The aim of this study was to evaluate computed tomography (CT) attenuation values of the peritoneum and to relate these values to the severity of peritonitis in patients with upper gastrointestinal tract (UGI) perforations. A total of 27 consecutive patients with UGI perforations who underwent CT and emergency laparotomy in our hospital were enrolled in this study. The CT attenuation values of the peritoneum were measured at a workstation by 2 independent investigators, and these values were analyzed in relation to the severity of illness. There were significant negative correlations between the peritoneal CT attenuation values and the sequential organ failure assessment score, acute physiology and chronic health evaluation II score, and the Mannheim peritonitis index. There was a significant negative correlation between the peritoneal CT attenuation values and the length of stay in the intensive care unit. Furthermore, patients with dysfunctions in 3 organs had significantly lower peritoneal CT attenuation values than those with dysfunction in 2 organs. In conclusion, evaluation of peritoneal CT attenuation values in peritonitis patients is simple and can be employed for objective assessment of the severity of peritonitis.

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We studied the predictive factors regarding prognoses and the post-operative hospitalization periods of patients with a colorectal perforation. We targeted 54 patients who had undergone surgery in our department during the past 7 years. We studied the predictive factors regarding prognoses and postoperative hospitalization in two groups for each, survivors and nonsurvivors for the former, and for the latter the group with a post-operative hospitalization period of 30 days or less (the short-term group) and of 31 days or more (the long-term group). There were 6 patients (11.1%) who died. In the nonsurvivors when compared to the survivors, there were significantly more patients found in a univariate analysis with Systemic Inflammatory Response Syndrome (SIRS), Acute Physiology and Chronic Health Evaluation (APACHE) II score high values, free perforation, fecal peritonitis, and Endotoxin absorption therapy. There were 30 patients (62.5%) in the long-term group. In a multivariate analysis, the number of comorbidities and wound Infection were selected as independent predictive factors of the post-operative hospitalization period. In colorectal perforation, therapy for sepsis is important for patients who have the prognosis predictive factors. Furthermore, for patients whose lives can be saved, in order to shorten the post-operative hospitalization period, sufficient peri-operative management for comorbidity and intra-operative and post-operative measures against wound infection are necessary.

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Laparoscopic surgery is a minimally invasive, cosmetically advantageous intervention, and it may be helpful in detecting and diagnosing lesions in emergency settings. In Saitama Children's Medical Center, we have performed emergency laparoscopic surgery on 596 children up to the end of 2008. After excluding cases of acute appendicitis and hypertrophic pyloric stenosis, these consisted of 75 cases, that included 17 ileus, 9 ventriculoperitoneal shunt disorders, 8 ovarian/tubal torsions, and 7 cases each of Meckel's diverticulum (excluding ileus) and diaphragmatic hernia. Diagnostic laparoscopy was performed on 21 cases, 6 of which did not need further treatment. There were 3 neonates : 2 with intestinal malrotation without volvulus and 1 with ovarian torsion. Intraoperative complications were found in 2 cases and both were small bowel injuries. Four cases were converted to open surgery. We believe that laparoscopy is indicated for virtually all pediatric abdominal emergency cases, with the exception of high-risk cases contraindicated for general anesthesia or pneumoperitoneum, or cases of strangulated ileus with intestinal necrosis.

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Laparoscopy has gained widespread acceptance in common surgical practice as a diagnostic and therapeutic tool, so surgeons are increasingly using laparoscopy in patients presenting with acute abdomen. This is also the case in pediatric surgery. Laparoscopy is the only minimally invasive technique to simultaneously allow for an appropriate diagnosis and proper treatment, or for selection of the correct abdominal approach, or both. Diagnostic laparoscopy allows direct visualization of the intra-abdominal organs with low morbidity and may find unexpected concomitant pathologies. Additionally, laparoscopy allows for the performing of the same surgical procedures as open surgery whenever indicated and also helps in the management of concomitant diseases. Another advantage of laparoscopy is the ability for peritoneal washing and cleaning the deep abdominal areas, with minimal destruction of the abdominal wall. To accommodate laparoscopy in any pathological status, surgeons must not hesitate to convert to open laparotomy if necessary. Even when forced to convert the procedure, surgeons may choose the most appropriate incision for treating the patient based on the laparascopic findings.

