Aim: To evaluate the disease state of acute cholangitis during preoperative treatment (AC during NAC), the effect on preoperative treatment and perioperative state, and clarify the associated risk factors in patients with pancreatic and biliary tract cancer. Methods: We retrospectively reviewed the records of patients who had undergone preoperative treatment for pancreatic or biliary tract cancer. We evaluated: 1. The comparisons of the frequency and severity of AC during NAC between pancreatic and biliary tract cancer; 2. The effect on NAC itself and perioperative status; and 3. The risk factors of AC during NAC. Results: 1. The frequency of AC during NAC was 36% for pancreatic cancer and 34% for biliary tract cancer. The average number of AC during NAC in biliary tract cancer was more often than those in pancreatic cancer (p=0.018). The coexistence rate of DIC and a severe grade were only noted in AC during NAC patients with biliary tract cancer. 2. The relative dose intensity (RDI) and complete rate of NAC were significantly reduced in patients with biliary tract cancer. There was a significant difference in the complication rate between the AC during NAC group and the Non cholangitis group. In addition, there was no mortality. 3. The significant risk factor of AC during NAC was cN1 in pancreatic cancer, and a low lymphocyte count of and high levels of ALP in biliary tract cancer. Conclusion: AC during NAC was more frequently noted in biliary tract cancer. It induces reduction of the dose of anticancer drugs and prolongation of preoperative treatment period. The low lymphocyte count and the elevated levels of hepatobiliary enzymes indicated high risk patients for AC during NAC.

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[Purpose] The rate of serious postoperative complications following emergency or semi-emergency surgery for ulcerative colitis (UC) are higher than in the case of elective surgery. We evaluated the impact of perioperative clinicopathological factors on serious complications associated with emergency operations in patients with ulcerative colitis. [Patients and Methods] Twenty-eight patients who underwent emergency or semi-emergency surgery for UC were identified from 249 patients at the age 16 or over who underwent colectomy in our hospital. A serious complication was defined as high-grade (from IIIa on up) on the Clavien-Dindo classification. [Result] Postoperative serious complications occurred in 9 (32.1%) patients. Preoperative pulse and respiratory rates were significantly higher (107±19 vs. 84±13/min; p=0.018, 20.6±5.6 vs. 16.1±3.2/min; p=0.023) and serum Ch-E was significantly lower (65±33 vs. 111±55 IU/L, p=0.013) in patients who had undergone emergency or semi-emergency surgery compared with elective surgery. There was no significant relationship between other perioperative clinicopathological factors and serious postoperative complications of emergency or semi-emergency surgery. [Conclusion] The patient's nutritional and general status may impact on development of serious complications after emergency or semi-emergency surgery for patients with UC.

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In recent years, laparoscopic surgery has become popular not only for elective cases but also for the emergency patients. Between January 2010 and December 2012 we experienced 827 cases of acute abdomen for which we performed emergency operations. Laparoscopic surgery was successfully performed in 586 cases. There were 389 cases of acute appendicitis, 112 cases of bowel obstruction, 98 cases of acute cholecystitis, 66 cases of colorectal perforation, 39 cases of upper gastrointestinal perforation, 30 cases of groin hernia strangulation, as well as other conditions in 66 cases. For each abdominal emergency disease, there was a significant difference in the success rate of laparoscopic surgery. The completion rate of laparoscopic surgery was about 20% in bowel obstruction, colorectal perforation, and the other abdominal emergency diseases. It is therefore necessary that we continue to accumulate additional case reports for further examination.

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Acute hemorrhagic rectal ulcer (AHRU) patients have been increasing concomitantly with the aging society. The aims of this study were to evaluate the clinical and endoscopic characteristics of patients with AHRU. This retrospective study involved 18 patients with AHRU diagnosed with urgent endoscopy in our department from January 2009 to August 2012. The subjects consisted of 8 men and 10 women with an average age of 80.7 yr. Most of these patients were elderly and bedridden with comorbidities, such as chronic renal failure, diabetes mellitus, arteriosclerosis obliterans, or cerebrovascular diseases. The ulcers were characterized as irregular-shaped lesions located around the dentate line. Endoscopic hemoclipping was performed in 10 cases where the vessel was exposed and hemostasis was successful in all cases. Rebleeding was not seen in any patient. In the treatment of AHRU, it is important to obtain an endoscopic diagnosis as soon as possible and to perform endoscopic hemoclipping in the cases with an exposed vessel.

