[Purpose] To evaluate the usefulness of MDCT for the diagnosis of a closed-loop in patients with small bowel obstruction (SBO) [Materials and methods] Fifty patients with SBO who underwent MDCT were enrolled. The MDCT images were interpreted independently by two of the authors and any discrepancy was resolved by consensus. The patients were divided into two groups, a closed-loop (CL) and an open-loop (OL) SBO group based on the interpretation of the MDCT. An MDCT diagnosis of CL was made if the small intestine was occluded at two adjacent points with a radial vascular distribution. SBO without MDCT evidence of CL was defined as OL-SBO. The MDCT diagnosis was compared with the clinical course and surgical findings. [Results] A MDCT diagnosis of CL was made in 17 patients. OL was diagnosed in 33. SBO was confirmed during surgery in 29 patients, including 14 CL and 15 OL. A comparison of the MDCT diagnosis and surgical findings revealed the sensitivity, specificity, positive predictive value and negative predictive value of MDCT to be 93%, 100%, 100% and 93%, respectively. Moreover, strangulation was evident in 9 (53%) of 17 patients with an MDCT diagnosis of CL, while it was not seen in the OL group. [Conclusion] These results suggest that MDCT is a useful adjunct for making a precise diagnosis of the presence of CL in patients with SBO associated with strangulation.

View full abstract

Between 2002 and 2010, 9 patients underwent emergency surgery in our department for gastrointestinal (GI) bleeding. The patients were divided into 2 groups on the basis of the source of bleeding: the upper GI bleeding (4 patients) and lower GI bleeding (5 patients) groups. The following factors were retrospectively investigated and compared for the 2 groups: patient characteristics, preoperative severity, operative management, and treatment outcome. This analysis showed that patient characteristics and preoperative severity were nearly similar for both groups. The duration between the onset of bleeding and surgery for the lower GI bleeding group was significantly longer than that for the upper GI bleeding group; the intraoperative bleeding count was significantly higher for the upper GI bleeding group. For all the patients from the upper GI bleeding group, the source of bleeding was definitively identified by preoperative endoscopy. However, for 2 patients from the lower GI bleeding group, emergency surgery was performed without accurate preoperative identification of the bleeding point. All the patients were alive at discharge. Our results suggest that it is important to immediately identify the source of bleeding by using various diagnostic modalities in the case of lower GI bleeding and to make sufficient preparations for intraoperative blood transfusion in the case of upper GI bleeding.

View full abstract

Internal hernia associated with small intestine obstruction is a rare disorder which is difficult to diagnose accurately prior to surgery. Among 172 cases undergoing laparotomy in our hospital under the diagnosis of ileus, internal hernia was seen in 7 patients, 2 men and 5 women whose age ranged from 15 to 86 years. An emergency laparotomy was performed within 24 hours after the diagnosis of small bowel obstruction or internal hernia in 4 patients and following bowel decompression with an ileus tube in 3 patients. Among 3 patients with the establishment of a preoperatively accurate diagnosis, 2 patients were diagnosed using multiplanar reconstruction MDCT images as having an internal hernia through a defect in the broad ligament of the uterus. The presence of transepiploic hernia in 1 patient, paracecal hernia in 1, intramesosigmoid hernia in 1, and a broad ligament hernia in 4 were confirmed under laparotomy. All of the 3 patients with high CT values on the mesenterium required small intestine resection. All but 1 case were discharged from hospital 6-32 days after surgery (median: 8 days). Multiplanar reconstruction MDCT images are useful for making an accurate diagnosis of internal hernia prior to surgery, and high CT values on mesenterium is an important sign of the necessity for resection of an incarcerated bowel.

View full abstract

Endoscopic submucosal resection (ESD) for duodenal lesions is difficult with the potential for the complication of perforation. In contrast, with laparoscopic resection for duodenal lesions, it is difficult to make a firm decision regarding the extent of resection required. Laparoscopic-endoscopic cooperative surgery (LECS) for gastric submucosal tumors was reported by Hiki et al. We performed a surgical approach with minimal invasion and excellent outcome for the removal of duodenal lesions using LECS. LECS for duodenal lesions was performed in 4 patients with adenomas (n3) and gastrointestinal stromal tumor (n=1). Conversion to open surgery was carried out in one patient. The postoperative courses in all cases were uneventful. The LECS approach is safe and curative for the removal of duodenal lesions.

