Background: The ABTHERA dressing kit for OAM was introduced in Japan in March 2019. However, the actual status of OAM using ABTHERA in Japan is still not clear, and factors affecting the prognosis of patients receiving this treatment remain unknown. Purpose: The purpose of this study was to analyze the clinical features and treatment outcomes and to identify factors related to the short-term survival of patients receiving OAM with ABTHERA. Methods: This study included 35 consecutive OAM patients managed with ABTHERA between June 2019 and June 2021. We divided the patients into trauma and non-trauma groups, and survivor and non-survivor groups. The patient demographic data, including the APACHE Ⅱ scores, were analyzed. Results: Two of 12 patients (16.7％) in the trauma group died, and 10/23 patients (43.5％) in the non-trauma group died. Primary fascial closure was achieved in 32/35 (91.4％) patients. The mean APACHE Ⅱ score was 19.7. The APACHE Ⅱ score was significantly higher in the non-trauma and non-survivor groups. Analysis showed that the APACHE Ⅱ score was associated with the short-term survival. Conclusion: The findings of the present study suggest that determination of the APACHE Ⅱ score is useful for predicting the short-term prognosis of patients with OAM treated with ABTHERA as part of damage control surgery.

We investigated knowledge gaps regarding abdominal compartment syndrome (ACS) among members of the Japanese Society for Abdominal Emergency Medicine. About a half of the respondents specialized in abdominal emergencies and the majority (86.1％) were familiar with ACS, but very few seemed to have an accurate understanding of the condition. Many of the respondents answered that they had no experience of intra-abdominal hypertension (IAH)/ACS, but we think it is possible that the diagnosis may have been overlooked. Thus, physicians should be made aware of the ACS guidelines, and as recommended, intra-abdominal pressure (IAP) should be proactively measured in cases considered as having risk factors. Following these suggestions actions could increase the number of cases diagnosed, which may lead to improved prognosis of patients with conditions that could predispose to IAH/ACS. The respondents accounted for only 6％ of the members, more than half of whom were surgeons. Therefore, surveys of emergency and intensive care specialists may yield different results. It will be necessary to investigate the epidemiology of IAH/ACS at multiple centers, beyond the level of academic societies.

Abdominal compartment syndrome (ACS) is a life-threatening emergency. In general, when the intra-abdominal pressure (IAP) fails to decrease despite medical treatment of ACS and the patient’s condition is categorized as grade Ⅳ (IAP 26 mmHg or higher) with organ damage, open abdomen management (OAM) is indicated because conservative treatment is not expected to be effective. However, once OAM has been established, the process to radical abdominal closure is not uniform, and the decision-making process always involves the need to choose between the ideal and practical.

Two or three decades ago, abdominal compartment syndrome was not very well known. Most general surgeons and physicians other than trauma surgeons were not aware of this condition. I believe that owing to this lack of knowledge, there could be some preventable mortality cases. After wide dissemination of new information by the World Society of Abdominal Compartment Syndrome, founded in 2004, the level of awareness about this condition has grown. However, because of its rarity, there are only a few physicians yet who are adequately equipped to diagnose and treat abdominal compartment syndrome, so it can be overused. There is also the risk of this impressive terminology being inappropriately applied to patients with abdominal distension and shock without abdominal compartment syndrome. In this article, I present some pitfalls of the diagnosis and treatment of abdominal compartment syndrome, especially concerning surgical treatment, based entirely on my experience. I would like to tell the younger generation that will encounter more and more cases of abdominal compartment syndrome my failure story.

Acute pancreatitis is a risk factor for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). As ACS is well known to be associated with a high mortality risk, one of the goals of treatment in patients with acute pancreatitis should be to prevent the development of IAH/ACS. There are numerous factors associated with increase of the intra-abdominal pressure in these cases, including inflammation of the pancreas itself, intestinal edema, and ascites. Proper fluid management is an important intervention for preventing IAH/ACS. Surgical decompression should be avoided if possible. The management of IAH/ACS utilizing the step-up approach should be implemented, from noninvasive treatment, including fluid strategies, to invasive treatments. While use of surgical decompression to manage ACS developing as a complication of acute pancreatitis has decreased in recent years, surgical decompression should be performed promptly in cases where it is difficult to control the intra-abdominal pressure. Drawing on the findings of recent studies and our own experience, herein, we discuss fluid strategies for preventing elevation of the intra-abdominal pressure, the step-up approach from noninvasive to invasive treatments, and the pitfalls in the treatment of ACS.