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‘Acute care surgery（ACS）’ has been widely recognized in Japan, though it is not precisely defined. The concept of ACS arose in trauma surgery, and includes ‘trauma’, ‘emergency surgery’ and ‘surgical critical care’. In the United States of America, an ACS fellowship training curriculum of 24 months has been established involving abdominal, thoracic, vascular, orthopedic, brain surgery, and so on. The ACS is, in other words, a new division which comprehensively attends to seriously injured or multiple traumatized patients, and patients in similar conditions suffering from some disease. Thus, it is of importance to train acute care surgeons with the intention of giving them broad surgical techniques. However, in Japan, not so much concern has been given to the development of individual acute care surgeons. Japan also needs proper acute care surgeons and suitable education programs. Experience in many kinds of surgery should be flexibly assigned to the trainee in a case-by-case setting not by departmentally-regulated vertical division. Furthermore, a longer period training curriculum is required in Japan. Abdominal surgery is essential in the ACS, and should provide not only basic surgical techniques but skills to manage severely traumatized patients.

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An Acute Care Surgery (ACS) system is a very effective program for the education of trauma and emergency surgeons， and such programs are now being introduced in Japan. We had hoped to introduce an ACS program immediately， but the establishment of a new ACS facility is both time-and cost-intensive, therefore we tried to introduce an ACS system at a university hospital equipped with an emergency and critical care center. Gastrointestinal surgeons, as one of the categories of the ACS system， particularly supported emergency general surgery. We had about 300 patients over one year. Patients who underwent an operation accounted for 55-65% of all patients. We additionally had 8-15 patients with trauma surgery in the same year. The number of cases was enough to obtain qualification as a board certified surgeon in Japan. We demonstrate herein how we introduced an ACS system smoothly from both the educational and practical clinical aspects.

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We studied acute care surgery in our Department of Emergency and Critical Care Medicine over the past 10 years. We reviewed 646 cases who underwent an emergency laparotomy in the 10 years from 2002, we divided the 10 years into half and approached from the number of cases, disease and contents of cases, number of operating clinicians and operations per doctor. For the 5 years from 2002, emergency laparotomies accounted for 371 cases, trauma for 181 cases（stab：63 cases, blunt：118 cases）, non-trauma for 190 cases, the annual average of the operating clinician was five, and operations per doctor were 10.3 cases (under 10 years' experience: 14.7 cases). For the 5 years from 2007, emergency laparotomies accounted for 275 cases, trauma for 115 cases (stab: 43 cases, blunt: 72 cases), non-trauma for 160 cases, the annual average of the operating clinician was three, and operations per doctor were 7.8 cases (under 10 years' experience: 26.0 cases). We understand that only these cases are not enough for a full review, but the quantity and quality of the operations were maintained at least to some extent during the training of acute care surgery parctitioners. For training acute care surgeons, a system is required which takes into consideration the characteristic of the department, experience and the skill of the doctor.

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There is no standard educational program for acute care surgery in Japan. How to train the young acute care surgeon? We introduce herein our attempt in the Tokyo Medical and Dental University (TMDU). Our Emergency Medical Center was established in 2007, and has an acute care surgery training program. This program consists of an emergency medical training period and a surgical training period, and accepted 21 residents, 6 of whom have to date achieved board certification in general surgery. We examined the number of operations at each hospital and by each resident. The TMDU Emergency Medical Center has 250 operative cases per year and most of them were emergency procedures including 15% trauma operations. The surgical training affiliated hospitals have 768-1,211 operative cases per year, including 60% digestive system cancer, and 20% endoscopic surgery. All residents rotated between both the emergency medical center and the affiliated hospital surgical division, and experienced adequate surgical procedures not only in trauma but also in laparoscopic surgery to meet the criteria for surgical certification. There is a significant deference between the emergency department and elective surgery in the target diseases and treatment strategies, so it is important to rotate between both divisions for the acute care surgery training program.