View full abstract

NOMI (nonocclusive mesenteric ischemia) is still a severe condition with a poor prognosis because of difficult early diagnosis and exact treatment, as well as the serious backgrounds associated with each case. However, recent extensive progress in diagnostic techniques using MDCT (multidetector row computed tomography) has enabled the early diagnosis of NOMI. Once NOMI has been diagnosed, prompt percutaneous transcatheter drug therapy to release vasospasm through the superior mesenteric artery should be introduced. On the contrary, in cases of intestinal necrosis, safe resection of the inviable intestine with laser Doppler flowmetry should be performed, following by the second-look operation within 24 hours after the first operation. Moreover, the management of background diseases should also be done concurrently from the start of the initial therapy. Thus in the future, the earlier correct diagnosis can be made and the appropriate treatment can be performed leading to a better prognosis.

View full abstract

Clinical features of twenty three cases of non-occlusive mesenteric ischemia (NOMI) were retrospectively studied. Thirteen patients survived (survival group) and ten died (non-survival group). The serum levels of lactate dehydrogenase and creatinine were significantly higher in the non-survival group, and increased creatine phosphokinase level and more severe acidosis were also noted in this group, although the difference was not significant. The patient's age, time interval between the onset of symptoms and hospital admission, white blood cell count and the serum level of C-reactive protein showed no significant difference between the two groups. All the four patients on chronic hemodialysis died. Findings of ischemia of the large intestine and portal vein gas were observed more frequently in the non-survival group. The rate of prostaglandin administration was significantly higher in the survival group. Early recovery of the circulation is the key to a better prognosis in NOMI patients.

View full abstract

Objective: The purpose of this retrospective study was to evaluate the predictive factors for the prognosis in patients with NOMI. Material and methods: 22 patients with a diagnosis of NOMI who had undergone surgery in our department during the past 8 years. We studied the predictive factors regarding the prognoses in two groups, namely the survivors and nonsurvivors. Evaluated prognostic factors were background factors, underlying diseases, preoperative states, the extent of ischemic bowel, the POSSUM score and the use of a vasodilator. Results: There were 7 patients (32%) who died and 15 patients (68%) who survived. In univariate analyses, the POSSUM score (p<0.001), the extent of ischemic bowel (p=0.047), and platelet depletion (p=0.0023) were significant prognostic factors. Conclusion: The POSSUM score, extent of the disease and platelet depletion were significant prognostic factors for NOMI. The POSSUM score in particular was a very useful item for prognostic prediction.

View full abstract

At our hospital, 17 patients with NOMI have been treated in the past 6 years; of these, 5 (29%) died in hospital. Angiography was proactively performed when NOMI was suspected on the basis of clinical findings and CT. Arterial infusion therapy was performed in 13 patients: 2 patients improved without surgery; 3 patients underwent laparotomy but intestinal resection was avoided; and for 1 patient the extent of resection was reduced during second-look surgery. Arterial infusion therapy comprised continuous intra-arterial administration of papaverine following bolus administration of prostaglandin E1 via a catheter placed in the superior mesenteric artery. If persistent peritoneal signs were evident, surgery was performed. Surgery was carried out in 12 patients. Mortality among the 8 patients who underwent both arterial infusion therapy and laparotomy was 25%. Patients who died had already developed multiple organ failure when treatment was started, as it had taken time for the diagnosis to be made. Early diagnosis and arterial infusion therapy on the assumption of surgery should contribute to improving therapeutic outcomes.

View full abstract

Although intra-arterial infusion of vasodilators is a standard strategy for treatment of patients with non-occlusive mesenteric ischemia (NOMI), it is ineffective for patients with severe NOMI because of its complexity and invasiveness. In this study, the efficacy of our strategy, which was based on aggressive emergency laparotomy, for the treatment of patients with severe NOMI was assessed. The average of the acute physiology and chronic health evaluation-II (APACHE-II) score in 17 patients with severe NOMI was extremely high (31.2), and all the patients were in shock when they were suspected as having NOMI. All patients underwent emergency laparotomy, and 14 patients (82%) needed resection of the necrotic bowel. Thirteen patients underwent re-exploration, 5 of which underwent bowel resection. Intra-arterial infusion of vasodilators was performed only in one patient after emergency laparotomy, which resulted in progression of transmural bowel necrosis. The hospital mortality rate was 47% (8 patients). Laboratory data and clinical examinations failed to diagnose bowel necrosis accurately. A definitive operation is risky for patients with severe NOMI because of their poor physical condition. Additionally, staged resections of the necrotic bowel are required frequently. Our strategy that combines prompt and staged exploration is useful for the diagnosis and treatment of severe NOMI.