Obturator hernias are most commonly seen in elderly and leptosomatic women, and cases with strangulation require emergency surgery. We report on three patients with obturator hernia seen at our facility who were treated successfully by a new laparoscopic inversion and ligation technique, with all three being discharged with no decline in the activities of daily living. As it is a relatively simple procedure to perform, we believe that this technique may be appropriate even for elderly patients or those whose frailty due to comorbidities precludes more invasive surgical procedures.

An 82-year-old woman had been treated for acute cholangitis by endoscopic papillotomy and biliary drainage 35 days earlier. She subsequently underwent laparoscopic cholecystectomy (LC) as radical treatment for bile duct stones, and the cystic duct was clipped with a Hem-o-lok ligation system. She was discharged on postoperative day 4. On day 47, the biliary stent was removed and a filling defect measuring 8 mm in size was observed in the lower common bile duct. The object occupying the defect area was removed endoscopically and was identified as the Hem-o-lok clip used for LC. Clip migration after LC has been reported rarely, although the cause remains unclear. A large percentage of patients with clip migration have biliary occlusion. Although clip migration is diagnosed within the first postoperative year in most cases, it is sometimes diagnosed later in the clinical course. Clip migration can occur at any time after LC, and when it is detected, endoscopic treatment should be considered.

We present a case of superior mesenteric venous thrombosis (SMVT) induced by ileo-ileal intussusception. A 53-year-old man with no significant past medical history was referred to our hospital with the complaint of epigastric pain. Plain abdominal computed tomography (CT) revealed superior mesenteric vein (SMV) enlargement and mesenteric edema. Contrast-enhanced CT further revealed a thrombus in the SMV and ileo–ileal intussusception without impending bowel necrosis. We performed an emergency surgery and confirmed that the intestine was not necrotic. We resected the bowel segment containing the intussusception, which was caused by a hard, elastic mass measuring 2 cm in diameter and located 310 cm distal to the ligament of Treitz, and performed end-to-end anastomosis. Histopathology identified the tumor as a tubular adenoma. We administered heparin after surgery, but not thrombolytic therapy, as the intestine was not necrotic. The patient was discharged without complications on postoperative day 14. He did not have coagulation disorder; thus, the SMVT might have been caused by the intussusception in the absence of hereditary thrombophilia.

A 27-year-old primipara at 7 weeks presented with the complaint of acute right lower quadrant pain. Abdominal physical examination revealed rebound tenderness at the McBurney’s point, and abdominal CT showed swelling of the appendix. No neoplastic lesion or lymphadenopathy was observed. We made the diagnosis of acute appendicitis and performed emergency laparoscopic appendectomy. The postoperative course of the mother and embryo were uneventful. The patient was discharged on the 7th day after the surgery. The histopathological diagnosis was perforated gangrenous appendicitis and appendiceal neuroendocrine tumor (NET) G1 measuring 7 mm in diameter, without mesenteric and vascular invasion. We decided not to perform additional resection. Appendiceal NETs account for less than about 3％ of all NETs and they are rarely diagnosed in pregnant women. In regard to the treatment policy, it is necessary to evaluate the test results and make a judgment on the most appropriate surgical procedure and possibility of continued pregnancy.

A woman in her 80s was admitted to our hospital with a history of abdominal pain which occurred after lunch. Abdominal CT revealed occlusion of the distal part of the superior mesenteric artery and a diffusely atherosclerotic aorta with ulcerated plaques. The patient was diagnosed as having embolism of the superior mesenteric artery and a shaggy aorta. We started the patient on conservative therapy with intravenous heparin infusion; however, her symptoms worsened. Therefore, we performed emergency laparotomy 18 hours later, and thrombectomy. Reperfusion of the superior mesenteric artery was achieved immediately after the procedure. However, the ileocecal region and jejunum remained severely ischemic, and both required resection. We conducted second-look and third-look operations to avoid excessive bowel resection. The final length of the residual bowel was approximately 200 cm and short bowel syndrome was avoided. Histopathological examination revealed cholesterin crystals in the embolus. We have presented a rare case of superior mesenteric arterial embolism due to cholesterin crystals released from a shaggy aorta.

