We analyzed the severity grade according to the guidelines for acute cholecystitis (AC), and compared the domestic guidelines with the Tokyo guidelines. Two hundred thirty-three AC patients who underwent cholecystectomy were enrolled. The AC severity grade according to the domestic guidelines was classified as Mild 20. 2%, Moderate 46.8%, and Severe 33.0%, while according to the Tokyo guidelines it was classified as Mild 42.1%, Moderate 57.1%, and Severe 0.8%. In the analysis of each set of guidelines, appropriate classification was demonstrated from the point of view regarding inflammatory findings. However, in comparison between the Mild and Moderate classifications in both guidelines, there was a significant difference in the inflammatory findings. The severity grade in the Tokyo guidelines showed more significant inflammation than the domestic guidelines. Therefore, large population-based studies related to the guidelines, especially the Tokyo guidelines are required to ascertain the outcomes depend on the severity grade. Furthermore, it was felt that the Tokyo guidelines required revision of the severity grade criteria depending on the results.

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In order to clarify the indication for liver transplantation (LT), the pathological examination of the liver explants in 52 patients who underwent LT for fulminant hepatic failure (FHF) was performed. The most important indication of LT for FHF was progressive hepatic encephalopathy after intensive medical treatments. The new guidelines by the acute liver failure group of Japan in 2008 and a new prognostic formula using the volume of the explanted liver was examined. The pathological examination of the explanted liver revealed the necrotic ratio, atrophic rates, and functional remnant liver volume. The one year survival rate after LT was 84.9%. In 86% of the patients, the score according to the new guidelines was no less than 5 (the expected mortality rate no less than 80%). The prognostic formula using the liver volume forecast a poor prognosis in 96% patients. The mean atrophic liver rate and necrotic rate were 57% and 64%, respectively. The functional remnant liver volume was less than 35% in 43 patients and the score of new guidelines was no less than 5 in 8 of 9 patients, whose functional remnant liver volume was more than 35%. In conclusion, our indication of LT for FHF was useful and adequate after pathological examination of the explanted liver.

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(Purpose) Superior mesenteric artery (SMA) embolisms are rare, and the treatment results to date have not been favorable. The treatment options for SMA embolisms are surgery and intervention, but it is not clear which offers the greatest advantage. We examined these treatment choices in patients with SMA embolisms. (Subjects and Methods) The subjects were 22 SMA embolism patients in our hospital between April 2001 and April 2010. Twelve patients underwent operations, 4 patients were treated by intervention, 2 patients received heparinization, and 4 patients received no treatment. We compared the operation group (Op group) with the intervention group (Iv group) for survival rate, laboratory data (white blood cell count, CRP, CPK, LDH, ALP, and BE), perioperative computed tomography findings (intestinal emphysema, ascites, and enlargement of intestine), and the time from onset. (Results) The survival rate was 75% (9/12) in the Op group and 100% (4/4) in the Iv group. In laboratory data, there was a significant difference only in CRP (Op group: Iv group=9.3±10.2: 0.4±0.5, p<0.05). In computed tomography findings, there was a significant difference only in enlargement of the intestine (p<0.05). Intestinal emphysema was recognized in 3 patients in the Op group only. The time from onset in the Iv group was shorter than in the Op group (Op group: Iv group=24±19hr: 9±3hr, p<0.05). (Conclusion) A strategy for the treatment of superior mesenteric artery embolisms should be decided considering CRP in the laboratory data, enlargement of the intestine and intestinal emphysema on computed tomography, and the time from onset.

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Vascular injuries, bowel injuries and organ injuries are often encountered in laparoscopic colectomy as accidental complications. Such injuries still sometimes occur even at present. We have performed 446 laparoscopic colectomy so far, among whom 14 cases of vascular injuries, 9 cases of bowel injuries and 1 case of organ injury have occurred. Though 12 cases of laparoscopic colectomy had to be converted to open surgery, conversion was not required in any of the vascular injury cases. In order to avoid these accidental situations, there are some significant steps that have to be followed in laparoscopic colectomy. Surgeons need to follow standard operative procedure, learn about the principle and characteristic of surgical devices, and acquire the skill of using those devices. Furthermore, the operator, his/her assistant and endoscopist should have sound anatomical knowledge concerning the membrane structure and proper dissection layer. The collaboration between clinicians can also lead to obtain a better surgical field of view. The surgeon, the assistant and endoscopist become the triunity. A coordinated operation should be carried out, and the visual field is ensured after the anatomical membrane structure and stratum disjunction are understood. However, we should not hesitate to convert to open laparotomy in those cases where the laparoscopic field of view is limited, or bleeding is poorly controlled.

