This study was conducted to examine the clinical features and problems of elderly patients with colorectal perforation. From April 2007 to December 2011, we encountered 108 cases of colorectal perforation, including 37 cases in people over 80 years of age (elderly group) and 71 cases in people under 80 years of age (non-elderly group). The preoperative conditions, postoperative complications and mortality were compared between the two groups. The time from the onset of perforation to the operation was significantly longer and the peripheral blood white blood cell count was significantly lower in the elderly group as compared to the values in the non-elderly group. In both groups, the POSSUM scores were significantly higher in the non-survivors than in the survivors. While there was no significant difference in the mortality between the two groups, postoperative respiratory complications were more frequent in the elderly group. Thus, while a similar prognosis to that in younger patients may be expected in elderly patients with colorectal perforation, it is necessary to pay close attention to the risk of postoperative respiratory complications and take prompt measures as necessary.
Bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor (VEGF), has been reported to significantly prolong survival when added to intravenous 5-fluorouracil-based chemotherapy as first-line therapy for metastatic colorectal cancer (CRC). Although, the adverse effects of bevacizumab are usually mild, the drug may occasionally cause serious adverse effects. In particular, attention must be paid to the risk of occurrence of gastrointestinal perforation events (GIP events) and cerebrovascular accidents. The reported incidence of GIP events is 2.2% and that of cerebrovascular accidents is 3.2%. GIP events usually occur after 2 courses of treatment and cerebrovascular accidents after 5-10 courses.
The data of 93 patients who underwent emergency enterostomy without stoma site marking at this hospital between April 2011 and March 2012 were reviewed retrospectively. The patients, consisting of 45 males and 48 females with an average age of 74.5 years included 45 cases (48%) of colon cancer, 16 cases (17%) of ileus, 15 cases (16%) of bowel perforation, and 9 cases (9.7%) of anastomotic leakage. The most common stoma type constructed was colostomy (39 cases, 42%), followed by loop colostomy (24 cases, 26%) and loop ileostomy (24 cases, 26%). Complications associated with the stoma construction developed in 34 cases, including wound infection in 16 cases (47%), abscess formation around the stoma in 11 cases (32%), stoma sinking in 3 cases (8.8%), fecal leakage in 2 cases (5.9%), and dermatitis around the stoma in 2 cases (5.9%). None of the patients died of complications. In conclusion, the principles of stoma site marking should be respected and care should be taken during emergency enterostomy to prevent surgical site infection, which was the most frequent complication in this study.
[Purpose] In patients who underwent emergency surgery for colorectal perforation at our hospital, we examined the clinical matters and factors that might reflect the prognosis, and reviewed the factors that may be important for risk management. [Subjects] The subjects were 43 patients with colorectal perforation who were treated at our hospital between July 2005 and January 2011. [Results] The SOFA, APACHE II and POSSUM scores, as well as the Mannheim Peritonitis Index (MPI), were significantly higher in the non-survivor group than in the survivor group. The prognosis was significantly less favorable in patients who were in shock before surgery, patients with preoperative BE values of less than -5.0mmol/L, and patients in whom the interval from the onset to the start of surgery was 24 hours or more. Furthermore, the mortality rate was higher in patients who were referred from hospitals in adjacent areas and those with serious underlying diseases. [Discussion] It may be important to shorten the interval from the onset to the start of surgery and promptly evaluate the clinical condition before surgery as prognostic factors in patients with colorectal perforation.
Materials and methods: 1) A total of 71 patients were provided nutritional support by the nutrition support team of Teikyo University Chiba Medical Center. We classified the patients into four groups according to the nutritional triage category and investigated the improvement rate following the nutritional triage. The nutrition triage categories were defined as follows: “ red” consisted of patients in an extremely poor nutritional state who required immediate treatment, “yellow” consisted of patients between the categories of “red” and “green”, “green” consisted of patients who were expected to improve with their current nutritional therapy, and “ blue” consisted of patients who required palliative care. 2）We interviewed 15 members of the nutritional support team regarding their understanding of the nutritional condition before and after the nutritional triage. Results: 1) There were 21 patients in the “red” group, 31 patients in the “yellow” group, 10 patients in the “green” group and nine patients in the “blue” group. The improvement rates according to the nutritional triage into the “red,” “yellow,” “green” and “blue” groups were 71.4%, 83.9%, 100% and 22.2%, respectively. The mean improvement rate was 74.6%. 2) When asked on the questionnaire survey about their understanding of the changes in the nutritional condition before and after the nutritional triage, the proportions of team members answering “ getting better” and “no changes” were 80% and 20%, respectively.