View full abstract

The mechanism and pathology of patients with severe acute pancreatitis with non-occlusive mesenteric ischemia (NOMI) are still unclear. Currently, there are some reports that vasoconstriction associated factors (angiopoietin-2, endothelin-1 and VEGF et al. ) have important role in the development of NOMI with severe acute pancreatitis. In our experience, one of characteristic pathological findings of NOMI is the non-consecutive enterointestinal damage. The diagnosis of NOMI is not easy in the early stage, so we attempt to use hepatic perfusion CT to diagnose it. Hepatic perfusion CT can evaluate hepatic portal flow (HPF) and hepatic arterial flow (HAF), separately. In our study, HPF of acute pancreatitis patients with NOMI was significantly slower than those without NOMI. Therefore, evaluation of hepatic perfusion in the early stage might be extremely helpful in the diagnosis of NOMI. In this paper, we would like to report the mechanism, pathology, diagnosis and treatment of NOMI in severe acute pancreatitis.

View full abstract

In patients with severe acute pancreatitis, narrowing of the abdominal arteries due to spasm reduces blood flow, causing a special condition called “nonocclusive mesenteric ischemia” (NOMI) which involves extensive mesenteric ischemia and intestinal necrosis. The accompanying collapse of the intestinal mucosal barrier can cause further bacterial translocation, possibly affecting the whole body and inducing multiple organ failure. Such mesenteric ischemia is difficult to assess simply using conventional testing methods. The present study was undertaken to analyze the level of fatty acid-bound protein of intestinal origin (I-FABP) distributed specifically in the small bowel mucosa and to evaluate its clinical significance. The study was additionally designed to evaluate the possibility of I-FABP serving as a marker for early diagnosis of injury to the intestinal mucosal barrier. The results from a monovariate analysis suggested that I-FABP was associated with the severity of acute pancreatitis and served as a prognostic factor differing from the conventional ones. I-FABP was the only parameter found to correlate with LDH (one of the indicators of cell damage). If these results were combined with the specific distribution of I-FABP in the small bowel mucosa and the results from comparison of I-FABP data with the CT findings, it seems likely that I-FABP could serve as an indicator of intestinal mucosal damage associated with NOMI seen in patients with acute pancreatitis.

View full abstract

The diagnosis of NOMI with CEUS (contrast enhanced ultrasound) discussed herein. After the intravenous injection of SonazoidTM, the contrast agent, the entire abdomen was scanned with 3.75MHz convex or 7MHz linear probe transmitting ultrasound of low mechanical index (0.2^0.4) to avoid the rupture of microbubbles. All of the NOMI patients (n=5) showed the bowel segments with no or little perfusion. Four patients (80%) showed the pattern of the mixture of normal perfusion and a perfusion defect in a short bowel segment, which may be a characteristic CEUS finding in NOMI. Although a future study with a larger population is needed to prove the clinical significance of CEUS, it can be used as a non-invasive and convenient diagnostic modality for NOMI.

View full abstract

A 62-year-old man was diagnosed as having oropharyngeal carcinoma (T2N2aM0). Chemo-radiotherapy was carried out and the disease responded with complete remission. Recurrence was later recognized, and S-1 was prescribed. However, the disease progressed. We performed an operation for acute abdomen, the cause of which was diagnosed pathologically as an intestinal perforation due to a metastasis from the oropharyngeal carcinoma.

View full abstract

A 69-year-old man experienced intense pain in the bilateral inguinal region after sneezing and was transferred by ambulance to our hospital. Abdominal computed tomography (CT) revealed incarceration of the sigmoid colon in the left inguinal region and a suspected prolapsed bladder in the right inguinal region. Emergency surgery was performed on the same day. Incarceration of the sigmoid colon without blood flow obstruction was observed in the left inguinal region. On the right side, since the suspected prolapsed bladder could not be visually confirmed, curative surgery was performed from an inguinal approach. After surgery, the patient experienced worsening of anemia and persistent pain. CT revealed a mesenteric hematoma of the sigmoid colon. Endoscopic examination revealed ischemic change but without necrosis of the sigmoid colon. Therefore, emergency intraoperative confirmation of the presence not only of the colonic necrosis but also of any damage to and hematoma in the mesenterium was deemed necessary. This report describes the management that stabilized the patient's condition and enabled his subsequent discharge.

