We conducted a retrospective review of the data of 165 patients over 80 years of age who had undergone emergency abdominal surgery at our institute between April 2003 and March 2009. There were 76 men and 89 women, ranging in age from 80 to 97 years (average, 84 years). Of all the patients, 148 (89%) had concomitant medical disease. A total of 106 patients (64%) had morbidity, and these patients had a lower Glasgow coma scale score and systolic blood pressure, a higher heart rate and a more prolonged prothrombin time than the patients without morbidity. Of all, 44 patients (26%) died, and these patients had a lower Glasgow coma scale score, systolic blood pressure and serum albumin, a higher heart rate, serum potassium, serum urea nitrogen and serum creatinine than the survivors. Furthermore, the POSSUM scores (PS and OS) were higher among the survivors than among the non-survivors, and also higher in the patients with morbidity than in those without morbidity. POSSUM is a good tool for predicting the morbidity and mortality and can be useful in determining the need for emergency abdominal surgery in patients over 80 years of age.

View full abstract

We prospectively evaluated the usefulness of computed tomography (CT) in the diagnosis and management of acute abdomen. Ninety-four patients with acute abdomen were enrolled. We compared the final diagnosis and management CT diagnosis and management. Then, we evaluated how many of the CT examinations were useful and the degree to which they were useful. In more than 90% of cases, CT was very useful for the diagnosis and management of acute abdomen.

View full abstract

In emergency abdominal emergency operations, there is insufficient opportunity for the prevention smoking, control of nutrition, control of blood sugar and preparation of the colon, which increases the risk of wound infection. In the case of perforation of the digestive tract, the abdominal cavity is highly contaminated, and protection of the abdominal wound is very important. We analyzed the incidence of wound infection following abdominal emergency operation according to the level of contamination of the abdomen (ileus, impaction by hernia, perforation of the upper digestive tract, perforation of the small intestine, acute appendicitis and colon perforation) before and after the use of the ring-drape. After the introduction of the ring-drape, the wound infection rates decreased in the case of ileus, impaction of nernia and acute appendicitis, whereas no such decrease was found in the case of colon perforation. Use of the ring-drape in abdominal emergency surgery is effective. But, in the case of colon perforation, some other provision is necessary, such as delayed primary closure.

View full abstract

The effect of insertion of a subcutaneous continuous suck drain catheter on the incidence of superficial surgical-site infection (s-SSI) has not yet been clearly reported. To evaluate the efficacy of such drainage, we implanted a subcutaneous continuous suck drain drainage catheter subcutaneously in patients with gastrointestinal perforation. Materials and Methods : From October 2006 to September 2008, 25 cases of gastrointestinal perforation were allocated to two groups, one in which a subcutaneous continuous suck drain drainage catheter was implanted and a group in which no such drainage catheter was inserted, and examined the frequency of occurrence of s-SSI and the operation time in the two groups. Result : Of the total, 13 cases from the subcutaneous continuous suck drain drainage catheter insertion group did not develop s-SSI, whereas 8 of the 12 cases in which no subcutaneous catheter was inserted developed s-SSI, representing an s-SSI occurrence rate of 66.6%. Conclusion : Insertion of a subcutaneous continuous aspiration drainage catheter demonstrated definitive potential for preventing s-SSI.

View full abstract

Reported wound infection rates are high after primary closure of contaminated wounds high. When wound infection develops, reopening of the wound and frequent changes of dressings with irrigation are required. For contaminated abdominal wounds after previous closure of the musculo-aponeurotic layer with PDS, the wounds are typically left open with loose, fine-mesh gauze inserted between the skin and subcutaneous margins down to the level of fascial closure. The wounds are managed with wet-to-dry dressings changed twice daily until postoperative days 5 to 7, when a clinical judgement is made as to whether to proceed with delayed primary closure (DPC) or to allow healing by secondary intention. The objective of this study was to determine the successful healing rate of wounds and identify the risk factors for failure. Methods : In this retrospective cohort study, we analyzed the efficacy of DPC for contaminated abdominal incisions after large bowel perforation in 21 patients between January 1, 2006 and December 31, 2007. The patient characteristics, risk factors for wound infection, and the clinical outcomes were compared in the DPC group versus the secondary healing group. Results : Seven wounds (33.3%) were closed by DPC and all healed successfully without development of wound infection. The remaining 14 wounds were considered to be unfavorable candidates for DPC and were allowed to heal by secondary intention. The percentage of patients who developed septic shock was significantly smaller (P=0.04) and the length of ICU stay was significantly shorter (P=0.03) in the delayed primary closure group. Conclusion : DPC of abdominal wounds is an effective method of wound management for contaminated abdominal wounds.