Our hospital started nutritional support team (NST) rounds in a single surgical department in June 2010. The conventional NST rounds at the request of an attending doctor continued as usual, but, the single surgical department rounds, the dietitian selected high risk patients from among those with serum Alb levels of 3.0 g/dL or less. For the abdominal emergency surgery cases in which the NST intervened, we divided them into group A before single surgical department rounds started, and group B after these rounds started. We compared both groups regarding the time to NST intervention, the effect, the outcome and hospitalization. For eight group A and six group B patients, the number of the interventions significantly increased in group B. The time to intervention in group A was 15 days whereas in group B it was 12 days, so it was shorter in group B. As for the effect, it was significantly better in group B. As for the outcome, A group had much leave hospital mortality and B group had much leave hospital of lighthearted. the majority of the group B patients left hospital in a much happier frame of mind than in the case of group A. Regarding the period of hospitalization after the intervention, it was 18 days in group A, and 15.5 days in group B, so it was shorter in group B. The single surgical department NST rounds proved beneficial for abdominal emergency surgery cases.
Management of the nutrition support team (NST) in an abdominal emergency is often difficult. We herein evaluated two different support methods in two different hospitals with which the first author was connected, and which proved to be practical and effective. In the first of these hospitals (a general emergency hospital), the first author belonged to the Department of Emergency and Critical Care Medicine, working full time in the ICU and as the NST director, and as such performed earlier support. In the second hospital (with a high-level emergency center), to which the first author was subsequently transferred as a digestive surgeon, the authors developed the existing support method for the NST and also established an early support system. In both hospitals, the end-point of the activity was that patients “could receive the required calories from the alimentary tract”. We continued support after the patients’ discharge from the ICU. Because the achievement rates reached 70% in both institutions, the NST appeared to be effective. Although understanding and cooperating with NST activity in hospitals and improvement of the nutritional support-technique of the team are still needed, it can be made possible in all institutions through cooperation among all hospital personnel. The outcome of abdominal emergencies can be expected to improve by starting involvement with the NST earlier, and subsequently continuing support from the nutritional team.
Since the start of our NST activities in April 2002, we have treated 940 cases a total of 5,470 times. As for cases of abdominal emergencies, we have treated 59 cases 481 times. These latter patients included 12 cases of gastrointestinal perforation, 11 of suture insufficiency, 6 of abdominal traumatic injury, 3 of rupture of aortic aneurysm, 6 of short bowel syndrome, 7 of serious severe acute pancreatitis, 2 of hemorrhagic enterocolitis, 3 of ischemic enterocolitis, 3 of pseudomembranous colitis, and 6 of acute hepatitis. TPN was first employed for cases with shock or sepsis. We made it rule to control the blood sugar to under 150 mg/dL with reinforcement insulin therapy. We adopted early enteral nutrition for cases in whom the intestinal tract was usable. We administered GFO, a functional diet comprising glutamine, dietary fiber and oligosaccharide, for cases not fed for over two weeks. For cases of renal failure undergoing haemodialysis, we administered 110% to 120% quantity of amino acids of the conventional composition. We used antiinflammatory nutrients, with increased n3 type fatty acids and antioxidants and reduced arginine, in a case of respiratory failure and severe infectious disease. Detection of occult blood and protein in the feces using a urinalysis tape and a search for the CD toxin in the watery diarrhea were useful for the diagnosis of enterocolitis. Most patients recovered and could leave the hospital.
A 76-year-old woman was admitted to our hospital complaining of persistent abdominal pain and an abdominal mass. Abdominal CT and US showed a localized intra-abdominal abscess associated with perforation of the small intestine by a fish bone. Especially, the US showed the fish bone located outside the small intestine. Because the vital signs were stable, we chose conservative treatment. Four months later, we performed laparoscopy-assisted surgery. The mass was removed with the fish bone by full-thickness small intestinal resection. The US was useful in our case, by allowing the patient to be treated by laparoscopy-assisted surgery.