An 86-year-old woman presented to the department of surgery with the chief complaints of right inguinal pain and vomiting. Abdominal computed tomography showed a right incarcerated obturator hernia, and emergency surgery was performed. The second patient was a 96-year-old woman who presented to the department of internal medicine with the chief complaint of vomiting. Abdominal computed tomography revealed a right obturator hernia with intestinal obstruction, and emergency surgery was performed. In both cases, laparoscopic hernia repair (transabdominal preperitoneal repair: TAPP) was performed using a self-fixating mesh (Parietex ProGrip^TM Laparoscopic Self-Fixating Mesh). While some reports of laparoscopic surgery for obturator hernia have been published, no standard operative method has been established yet. TAPP is useful in that it prevents the development of inguinal hernia, which often occur in association with obturator hernia, is minimally invasive, and allows qualitative diagnosis of the incarcerated small intestine. In addition, tacking is one of the causes of chronic postoperative pain after TAPP, and a self-fixating mesh would be useful to avoid the pain caused by tacking is avoided.

A 92-year-old man visited our hospital with the chief complaint of swelling and hardness in the right inguinal region and pus discharge from the right scrotum. Based on the findings of detailed examination, we made the diagnosis of cecal incarceration of right inguinal hernia with a scrotal abscess. Extensive subcutaneous inflammatory thickening was noted in the area extending from the right inguinal region to the scrotum, but as there was no evidence of intraperitoneal inflammation, we selected laparoscopic surgery. Because the incarcerated cecum was found to be perforated, we performed ileocecal resection. On the other hand, the inguinal region was highly inflamed and highly sclerosed, so that simultaneous repair of the inguinal hernia was judged as being difficult, and we did not perform single-stage repair of the inguinal hernia. The patient developed postoperative wound infection, requiring incisional drainage of the wound, and was discharged on the 16th day. The scrotal abscess healed spontaneously by about 3 months after surgery. Until now, 6 months after the surgery, the patient has developed no recurrence of the scrotal abscess or hernia incarceration. In cases of ileocecal incarceration of inguinal hernia with a scrotal abscess, surgery by the laparoscopic approach could be considered as a treatment option if the inflammation is confined to the inguinal area or the scrotum.

Endoscopic biliary stent placement is a minimally invasive procedure performed in elderly and other high-risk patients. Therefore, the number of cases is increasing, but so is the number of complications associated with the procedure. The estimated stent migration rate occurring as a complication of this procedure is 5％-10％; however, gastrointestinal perforation is uncommon. Herein, we report our experience of a case of colonic perforation caused by biliary stent migration in a 91-year-old man. The patient had undergone stent placement (straight plastic stent, 7Fr, 9 cm) for the treatment of calculous cholangitis of the common bile duct 15 months prior to his first visit to us. The patient visited our hospital with primary an approximately 3-week history of lower abdominal discomfort. Abdominal computed tomography showed colonic perforation and abscess formation around the stent, and we performed laparotomy. No intraperitoneal contamination was noted during the procedure, and the stent was found to have penetrated the posterior wall of the sigmoid colon. The migrated stent was removed, and the abscess was drained. The procedure was completed by closing the perforation site by suturing. The patient was discharged 10 days after the surgery. In patients presenting with abdominal pain developing after biliary stent placement, it is essential to bear in mind the possibility of stent-associated intestinal perforation.

The patient, a 69-year-old woman, was brought to the hospital by ambulance complaining of abdominal pain and vomiting for the previous 8 hours. Abdominal CT showed the target sign and dilatation of the proximal intestine. Based on the findings, we diagnosed the patient as having ileus caused by an intestinal calculus, and performed emergency surgery. A single port laparoscopic surgery was performed, and intraperitoneal observation revealed piled-up intestine in the jejunum. After repair was performed using the Hutchinson technique with atraumatic intestinal forceps, we found a mass lesion in the advanced part of the intestine. The small intestine was pulled out through a small incision wound, and partial resection of the small intestinal segment containing the mass was performed. Histopathological examination revealed an inflammatory fibroid polyp (IFP). In this study, we report on the results of safe laparoscopic surgery performed using the single hole technique, with a review of the literature.