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Acute Care Surgery (ACS) is a new concept of surgery which includes the three specialties of “trauma surgery”, “surgical intensive care”, and “emergency general surgery”. However, there is no formal curriculum or educational institutions in Japan, and it is still unclear how to practice ACS, and how to educate young surgeons in the skills required for ACS. We performed 222 emergency surgeries in 2011 to 2013, and in 167 trauma cases, we achieved an overall survival rate better than 73.6% compared with the predicted rate of 65.8%. In our three-year experience in aggressive trauma resuscitation and patient collection from a wide catchment area with the emergency helicopter airlift system, sufficient number of severe trauma cases was provided to educate acute care surgeons (20 cases per year) and surgical fellows (10 cases per 3 months). From such a point of view, we think that our department could act as a model for an Acute Care Surgery educational institution.

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We, at the Nippon Medical School Advanced Critical Care Center, have provided emergency surgeries for critically ill medical patients, and postoperative intensive care as well as trauma surgeries. The American Association for the Surgery of Trauma introduced a new surgical field“Acute Care Surgery”which consists of“Trauma Surgery,”“Emergency Surgery,”and“Surgical Critical Care,”and these are the clinical practices we have provided for a long time. In recent years, it has been difficult to train young surgeons in advanced critical care, because of the decrease in trauma operation cases and the increase in non-operative management. However, acute care surgeons who deal with trauma cases and also emergency operations for critically ill are a social necessity. It is our goal to find out the way to develop young acute care surgeons. In this paper, we introduce our training curriculum for acute care surgeons.

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We established the first “Acute Care Surgery Center” in Japan, which provides trauma surgery, emergency general surgery, and surgical critical care. This center was founded by Senshu Trauma and Critical Care Center (STCCC) and the Department of Surgery, Rinku General Medical Center (RGMC). At this center, STCCC treats patients requiring intensive care, while RGMC will treat those who require endoscopic surgery or do not need intensive care. The Acute Care Surgery Center specializes in treatment of patients who have undergone trauma or require emergency surgery with intensive care. This center can also manage patients with various other ailments who do not need intensive care. It is critical that an Acute Care Surgery center maintains a good balance of trauma surgery, emergency general surgery, and surgical critical care. This center can be used as a model center that provides a new type of acute care surgery in Japan.

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A-61-year-old male underwent total gastrectomy and Roux-en-Y reconstruction for gastric carcinoma. He suffered from hiccup and bloody vomiting about 12 hours after surgery. Decompression using a nasogastric tube was able to gradually reduce the symptoms, however the laboratory data showed a C-reactive protein level of 26mg/dL on the 2nd postoperative day. As a result, we used plain CT to determine whether there was an anastomotic leakage or intraperitoneal abscess. Since we could not find any clear obstruction or abscess for the dilatation of the afferent and efferent loops, we performed decompression again in the same manner. Abdominal CT scan with the administration of gastrointestinal contrast via a nasogastric tube on the 3rd postoperative day demonstrated marked dilatation of the jejunum from the esophagojejunal anastomosis to the jejuno-jejunostomy, and increased ascites. We performed an emergency laparotomy under the diagnosis of strangulated ileus due to an internal hernia. We confirmed necrosis of the majority of the hanging jejunum, with the hanging jejunum on the anal side from the transverse mesocolon strangulated via counterclockwise insertion into the gap between the hanging mesojejunum and the transverse mesocolon. The patient underwent a second operation for removal of the necrotized intestine and Roux-en-Y reconstruction, and he was discharged from hospital with a good postoperative course on the 18th day after reoperation. We should recognize the complication of an internal hernia from several hours after total gastrectomy and Roux-en-Y reconstruction, as in this case.