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The diagnosis of traumatic pancreatic injury in the acute stage is difficult to establish blood tests and abdominal findings alone. Moreover, to determine treatment strategies, it is important not only that a pancreatic injury is diagnosed but also whether a pancreatic ductal injury can be found. At our center, to diagnose isolated pancreatic injuries, we actively perform endoscopic retrograde pancreatography (ERP) in addition to abdominal CT at the time of admission. For cases with complications such as abdominal and other organ injuries, we perform a laparotomy to ascertain whether a pancreatic duct injury is present. In regard to treatment options, for grade III injuries to the pancreatic body and tail, we basically choose distal pancreatectomy, but we also consider the Bracy method depending on the case. As for grade III injuries to the pancreatic head, we primarily choose pancreaticoduodenectomy, but also apply drainage if the situation calls for it. However, pancreatic injuries are often complicated by injuries of other regions of the body. Thus, diagnosis and treatment of pancreatic injury should be based on a comprehensive decision regarding early prioritization of treatment, taking hemodynamics into consideration after admission, and how to minimize complications such as anastomotic leak and pancreatic fistulas.

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[Background] The surgical indications for treating pancreatic injury have so far been dependent on the extent of such injury to the main pancreatic duct. However, the prognosis of pancreatic injury often is associated with the development of shock and the resulting hemodynamics. An investigation was carried out on a treatment strategy for pancreatorrhagia in 7 cases with traumatic pancreatic injuries. [Method] Pancreatorrhagia was defined as a disease in which extravasation from the pancreatic parenchyma was revealed upon CT findings. [Results] There were 7 male demonstrating pancreatorrhagia with a mean age of 34.3±13.0 years. Six of 7 cases underwent emergency abdominal surgery. In their laparotomy findings, all cases revealed persistent bleeding from the blood vessels of the pancreatic parenchyma and the area surrounding the pancreas, so suturing and surgical hemostasis were performed. Injury of the main pancreatic duct was observed in all 6 cases, and we were able to save the lives of the patients by performing pancreatectomy and drainage. On the other hand, the one patient who was treated by transcatheter embolization died from hemorrhagic shock. [Conclusion] Prompt abdominal hemostasis for traumatic pancreatorrhagia, and appropriate surgery, including damage control surgery, is therefore believed to lead to an increased survival rate.

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We reviewed 16 cases with traumatic pancreatic injuries over a 5-year period. The classification system used was the 2008 version of the Japanese Association for the Surgery of Trauma. Under this system, grade IIIb is the most severe type, with pancreatic duct injury. Of our 16 cases 7 were Grade IIIb (head 4, body 2, tail 1). Four cases (IIIb head) were treated with PD and PPPD. Three cases required an emergency room laparotomy (ERL), 2 cases required damage control surgery (DCS) and 1 case required a resuscitation thoracotomy/emergency room thoracotomy (ERT) with a thoracic aorta clamp. Death occurred in 1 case (Grade IIIb Ph). In cases of severe shock due to intra-abdominal hemorrhage, hemostasis via an emergency laparotomy is important. The second priority is the intra-operative diagnosis of the main pancreatic duct. Furthermore, it is necessary to perform DCS.

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Pancreatic duct disruption accompanied by pancreatic trauma is very severe. Endoscopic retrograde pancreatography (ERP) is considered the main diagnostic modality. However, it is invasive and can be associated with significant complications. We diagnosed pancreatic trauma based on only Computed tomography (CT) scan data. We operated based on specific signs of pancreatic injuries on CT scans, such as edema or hematoma of the pancreatic parenchyma, fractures or lacerations of the pancreas, active hemorrhage and, in all cases, there were main pancreatic duct injuries. Certain drainage of the pancreatic juice is necessary for pancreatic duct disruption. The operation method was selected according to the location of the damage. If it is at all possible pancreas preserving surgery should be performed. It is necessary to select the operation according to the patient's age and general condition, the cause of the injury, the range of the injury, and the experience of the surgeon. When the main duct injury was not certain, ERP during the operation was very useful. We report on a method of endoscopically treating a pseudocyst, which has adhered to the stomach, secondary to pancreatic main duct disruption. Transgastric placement of a stent into the pseudocyst is possible in restricted cases.

