The possibility of having to convert to an extended operation and the incidence of complications are high in emergency surgery for abscess-forming appendicitis. Our hospital has employed interval appendectomy (IA) for the treatment of abscess-forming appendicitis since 2008, in which conservative treatment is applied to alleviate the abscess and appendectomy is performed after about 3 months when the patient wishes to undergo surgery. We investigated 32 patients with abscess-forming appendicitis. Conservative treatment was successful in 29 of the 32 patients (91%) within an average of 17.2 days of hospital stay. Sixteen of the 29 patients requested surgery and underwent IA. Laparoscopic appendectomy was performed in 14 of the 16 patients (87.5%). The mean operation time in the 16 patients was 96 minutes, and the mean duration of hospital stay for surgery was 9.4 days. No complication occurred in any of the appendectomized patients. The total duration of the hospital stay was long because we applied conservative treatment at the outpatient clinic and then surgery after abscess remission, which is a problem to be resolved, but conversion to an extended operation occurred only in a few cases and no complications developed employing this therapeutic policy, suggesting its usefulness for the treatment of abscess-forming appendicitis.

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【Background】 We retrospectively evaluated the usefulness of POSSUM and P-POSSUM in emergency abdominal surgery. 【Materials】 One hundred and ten patients who underwent emergency abdominal surgery from November 2006 to October 2009 were studied. 【Methods】 We calculated PS, OS, POSSUM, and P-POSSUM using the clinical records. 【Results】 The overall morbidity with a calculated PS≥30 was significantly higher than that with a PS<30 (82% vs 23%). All nonsurvivors were cases with a PS over 35. The overall morbidity in the high risk group calculated by POSSUM as 71~80%/81～90%/91～100% was 45/60/72%, respectively. All nonsurvivors were cases with a predicted mortality of more than 70% by POSSUM, and the overall mortality in the high risk group predicted as 71～80%/81～90%/91～100% was 20/33/83%, respectively. The overall mortality predicted as 71～80%/81～90%/91～100% by P-POSSUM was 20/33/83%, respectively. 【Conclusion】 POSSUM and P-POSSUM are useful for predicting the high risk group, but both systems over-predict morbidity and mortality.

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The place of diagnostic imaging in trauma care has increased dramatically as a result of the advent and advances in multi-detector row CT (MDCT). MDCT is very useful, because utilizing it appropriately has not only made accurate diagnosis in a short time possible, butbased on treatment policy determinations at the treatment stage it has enabled accrate identification of lesions, and even the anatomical confirmation required for treatment. Classification that emphasizes the vascular damage findings has been performed in the classification of organ damage based on the CT findings, and application to treatment policy determinations is desired. In order to make the most of the advantages of MDCT, in addition to maintaining the physical environment of institutions in terms of their hardware aspects, it is also necessary for the staff of the departments involved, including physicians, nurses, and clinical radiology technicians, to form a common understanding of trauma care, and to attempt to improve their collaboration as a team and their competence as individuals.

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In patients with severe blunt liver injury who were treated according to our unique protocol, we investigated the treatment results, prognosis, and complications. Subjects : Among patients with blunt liver injury who were treated in our hospital between January 2005 and March 2010, the subjects were 57 patients meeting the following conditions : unstable circulatory kinetics, type Ib or III evaluated according to the classification established by the Japanese Association for the Surgery of Trauma, or the extravascular leakage of contrast medium on CT. Protocol : In FAST-positive non-responders, an emergency laparotomy was performed. In the other patients, angiography was conducted when CT revealed the above findings. In patients with extravascular leakage, transcatheter arterial embolization (TAE) was selected. In those without leakage, conservative treatment was performed. Results : Emergency laparotomy was conducted in 7 patients. Of these, 1 died. Non-operative management (NOM) was carried out in 49 patients (including 27 who underwent TAE). There was no patient in whom NOM was switched to laparotomy, and there was no liver injury-associated death. There were no NOM-related complications requiring surgery in any patient. Conclusion : In patients with blunt liver injury, excluding non-responders, NOM is possible regardless of the morphology of the liver injury.

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The strategies of initial management are discussed for hemodynamically unstable patients with complex hepatic trauma. Of 23 cases with hemodynamic instability, early angioembolization (early AE) was adopted for 14 cases, acute celiotomy for 4 cases and active observation for 5 cases. We lost two patients in early AE and one in the acute celiotomy. In successful cases with early AE, an exploration for injury of the hepatic vein or juxtaheatic vena cava revealed the completion of hemostasis, suggesting that an early AE could be comparable to a mandatory surgical procedure only with the arrest of arterial hemorrhage. An early AE, however, failed in the cases of extrahepatic vascular injury including hepatic artery, portal vein and the infrahepatic vena cava. Discretion when performing acute celiotomy should be used when injury exists to the retrohepatic vena cava.