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Primary laparoscopic appendectomy (LA) for treatment of appendicitis was introduced in December 1997 and is now the first-line surgical procedure. In this retrospective study, we investigated the indications of LA by examining 344 of our primary LA cases along with 88 primary open appendectomy (OA) cases conducted between January 1996 and December 1997 prior to the introduction of LA no significant difference in operation time and intraoperative complications was observed between LA and OA, Transition to OA was conducted in only one patient with gangrenous perforation. Cases of perforation and abscess formation are considered to be appropriate indications for LA as LA allows accurate identification of the affected region and the condition of the surrounding area, ensuring a correct and safe operation compared to OA.

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Seventy-one children who underwent laparoscopic appendectomy over the 8 years previous to the study were investigated. The patients were divided into 2 groups : those who had undergome surgery within 24 hours (EA group) and after conservative treatment (IA group). The condition of appendicitis on CT was classified into appendiceal mass (Group A), perforation (Group B), and non-perforation (Group C). Perioperative complications were mainly investigated in these groups. The EA group included 45 patients, and postoperative complications occurred in 2 of 12 patients in Group A (wound infection and intraperitoneal abscess in 1 each) and 2 of 14 patients in Group B (postoperative ileus and intraperitoneal abscess in 1 each). The IA group included 26 patients, and complications occurred only during conservative treatment in 2 of 7 patients in Group A (recurrence of inflammation and ileus in 1 each) and 2 of 2 patients in Group B (recurrence of inflammation and emergency surgery for the aggravation of symptoms in 1 each). No complication occurred in Group C of either the EA or IA group. Treatment was not switched to laparotomy in any patient in the EA or IA group, and no complication occurred during surgery. The total duration of hospitalization was shorter in the EA than in the IA group in all Groups A, B, and C. The risk of postoperative complications was high in the EA group, whereas complications during conservative treatment were problematic in the IA group.

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The aim of this study was to evaluate the outcome of laparoscopic appendectomy (LA) for children (child LA) vs open appendectomy (OA) for children (child OA) and child LA vs LA for adults (adult LA) in patients with appendicitis. Methods : We retrospectively analyzed the clinical records of 1069 patients who had undergone laparoscopic or open appendectomy for appendicitis between May 1995 and Jul 2010 at the Department of Surgery of Juntendo University Urayasu Hospital. Of them, 153 had undergone child LA, 63 child OA, and 605 adult LA. We compared these groups for background factors, and intraoperative and postoperative findings. Results : (Study 1) : child LA vs child OA. Patient demographics were similar in the child LA and child OA groups. Wound infection was significantly more common in the open group at 7.9% than in the laparoscopic group at 1.9% (p<0.05). Hospitalization was significantly shorter in the laparoscopic group (p<0.001). (Study 2) : child LA vs adult LA. Patient demographics were similar in the child LA and adult LA groups. Postoperative course, intra/postoperative complications and conversion rate to the open procedure did not differ significantly between the two groups. Conclusions : Our findings indicate that child LA is safe and useful comparable to child OA or adult LA in treating appendicitis.

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Laparoscopy has recently been used to treat intussusceptions. We reviewed our experience with the laparoscopic approach and investigated the indication and limits of laparoscopy. We performed 23 cases for laparoscopic reduction, and 4 cases of laparoscopic examination only to determine whether a pathologic lead point was present or not. In 15 of 23 cases (88%), intussusception was successfully reduced with laparoscopy. Spontaneous reduction was revealed in 6 cases. 2 cases required conversion to an open procedure. Although there remains a group who require a conversion to an open procedure, the laparoscopic approach should be considered as a safe and effective option not only for treatment but also for diagnosis.