View full abstract

A 68-year-old man visited a physician with the chief complaint of right hypochondrium pain. He was diagnosed as having acute cholecystitis and hospitalized. However, as the symptoms did not improve, he was referred to our hospital. On arrival, he was already showing the symptoms of peritoneal irritation. Generalized peritonitis due to gallbladder perforation was diagnosed according to the results of an abdominal CT performed by the previous physician and abdominal paracentesis performed in the emergency room at our hospital. He underwent an emergency laparotomy. A perforation with a diameter of approximately 3 mm was visually confirmed in the body of the gallbladder, as well as bile spillage from the perforation and moderate biliary ascites in the abdominal cavity. Cholecystectomy and abdominal cavity drainage were performed. There were no stones in the gallbladder. Pathological examination showed little evidence of cholecystitis, while no cause for the perforation, such as intravascular thrombosis in the vicinity of the perforation, was found. After the operation, he was put on a mechanical ventilator and polymyxin Bimmobilized fiber column (PMX) hemoperfusion treatment was administered. After showing satisfactory progress, he was discharged from the hospital in remission on the 11th day after the operation. Spontaneous gallbladder perforation should be considered in cases of generalized peritonitis without free air with ascites retention around the gallbladder.

View full abstract

A 53-year-old woman was transported to our clinic by ambulance after suddenly having stabbed herself in the abdomen with a kitchen knife after quarreling with family members at home. The patient had a deep stab wound in her upper abdomen upon arrival, and a grade IIIa hepatic injury (S4) was observed on abdominal CT imaging. The patient was hospitalized for conservative therapy since she responded to initial fluid therapy. Transcatheter arterial embolization (TEA) was performed following the formation of a left hepatic artery pseudoaneurysm, and an arterio-portal (A-P) shunt with the portal vein main trunk via the aneurysm were observed on abdominal CT on day 2. Following TEA, since the A-P shunt was no longer observed and the patient progressed favorably, she was transferred to the department of neuropsychiatry. Hepatic artery aneurysms following hepatic injury are normally pseudoaneurysms that occur as complications in roughly 1% of hepatic injury cases. Although this complication influences the prognosis since it can cause delayed hepatic rupture and biliary tract hemorrhage, several weeks following injury are required until pseudoaneurysm formation. This case was an extremely rare case in which the hepatic pseudoaneurysm formed accompanying A-P shunt soon after that was subsequently treated by TAE, a description of which is reported herein.

View full abstract

A 54-year-old woman was admitted to our hospital with sudden onset of abdominal pain. A plain abdominal CT scan revealed a dilated small bowel loop, so she was diagnosed as having a small intestinal ileus. Thought an intestinal tube had been inserted for four days, the symptoms did not improve, so the patient was referred to our department for consultation. Enhanced CT scan revealed a dilated small intestine in the pelvic cavity, and forward displacement of the uterus. We diagnosed an internal hernia through the broad ligament of uterus, so an emergency operation was performed. At surgery, we found an abnormal defect in the left broad ligament, with a 60cm-long portion of the ileum from the ileocecal valve herniated through this defect. The herniated ileum was reduced and no bowel resection was needed. The defect of the broad ligament was sutured and closed. The patient's postoperative course was uneventful and she was discharged on the 9th postoperative day. Preoperative diagnosis of such conditions is generally difficult, so we report on our case including the feature of the use of the CT findings.

View full abstract

A 74-year-old man had undergone pylorus preserving pancreatoduodenectomy and spleen-preserving distal pancreatectomy for intraductal papillary mucinous adenoma in November 2004. He was admitted for right lower abdominal pain in August 2009. US and CT showed a linear shadow in the small intestine. We thus diagnosed a small intestinal perforation due to a lost biliary catheter tube. An emergency operation was performed. We removed the foreign body and sutured the site of the small intestine. The patient's postoperative course was uneventful and he was discharged on the 10th day after the operation. Although a small intestinal perforation due to a lost biliary catheter tube is a rare complication, it must be kept in mind.

View full abstract

A 50-year-old man was brought to our hospital due to onset of left chest pain while drinking alcohol. Chest computed tomography showed mediastinal emphysema and left pleural effusion. Left thoracic drainage showed a black effusion contaminated with food residue. An esophagogram showed extravasation of contrast medium from the lower esophagus into the left pleural cavity. We diagnosed spontaneous esophageal rupture. Surgery was performed 15 hours after the onset. Primary repair without reinforcement, drainage, and gastrostomy were performed via a left thoraco-abdominal serial incision. The patient was discharged on the 31st postoperative day. When surgery is performed early and the perforation site is small without necrotic change, there is a possibility of reinforcement not being necessary.