View full abstract

We retrospectively examined the complications of wound closure and methods for preventing complications in patients undergoing surgery for pan-peritonitis. Sixty patients with acute abdomen underwent emergency surgery after introducing SSI surveillance at our institution. We measured the rate of SSI, postoperative ileus and abdominal wall hernia and preventive measures against these complications between cases with (group A) and without (group B) pan-peritonitis. SSI developed in 78% of patients in group A and 33% of patients in group B (p=0.002), postoperative ileus developed in 6% of patients in group A and 5% of patients in group B (p=NS), and abdominal wall hernia occurred in 17% of patients in group A and 0% of patients in group B (p=0.024). Perforation of the lower intestinal tract, surgery for pan-peritonitis and performance of colostomy were risk factors related to surgery for acute abdomen. Intensive washing of the abdomen, wound closure under decreased tension, and insertion of a subcutaneous drain were performed for the prevention of complications. Attention must be paid to the possible development of abdominal wall hernia in patients with pan-peritonitis caused by perforation of the lower intestinal tract post-colostomy.

View full abstract

Although damage control surgery (DCS) is a standard strategy for patients with severe abdominal trauma, this strategy is also extremely useful for patients with acute abdomen. Temporary abdominal closure is frequently performed in DCS, and in the present study, we preferentially selected vacuum packing closure (VPC) for temporary abdominal closure in DCS. VPC was performed in 23 patients with acute abdomen. The average Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score was extremely high (APACHE-II=32.3) in the patients who underwent VPC for temporary abdominal closure in DCS. The abdominal compartment syndrome (ACS) did not develop in these patients, although only 1 patient developed intestinal perforation due to the packing pressure ; however, no other severe complications were observed. When it is difficult to close the abdominal wall in patients with acute abdomen, or when second-look operations are intended for emergency surgery of severe acute abdomen, VPC is an excellent method for temporary abdominal closure in these patients, just as in patients with trauma.

View full abstract

Although the concept of damage control and an improved understanding of the pathophysiology of the abdominal compartment syndrome have represented great advances in the management of both traumatic and non-traumatic surgical conditions, many patients require open abdominal management. We evaluated the effect of vacuum pack closure as a temporary abdominal wall closure technique and the anterior rectus abdominis sheath turnover flap method for early fascial closure in patients requiring open abdominal management (OAM). Methods : Fifty-four patients (21 trauma and 33 non-trauma) requiring OAM were reviewed. Results : The mean duration of OAM was 13.9 days and 12 trauma and 15 non-trauma patients survived. There were no cases that developed enteric fistula or abdominal abscess. After the introduction of vacuum pack closure, extension of the interval between the initial surgery and formal abdominal wall closure was observed. Anterior rectus sheath turnover flaps were used in 11 patients who were unsuitable for standard fascial closure due to of prolonged visceral edema. Of these, wound infection developed in 4 and of 10 survivors who did not develop fascial dehiscence or herniation. Conclusions : Vacuum pack closure and early fascial closure using the anterior rectus sheath turnover method may prevent the development of enterocutaneous fistula and reduce the need for skin grafting and later abdominal wall reconstruction in the early management of patients with OAM.

View full abstract

A nine-year-old boy presented with abdominal pain and vomiting of sudden onset. He had a past history of undergoing laparoscopic left orchidopexy at the age of one. Contrast-enhanced computed tomography (CT) revealed an expanded loop of small intestine with contrast enhancement in the right paraumbilical region. Incarcerated small intestine was also shown in the right perirectal fossa without contrast enhancement. Decrease of the lumen volume of the small intestine in the right perirectal fossa was associated with resolution of the clinical symptoms. The suspected preoperative diagnosis was perineal hernia. Laparoscopic surgery revealed adhesion among the sigmoid colon, omentum and anterior parietal peritoneum, and the right perirectal fossa and the right side of the rectum formed a sac by the adhesion. The hernia sac was dissected open. Abnormality of the pelvic floor musculature was not recognized. These findings confirmed a postoperative diagnosis of acquired intrapelvic hernia. The definition of perineal hernia is a peritoneal protrusion through a defect or opening of the pelvic floor musculature. The findings in this case did not conform to that definition. It was suspected that the adhesion after orchidopexy formed a sac which could have caused herniation of the small intestine into the right perirectal fossa.