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Non-operative management (NOM) of blunt hepatic injuries for hemodynamically stable patients has become safe and standard practice over the past two decades, however the indication and limitation of NOM have not yet been sufficiently discussed. Here we propose a modified indication of NOM based on our experiences with 183 cases from 2001 to 2008. Our indication consists not only of “hemodynamic stability” as a physiological indicator, but also the “location and extension of hepatic injury” as an anatomical indicator. Our proposal of the “location and extension of hepatic injury” is essential for deciding on the appropriate operative procedures, although it has not been discussed thoroughly. Therefore, our modified indication for NOM is indispensable, and it is the essence of our treatment strategy for hepatic trauma.

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We assessed Non-operative management (NOM) of severe blunt hepatic injuries (BHI) from the anatomical perspective. In the case of hepatic arterial injuries demonstrated through extravasation of contrast media and pseudoaneurysm formation on enhanced CT scans, transarterial embolization (TAE) was essential for arresting active arterial hemorrahge with a low risk of rebleeding in hemodynamically stable patients with severe BHI. For hepatic vein/IVC injuries, the need for salvage surgery in the acute phase after injuries in severe BHI patients with immediate response to fluid resuscitation was seen as a decisive factor. In the case of parenchymal injuries, hepatic injury in 4 or more segments indicated the need for surgery for the infectious complication in the late phase after injuries. For portal vein (branch) injuries, the significance of NOM of severe BHI was undetermined. In the case of bile duct injuries, biliary peritonitis caused by bile leakage can be managed successfully by endoscopic and radiological interventions in the majority of hemodynamically stable patients with severe BHI. Careful assessment of biliary infectious complications is necessary in the late phase of NOM for severe BHI. For hemoperitoneum, hepatic vein injuries should be suspected in patients with increasing hemoperitoneum after TAE for severe BHI.

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【Background】 At our department, classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (DCS) scoring system have been used to determine the efficacy of the treatment strategy in trauma patients. 【Cases and Methods】 We examined 247 out of 289 hepatic injury patients, excluding cardiopulmonary arrest cases. The present study was undertaken to establish a valid strategy for the treatment of hepatic injury. We further evaluated the Japanese trauma treatment system via data on emergency operation cases from the Japan trauma data bank. 【Result】 Interventional Radiology (IVR) treatment cases were all stable or responder patients and all survived with effective hemostasis. Transient responder or non responder patients that needed hemostasis were treated with an emergency laparotomy, and DCS was required in all the cases that eventually died. In the Nippon Medical School, Chibahokusou Hospital, as for the type III hepatic injury (JAST 2008) cases that needed emergency room laparotomy, an operation was performed within an average of 26.4 minutes from arrival at the hospital to the operation. According to the JTDB data, the emergency operation implementation rate within one hour was only 10.6% and within two hours was 46.9% in the severe trauma patients over ISS 50. 【Conclusion】 : According to the initial fluid resuscitation criteria of the trauma center, an emergency laparotomy should be selected for hepatic injury in transient responder and non responder cases.

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Pancreatic injury may occur not only as a result of trauma, but also during an operation. Although the incidence of postoperative pancreatic fistulae with pancreatic injury has certainly decreased, there are many cases who require medical treatment following the development of a pancreatic fistula. We present two patients with pancreatic ductal injury that happened during an operation. Endoscopic retrograde pancreatography (ERP) showed leakage of contrast material localized to the pancreatic parenchyma. We placed a pancreatic stent in each case, after which closure of the pancreatic duct fistula was confirmed. We report on the utility of endoscopic pancreatic stenting for pancreatic ductal injury.

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[in Japanese]

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A 91-year-old woman was admitted with abdominal pain. On palpation there was muscle guarding with tenderness in the lower abdomen. Detailed evaluation using Multi-detector CT (MDCT) images showed multiple press through packages (PTPs) in the ileum. Emergency surgery was performed on the same day. Based on the laparoscopic findings, inflammation was observed only on the serous surface of the small intestine in the lower abdomen. We changed over to a laparotomy. A PTP, which had perforated 10cm proximal from the end of the ileum, was found. Moreover, 10cm towards the oral side from this perforated site, another perforated site caused by another PTP was observed. An ileocecal resection was performed so that both perforated sites fell within the range of the resection. We encountered a very rare case in which multiple ileal perforations were caused by the accidental ingestion of multiple PTPS. MDCT is useful to detect the exact location and number of PTPs and when selecting the appropriate surgical approach.

