The clinical features and outcomes of 85 cases of colonic diverticular bleeding diagnosed at our hospital between January 2002 and January 2012 were examined. The source of the bleeding was in the right hemicolon in 41 cases (37.6%), in the left hemicolon in 32 cases (37.6%), and could not be determined in 12 cases (14.1%). Spontaneous hemostasis was accomplished in 60 cases (70.6%), endoscopic treatment was needed in 21 cases (24.7%), emergency surgery in 2 cases (2.4%), elective surgery in 1 case (1.2%), and IVR (interventional radiology) in 1 case (1.2%). Re-bleeding did not occur in any of the 7 cases in which the endoscopic treatment was performed using the distal attachment. Therefore, it is useful to maintain a frontal view of the bleeding point using the distal attachment, and use an endoscope equipped with a water jet while performing endoscopic treatment for colonic bleeding.

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Purpose: We compared the degree of wound pain after appendectomy through an alternate incision (AI) with that after appendectomy through a pararectal incision (PI). Subjects: The subjects of this study were patients who had undergone appendectomy via an AI or PI at our hospital. Patients who were under 25 y of age, had abscesses, and/or had difficulty in communicating were excluded from the study. Out of the 45 subjects of this study, 24 had undergone appendectomy via an AI (AI group) and 21 had undergone the surgery via a PI (PI group). Method: A questionnaire survey was carried out to evaluate the following parameters: (1) wound length, (2) wound length index (wound length ÷ body surface area), (3) total pain score calculated using the modified Prince-Henry score (mPHS), (4) days required to reach Grade B in mPHS, (5) and duration of painkiller use. Results: The wound length in the PI group was higher than that in the AI group (AI, 4.10 cm; PI, 6.64 cm; p < 0.001). The severity of the wound pain was greater in the PI group than that in the AI group (total pain score: AI, 4.29; PI, 7.81; p = 0.013; day to Grade B: AI, 2.33 days; PI, 3.62 days; p = 0.022). The duration of painkiller use was longer in the PI group than that in the AI group (AI, 1.21 days; PI, 2.88 days; p = 0.042). However, when the analysis was limited to only patients with a drain, no significant difference in the total pain score, days to development of Grade B, or duration of painkiller use was observed between the two groups. Conclusion: In order to reduce postoperative wound pain after appendectomy, surgeons should choose AI over PI as far as possible. Furthermore, drainage is no longer needed and should never be implemented?.

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Ever since Wang et al. reported the significant role of high-mobility group box 1 (HMGB1) in mouse sepsis in 1999, a number of investigators have recognized its important role in various inflammatory conditions and diseases. Fulminant hepatic failure (FHF) remains a serious clinical condition that is associated with a high mortality rate. We are focusing on HMGB1 as a therapeutic target for FHF. We investigated the plasma and hepatic tissue levels of HMGB1 in patients with FHF and in a drug-induced rat FHF model. Then, we investigated the effects of HMGB1-targeted therapy, including anti-HMGB1 neutralizing antibody, gene transfer of the A box domain of HMGB1 which antagonizes HMGB1, recombinant human thrombomodulin, and an HMGB1 adsorption column, employing animal models. We obtained promising results from each of the experiments. Experiments focusing on HMGB1 appear to offer hope towards establishment of clinically useful treatments for FHF.

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The usefulness of a transanal decompression tube for obstructive colorectal cancer was evaluated. A total of 37 patients were divided into the transnasaldecompression-tube inserted group (TNDT group; n=21), and a non TNDT group (n=16). The mean age of the patients in the non-TNDT group was significantly higher, and these patients showed a poorer nutritional status, and higher serum C-reactive protein levels than those of the TNDT group. The tumors were located in the left-sided colon in 20 patients of the TNDT group, and 5 patients of the non TNDT group. In all, 16 patients of the TNDT group and 5 patients of the non TNDT group underwent single-stage surgery. One patient of the TNDT group developed the complication of perforation of the tumor during the tube insertion. None of the patients who underwent single-stage surgery showed anastomotic leakage. Four patients of the non TNDT group died after the surgery, while none of the patients of the TNDT group died. The transanal decompression tube is an excellent tool for the relief of malignant obstruction in the left-sided colon, if the patients are in a good general condition.