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As for the treatment for injuries of the main pancreatic duct, removal or reconstruction of the pancreas is reliable; however, the treatment method for pancreatic injuries (type IIIb) (JAST) has not been established yet. There were 14 cases of pancreatic injuries (type IIIb) in our hospital and relevant institutions encountered within 28 years, and emergency Endoscopic Retrograde Pancreatography (ERP) was performed 10 times (one of them being in surgery). As for the treatment method, pancreaticoduodenectomy was performed in 5 cases, distal pancreatectomy in 3, the Letton & Wilson approach in 3, and 1 case each for suturing the main pancreatic duct, drainage treatment and endoscopic stent treatment. Although one patient died at the beginning of surgery, the overall results were still satisfactory. When the surgical approach is considered, reliable evaluation of the main pancreatic duct is very important and ERP is very useful. According to the different symptoms, there will be some cases in which surgery can be avoided by using endoscopic stent placement. ERP will gradually become more important.

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Pancreatic trauma is a relatively rare abdominal injury, with a mortality rate of approximately 15% when the cause of injury is blunt trauma or a stab wound. The mortality rate tends to be higher when the patient is in a state of shock on arrival at hospital. The mortality rate also rises when associated organ injury is present, or when surgical treatment for pancreatic duct disruption is deferred because of a delayed diagnosis. In the absence of these risk factors for mortality, pancreatic duct repair (PDR) is an adaptable procedure, provided that the injured pancreatic site is localized to a small area within the pancreatic neck or body. PDR consists of creating an end-to-end anastomosis of the pancreatic duct and pancreatic parenchyma. Insertion of a stent through the pancreatic duct is necessary to avoid duct stenosis and to reduce ductal pressure. Postoperative pancreatic complications following PDR include pancreatic fistula (26%), pancreatitis (13%), pancreatic cyst (8.7%), and intra-abdominal abscess (4.3%). The normal intra-operative time for PDR is 200 min in our institution. In comparison with distal pancreatectomy, the rate of postoperative pancreatic complications following PDR is slightly higher, except for intra-abdominal abscesses; the intra-operative time for PDR is also longer. However, PDR is a preferable procedure with regard to preservation of pancreatic and splenic function. In addition, reconstruction is anatomically and physiologically simple.

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The principle of treatment for pancreatic trauma with major pancreatic ductal injury is an operation. However, even if the pancreatic duct is injured, diffuse peritonitis can be avoided through the use of endoscopic pancreatic stents. Endoscopic pancreatic stents reduce leakage of pancreatic juice, and induce the formation of pseudocysts, which can be treated with endoscopic transgastric or transduodenal drainage. The first step of management for pancreatic trauma is to perform endoscopic retrograde pancreatography. It is important, because the treatment of pancreatic trauma depends on the injury of the major pancreatic duct. Furthermore, when interventional radiology and an operation can be performed, non-operative treatment with an endoscopic pancreatic stent is one option of treatment for pancreatic trauma with major pancreatic ductal injury.

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A 50-year-old woman visited her family doctor with sudden abdominal pain after lunch and was sent to our hospital. Enhanced computed tomography showed an encapsulated and dilated small intestinal loop in the right abdomen and the contrast effect was poor. Furthermore, the right kidney located in the pelvic cavity. Suspecting a strangulated intestinal obstruction caused by an internal hernia, we conducted emergency surgery five hours after symptom onset. A laparotomy showed almost all of the small intestine was incarcerated into the paraduodenal hernia orifice from left to right, and intestinal loops were located in the retroperitoneal space where usually the right kidney exists. The incarcerated small intestine was repositioned and the hernia orifice was sutured. The normal color of the small intestine recovered gradually, and resection was avoided. We report a rare case of right paraduodenal hernia accompanied with right pelvic kidney.