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An 80-year-old man was admitted to our hospital with septic shock. A CT scan demonstrated massive feces in the rectum and sigmoid colon and extreme distension of the proximal colon. His white blood cell count increased with severe metabolic acidosis and renal dysfunction. He suffered from disseminated intravascular coagulation (DIC). Furthermore he suffered acute respiratory distress syndrome (ARDS), and the platelet count decreased to 27000/m³ despite intensive care with respiratory support and administration of antibiotics and immunoglobulin. He developed melena, and underwent an examination of a colic endoscopic examination in the ICU which showed mucosal necrosis in the sigmoid colon, but no necrosis was seen in the lower rectum. Under a diagnosis of obstructive colitis, a sigmoidectomy and descending colostomy was performed. Postoperative pathological examination of the colon showed ulcerative lesions from the upper rectum to the sigmoid colon. Rapid improvement of the DIC and ARDS was obtained following the operation, with rescue of the patient. Obstructive colitis is generally caused by colon cancer, but cases of fecal impaction are rare. Preoperative endoscopy was useful for the diagnosis in our present case.

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We present a case of typical CT images showing an internal hernia through a defect in the broad ligament of the uterus. A 41-year-old woman was referred to our hospital because of abdominal pain, nausea and vomiting. An abdominal X-ray examination revealed dilatation of the small intestine with air-fluid levels. An abdominal CT scan showed a dilated small bowel loop in the pelvic cavity with displacement of the uterus and rectum, and stenosis of the small intestine at caudal side of the left round ligament of the uterus. Intestinal obstruction due to broad-ligament hernia was suspected and an emergency operation was performed on the same day. After laparotomy, the operative findings revealed a 3cm defect in the left broad ligament of the uterus, and a part of the small intestine, about 30cm long, that was incarcerated through the defect. The constricted bowel was easily freed and the orifice was closed. The patient was discharged on the fifth postoperative day without complications.

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A 60-year-old woman complaining of pharangeal discomfort after eating fish was referred to our hospital with a suspected foreign body in her esophagus. On cervical CT, a 25-mm linear high-density object suggestive of a fish bone was observed below the esophageal entrance. We could view the fish bone in the cervical esophagus with esophageal fiberoscopy, however, it was not possible to remove the bone using suction via the fiberscope. We removed it surgically using a transcervical approach. The fish bone was close to the common carotid artery, but we were able to remove it easily without accompanying hemorrhage or abscess. The patient was discharged 4 days after surgery without any complication. Esophagoscopy is a reliable method for the treatment of esophageal fish-bone impaction, but surgical intervention is unavoidable in cases where the fish bone is irretrievable.

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We report on a patient in whom middle colic arterial rupture was diagnosed with abdominal CT, followed by an emergency laparotomy. A 52-year-old man complained of abdominal pain and diarrhea and went into a state of shock. Abdominal CT showed an aneurysm of colic artery within the mesenteric hematoma. An emergency laparotomy was performed. We recognized the hematoma within the transverse mesenterium and identified an aneurysm measuring 10×5mm which was located in the middle colic artery ; therefore the hemorrhage in this case was diagnosed as coming from the aneurysm and resection of the aneurysm was performed. The histological examination demonstrated the possibility of segmental arterial mediolysis because no definitive evidence of arteriosclerosis or arteritis could be observed.

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A 47-year old man with abdominal pain, diarrhea and vomiting was transported by ambulance to our hospital. Blood pressure and transdermal oxygen saturation level were not able to be measured. CT scan showed pleural fluid and ascites, and the level of Hb was 7.1mg/dL. As the level of Hb did not decrease, an operation was not performed. The day after admission, the patient’s breathing state deteriorated, and his blood pressure decreased gradually. CT scan revealed increase of ascites around the spleen and high density fluid behind the spleen. An emergency operation was performed. After laparotomy, a massive hemoperitoneum due to rupture of the spleen was recognized, and the spleen was excised. Moreover, a solid mass and stenotic lesion existed at the pylorus of the stomach, and the surrounding lymph nodes were swollen. Therefore, the stomach cancer was suspected. On postoperative day (POD) 5, the stomach cancer was confirmed endoscopically and histopathologically and metastasis from the stomach cancer was diagnosed histopathologically in the spleen. On POD 15, complications with septic shock and disseminated intravascular coagulation occurred, and on POD 38, the patient died.