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We performed a citation analysis of the Tokyo Guidelines (International clinical practice guidelines for acute cholangitis and cholecystitis) and the JPN Guidelines 2006 (English version of Japanese clinical practice guidelines for acute pancreatitis) to validate international recognition and application of both sets of guidelines. Articles in the TG07 and JPN guidelines were cited by many authors all around the world in the journals associated with various fields. The diagnostic criteria and severity assessment of acute cholangitis and cholecystitis established by the TG07 have been utilized by many clinical studies. In order to enhance the clinical usage and popularization of the updated Tokyo Guidelines (TG13), we developed a mobile application.

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We reviewed the revised process of the JPN Guidelines for acute pancreatitis (AP) with a specific focus on the items at diagnosis, severity assessment, and the criterion for transfer. The diagnostic criteria for acute pancreatitis were revised by the Research Group for Intractable Diseases and Refractory Pancreatic Diseases, Japanese Ministry of Health, Labour and Welfare (JMHLW Criteria). Blood amylase was initially recommended in the laboratory examination, and subsequently blood lipase is now the first step for diagnosing AP. The revised criteria for severity assessment of AP consist of nine poor prognostic factors and the computed tomography (CT) grades based on contrast-enhanced CT. The new criteria assess the severity of AP as mild to severe. The criterion for transfer was a score of 2 or more of previous severity assessment criteria, and was revised to those of 3 or more of existing criteria. It is desirable to transfer patients with severe AP to a medical institution where full-time physicians exist who are specialized in intensive care, endoscopic treatment, radiological intervention, and staffed by cholangiopancreatic surgeons.

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Contrast-enhanced computed tomography (CECT) is useful in assessment of disease severity and/or prediction of the prognosis in patients with acute pancreatitis. Local complications in acute pancreatitis are defined based on CECT criteria in the revised version of the Atlanta Classification of acute pancreatitis. Although aggravation of impairment of pancreatic microcirculation in necrotizing pancreatitis has been claimed in experimental studies, there was no evidence that CECT aggravated the clinical severity of patients with acute pancreatitis. Contrast medium had long been a contraindication in principle in acute pancreatitis. However, the absolute contraindication has been changed to careful administration in drug information since 2012. On the other hand, The Japanese guidelines for the administration of contrast medium in patients with renal disease were published in 2012. Informed consent on application of contrast medium in acute pancreatitis should be mandatory when contrast medium is to be adminsitered in acute pancreatitis patients with kidney damage.

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Bundles that define mandatory items or procedures to be performed in clinical practice have been increasingly used in guidelines in recent years. Observance of bundles enables improvement of the prognosis of target diseases as well as guideline preparation. Pancreatitis Bundles defined by the JPN Guidelines 2010 for management of acute pancreatitis, were not only first bundles in Japanese practice guidelines but also the world's first bundles for acute pancreatitis. The pancreatitis bundles included those interventions that are judged to be important on the basis of a recommendation classification of “A or B”. Each item includes assessment of severity after a diagnosis of pancreatitis has been made, differentiation of pathogenesis, management of gallstone-induced pancreatitis, a sufficient dose of fluid replacement and monitoring, pain control, prophylactic administration of wide-spectrum antibiotics and cholecystectomy following resolution of pancreatic symptoms caused by cholecystolithiasis. Hereafter, the efficacy of these indicators and the significance of their achievement should be examined carefully. The assessment of the compliance rate with the guidelines as well as the assessment of the guidelines itself should thereafter become possible.