View full abstract

A 72-year-old man undergoing radiation therapy and chemotherapy chemoradiotherapy for lung cancer and metastatic brain cancer developed intermittent abdominal pain with high fever. Subcutaneous emphysema was observed in the right lower abdomen, and the scrotum was enlarged to the size of the head of a newborn, with severe tenderness. Abdominal CT showed free air in the peritoneal cavity and intestinal herniation into the scrotum. Intestinal perforation in the incarcerated inguinal hernia was diagnosed and emergency operation was performed. The caecum and ascending colon were incarcerated in the inguinal canal and the ascending colon was perforated, causing the fecal contents to leak out into the peritoneal cavity. We performed resection of the incarcerated colon and ileostomy. The hernia sac was difficult to separate because of adhesion, which necessitated excision of the testicle as well. However, successful combined-modality therapy enabled the patient to be transferred to the Department of Internal Medicine on day 51 after the operation. Only nine cases of incarcerated inguinal hernia of the caecum have been reported in Japan. As for the cases of perforation of the colon in an incarcerated hernia, as few as 8 cases have been reported so far : 4 of these cases showed herniation of the caecum. Incarcerated inguinal hernias of the caecum can be more easily perforated than those of the rest of the intestine, suggesting the need for particular caution to be exercised in these cases.

View full abstract

We report a case of perforated undifferentiated gastric cancer with metastatic small-intestinal tumors. A 64-year-old man was found fallen flat in his home, and was transported by emergency ambulance to our hospital. He showed evidence of SIRS and had severe tenderness and muscle guarding over the entire abdomen. Abdominal CT showed a mass in the pylorus with free air in the peritoneal cavity, ascites and lymphadenopathy. An upper gastrointestinal endoscopy revealed a type 3 tumor in the pylorus of the stomach. We diagnosed general peritonitis caused by perforation of the gastric tumor, and performed emergency operation. A perforated gastric tumor in the pylorus was found, along with three tumors in the small intestine, but no tumor was detected in the liver. In addition to distal gastrectomy, we performed partial resection of the small intestine. The pathological diagnosis was an undifferentiated hCG-producing (+) carcinoma, and metastatic small intestinal carcinomas.

View full abstract

A 38-year-old woman involved in a traffic accident was referred to our hospital complaining of upper abdominal pain. Abdominal computed tomography revealed transection of the pancreatic body (type IIIb pancreatic injury), and a 2-cm-deep laceration of the liver parenchyma (type II liver injury). Emergency laparotomy revealed complete pancreatic transection with injury of the main pancreatic duct on the left border of the superior mesenteric vein, and injury of segment 4 of the hepatic parenchyma. We performed distal pancreatectomy and local hemostasis for the liver. The postoperative course was good, and the pancreatic exocrine function was acceptable after discharge. Distal pancreatectomy should be performed for patients with transection of the pancreas a procedure to preserve pancreatic function should only be performed if the distal resection entail resection of greater than 80% of the pancreas.

View full abstract

We report a case of alimentary ileus resulting from a spilled bezoar, with bibliographical consideration. The case was a 67-year old male with a past history of pylorogastrectomy for gastric cancer at the age of 46, who presented to the outpatient department with a history of emesis and intermittent abdominal pain, preceded several days earlier by epigastric discomfort. Abdominal examination revealed upper abdominal tenderness and increased intestinal peristalsis. The patient was admitted with the diagnosis of adhesive ileus. CT revealed a 5×4-cm heterogeneous gas-containing low-density mass in the small bowel and a mild distention on the oral side of the small bowel. A contrast study of the small bowel showed a chicken-egg-sized translucent image. With the suspected diagnosis of ileus caused by a spilled bezoar, laparotomy was performed, which revealed palpable and hard contents in the small bowel approximately 160cm from the distal end of the ileum. Partial resection of the small bowel was performed, and the resected segment was found to contain a brown-colored bezoar measuring 7×4.5×4cm in size.

View full abstract

An 81-year-old woman complained of wheezing and dyspnea three days after undergoing upper gastrointestinal endoscopy, which had revealed a gastric ulcer, at a medical clinic. She was referred to a hospital, where she was diagnosed as having esophageal hiatus hernia. Although she was transferred to our center and decompression of the stomach through tube insertion was attempted, it was found to be impossible due to perforation of the gastric ulcer in the esophageal hiatus hernia. In this case, the hernia sac expanded because of leakage of gas and gastric juice, causing cardiac failure. Emergency laparotomy was necessary to reduce the size of the hernia sac. The circulatory dynamics immediately stabilized after decompression of the hernia sac, and the postoperative course was excellent.

View full abstract

A 32-year-old man was transferred to our hospital with the diagnosis of acute pancreatitis associated with renal failure. The renal failure improved with intensive care, and the patient was transferred to the previous hospital for continuation of the treatment for pancreatitis. However, the patient developed shock 4 days later and was transferred again to our hospital. Abdominal computed tomography showed the upper abdominal cavity filled with peripancreatic fluid, therefore, the diagnosis of pancreatic abscess complicating acute pancreatitis was made. Intensive respiratory management and continuous hemodialysis were initiated. Computed tomography performed 25 days after admission showed a large amount of gas in the pancreatic abscess. Perforation of the 2nd portion of the duodenum was diagnosed based on leakage of the contrast medium. Enteral nutrition via a transnasal tube inserted into the jejunum was initiated. Two percutaneous drainage tubes were placed in the abscess. Continuous lavage and drainage were performed daily through these tubes. As a result of these treatments, the abscess cavity gradually became smaller. Although the duodenocutaneous fistula was initially refractory, it eventually closed with conservative treatment.