The patient was a 53-year-old male, who was transported to our hospital with the chief complaint of abdominal pain since falling down. On abdominal dynamic CT, the tail of the pancreas showed poor contrast effect and a hematoma was discovered expanding into the surrounding area; the findings were deemed to suggest pancreatic injury associated with main pancreatic duct injury. Surgical treatment was recommended, but refused, therefore, the patient was treated conservatively. On the 10th day of illness, the main pancreatic duct was found to become obfuscated in the tail area on MRP, and CT revealed two cystic lesions in the tail of the pancreas. Fever and abdominal pain set in from the 12th day of illness, and CT revealed a swollen pancreatic cyst on the 16th day of illness, which was thought to represent pancreatic pseudocyst formation. After the limit of conservative treatment was reached, endoscopic drainage was carried out to secure a field of view at the time of surgery. In the endoscopic retrograde pancreatography (ERP) carried out on the 17th day of illness, the pancreatic tail could not be visualized. Successful drainage was accomplished by transnasal introduction of a pig-tail catheter into the cyst, and the cyst was eradicated. The tube was changed to a pancreatic duct stent on the 66th day of illness. There was no recurrence of abdominal pain or of the cyst formation, the patient recovered satisfactorily, and was discharged from the hospital on the 70th day. Stenting is a low-invasive and effective treatment strategy for pancreatic duct injury, however, since its applicability is still not yet very well defined, further accumulation of cases is necessary.
A 74-year-old woman with chronic rheumatoid arthritis visited our hospital complaining of abdominal pain and vomiting. Abdominal enhanced CT revealed extrinsic compression of the right side of the uterus. Under a diagnosis of tumor or inflammation of the small intestine, we performed emergency laparoscopic operation. Ileal stenosis and lymph node swelling were found about 30 cm proximal to the ileal end, and we resected this lesion through a small laparotomy. Pathological examination showed non-specific inflammation and a single ulcer, and we made a final diagnosis of simple ulcer of the ileum. The postoperative course was uneventful and the patient was discharged 9 days after the operation. Small bowel ulcers can be induced by a variety of causes, however, the mechanism of formation still remains unclear.
We report the case of a 37-year-old woman with severe acute proctocolitis and metabolic acidosis with loss of consciousness caused by a self-administered alcohol enema. The patient had a 10-year history of bipolar disorder. She was unconscious and in shock at arrival in the emergency room. After resuscitative procedures, a colonoscopy performed to determine the cause of the rectal bleeding showed severe inflammatory changes of the mucosa extending from the rectum to the descending colon, suggestive of ischemic colitis. She regained consciousness on the second day. On day 8, a repeat colonoscopy revealed healing of the rectum and sigmoid colon. We continued to treat the patient conservatively. On day 29, colonoscopy and radiography revealed inflammatory and stenotic changes of the descending and transverse colon. We performed a temporary colostomy on the right side of the transverse colon and the patient was discharged 23 days later. This is a rare case of severe and extensive proctocolitis caused by a self-administered alcohol enema.
The patient was an 80-year-old woman who presented to our hospital with a one-week history of constipation and nausea. Intestinal obstruction due to a left incarcerated obturator hernia was diagnosed by pelvic computed tomography (CT), and partial resection of the small intestine was performed. Because the hernia sac could not be inverted due to severe inflammation, the hernia orifice was sutured to the uterus to complete the surgery. On postoperative day 4, the patient developed persistent fever. On postoperative day 9, pain and subcutaneous emphysema occurred in the left thigh, and CT revealed abscess formation extending from the left obturator and pectineus muscles to the thigh. On postoperative day 12, CT-guided drainage was performed, which was followed by a reduction in the size of the abscess. The patient was discharged approximately 2 months later, without sequelae. This case serves to emphasize that an obturator hernia associated with intestinal necrosis/perforation may rarely be complicated by postoperative femoral abscess formation. Thus, along with observation of the femoral area and careful postoperative management, safety and immediate drainage under CT or ultrasonographic guidance is necessary in case of abscess formation.