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Diagnostic criteria of acute cholangitis and cholecystitis in the Tokyo Guidelines (TG07) have been extensively used all over the world as the first standard. However, the clinical assessment of TG07 by means of multicenter analysis conducted by the TG07 Revision Committee showed some limits in these criteria. The TG07 diagnostic criteria of acute cholangitis have not enough diagnostic capacity as those of life-threating disease, due to the inappropriate combination of their diagnostic items., and so they have been revised as criteria to establish the diagnosis by cholestasis and inflammation based on clinical signs or blood test in addition to biliary manifestations based on imaging. The TG07 diagnostic criteria of acute cholecystitis had a good diagnostic capacity, but the criteria for a definitive diagnosis were ambiguous and unsuitable for clinical use. The definitive diagnosis was revised, as a clear and simple criterion based on imaging findings of acute cholecystitis in addition to suspected diagnosis by local and systemic inflammation signs based on clinical signs or blood tests. The revised diagnostic criteria for acute cholangitis and cholecystitis have better diagnostic capacity and are more suitable for clinical use than the TG07 criteria.

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[in Japanese]

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In 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were first published in the Journal of Hepato-Biliary-Pancreatic Surgery. Regarding acute cholecystitis, TG07 helped the spread of early laparoscopic cholecystectomy without gallbladder drainage. On the other hand, some surgeons have emphasized that routine early cholecystectomy may lead to an increased risk of biliary tract injury. These situations require a re-evaluation of gallbladder drainage for acute cholecystitis. Regarding acute cholangitis, recently single- or double-balloon enteroscopy-assisted biliary drainage (BE-BD) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) have been reported as special techniques for biliary drainage. Thence, revised Tokyo Guidelines (TG13) have been prepared in accordance with the new evidence, and were released in January 2013 on the web. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) systems were utilized to provide the level of evidence and the grade of recommendations. This article presents the reason and evidence for the revision in the “Drainage for acute cholangitis, cholecystitis” of TG13.

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Recent years, bundles that define mandatory items or procedures to be performed in clinical practice have been increasingly used in guidelines. Observance of bundles enables improvement of the prognosis of target diseases as well as guideline preparation. There were no bundles adopted in the Tokyo Guidelines 2007, but the updated Tokyo Guidelines2013 (TG13) have adopted this useful tool. Critical parts of the bundles in TG13 include diagnostic process, severity assessment, transfer of patients if necessary, therapeutic approach, and time course. Their observance should improve the prognosis of acute cholangitis and cholecystitis. When utilizing TG13 management bundles, further clinical research needs to be conducted to evaluate the effectiveness and outcomes of the bundles. It is also expected that the present report will lead to evidence construction and contribute to further updating of the Tokyo Guidelines.

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A 72-year-old male underwent subtotal stomach-preserving pancreaticoduodenectomy for cancer of the lower bile duct. Contrast-enhanced CT showed an unruptured pseudoaneurysm of the common hepatic artery on the 14th day after the operation. A coronary stent graft was placed for the pseudoaneurysm to maintain the blood flow to the liver and minimize the risk of complications following embolization of the common hepatic artery. Complete pseudoaneurysm exclusion was seen after the procedure, with preservation of the hepatic arterial flow. Contrast-enhanced CT performed 3 months after the procedure showed patency of the stent graft and blood flow in the hepatic artery. Successful utilization of coronary stent grafts for visceral arteries has the advantage of both maintaining the peripheral blood flow and occluing a pseudoaneurysm, although it is usually used only for the treatment of coronary arteries in Japan. This technique may also prove to be a safe and efficacious alternative to coil embolization for patients with portal vein occlusion.

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A 67-year-old man with abdominal pain and fever was referred to our hospital. Physical examination revealed tenderness, rebound tenderness and muscle guarding over the entire abdomen. The white blood cell count was 6,700/mm3 and the serum C-ractive protein level was 21.7 mg/dL. Further investigation by abdominal computed tomography (CT) showed wall thickening of the sigmoid colon and free air in the abdominal cavity, and multiple liver metastases The patient was diagnosed as having perforated sigmoid colon cancer, however, preoperative examination revealed that the patient also had unstable angina pectoris. Although emergency operation was needed for the perforated sigmoid colon, we first undertook percutaneous coronary intervention for the two diseased coronary arteries. Subsequently, abdominal surgery was performed; purulent ascites and severe inflammation of the sigmoid colon were noted, however, the perforation could not be identified; therefore, abdominal irrigation and drainage was performed, followed by colostomy with double orifices. The patient developed pneumonia and pulmonary edema postoperatively, but could be discharged from the hospital on the 87th postoperative day.