View full abstract

A-58-year-old man was brought to our ER in a shock state two hours after he had stabbed himself on the left side of the navel with a kitchen knife in an attempt to commit suicide. We performed emergency laparotomy for hemostasis and partial resection of the small bowel segment that had been damaged by the knife and was protruding from the stab wound. He developed ileus after the surgery, and contrast-enhanced CT showed a low-density area within the abdominal cavity extending to the left iliopsoas muscle, and hydronephrosis of the left kidney. Laparotomy was performed again. We discovered a retroperitoneal injury of the measuring two centimeters in diameter and turbid ascites ; irrigation and drainage were performed. After the second operation, the urine output decreased gradually, with increased drainage from the retroperitoneal drainage tube. The retroperitoneal drainage fluid was similar to urine in appearance and in chemical characteristics. Therefore, we diagnosed left ureteral injury. Percutaneous nephrostomy was performed, and after the inflammation subsided, reconstruction of the left ureter was undertaken. The patient was discharged from the hospital in good condition on day 56 after the second laparotomy. Ureteral avulsion due to an abdominal stab wound is uncommon, but must always be borne in mind in the relevant clinical setting. Placement of retroperitoneal drains near the injured site may facilitate the diagnosis of ureteral avulsion.

View full abstract

An 81-year-old female with previous histories of angina pectoris and hypertension was admitted to our hospital because of severe abdominal pain. An emergency laparotomy was performed under the diagnosis of ischemic colitis with suspected bowel necrosis. The gangrenous area of the colon was observed to extend from the cecum to the sigmoid colon. We conducted a subtotal colectomy and ileostomy. Gangrenous ischemic colitis spreading to the entire colon is rare and is associated with a poor prognosis. Early diagnosis and complete removal of the necrotic bowel are essential in the treatment of patients with gangrenous ischemic colitis.

View full abstract

A 70-year-old man was admitted to our hospital with upper abdominal pain. He had previously undergone Billroth typeII total gastrectomy for advanced gastric cancer. Abdominal CT showed a dilated afferent loop. We diagnosed acute afferent loop obstruction caused by cancer recurrence or peritoneal dissemination. He was treated by endoscopic decompression of the afferent loop, followed by continuous drainage. After drainage, we successfully inserted a self expandable metallic stent (EMS). The patient was able to spend the final 6 months of his life at home with an adequately maintained quality of life due to this intervention. Our experience using the EMS in this patient suggests that endoscopic drainage, which is minimally invasive, should perhaps be considered when acute afferent loop obstruction occurs as a result of tumor recurrence.

View full abstract

A 30-year-old woman in her 27th week of pregnancy was transferred to our hospital with the chief complaints of persistent abdominal pain, nausea and vomiting for 24 hours. She had undergone choledochojejunostomy five years ago for a congenital choledochal cyst. Her vital signs revealed that she was in shock. An abdominal CT showed small bowel dilatation and ascites. Based on the findings, ischemia of the upper part of the small bowel was suspected. Fetal bradycardia appeared as a result of fetal distress. Multiple dilated loops of the small bowel were detected at laparotomy, secondary to internal hernia. The upper ileum was ischemic and necrotic. About 80cm of the small bowel was resected, followed by ileo-ileo anastomosis. Choledochojejunostomy was performed 21 days after the operation, The patient showed good postoperative recovery. Intestinal obstruction during pregnancy is very rare. However, it significantly influences the maternal and fetal mortality rates, typically due to a delay in the diagnosis and proper treatment. Here, we report a rare clinical case, along with a review of the relevant literature.

View full abstract

Hemorrhagic shock due to a simple ileal ulcer is a rare condition. A 38-year-old man suffering from massive melena was admitted to a local hospital. On the second hospital day, he had another episode of massive melena and was transferred to our Center. Endoscopic examination showed no hemorrhagic lesion in the esophagus, stomach or duodenal bulb. Computed tomography of the abdomen showed a suspicious lesion in the ileum. On the following day, he again developed massive melena and shock. Emergent laparotomy was performed. An ulcerative lesion was detected 50cm proximal to the ileocecal junction. There were no abnormal findings on the serosa, and no enlarged lymph nodes. The ulcerative lesion of the ileum (12cm) was resected. Macroscopically, the ulcer was deep, with an exposed artery. The pathological finding was a simple ulcer. The postoperative course was uneventful and the patient was discharged 24 days after the operation. Therefore, emergency surgery may need to be considered to treat hemorrhagic shock caused by an ulcer in the small intestine.

View full abstract