A man in his 20s fired a rifle on himself and was transported to our hospital emergency by ambulance. Clinical examination revealed an entrance wound of the bullet in the precordial region, and an exit wound with persistent bleeding in the left abdomen. CT showed left 10th rib fracture, bone fragments at the exit wound, splenic injury in the lower pole, and bloody fluid in the left subphrenic region. During emergency surgery under the diagnosis of traumatic splenic injury, we performed partial resection of the spleen and cauterization. Six days after the surgery, intestinal perforation was diagnosed from the fecal discharge observed at the bullet exit wound. During the second surgery, a perforation was detected in the descending colon and we performed left hemicolectomy. Subsequently, the patient was transferred to a local hospital without any complications. Since gunshot wounds are very rare in Japan, we report this case to share our experience in the field of trauma care.

A woman in her 40s developed abdominal pain and vomiting, was diagnosed as having and admitted for ileocecal obstruction, responded to ileus tube placement, and discharged. However, she developed ileus again one month later and was re-hospitalized. Colonoscopy revealed a circumferential annular ulcer at the end of the ileum. We performed laparoscopic right colonic resection, under the suspicion of intestinal obstruction caused by an inflammatory bowel disease such as tuberculosis or tumor. Postoperative histopathological examination of the resected specimen revealed epithelioid granulomas with Langhans giant cells and necrosis, but no caseating granulomas. Staining for mycobacteria was negative, but QuantiFERON (QFT) testing was positive, and we diagnosed intestinal tuberculosis. Herein, we report our case, with a review of the literature on intestinal obstruction caused by intestinal tuberculosis in Japan.

A 60-year-old male patient who presented with a one-month history of discomfort/pain in his lower abdomen was admitted to our hospital. He gave a history of having suffered from cystitis for over a decade. The results of urinalysis came back negative, but abdominal CT and cystography at our hospital showed a vesico-appendiceal fistula. MRI showed no diffusion restriction in the pelvis, and cystoscopy showed no bladder tumor, so that neither a tumor of the appendix nor a bladder tumor was suspected. We performed laparoscopic appendectomy and partial cystectomy on the 2nd hospital day and discharged the patient on the 7th postoperative day. The resected specimen showed an appendiceal diverticulum, but no tumor. A diverticulum with inflammatory cell infiltration was observed in the area of the fistula. There were no specific findings in the bladder. The patient was diagnosed as a case of vesico-appendiceal fistula secondary to appendiceal diverticulitis. There was no dysuria or evidence of recurrence at the follow-up examination performed at the follow up 2 years after the surgery, and the patient was relieved of the long-standing cystitis.

Gallbladder torsion commonly occurs in older women and causes gallbladder wall ischemia, necessitating emergency surgery. From 2016 to 2022, we encountered three cases of gallbladder torsion at our hospital. Case 1 was a 99-year-old woman who visited our hospital complaining of epigastralgia. Abdominal computed tomography (CT) showed thickening of the gallbladder wall and disruption of the cystic duct. Case 2 was an 82-year-old woman who visited our hospital complaining of right hypochondralgia. Abdominal CT showed an enlarged gallbladder and a whirl sign of the cystic duct. Case 3 was an 89-year-old woman who visited our hospital complaining of right hypochondralgia. Abdominal CT showed a swollen gallbladder and disruption of the cystic duct. In all cases, a preoperative diagnosis of gallbladder torsion was made based on the characteristic imaging findings. Preoperative diagnosis of gallbladder torsion has been considered challenging; however, the preoperative diagnosis rate has risen to approximately 70％ in recent years due to improvements in the diagnostic imaging modalities and increased recognition of the disease. With the increasing average life expectancy, the number of cases of gall bladder torsion is also expected to increase further. Therefore, it is essential to understand the risk factors and characteristic imaging findings to facilitate early diagnosis and prompt therapeutic intervention.

The patient was a 69-year-old woman who visited our hospital with the chief complaint of intermittent abdominal pain. Findings of abdominal computed tomography (CT) led to the suspicion of intussusception. She was admitted to the hospital after a colonoscopy. As her symptoms were recurrent, we performed emergency laparoscopic cecal resection. The resected specimen showed intussusception into the cecum with a mass at the base of the appendix as the leading part. The pathological diagnosis was low-grade appendiceal mucinous neoplasm (LAMN). LAMN corresponds to conventional mucinous cystadenoma or mucinous cystadenocarcinoma, and was newly classified in the Japanese Classification of Colorectal Carcinoma (eighth edition). There is no clear established treatment. Furthermore, in cases with appendiceal intussusception, there is also the problem of whether the incarceration needs to be released or not, complicating selection for the most suitable treatment strategy. Thus, we believe it is necessary to collect cases in the future and establish appropriate clinical guidelines as soon as possible.