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Recently, with the advances in diagnostic and therapeutic endoscopic techniques, there have been increasing reports of iatrogenic gastrointestinal perforation. The mortality rate of esophageal perforations is especially high, therefore, appropriate diagnosis and treatment are important, just as in cases of spontaneous esophageal rupture. We report a case of iatrogenic esophageal rupture during a hemostatic procedure for bleeding esophageal varices in a patient with liver cirrhosis, which was successfully treated by prompt surgical treatment, T-tube-based external drainage, and enteral nutrition. Attending surgeons may hesitate to opt for surgical treatment due to the high mortality and postsurgical complication rates in cases with cirrhosis of the liver, however, early surgical intervention before worsening of the patient's general condition may yield a favorable outcome.

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The case pertains to a woman in her seventies. She consulted a nearby doctor with the chief complaint of fever and abdominal pain and was diagnosed by careful examination as having thrombosis of the cranial mesenteric vein and referred to our hospital. CT revealed a thrombus in the superior mesenteric vein extending from the ileocolic vein to the section merging with the splenic vein. Moreover, edematous change and parenteral air were observed in the ileocecum, and gastrointestinal perforation at this site was suspected. From the above, the patient was diagnosed as having thrombosis of the superior mesenteric vein and gastrointestinal perforation, and an emergency operation was carried out. Penetration into the mesentery was observed from the ileocecal valve to the ileum on the approximately 3cm oral side. Mild edema was observed almost throughout the length of the ileum；however, the color was normal. Ileocecal resection and colostomy were carried out. Laboratory examination at admission to our hospital revealed decreased serum protein C and S levels. We report this case due to the rarity of thrombosis of the superior mesenteric vein associated with protein C and S deficiency disease.

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An 87-year-old female was admitted to the hospital because of vomiting. She was diagnosed as having diaphragmatic hernia with gastric volvulus based on chest radiography, computed tomography (CT), and a gastrografin study. Endoscopic repositioning of the gastric volvulus was initially attempted due to the poor general condition of the patient. The omentum, left kidney and colon had herniated through a left lateral defect in the left diaphragm (foramen of Bochdalek), and the stomach was rotated. The defect was covered with the stomach, and stomach was fixed to the abdominal wall, due to the high risk of thoracotomy. The patient was discharged without complications. This report is being presented as that of a case which was difficult to treat because of the patient's poor general condition. In such patients, minimally invasive surgery should be considered for the treatment of a Bochdalek hernia, which generally requires a thoracotomy.

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A 25-year-old man with a 2-year history of Crohn's disease visited our emergency room complaining of abdominal pain 6 hours after a traffic accident. Signs of peritoneal irritation were recognized over the entire abdomen, and a chest x-ray revealed the presence of free air in the subphrenic space. Abdominal contrast-enhanced CT revealed free air and a fluid collection at the surface of the liver. More free air was found in the mesenteric fat tissue of the small intestine. We performed emergency surgery under the diagnosis of perforation of the small intestine. Partial resection of the perforated small intestine was performed. The resected specimen revealed a longitudinal ulcer compatible with Crohn's disease and a perforation along the ulcer. An abrupt increase of the intraluminal pressure due to blunt abdominal trauma was assumed to have been the cause of this perforation. Patients with Crohn's disease may be at a higher risk of developing traumatic intestinal perforation.