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It is necessary for ovarian tumor in pediatric population to be diagnosed and treated emergently because of the association of adnexal torsion. Laparoscopic approach for ovarian tumor is very efficient with some advantages in terms of both diagnosis and treatment, and is selected as one of the standard procedures even in the emergency situation, as the majority of ovarian tumor in children are benign mature cystic teratoma. Furthermore, [the associated conditions as adnexal torsion included contralateral ovary] are observed at the same time, and treatments such as puncture or detorsion are possible immediately after diagnosis. Enucleation with preservation of the ovary or salpingo-oophorectomy is reported which is performed laparoscopically or by mini-laparotomy after laparoscopic detorsion. And as the significance of a second look laparoscopy for necrotic appearance of the twisted ischemic ovary has been discussed, laparoscopic approach for ovarian tumor in children will become more conservative and less invasive as ovary-preserving surgery.

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A 16-year-old male was admitted to the hospital after a player on the opposing football team had kneed him in the left upper abdomen. Ten hours after injury, the patient was transferred to Otaru Ekisaikai hospital with symptoms requiring treatment. Upon admission, the patient complained of intense pain, and muscle guarding was observed in the entire abdomen. An abdominal CT scan showed fluid collection and free air in the abdominal cavity. Laparotomy was performed 15 hours after injury, and it revealed a perforation of the duodenum in the fourth portion and contamination of the abdominal cavity by intestinal fluid. A partial duodenectomy of the perforated site, deuodeno-jejunostomy, and drainage of the anastomotic site using a nasogastric tube were performed. The postoperative course showed no serious complications, and the patient was discharged on post-operative day 16. Traumatic duodenal perforation as a result of a sports injury is not common.

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A 53-year-old male visited a local hospital with worsening epigastric pain. A gastrointestinal perforation was suspected and he was therefore referred to our hospital. He went into shock 15 minutes after arriving at our hospital and emergency surgery was perfomed based on a diagnosis of intraabdominal bleeding. A laparotomy revealed bleeding from the middle colic artery region, and the blood vessel was ligated and transected. Postoperative abdominal angiography revealed irregularity of vessel diameter and anneurysmal changes in the anastomotic branches between the middle and left colic arteries. Considering the risk of rupturing in the future, a transverse colectomy including the aneurysm was performed. The postoperative course was uneventful, and the patient was discharged in a good condition on day 61 after the initial surgery. Considering the multiplicity of middle colic artery aneurysms, it is important in such situations to confirm whether or not this is the case.

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A 75-year-old woman was admitted to the hospital with severe abdominal pain and vomiting. An abdominal CT scan showed hepatic portal venous gas and air bubbles in the enteric wall. Under a pre-operative diagnosis of strangulated ileus, an emergency operation was performed. Ischemia of the small intestine was extensive and necrosis had occurred in part of the ileum, therefore an extended resection of the small intestine including the ileocecal region was needed. Histopathological examination revealed enteric necrosis accompanied by hemorrhage and neutrophil infiltration. Furthermore, air bubbles were seen in the submucosa, which are a feature of gas gangrene. The Gram stain moreover showed proliferative mucosal growth of Gram-positive rods. The patient had eaten pork which was past its ‘eat by’ date earlier in the day when she developed the abdominal pain. Accordingly, necrotic enteritis probably caused by Clostridium infection was diagnosed. The postoperative course was uneventful and the patient was discharged on postoperative day 24.

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A 58-year-old man underwent a distal pancreatectomy with splenectomy for a non-functioning endocrine tumor of the pancreas in January 2009. Pain developed in the left hypochondrium on postoperative day 6, and computed tomography on postoperative day 10 revealed a fluid cavity of 5cm in diameter at the stump of the pancreas. The patient was diagnosed as having a pancreatic fistula and conservative treatment was initiated. However, on postoperative day, 20 his general condition had deteriorated and computed tomography showed the fluid cavity had increased to 8cm in diameter. On postoperative day 21, endoscopic retrograde pancreatography demonstrated a contrast medium leak from the stump of the main pancreatic duct, and an endoscopic nasal pancreatic drainage tube was inserted. As the pancreatic juice was mucinous, leading to poor drainage, use of negative pressure and dressing of the tube was started twice a day. The tube was removed 20 days after endoscopic nasal pancreatic drainage was started because there was no discharge despite application of negative pressure, and because computed tomography showed that the size of the cavity had decreased to 3cm in diameter. A pseudocyst formed at the stump of the pancreas, but the size of the cyst had not changed and the patient was doing well 18 months after surgery.