A woman in her 80s with a history of diarrhea and hematochezia was transported by ambulance to our hospital with dehydration and shock. Contrast-enhanced abdominal CT revealed possible presence of colonic necrosis caused by occlusion of the inferior mesenteric artery, therefore, emergency left hemicolectomy and colostomy were performed. Following this surgery, the patient recovered gradually from the septic and hypovolemic shock, and was discharged from the hospital on day 64 after surgery. Acute occlusion of the inferior mesenteric artery is rather rare among cases of acute mesenteric vascular occlusion, however, the prognosis is as poor as that of superior mesenteric artery occlusion reported previously. Early and appropriate treatment could improve the prognosis in patients with acute inferior mesenteric artery occlusive disease.
A 73-year-old man was admitted to the hospital because of dysphagia. Upper gastrointenstinal endoscopy showed a mass at the lower end of the thoracic esophagus, and endoscopic biopsy confirmed squamous cell carcinoma. Chest CT examination revealed lymph node metastases (cT2N1M0, cStage III). Because of respiratory dysfunction caused by chronic obstructive pulmonary disease (COPD), we considered that a radical esophagectomy may not be feasible, and selected chemoradiotherapy. After chemoradiotherapy, the esophageal tumor reduced significantly in size, although severe stenosis persisted. While the patient received endoscopic dilatation and palliative chemotherapy, he suffered from recurrent episodes of acute cholecystitis due to gallbladder stones. Therefore, both laparoscopy-assisted esophageal bypass operation for esophageal cancer and laparoscopic cholecystectomy were performed on the same day. The patient was managed to postoperative respiratory function disturbance by COPD and suffered minor leakage from the anastomosis; both disorders improved with conservative treatment, and the patient was discharged. After the operation, the patient was able to maintain oral intake without complications for 11 months, until he eventually died at 12 months.
A 63-year-old man was admitted with a 1-year history of upper abdominal pain. Abdominal CT showed a thickened wall of the stomach with inflammatory changes extending from the antrum to the descending part of duodenum and abnormalities around the duodenal bulb suggestive of free fluid and air. Laparotomy was performed on suspicion of perforated duodenal bulb ulcer, and a perforated duodenal bulb ulcer was confirmed in the duodenal bulb, in the superior to posterior wall. T-tube duodenostomy and omental patch repair were performed. From postoperative day (POD) 1 to POD12, a somatostatin analogue was injected with a proton-pump inhibitor, which led to a rapid decrease in the amount of discharge from the omental patch drain and T-tube. On POD 13, duodenography showed no leakage from the duodenal bulb, and the patient went on a diet again was restarted on oral feeds. On POD 26, after the fistula formation was accomplished, the T-tube was removed inward from the stomach via the mouth. On POD 39, the patient was discharged. Thus, perforated duodenal bulb ulcer was treated effectively with a somatostatin analogue, proton-pump inhibitor, T-tube duodenostomy, and omental patch repair, without any postoperative complications.
The patient was an 83-year-old man with the short bowel syndrome associated with a 20-cm-long residual segment of the jejunum after surgery for superior mesenteric artery embolism. The patient had been unable to eat orally, being maintained on total parenteral home nutrition for over five and a half years, and developed severe macrocytic, normochromic anemia and neutropenia. Upper gastrointestinal endoscopy/colonoscopy and bone marrow examination revealed no abnormal findings. Hematologic examination revealed markedly reduced serum zinc and copper levels, and the patient was diagnosed as having anemia and neutropenia caused by zinc and copper deficiency. As excessive zinc administration was considered to be the cause of it was considered that excessive zinc administration might impair copper absorption, zinc was given orally, while copper was administered by the parenteral route. After a month, the anemia and neutropenia improved, along with improvement of both the serum zinc and copper levels. Regular examinations of the blood for trace elements is necessary in patients receiving long-term home parenteral nutrition.
Because torsion of the gallbladder is a relatively rare cause of acute abdomen, preoperative diagnosis has been difficult. Recently, we encountered a patient with torsion of the gallbladder in whom the diagnosis was made preoperatively. An 86-year-old woman was admitted to our hospital with the diagnosis of acute cholecystitis. Abdominal ultrasonography showed swelling of the gallbladder in the absence of any gallstones. MDCT (Multi Detector-row Computed Tomography) revealed thickening of the gallbladder wall, and a part of the wall was non-enhancing, the findings suggesting. that the neck of the gallbladder was twisted clockwise around the axis of the cystic duct. Emergency open cholecystectomy was performed, and the operative findings included torsion of the gallbladder with a 360-degrees volvulus. The patient was discharged without event.