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We report herein on an unusual case of cecal perforation due to a migrated biliary stent. The patient was a woman in her nineties who was admitted with fever and vomiting. We suspected acute cholangitis secondary to underlying choledocholithiasis. She underwent endoscopic retrograde cholangiography (ERC), followed by the placement of a plastic stent. Thereafter, her symptoms rapidly improved and she was discharged. She presented again 4 months thereafter with fever. An X-ray showed that the stent had migrated in the pelvic cavity. Another stent was replaced for recurrent acute cholangitis. Seventeen days later, she had right lower quadrant pain. A CT scan showed that the migrated stent had perforated the cecum. The patient underwent a laparotomy under the diagnosis of cecal perforation. Intraoperatively, purulent peritonitis secondary to cecal perforation was observed due to the migrated stent. The stent was removed with a cecectomy. The postoperative course was uneventful, and she was discharged with no symptoms. Endoscopic biliary stenting is a common procedure in the management of acute cholangitis. One of the late complications of biliary stenting is migration, which infrequently results in bowel perforation. Therefore, it has been suggested that stents which have been noted to have migrated should be removed endoscopically before they cause bowel perforation.

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We report herein on a case of unexplained spontaneous splenic rupture. A woman in her 50s visited our hospital feeling generally unwell with sudden left hypochondralgia. The systolic blood pressure was more than 80 mmHg, and the Hb level was 9.2 g/dL, showing hypotension and anemia. Abdominal computed tomography (CT) showed low density areas in the spleen and the splenic capsule, as well as fluid collection around the liver, and the patient was admitted as an emergency case due to intraabdominal bleeding. After admission, parenteral fluid therapy increased the blood pressure, and conservative treatment was selected. In the blood biochemistry the day after admission, there was no progression of anemia, but an abdominal CT revealed an increase in the volume of fluid collection. Laparoscopic splenectomy was performed under the diagnosis of intraabdominal bleeding due to atraumatic splenic rupture. The spleen had a rupture appearing at the middle pole. In the pathological examination, the presence of a hematoma in the spleen was confirmed without any hemorrhagic lesion, such as a tumor. The final diagnosis was spontaneous splenic rupture, as there was no history of trauma or underlying disease. The postoperative course was uneventful, and the patient was discharged on day 10 after surgery.

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A 19-year-old man had suddenly developed abdominal pain with a fever of 39ºC two days previously to visiting a local clinic. He received a diagnosis of infectious enteritis and was prescribed oral medication；however, since his symptoms did not improve, he visited our hospital. He had peritoneal irritation signs, mainly in the area extending from the right lower quadrant to below the umbilicus. Severe inflammation was suggested by the blood test results. An abdominal CT scan revealed an intraperitoneal abscess. The abscess cavity was located close to the distal segment of the small intestine and compressed the mesenteric vessels；therefore, we performed emergency surgery under the strongly suggested diagnosis of an abscess formation with intestinal perforation. Laparoscopy revealed a diverticulum in the ileum about 100 cm proximal to its distal end. Since the diverticulum involved fluid retention in the ileal segment adjacent to the mesentery, our diagnosis was abscess formation caused by a perforated ileal diverticulum. We resected the intestine including the diverticulum via open abdominal surgery. We have experienced a case of perforated intestinal diverticulum that could be surgically treated under laparoscopic assistance and hereby report on it with a review of the literature.

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We report herein on a case of secondary gastrointestinal amyloidosis with nonocclusive mesenteric ischemia. A 67-year-old woman was admitted to our hospital with pleurisy. She complained of severe abdominal pain and persistent diarrhea from the day after admission. Colonoscopy showed mucosal edema and an indistinct vascular pattern, and the biopsy pathology showed a pattern of nonspecific inflammation. First, we suspected nonocclusive mesenteric ischemia based on the abdominal contrast-enhanced CT and angiography findings, and treated the patient with arterial infusion therapy. Finally, we were able to make the diagnosis of AA type amyloidosis from the normal findings of the endoscopic biopsy of the rectal mucosa. The patient died 71 days after from sepsis associated with MRSA infection. The autopsy findings showed diffuse deposition of amyloid proteins in the intestinal mucosa.