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A 70-year-old man, who had undergone a laparoscopy-assisted colectomy for transverse submucosal colon cancer, presented with a sudden onset of abdominal pain and vomiting about 2 months after surgery, and was admitted. Although plain-film examination showed no specific findings, abdominal contrast-enhanced computed tomography (CT) revealed an internal hernia at the site of the mesenteric defect causing segmental obstruction of the jejunum. Laparotomy showed that a 1-m segment of the proximal jejunum had herniated through a mesocolic defect of the transverse colon. We repositioned the herniated jejunum, and closed the mesenteric defect. An internal hernia after laparoscopic colectomy is a rare complication. According to some previously-published case reports, the diagnosis of postoperative internal hernia is often delayed. CT enables early detection and correct diagnosis. Our experience suggests that closure of the mesenteric defect might be necessary as prophylaxis against a postoperative internal hernia.

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A 32-year-old male visited a local hospital with abdominal pain and vomiting. An intestinal obstruction was suspected and he was referred to our hospital. He had no history of laparotomy. The abdominal pain involved swelling and mild tenderness mainly in the umbilical region, and there were no symptoms of peritoneal irritation. CT images revealed a giant sac-like structure and an enlarged small intestinal loop in the right upper abdomen, and because the ascending colon was laterally displaced, we determined that there was a high possibility of ileus caused by a right paraduodenal hernia. Considering the possibility of a strangulation ileus, we performed emergency surgery on the same day. There was no ligament of Treitz inside the abdominal cavity, and the small intestine had intruded by approximately 200cm via the peritoneal aperture as the hernial orifice, generated on the right side of the superior mesenteric blood vessels. The hernial orifice was opened to draw out the small intestine, and we confirmed that there was no ischemia or necrosis. The hernial orifice was sutured closed and the abdominal cavity was closed. The patient did not present with any circulatory disorders of the intestinal tract and the surgery was completed after only resetting the small intestine, closing the hernial orifice, and performing a preventive appendectomy, but there are some cases that require an extensive small intestinal resection. It is therefore believed that performing diagnostic imaging tests while keeping this disorder in mind would allow for a timely preoperative diagnosis and appropriate surgery at an early stage.

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We herein report on three cases of giant villous tumors of the rectum accompanied by electrolyte depletion syndrome (EDS) and review the related literature. In case 1, a giant villous tumor with a long axis of 15cm occupying the entire circumference of the upper rectum was detected on detailed examination performed for frequent diarrhea and EDS in an 81-year-old woman. In case 2, a 67-year-old woman presented with persistent watery diarrhea, and a 17×8cm villous tumor was discovered in the rectosigmoid colon. In case 3, a 10×10cm villous tumor was found in the upper rectum on detailed examination performed for the chief complaint of melena in a 73-year-old man. All cases had mucus production and EDS, and a villous tumor complicated by EDS was therefore suspected. EDS improved in these cases following surgery and the patients' postoperative course was uneventful. Villous tumors accompanied by EDS is relatively rare. Patients presenting with persistent watery diarrhea should be evaluated for a giant villous tumor complicated by EDS, as serious EDS may sometimes occur.