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We describe 2 patients with large transanal foreign bodies. Patient 1: A 65-year-old man consulted our hospital because of anal and abdominal pain. A plain abdominal radiograph revealed a steel wire in lower abdomen. Computed tomography showed free air, a shoehorn in the sigmoid colon, and a steel wire penetrating the sigmoid colon wall. Emergency surgery was performed, and a steel wire was found to penetrate the sigmoid colon wall and enter the peritoneal cavity. A shoehorn was found in the sigmoid colon. Both objects were removed transanally. The perforated colon was resected. The patient was discharged on the 13th postoperative day. Patient 2: A 58-year-old man presented with a rectal foreign body. Computed tomography revealed a bar-shaped object, extending from the rectum to sigmoid colon, without intestinal perforation. The object was removed using a forceps under lumbar epidural? anesthesia. The patient was discharged on the first postoperative day. Conclusions: Transanal foreign bodies should be carefully treated on the basis of medical history, abdominal findings, and diagnostic imaging studies, because such patients may present with only mild abdominal symptoms.

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This paper presents two cases of spontaneously ruptured aneurysms of the middle colic artery due to segmental arterial mediolysis (SAM). Case 1, a 60-year-old man, was admitted to our hospital in an emergency because of abdominal pain. Abdominal computed tomography (CT) revealed fluid collection in the abdominal cavity and mesenteric hemorrhage. Emergency angiography showed extravasation from an aneurysm of the middle colic artery. Emergency surgery was performed, which revealed bleeding from the left branch of the middle colic artery. The affected vessel was ligated and the transverse colon was partially resected. Case 2, a 55-year-old woman, complained of abdominal pain and went into shock. Abdominal CT was performed because her blood pressure rose in response to primary infusion. The patient went into shock again after the CT examination, therefore, emergency surgery was performed after intubation and intra-aortic balloon occlusion to maintain the blood pressure. The origin of the hemorrhage was difficult to determine, but we assumed that the mesenteric hemorrhage had developed from a branch of the middle colic artery within the transverse colon, and ligated the root of the middle colic artery and resected the left half of the colon in which the mesenteric hemorrhage was located. In both cases, pathological findings indicated destruction and dissociation of the internal elastic lamina with hemorrhage; therefore, both patients were diagnosed as having spontaneously ruptured aneurysms due to SAM.

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We report the case of a 70-year-old man with internal hemorrhoid. After hemorrhoidectomy, the patient presented with anal infection, diarrhea, fever and leucocytosis. CT showed intraperitoneal free air, therefore, emergent laparotomy was performed. Multiple ileal perforation was detected, necessitating ileocecal resection of an intestinal segment about 110 cm long. At that time, we suspected intestinal Behcet's disease, because the patient also had oral and genital ulcers. Histopathological examination of the resected ileum revealed only non-specific inflammation. The serum cytomegalovirus antibody titers increased rapidly and declined after the operation, therefore, we made the diagnosis of cytomegalovirus enteritis. Until now, about 4 years since, the patient has had no recurrence of the abdominal symptoms.

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A case of splenic pseudoaneurysm after blunt splenic injury in a 63-year-old female is reported. She was transferred to our hospital due to multiple traumatic injuries sustained in a traffic accident. Enhanced computed tomography (CT) showed blunt splenic injury with intra-abdominal hemorrhage. Urgent angiography showed no extravasation from the splenic artery, and non-operative management was chosen, because the hemodynamics was stable. On the 9th hospital day, the patient felt sick after defecation. At that time, her systolic blood pressure and heart rates were <70/mmHg and <50/min, respectively, however, her condition immediately improved after fluid loading and administration of atropine. Ultrasonography performed at the same time showed no increase in the size of the hematoma around the spleen, however, a splenic pseudoaneurysm was suspected. Enhanced CT performed on the 11th hospital day revealed a splenic pseudoaneurysm with a diameter of 8mm, therefore, urgent catheter embolization was performed. Recently, non-operative management (NOM) has been the standard of care for hemodynamically stable blunt splenic injuries. A feared complication of NOM is delayed splenic rupture, and splenic pseudoaneurysm has attracted attention as a cause of delayed splenic rupture. Suitable and timely treatment of splenic pseudoaneurysm is necessary, because its rupture is life-threatening.