View full abstract

An 82-year-old female was referred to our hospital from another institution due to vomiting. No abnormality in her vital signs was noted. However, her abdomen was full and soft, showing no signs of peritonitis. Slight anemia and inflammation were observed, but arterial blood gas analysis showed parameters within their normal ranges. Abdominal X-ray revealed wide-spread dilatation of the intestine, but no free air. Abdominal computed tomography showed a large amount of gas in the intestine, gas in the intestine wall, and free air in the abdomen. Therefore, we diagnosed the patient as having pneumatosis cystoids intestinalis, and started treatment with an intravenous drip and prohibited eating and drinking. After three days of treatment, the patient showed reduced intestinal gas. After four days, colon fiberoscopy showed a normal intestine. She continued to show a favorable recovery, and started oral food intake on the sixth day. Gas in the wall of the intestine and free air decreased based on abdominal computed tomography findingds, and she was transferred to another hospital on the eighth day.

View full abstract

Case 1 was an 84-year-old woman who was admitted to our hospital because of sudden upper abdominal pain and nausea. An abdominal CT scan revealed advanced portal venous gas and ileus. Since the development of pain and metabolic acidosis appeared, we performed an emergency operation. As irregular necrosis from the ileum to the right hemi-colon was observed, we resected the necrotic intestine. There was no occlusion of the mesenteric artery. We diagnosed the patient as having non-occlusive mesenteric ischemia. She was discharged on postoperative day 39. Case 2 is a 79-year-old woman referred to our hospital following the sudden onset of upper abdominal pain and nausea with a diagnosis of post-operative ileus. An abdominal CT scan revealed advanced portal venous gas and pneumatosis intestinalis. As strong abdominal pain and metabolic acidosis were observed at the first hospital visit, we performed an emergency operation under the diagnosis of intestinal necrosis. Intraoperatively, only postoperative adhesion was observed, without any ischemic change in the intestine. An adhesiotomy was performed, and the patient was discharged on postoperative day 28. Interestingly, these two clinical findings appeared quite similar, but had a contrasting operative course.

View full abstract

A 71-year-old male was admitted to our hospital because of abdominal pain. Enhanced CT revealed abdominal hemorrhage and superior mesenteric artery occlusion. We performed transcatheter coil embolisation for the bleeding from the right colic artery. Since we suspected SMA dissection, laparotomy was performed for bypass grafting. Intraoperative findings showed an embolus in the ileocecal artery, therefor we performed an embolectomy, after which the blood flow improved gradually. We completed surgery without any resection of the intestinal tract. The postoperative course was uneventful, however intestinal obstruction necessitated a right hemicolectomy three months after the first surgery. Cicatrization and stenosis were found at the ileum end and ascending colon. Since embolectomy can cause delayed bowel stenosis, careful observation of the clinical course is recommended.

View full abstract

Emergency open surgery is often chosen for the treatment of obturator hernia, however, as in cases of hernia incarcerations, an increasing number of cases of elective operations after closed reduction have been reported recently. We report on a case of obturator hernia in a 106 year old woman whose elective surgery was performed after two-time closed reductions. We performed a closed reduction for an obturator hernia in the patient. Four months later she had a recurrence of the obturator hernia and she visited the hospital within four hours of the onset of symptoms. On this occasion we performed a closed reduction again and performed the elective operation later. The elderly, who have a higher complication rate, will greatly benefit from closed reductions because they can avoid an emergency operation with its associated risks. However, closed reduction may result in a higher rate of late-onset short bowel perforation owing to the fact that the incarcerated bowel cannot be identified. Therefore, it is dangerous to perform closed reductions without careful consideration. We report on the indications of closed reductions for obturator hernias with a review of the literature.

View full abstract

A 62-year old patient underwent a radical tension-free hernia operation for a bilateral inguinal hernia in August 2009. He had a past medical history of bronchial asthma and no experience of laparotomy. On the 1st postoperative day, the patient developed abdominal pain and vomiting and was diagnosed as having ileus. Intestinal intubation was performed, but the symptoms did not improve and peritoneal irritation was also observed. Consequently, an emergency laparotomy was performed on the same day. The laparotomy findings indicated massive hemorrhagic ascites and intestinal necrosis. Furthermore, the appendix epiploica of the sigmoid colon had adhered to the peritoneum close to the right internal inguinal ring and formed a band, and the jejunum was impacted and strangulated. The strangulated portion of the small intestine was removed and no damage was confirmed in the peritoneum at the hernia repair site. Intestinal obstruction following radical inguinal hernia operation (Tension-free) is rare. In this case, the peritoneal band existed at the hernia repair site so that the small intestine slid into the space made when the hernia sac was dissected, allowing the intestinal obstruction to occur.

View full abstract