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An 8-year-old boy with no surgical history suddenly suffered from abdominal pain and vomiting, and gradually became unable to move, following which he was referred to our hospital. On admission, the muscular defence was observed over the whole abdomen. An abdominal CT scan detected remarkable abdominal ascites and the thickening of the ileum wall. We performed emergency surgery on the same day under the suspected diagnosis of strangulation ileus. The full amount of bloody ascites was revealed intraoperatively, and Meckel's diverticulum was located in the ileum 70cm proximal to the end of Bauhin’s valve. A fibrous band, which extended from the top of Meckel’s diverticulum had adhered to the mesentery near the end of Bauhin's valve, resulting in a strangulated ileal loop 80cm proximal to the end of Bauhin's valve. Because the strangulated ileum was necrotic, we performed ileocecal resection including Meckel's diverticulum after cutting the band. The fibrous band was pathologically identified as a vessel structure, so we finally diagnosed this case as strangulation ileus caused by a mesodiverticular vascular band of Meckel's diverticulum.

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Gallbladder injury due to a blunt trauma is extremely rare. We experienced a case of gallbladder injury with bleeding from a branch of the cystic artery. An 82-year-old man was brought into the hospital by air ambulance, because he had lost consciousness in a car accident. Enhanced CT revealed extravasation from a cystic duct branch and right kidney injury. Successful treatment was achieved using selective TAE. However, the patient exhibited signs of peritoneal irritation and CT revealed increased accumulation of ascitic and pericholecystic fluid on the day following admission. Laparotomy was performed with a diagnosis of biliary peritonitis due to gallbladder necrosis. There were pericholecystic blood clots and complete avulsion of the gallbladder with perforation. A cholecystectomy was performed. The postoperative course was uneventful. Based on the literature, the following recommendation of a definitive therapeutic strategy was proposed：If vital signs are stable after hemorrhage control by TAE, a gallbladder perforation must be considered and careful observation is important.

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A 12-year-old girl was admitted to our hospital with lower abdominal pain. She was diagnosed as having acute appendicitis and underwent a laparotomy. Soon after the appendectomy, hemorrhagic ascites was revealed. There was no bleeding at the surgical site. The patient had progressive anemia after the operation, and was diagnosed as having right ovarian hemorrhage. Conservative treatment improved the patient’s anemia. After the diagnosis of acute appendicitis, we should pay attention to the coexistence of other diseases.

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We report herein on a case of blunt duodenal injury that was missed during the primary surgery. A 79-year-old female was transferred to our hospital following a road traffic accident. Computed tomography (CT) revealed fractures of the ninth and tenth ribs. However, due to a temporary reduction of systolic blood pressure, an enhanced CT was performed that revealed intra-abdominal hemorrhage due to injury of the spleen and adjacent tissue at the greater curvature. Emergency surgery revealed a gradeⅠ splenic injury and an omental and mesenteric hematoma with 1,000 mL of bloody ascites. Therefore, we performed a splenectomy, but on postoperative day 2 the patient developed severe abdominal pain, high fever, and septic shock. We suspected some missed injury, and performed a second emergency surgery, which revealed a gradeⅡ duodenal laceration requiring simple closure and duodenal diverticulation. Despite some postoperative complications, including acute respiratory distress syndrome and leakage at the repair site, the patient was successfully discharged after 89 days of admission. It is important to consider that duodenal injury can easily be overlooked during emergency surgery; performing appropriate surgical procedures can help to avoid postoperative complications.

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A 94-year-old woman was transferred from another hospital because of abdominal pain and vomiting occurring the day before. Based on the CT scan perforation of the sigmoid colon by a fish bone and small intestinal obstruction was diagnosed, and the patient underwent an emergency operation. Laparotomy showed a small amount of glutinous ascites and diffuse adhesions with a kink of the mid small intestine. Postoperative course was uneventful. We do not usually encounter adhesions without a previous history of laparotomy. In addition, accidental ingestion of fish bones often causes perforation or penetration of the digestive tract, resulting in peritonitis or an intraabdominal abscess, but intestinal obstruction rarely occurs. We report herein on a case of small intestinal adhesions resulting from perforation of the sigmoid colon by a fish bone, and review the relevant literature.