An 84-year-old man was admitted to our hospital with abdominal pain and melena. He had a history of cerebral infarction and ischemic heart disease and was receiving regular anticoagulant drug therapy with warfarin and aspirin. Laboratory data revealed a prothrombin time-international normalized ratio (PT-INR) of 16.11 and serum Hb of 7.3g/dL. Computed tomography (CT) demonstrated a hematoma involving the? circumferential thickness of the intestinal wall and intraabdominal fluid collection. At first, the patient was treated conservatively with vitamin K infusion, fresh frozen plasma, and red blood cell and platelet transfusions. However, the abdominal pain worsened and the anemia persisted. Therefore, emergency surgery was performed for an intramural intestinal hematoma caused by anticoagulant drug therapy with warfarin and aspirin. The peritoneal cavity contained fresh blood. The adjacent mesentery was thickened because of a hematoma. The small intestine was dilated with a purple line of demarcation, necessitating partial resection. The treatment of first choice for an intramural hematoma is conservative. However, surgery should be considered if the patients’ data, vital signs and condition show any signs of deterioration.
We report a case of transanal rectal foreign body. A 32-year-old man was admitted to our hospital because he had inserted 500mL of liquid plaster into his anus and could not pull the material out by himself. A plain X-ray of the abdomen showed a foreign body shadow in the rectum. Abdominal computed tomography showed the plaster in the pelvic space, without free air. Because removal by the anal approach was difficult, we performed emergency laparotomy and the plaster (18×6cm in size) was removed from the sigmoid colon; low anterior resection was also needed because of severe damage to the rectal mucosa. The patient was discharged 11 days after the operation without any complications. To the best of our knowledge, this is the first reported case of a transanal rectal foreign body (plaster) in the Japanese literature.
We report 2 cases of colon perforation caused by ingestion of foreign bodies. Case 1: A 37-year-old man visited our hospital complaining of abdominal pain, abdominal distension and diarrhea. Physical examination revealed tenderness, rebound tenderness, and muscle guarding in lower abdominal region. Abdominal CT showed wall thickening of the small intestine in the pelvic region and a linear high-density area on the right side of the rectum. Colon perforation caused by a foreign body was diagnosed and surgery was performed. Intraoperatively, a toothpick was found to penetrate the right side of the rectosigmoid wall. The rectosigmoid colon was resected and a single-barrel sigmoid colostomy was performed. Case 2: A 75-year-old man complaining of lower abdominal pain was admitted to our hospital with suspected panperitonitis. Physica1 examination showed tenderness and muscle guarding throughout the abdomen. Abdominal CT revealed thickening of the wall of the sigmoid colon, which contained an arc-shaped high-density area. Emergency operation was performed, which revealed a fish bone penetrating the sigmoid colon. We then performed sigmoidectomy and a single-barrel descending colostomy and removed the fish bone.
A 43-yea-old-man with a history of thoracic trauma five years previously was admitted to our hospital because of abdominal pain and distension. Chest and abdominal X-ray and CT revealed a prolapse of the transverse colon and greater omentum via the left diaphragm into the left thoracic cavity. A diagnosis of delayed traumatic diaphragmatic hernia was made, and emergent thoracotomy and laparotomy were performed immediately. The defect in the left diaphragm through which the colon and omentum had herniated into the thoracic cavity measured 5cm in diameter. The herniated organs were reduced back into the abdominal cavity and the diaphragmatic defect was repaired with a PTFE patch. At present, 15 months after the surgery, the patient remains alive without any signs of recurrence. We think that the PTFE patch is quite effective for the repair of traumatic diaphragmatic hernias that cannot be repaired by direct suture.
We report on a case of acute cholecystitis complicating unresectable bile duct cancer. A 77-year-old woman was admitted for stent placement in the common bile duct. After admission, the patient was kept nil by mouth, and treated with antibiotics. However, since the symptoms did not improve, surgery was performed. A small incision was made through the fundus of the gallbladder and a fistula tube was placed in the lumen of the gallbladder; then, 20 days later, cholecystography was performed. From the 21 to 25th postoperative day, absolute ethanol was instilled into the fistula tube, and ablation of the gallbladder was performed. On the 28th postoperative day, the fistulous fistula tube was removed. After discharge from the hospital, the patient showed no signs of recurrence of the acute cholecystitis, and outpatient chemotherapy could be administered for 18 months.