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A 53-year-old man operated for a retroperitoneal tumor suffered from massive melena of sudden onset and developed hemorrhagic shock on the 12th day after the operation. No improvement of the hemodynamic status was obtained with rapid infusion of fluids and a vasoconstrictor agent. We started cardiopulmonary resuscitation because the patient showed agonal breathing and attenuation of the pupillary light reflex. A large amount of blood was transfused which provided some hemodynamic stability. An emergency digital subtraction angiography of the left external iliac artery demonstrated extravasation of the intra-arterial contrast medium into the bowel lumen. We made a diagnosis of arterioenteric fistula and performed a stent-graft transplantation covering the fistula entry. Although the hemodynamics improved with this procedure, the patient’s general status worsened and he died of multiple organ failure 29 hours later. We report a case of arterioenteric fistula that followed a rapidly fatal course. We have discussed what might be needed for life-saving potential life-saving measures?.

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A-60-year-old man with liver cirrhosis who had undergone four previous surgeries, namely, distal gastrectomy, operation for ileus and hepatectomy twice for hepatocellular carcinoma was admitted to our hospital with melena and hemorrhagic preshock. Upper gastrointestinal endoscopy failed to reveal the source of bleeding. However, contrast-enhanced abdominal CT suggested the presence of varices in the small intestine, continuous with the right inferior epigastric vein as the collateral efferent? vessel on the abdominal wall. Active bleeding from these varices was strongly suspected and an emergency laparotomy was performed. As the findings were compatible with the preoperative CT findings, the right inferior epigastric artery and vein were both ligated, and partial resection of the adherent small intestine was performed. The postoperative course was uneventful. The possibility of ruptured small intestinal varices should also be considered in patients with portal venous hypertension presenting with gastrointestinal bleeding, especially after a previous laparotomy.

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A 62-year-old man underwent thoracoscopic partial hepatectomy via the diaphragm for hepatocellular carcinoma. Twenty-one months after the surgery, he began to complain of colicky upper abdominal pain and was brought to our emergency room. Abdominal X-ray showed small intestinal gas along with an abnormal gas collection in the right supradiaphragmatic space. Small bowel obstruction was diagnosed, and the patient was observed under “nothing nil by mouth”. His epigastralgia persisted for 4 days, and tenderness was found on palpation of the right upper quadrant. A repeat abdominal X-ray showed air-fluid levels and enlargement of the abnormal intrathoracic gas shadow. Intestinal obstruction due to incarceration of a diaphragmatic hernia was diagnosed and emergent surgery was performed, which revealed incarceration of the transverse colon and greater omentum at the diaphragmatic hernia orifice. The hernia orifice was the scar of the partial hepatectomy in the diaphragm. The possibility of iatrogenic diaphragmatic hernia should always be borne in mind in patients with a history of transdiaphragmatic surgery.

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A 60-year-old-man was admitted to our hospital following intentional ingestion of hydrochloric acid. Examination revealed diffuse upper gastrointestinal injury, acute pancreatitis, hemolytic anemia, and laceration of the forehead. After stabilizing the vital parameters, despite our attempts to treat the esophageal and pyloric stenosis, scar retraction of the esophagus slowly progressed over a period of 10 months, resulting in complete esophageal obstruction. Many reports recommend surgery at 6 months after the ingestion of a caustic substance to avoid anastomotic stenosis. However, our case suggests that stenosis may continue to progress for as long as 10 months, therefore, surgical intervention should be withheld for approximately a year to avoid the risk of anastomotic stenosis.

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A 90-year-old male suffering from dementia was transferred to our hospital with the complaints of vomiting, fever and disturbance of consciousness. Vital signs suggested that the patient was in hypovolemic shock, and the abdomen was extremely bloated. Laboratory examination revealed dehydration-induced acute pre-renal failure and acidosis. CT revealed a double-lumen structure in a part of the small intestine, the so-called target sign. Therefore, we made the diagnosis of invagination and performed surgical treatment, however, the surgical findings clarified the cause of the ileus as accidental ingestion of a foreign body. The foreign body was a patch used for cooling that had rolled like a sponge cake in the small bowel. When encountering patients with mental disorder cognitive decline, it is necessary to keep in mind the possibility of their ingesting foreign bodies.

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