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A 76-year-old woman was admitted to our hospital with abdominal pain after taking a laxative because of recalcitrant constipation. After admission to our hospital, her symptoms had worsened and she showed signs of peritoneal irritation. In addition, her serum CEA level was elevated and intestinal necrosis was suspected based on the findings of enhanced abdominal CT. Emergency surgery was performed. Her necrotic colon (from the ascending colon to the descending colon) was totally removed. After the surgery, the serum CEA level normalized. In this case, obstinate constipation and promoting intestinal movement by taking a laxative might have caused intestinal ischemia and necrosis.

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A 70-year-old woman, who received a hard blow to her right hypogastrium 2 weeks previously, was admitted to another hospital due to severe abdominal pain with the diagnosis of an intraabdominal abscess due to acute appendicitis or diverticulitis based on the abdominal contrast enhanced CT findings. At that time, the previous doctor was unaware of the history of the trauma. Medical treatment for 2 weeks was ineffective. A repeated abdominal contrast enhanced CT showed growth of the abscess together with free air, so she was transferred to our hospital as a case for emergency surgery. Intraabdominal laparoscopy showed turbid ascites and an intestinal perforation. Following a laparotomy, perforations were noted in the 3 sites, resection of 60 cm of the perforated and functional end to end ileum-ileum anastomosis were performed. From the patient's history, our diagnosis was traumatic delayed intestinal perforation and this was confirmed pathologically by the presence of metachronous perforations. This was a rare case of traumatic delayed intestinal perforation, which was complicated by metachronous perforation of the oral side of the intestine.

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A 69-year-old man presented to the emergency room in the evening with a non-reducible painful lump in his left inguinal region which had been present since that morning. He had been diagnosed as having inguinal hernia at another clinic 6 months previously and chosen a careful observation approach because he could reduce the hernia manually. Local examination revealed a fist-sized non-reducible lump in his left inguinal region and abdominal X-ray demonstrated small bowel obstruction. He was diagnosed as having an incarcerated inguinal hernia and emergency surgery was performed. Several loops of the small intestine adhering to one another were observed in the hernial sac. A median incision was added together with the inguinal incision to reduce the protruded intestine into the abdominal cavity. The intestine was not resected. The posterior wall was repaired with a mesh plug. The postoperative course was uneventful.

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A 79-year-old man was admitted to our hospital with constant right lower abdominal and inguinal pain. He had a bulging mass and tenderness in the right inguinal region. He was diagnosed as having a right incarcerated inguinal hernia. Abdominal CT showed the small intestine incarcerated in the right inguinal hernia. The manipulation of the inguinal hernia was completed, but the patients still had constant right lower abdominal pain. An emergency operation was performed under the diagnosis of perforative peritonitis in the incarcerated small intestine. Intraoperative findings showed peritonitis due to appendiceal perforation with the incarcerated inguinal hernia. Appendectomy and inguinal hernioplasty were performed via ileopubic tract repair. Cases similar to our reported case are rare. Therefore, we report herein on this case of peritonitis due to appendiceal perforation with an incarcerated inguinal hernia.

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Non-traumatic rupture of the spleen is a rare condition, and several cases complicated with alcoholic chronic pancreatitis have been reported to date. A forty-year-old man who drank a bottle of whisky every day felt severe back pain and visited Akita City Hospital. An abdominal CT scan showed rupture of the spleen and extravasation of the contrast media, hematoma with an amount of bloody ascites, and a pancreatic cyst. Subsequently, he underwent abdominal angiography but transcatheter arterial embolization was not done because of the lack of extravasation at that time. We upgraded the patient’s general condition with a blood transfusion and his anemia was improved, so on the next morning, he underwent a laparotomy. There was a subcapsular hematoma mimicking rupture of the spleen, and he underwent a splenectomy. He developed alcohol withdrawal a couple of days after surgery, and an intra-abdominal abscess was noted adjacent to the pancreatic tail, which decreased with antibiotic therapy. He was discharged from the hospital on postoperative day 18.