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In May, 2009 an 82-year-old man was admitted to our hospital with palpitations and abdominal pain. He was found to be anemic, and gastrointestinal endoscopy showed two protruding tumors, one located at the gastric angle and the other incarcerated into the duodenum. The pathological findings of both biopsy specimens showed moderately differentiated tubular adenocarcinoma. An upper gastrointestinal series showed one tumor located at the antrum and the other in the duodenal bulb. We diagnosed synchronous multiple gastric cancers, and performed a distal gastrectomy with a D2 dissection. During the laparotomy we palpated a soft mass in the duodenal bulb, which was repositioned into the stomach by hand. The pathological stage was pT1 (M, SM), ly0, v0 and pN1. Ball valve syndrome is defined as clinical phenomenon in which obstruction of the lumen of the pylorus has occurred by intussusception of a gastric tumor. We report a rare case of ball valve syndrome in which one lesion of multiple gastric cancers had prolapsed into the duodenal bulb.

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We report on a case of penetration of a Patch^® into the small intestine after an operation for incisional hernia in a 71-year-old man, in which the Composix Kugel Patch^® method was employed. The patient, who had previously undergone a distal gastrectomy for gastric cancer with an upper midline incision in March 2003, underwent surgery for incisional hernia with the Composix Kugel Patch^® method in July 2003. The patient felt tenderness in the lower incisional region in November 2009. A computed tomography scan of the abdomen revealed that adhesion had occurred between the Patch^® and the small intestine and an abscess was present in the abdominal wall. He subsequently underwent surgery. The small intestine was partially excised and the infected Composix Patch^® was removed. We reconstructed the abdominal wall using the left deep fascia of the thigh. The patient was discharged from the hospital on the 27th day after surgery. No recurrence of the hernia or abscess formation has been observed. We report on this case of penetration formation into the small intestine of a Composix Kugel Patch^® used to treat a previous incisional hernia of the abdominal wall.

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Pancreatic cancer often leads to duodenal invasion, but rarely causes duodenal bleeding. We report on the case of a 65-year-old man admitted to the emergency room with loss of consciousness. He was initially diagnosed as being in a hyperglycemic coma, and massive volume resuscitation was started, as he presented with hematemesis and melena together with hypovolemic shock. Emergency gastrointestinal endoscopy was performed with a massive supplementation of saline solution, a blood transfusion, and continuous insulin infusion. Hypertonic saline with epinephrine infusion and clipping were performed because of bleeding from a duodenal ulcerative lesion. Gastrointestinal endoscopy was required repeatedly, due to recurrent duodenal bleeding. A computed tomography scan revealed pancreatic head cancer, invading the duodenum and portal vein. A pancreatoduodenectomy was performed as a radical treatment for the pancreatic cancer with duodenal bleeding. The patient's postoperative course was uneventful.

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A 45-year-old woman attended the emergency department of a hospital because of upper abdominal pain and was admitted in December, 2009. An abdominal CT scan showed a dilated intestine in the space between the portal vein and inferior vena cava. Under the diagnosis of a Winslow foramen hernia, an emergency operation was performed. Operative findings showed that a 90-cm portion of the small intestine about 400cm distal to the ligament of Treitz had herniated through the foramen of Winslow into the omental bursa. Manual reduction of the hernia was performed via the Kocher maneuver. Intestinal resection was needed due to the presence of intestinal necrosis. No plication suture of the foramen of Winslow was required. We recognized a fixed abnormality of the ascending and descending colons. Hernia through the foramen of Winslow is very rare, accounting for about 8% of all internal hernias. We report on a case of herniation through the foramen of Winslow diagnosed preoperatively, and analyzed a total 33 domestic cases, including our case.

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An eighty-three-year old woman was transferred to our hospital with abdominal pain and vomiting. She had been taking warfarin for two years. Enhanced abdominal computed tomography showed a thickened jejunum and fluid collection which appeared to be bloody ascites. An emergency operation was performed. Intraoperatively we found a mesenteric hematoma which was pressing on the mesenteric vein so tightly that the jejunum was congested, but free of necrosis. No surgical procedure was performed but we placed a jejunal tube for intestinal decompression. The patient's post operative course was uneventful. This is a rare case of mesenteric hematoma which was extremely difficult to be diagnosed preoperatively, and was thought to be caused by anticoagulation medication.

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