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We experienced a case of intraperitoneal spontaneous rupture of the urinary bladder due to radiation cystitis thirty one years after the patient had undergone radiation therapy for uterine cancer. A 96-year-old woman was admitted to our hospital with acute abdominal pain. She had undergone radiation therapy for uterine cancer 31 years earlier. Because panperitonitis was suspected, an emergency laparotomy was performed. At laparotomy, no apparent perforation was seen in the gastrointestinal tract, but rupture of the bladder was identified. It was too difficult to suture the perforation site directly, so we performed closure of the perforation site with the greater omentum. In a review of the published literature from 1969 to 2010 in Japan, 50 cases of intraperitoneal spontaneous rupture of the bladder associated with radiation cystitis, including our case, have been reported. Our case was the oldest patient in whom the patient's life was saved. We believe that the experience associated with this case is very valuable, so we report on it herein.

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A 80-year-old woman was admitted to our hospital with abdominal pain and constipation. An abdominal CT scan demonstrated multiple masses and free air. An emergency operation was carried out under the diagnosis of perforative peritonitis. There were numerous tumors on the small intestine with peritoneal dissemination in the abdominal cavity, with a perforation located about 280cm distal from Treiz's ligament, and a metastatic tumor located in both lobes of the liver. We performed a partial resection of the small intestine, resection of 6 of the small intestine and mesenteric tumors, and a partial resection of the major omentum. Histological findings revealed proliferation of epithelioid cells. Tumor cells were positive for c-kit, and partially positive for CD34. All resected tumors were diagnosed as gastrointestinal stomal tumors (GISTs). GISTs should be considered as one of the causes of perforative peritonitis. A case of multiple GISTs of the small intestine with perforation is herein described with a brief review of the literature.

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A 88-year-old woman referred for appetite loss and vomiting was found on abdominal computed tomography (CT) to have a hernia through the foramen of Morgagni prolapsed with the transverse colon and omentum, with stenotic sigmoid colon cancers further detected. We suspected a strangulated Morgagni's hernia and performed emergency surgery. Laparotomy disclosed a hernia located at the foremen of Morgagni with a sac containing the transverse colon, jejunum and omentum. After removal of the sac manually, the hilum was closed with a continuous suture. In addition, Hartmann's operation was performed based on the diagnosis of a large bowel obstruction by sigmoid colon cancer. These findings can be justified since the ileus symptoms of Morgagni's hernia were potentiated by increased large bowel pressure due to stenosis by the sigmoid colon cancer. We report herein on this rare case in which Morgagni's hernia was complicated with sigmoid colon cancers, together with a review of the literature.

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A 90-year-old female patient with vomiting and loss of appetite underwent an endoscopic examination of the upper gastrointestinal tract, which revealed multiple ulcers at the greater curvature of the stomach and a large quantity of gastric contents. Abdominal computed tomography (CT) showed an organoaxial gastric volvulus, but there were no ischemic changes. Inflammatory reactions appeared on the third disease day, and the CT scan showed abdominal free air. An emergency operation was performed. The greater curvature had rotated, and had adhered to the right lobe of the patient's liver. There was a perforation in the stomach. We affixed the stomach to the abdominal wall after performing a partial gastrectomy. Histological examination of the resected specimen showed ulcerative lesions composed of necrotic inflammatory granulation tissue and regenerative gastric mucosa. Several blood vessels contained thrombi with various phases of organization. It was thus concluded that the perforation of the stomach had been caused during a period of chronic ischemia.

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A 71 year-old-female with shoulder and back pain and hematemesis was transferred to our hospital as an emergency. CT scans showed that an abscess of the left neck extended to the inferior mediastinum. On admission, she was treated with cervical and thoracic drainage and a large volume of matter was discharged from the abscess. αStreptococcus (group A) was detected with a culture test. Despite intensive care (chemotherapy, drainage, and so on), the patient died on the eleventh hospital day with multiple organ failure. Because of the deterioration of the respiratory system and the patient's poor general condition, we did not try mediastinal drainage with thoracotomy. If we had diagnosed Descending Necrotizing Mediastinitis (DNM) and tried early and aggressive drainage through a thoracotomy, there was some possibility that she might have survived the DNM. This report also includes a review of the relevant literature.