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A 86-year-old woman was referred to our hospital with abdominal pain and was diagnosed as having ileus. On the following day, abdominal CT showed intraperitoneal free air, and a structure of highly concentrated material appeared to be a foreign body around the sigmoid colon. An emergency operation was performed and a small hole in the sigmoid colon was found. We removed the perforated colon and performed a sigmoid-colostomy. The perforation was induced by a pink resilient material, which was identified as dental impression material for an artificial tooth. There has been no reported case of bowel perforation induced by dental silicon impression material, thus, this case was thought to be very rare.

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We report herein on a rare case of abdominal actinomycosis in a 7-year-old girl. She presented with peritoneal irritation in the right lower quadrant, accompanied by leukocytosis and elevation of C-reactive protein levels. Computed tomography showed a granuloma continuing from the tip of the appendix. A preoperative diagnosis of perforated appendicitis forming a granuloma was made. An emergency operation was performed. Laparotomy revealed an elastic hard mass mimicking a malignant retroperitoneal tumor that involved the retroperitoneum, sigmoid colon, urinary bladder, and greater omentum. Sclerosis of the peritoneum continued to the peritoneal reflection in the rectouterine pouch; thus, the mass could not be removed completely. The final diagnosis of actinomycosis was made by a postoperative histopathological examination. The patient has experienced no recurrence, 7 years post-operatively, with long-term postoperative antibiotic administration. The treatment strategy and the role of surgery in a pediatric case of abdominal actinomycosis are discussed.

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An 89-year-old woman was transferred to our hospital following a diagnosis of rectal perforation 3 h previously. Damage control strategy (DCS) was adopted because she was in a state of shock on arrival (HR 106/min, BP 67/42 mmHg, RR 42/min, APACHE-II 32). On day 1 of admission, the perforated segment of the rectum was resected, and a temporary abdominal closure was performed using a vacuum packing closure (VPC) method. Because her vital signs stabilized without the use of vasopressors on day 3, a permanent stoma was formed and the abdominal dressing was switched from VPC to a vacuum-assisted closure device. The volume status was observed to be balanced on day 6 and fascial closure was also achieved on that day. At our hospital, 9 cases of peritonitis required DCS and open abdominal management between April 2012 and March 2013. Of these, 4 cases required more than 100 h to achieve fascial closure, and abdominal dressing was switched from the VPC method to a vacuum-assisted closure device. In addition to describing the clinical course of this case, we also report the clinical course and complications associated with the other 3 of these 4 cases.

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A-78-year-old man was brought to our hospital by ambulance following a bicycle accident. Computed tomography (CT) revealed a left hemopneumothorax and rib fractures but no abnormal findings were observed on the abdominal scan. The next day the patient developed sudden onset of abdominal and back pain and went into shock. Enhanced CT revealed a retroperitoneal hemorrhage around the pancreatic head with extravasation. On emergency angiography through the celiac and superior mesenteric artery, abnormally meandering and irregularly dilated vessels with extravasation were observed in the arcade of the gastroduodenal artery and inferior pancreaticoduodenal artery suggesting segmental arterial mediolysis （SAM）, and transcatheter arterial embolization was performed. The patient had an uneventful recovery and was discharged on postoperative day 48. Although SAM is a rare disease its abrupt onset requires immediate diagnosis based on the unique features on angiography. In this case rapid identification resulted in successful treatment.

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An 81 year-old male was delivered to our hospital with the chief complaint of anorexia. Abdominal CT showed obstructive sigmoid colon cancer, and an emergency operation was performed. There was severe enterectasis of the colon but no perforation or obstructive colitis. We performed only a transverse loop colostomy. However, the patient developed septic shock due to bacterial translocation just before the operation. We performed hemodiafiltration and direct hemoperfusion with polymyxin B immobilized fiber under intensive care after the operation. We detected Escherichia cloacae and E. coli from the blood culture. His condition improved, and we performed extubation on postoperative day 6, sigmoidectomy and stoma closure on postoperative day 34, and the patient was discharged on postoperative day 51 after the first operation. Septic shock due to bacterial translocation sometimes occurs in the case of obstructive colon cancer. We need to perform a decompressive procedure and intensive care without delay in such case.

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