladder containing 38 mixed stones had tightly adhered to the liver. The postoperative courses of both mother and fetus were well and uneventful. She was discharged on the fifth postoperative day. We herein described a successful laparoscopic cholecystectomy in a pregnant woman with a special reference to the knacks and pitfalls of the operation for pregnant patients.

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A 22-year-old male with a diagnosis of left inguinal hernia at the age of 16 presented with severe acute pain in his left inguinal region. The patient was admitted to the emergency room of our hospital after visiting his family doctor. Physical examination revealed diffuse abdominal tenderness. Anemia developed and a CT scan depicted a hyperattenuated area in the left lower abdomen attributed to bleeding. Abdominal bleeding was diagnosed and an emergency operation was perfomed. Laparoscopically, we found coagula in whole abdomen, mainly in the left upper abdomen. The greater omentum had adhered to the left upper abdomen, and sucked into the left inguinal region. Since obvious bleeding points were hard to detect laparoscopically, we consequently performed open surgery through a small incision at the upper median abdomen. A bleeding point was identified in the greater omentum adherent to the left inguinal hernia and that segment of the greater omentum was successfully resected. The postoperative course was uneventful. Omental bleeding associated with inguinal hernia is very rare. We report this case with a review of some relevant literature.

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A 75-year-old woman had undergone laparotomy for cholelithiasis about 30 years previously, and had been suffering from an incisional hernia from about 20 years previously, which had developed into an enormous hernia with obesity (BMI 37.3kg/m²). The patient who had also been suffering from vomiting from several years previously, was admitted to hospital because of small bowel obstruction. Computed tomography showed a giant incisional hernia with a 12×12cm orifice, in which a markedly distended stomach and small bowel were encased. After successfully treating the bowel obstruction with conservative management, a operation was performed using a Composix Kugel Patch (XL size). The postoperative course went well without any complications such as abdominal compartment syndrome or cardiopulmonary disorder.

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The case reported here was a 53-year-old male who underwent radical gastrectomy for gastric cancer 18 years earlier, and who came to our hospital suffering from sudden abdominal pain. Abdominal CT revealed accumulation of ascites and the whirl sign, on the basis of which the patient was diagnosed with strangulated ileus and underwent an emergency laparotomy. The laparotomy revealed a large accumulation of chylous ascites, and accumulation of a whitish liquid was also observed in the mesentery. Although the mesentery of the small intestine had been convoluted about the axis of the ascending jejunal limb, since intestinal blood flow improved following removal of strangulation, intestinal resection was not performed. Since the ascites exhibited an elevated triglyceride level of 246mg/dL, it was determined to be lymph. The patient was discharged on day 12 of hospitalization. Reports of strangulated ileus presenting with chylous ascites are rare and only 6 cases have been reported in Japan. Since the pressure in the lymphatic system is lower than that of the vascular system, the potential for the occurrence of strangulated ileus presenting with chylous ascites was suggested as a result of lymph flow being interrupted even in cases of strangulation that would not completely interrupt blood flow.

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We report on a case of hepatic portal venous gas (HPVG) related to traumatic pneumatosis of the ileum. The patient was an 84-year-old woman. She was injured in a traffic accident and admitted to our hospital with multiple bone fractures of the limbs and blunt abdominal injury with abdominal pain. Computed tomography (CT) revealed partial pneumatosis of the ileum with HPVG. Emergency partial resection of the pneumatous ileum was carried out. The postoperative course was uneventful and HPVG could not be recognized on an abdominal CT examination performed on the second postoperative day. The surgical indication of HPVG still remains unclear, however, rapid improvement of the HPVG in our case was rapidly obtained by emergency resection of the involved intestinal segment.

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Gallbladder injury due to a blunt abdominal trauma is extremely rare with around 2% seen in abdominal wounds because of anatomical protection. We experienced a case of solitary gallbladder injury. A 34-year-old male got a blow in the abdomen from the handlebars of his motorcycle during a motocross competition. He was transferred to a nearby hospital by ambulance. However, the CT findings were almost normal, so he went back home. Meanwhile, the abdominal pain began to increase, so he visited our hospital. Enhanced CT revealed a hemorrhage in the gallbladder and fluid collection around the gallbladder and in Morison's pouch. An emergency operation was performed with the diagnosis of biliary peritonitis secondary to a ruptured gallbladder. Cholecystectomy was performed with abdominal drainage. A perforation of the gallbladder neck was revealed. A gallbladder injury must be considered in such cases when the diagnostic imaging is difficult, and if continuing upper abdominal pain is noted, immediate treatment would appear to be necessary following the injury.

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A 48-year-old man visited a nearby hospital with the chief complaint of abdominal pain. Contrast enhanced abdominal CT suggested rupture of a splenic aneurysm, and he was immediately transferred to our hospital for treatment. Blood biochemistry at the time of hospital admission showed an Hb level of 8.7g/dL, which indicated anemia, and creatinine phosphokinase (CPK) were increased at 2.039 IU/L. His past illness were rhabdomyolysis and malignant hyperthemia diathesis. In addition, he had undergone hemodialysis due to acute renal failure resulting from myoglobinuria. As all of these indicated that it was difficult to apply surgical treatment requiring general anesthesia, we decided to perform transarterial embolization (TAE), considered to be less invasive. Contrast study detected a saccular aneurysm, the longest diameter of which was 7cm, in the proximal splenic artery. Utilizing a microcoil, endovascular embolization of outflow and inflow vessels of the aneurysm was performed to control bleeding. After TAE, fluid management was carefully done to prevent renal failure associated with myoglobinuria. The patient was discharged on the 13th day of illness. In this study, we report on a case of splenic aneurysm rupture with rhabdomyolysis and malignant hyperthermia diathesis, which was successfully managed by TAE. We discuss this case with some bibliographic consideration.

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