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The patient was a 39-year-old woman working in our hospital as a nurse. The chief complaint was right upper abdominal pain. While driving her car, she was struck from the rear and suffered an upper abdominal lesion from the seat belt. The pain improved for a time, but on the 5th day after the accident, the pain appeared again. On the 8th day she came to our hospital. An abdominal CT scan and ultrasonography showed thickening of the gallbladder wall with suspected hemorrhage. The patient wanted to be treated as an outpatient, so we decided to continue conservative care. On 14th day, the pain was alleviated and imaging thereafter revealed recovery of the gallbladder to a normal condition. Cases of gallbladder injury in blunt trauma treated with conservative care are rare, so we report on our present case with a review of the literature.

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A-50-year-old female was admitted to the emergency room following an abdominal stab wound. Emergency laparotomy was performed because of hemorrhagic shock and evisceration of the mesentery. A massive intramesenteric hematoma of the transverse colon and omental hematoma was found, but no injuries were noted to any of the other intraperitoneal and retroperitoneal structures. On postoperative day 6, the patient complained of abdominal pain. Abdominal CT showed free air around the duodenum, and primary repair and serosal patch using the jejunum was performed for the duodenum injury in the third portion. Duodenal penetrating injuries are frequently overlooked because of the absence of retroperitoneal bile staining, hematoma, and air, thus preventing a proper exploration. We consider that proper mobilization of the retroperitoneum is needed for patients with injuries around the retroperitoneum.

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We present the case of a 43-year-old woman who was on inhaled steroids and oral Uniphyl and Singulair for bronchial asthma treatment. She had been suffering from nausea and vomiting since mid-January. One morning in late January immediately after vomiting, she developed back pain and dyspnea, and was transported to a nearby clinic. The patient was then referred to our hospital for suspected spontaneous esophageal perforation. Upon admission, the patient was having asthma with severe wheezing. Computed tomography demonstrated emphysema in the area between the cervix and the lower mediastinum, and a left-sided pleural effusion. An upper gastrointestinal series confirmed contact medium leakage from the left side of the lower esophagus. Since the leakage did not spread into the thorax, the patient was diagnosed as having an intramediastinal esophageal rupture. Although conservative therapy was considered, there was concern regarding infection exacerbation related to the steroid administration, hence surgery was elected which included a left thoracotomy, irrigation and drainage of the mediastinum and thorax, suture closure of the perforation and suture fixation of the gastric fundus. Since the asthma was controlled with steroids and no sign of anastomotic leakage was detected following surgery, the patient was discharged from the hospital 16 days postoperation.

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A 69-year old man had noted constipation two weeks previously, and was transported by ambulance to the emergency department of our hospital because of sudden vomiting and lower abdominal pain. He had severe tenderness with peritoneal signs, and was in a state of shock. Abdominal CT showed a dilated bowel with feces at the sigmoid colon. We suspected obstructive colitis due to fecal impaction with general peritonitis and performed emergency surgery on the same day. Intraoperative findings revealed the ischemic change with an ulcer ranging from the transverse colon to the descending colon. The diagnosis was obstructive colitis due to fecal impaction. We performed an extended left hemicolectomy and colostomy. Postoperatively, the patient's condition was relieved without complications and he was transferred to another hospital. We should consider the possibility of obstructive colitis in elderly people who have developed obstruction of the bowel from extensive fecal impaction.

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Case 1. A 54-year-old woman with a past history of abdominal surgery was transferred to our hospital because of unresolved abdominal pain of 3 days' duration. Abdominal distension and muscle rigidity were observed. Abdominal computed tomography (CT) showed a dilated small bowel loop without contrast enhancement with the point of discontinuity of the small bowel located in immediate proximity to the left of the uterus. An emergency laparotomy was performed and a strangulated hernia through the broad ligament (fenestra type) with small-bowel necrosis was found. Partial resection of the small bowel and direct closure of the hernia defect were performed. Case 2. A 50-year-old woman without any past medical history was admitted to our hospital for abdominal pain. Her lower abdomen was tender without rebound tenderness. CT images yielded findings that were similar to those of the patient in Case 1 with an enhanced dilated small bowel. Laparoscopic repair of the hernia was performed. A pouch-type hernia protruding through the broad ligament was detected. Laparoscopic reduction and direct closure of the hernia defect were performed. Although internal hernia through the broad ligament of the uterus is a rare condition, early diagnosis based on the patient's history and CT findings is very important to allow a minimally invasive laparoscopic surgery to be performed.

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