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A 64-year-old man, who had undergone hemodialysis for 11 years, presented with left abdominal pain. Computed tomography showed a 10cm hematoma located in the left retroperitoneal space, and that multiple cysts and leakage of radiocontrast agent were noted in the hematoma. He was diagnosed as having a retroperitoneal hemorrhage from the left kidney, and spontaneous rupture of the renal cyst was suspected. Securing the visceral hemostasis was required to allow hemodialysis to continue, so emergency surgery was planned. The patient underwent nephrectomy through a median incision, and first the left renal vessels were ligated before manipulation of the kidney. The resected specimen revealed hemorrhage in the renal cysts, one of which had ruptured. Rupture of the renal cysts due to spontaneous hemorrhage is very rare. We report herein on the present patient with some review of the literature.

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We report a case of a gastrointestinal stromal tumor (GIST) with intussusceptions of the small intestine. A 62-year-old man was admitted to hospital with melena. After hospitalization the patient had abdominal pain and vomiting. Abdominal computed tomography demonstrated a multiple concentric ring sign incarcerated intestine containing a high density tumor of the small intestine. Radiography of the upper jejunum showing narrowing and a ring-shaped translucency 2.4cm in size. Surgery confirmed intussusception due to a tumor of the jejunum, and partial resection of the jejunum was carried out. An intussusception of the small-intestine tumor 3cm in diameter was found during the operation at a location 30cm from the Treitz ligament; consequently a portion of the small intestine including the tumor was resected. Histopathological examination revealed proliferation of oval-shaped mesenchymal cells. The immunohistochemical analysis revealed that the tumor cells were positive for c-kit, but negative for CD34 and α-smooth muscle actin. The tumor was diagnosed as a GIST of the small intestine, uncommitted type. GIST should be considered in the differential diagnosis of intussusception.

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A 58-year-old woman had undergone repair of a left groin hernia with a mesh plug in September 2007. In May 2010, she was admitted to our hospital with abdominal pain and bulging of the left groin region. A diagnosis of an incarceration of a femoral hernia was made because contrast-enhanced CT showed small bowel obstruction, incarcerated intestine, and compression of the left femoral vein. An emergency operation was performed. Laparoscopic examination revealed that the small intestine was incarcerated into the left femoral ring. The incarcerated intestine was released by saline infusion with a Nelaton tube. A plug was inserted into the hernia sac and fixed to the hernia orifice. Bowel resection was not carried out. The postoperative course was good and the patient was discharged on the 10th postoperative day. Laparoscopic surgery is useful for both diagnosis and treatment of incarcerated femoral hernias.

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We report on a case of obstructive colitis associated with sigmoidal cancer which was diagnosed before the operation. A 84-year-old man visited our hospital with left lower abdominal pain. Based on colon fiberoscopy, a diagnosis was made of sigmoid colon cancer. However, the patient had strong lower left abdominal pain with high immune-related inflammation. We recognized that it was probably as a result of the obstructive colitis. Abdominal CT and the double contrast enema findings revealed an abnormality in the wall at the descending colon 10cm orally from the tumor. During the operation, the wall induration and the ulceration by the inflammation existed at the same site. Histopathological examination revealed a diagnosis of the obstructive colitis. The postoperative course was uneventful. It is difficult for us to diagnose obstructive colitis preoperatively, but it would appear that the surgeon needs careful consideration regarding the decision of the excision range.

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A 28-year-old man with no medical history visited our hospital with lower abdominal pain and fever. The physical examination revealed a large firm lower abdominal mass with tenderness but no signs of peritonitis. Laboratory findings showed leukocytosis and a slight elevation of the CRP. Abdominal enhanced 3D-CT revealed a wandering spleen which had clockwise rotation in the pelvis with infarction. We therefore performed a splenectomy. No postoperative complication occurred and the patient was discharged on the 8th day after the operation.

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A 61-year-old man visited the emergency department of our hospital with epigastric pain, vomiting and diarrhea. An abdominal enhanced CT scan showed a slightly dilated intestine with edematous change and dissection of the superior mesenteric artery with thrombosis of the false lumen and narrowing of the true lumen. After conservative therapy, his symptoms and general condition improved. On the third hospital day, enhanced CT images revealed that the false lumen was relieved. The patient recovered completely and was discharged on the ninth day.

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