The present study was conducted to examine the clinical usefulness, problems, and indications of antibiotic administration as the first-line treatment for acute appendicitis. We conducted a retrospective analysis of the clinical data of 60 patients who had undergone conservative treatment for acute appendicitis. Patients were divided into two groups: 49 patients in whom conservative therapy was effective and 11 patients in whom it was not. All patients in the latter underwent emergency appendectomy, and we compared the clinical outcomes between the groups. There were significant differences between the two groups in the incidence of complicated appendicitis, coprolites, ascites, elevated serum C-reactive protein concentrations, and elevated white blood cell counts. In acute appendicitis patients with elevated white blood cell counts and serum C-reactive protein concentrations after conservative treatment, change of the treatment strategy from conservative treatment to surgical treatment should be considered.

Transcatheter arterial embolization (TAE) is a widely adopted intervention for abdominal hemorrhagic emergencies. Embolization materials for TAE should be selected based on factors such as the vascular anatomy and patient background. Gelatin sponge is a non-permanent particle embolic material that is often used, while its embolization mechanism involves thrombosing capability. N-butyl-2-cyanoacrylate, a permanent and strong liquid embolic material, is less affected by coagulopathies, so that it is preferred for cases with coagulopathies. Metallic coils provide a secure embolization effect at the focus of the vascular injury. In this article, we discuss about how embolic materials should be selected and used for various abdominal hemorrhagic emergencies.

Hemorrhage occurs in a reported 4％ to 16％ of patients following pancreaticoduodenectomy (PD), most often caused by local infection or vascular erosion secondary to leakage of pancreatic juice or bile from insufficiently secure anastomoses. Surgical exploration is less commonly selected for treatment, because the presence of adhesions and increased tissue friability after surgery would make it technically challenging. Endovascular coil embolization of the affected artery is currently considered as one of the most effective techniques for treating visceral arterial bleeding. However, the liver has many potential collateral pathways that communicate with the adjacent arterial system, and a sudden complete blockage of the hepatic arterial flow immediately after surgery may induce an ischemic insult of the liver parenchyma. An ideal solution to address this dilemma is placement of a stent graft, which would allow complete hemostasis to be achieved while preserving the hepatic arterial flow. In Japan, the GORE^Ⓡ VIABAHN^Ⓡ Endoprosthesis with a Heparin Bioactive Surface was the first stent to gain approval from the PMDA on February 15, 2016．In this lecture, we will present an overview of the VIABAHN ^Ⓡ stent graft, along with a discussion of our own experience of the use of this stent device in the context of the history of endovascular therapy for post-PD complications.

TAE is the treatment of choice for cases of upper gastrointestinal bleeding that are difficult to treat endoscopically. The upper gastrointestinal tract is a region characterized by complex anastomoses of blood vessels, and embolization requires a thorough understanding of the vascular anatomy. In particular, excellent results have obtained with NBCA, an embolization material that has recently begun to be covered by insurance, because embolization with this substance is relatively unaffected by the blood coagulability. Familiarity with its use ensures its safe use. The upper gastrointestinal tract is a good candidate, in particular, for NBCA embolization, because it is an ischemia-prone organ with many vascular anastomoses.

Transcatheter arterial embolization (TAE) is the main interventional radiological procedure used for lower gastrointestinal bleeding (LGIB). Colonic diverticular bleeding and small bowel bleeding are relatively common indications for TAE. Selective embolization is the key to effective treatment, despite some anatomical differences between the small intestine and large intestine. Herein, we provide an overview of interventional radiology for LGIB, by presenting a case each of colonic diverticular bleeding, small bowel bleeding, and rectal arteriovenous malformation.

Transcatheter arterial embolization (TAE) is currently accepted as the key procedure for lower gastrointestinal bleeding. Proper selection of the embolization materials and adequate caution to minimize the embolization area are mandatory for successful and safe outcomes. In general, a selective approach using a microcatheter into the vasa recta, the major bleeding source in the lower bowel, is adopted, and embolization is performed using metallic coils or n-butyl-2-cyanoacrylate. In cases where the bleeding vasa recta cannot be identified or approached, the usefulness of preemptive embolization using imipenem cilastatin (IPM/CS) has recently been reported.

Pancreatectomy is one of the most difficult gastrointestinal surgeries, with a high postoperative complication rate. Among them, hemorrhagic complications are the most serious and can be fatal. Pseudoaneurysm associated with pancreatic fistula is often the source of bleeding, and pancreatic fistula treatment with appropriate drainage management is key to its prevention. Detection of bloody drainage from the drain or gastrointestinal hemorrhage after pancreatic resection should immediately alert the surgeon to the possibility of intraperitoneal bleeding, and a contrast-enhanced CT and angiography should be promptly performed to identify the source of the bleeding. Interventional radiology (IVR) is the treatment of first choice, however, hepatic artery embolization could be complicated by liver dysfunction and abscess formation. For this reason, use of covered stent-grafts, which can stop bleeding while preserving hepatic blood flow, has recently been reported as being useful. However, since IVR is not suitable for some patients, it is essential to select an appropriate treatment method that considers laparotomy.

Both the VIABAHN^Ⓡ endoprosthesis and coil embolization have been used for the treatment of visceral arterial injuries. In coil embolization, the blood flow through the treated vessel is interrupted, whereas with VIABAHN^Ⓡ, the blood flow in the treated vessel can be potentially preserved. However, not all abdominal vascular injuries that can be treated by coil embolization are suitable indications for the use of VIABAHN^Ⓡ. In this paper, we propose six considerations for selecting the most appropriate endovascular treatment method for vascular injuries: 1) the diameter of the injured vessel; 2) the risk of organ ischemia associated with embolization; 3) the access route to the injury; 4) the availability of VIABAHN^Ⓡ at the facility; 5) the cost and time required for the procedure; and 6) the risk of occlusion of VIABAHN^Ⓡ. In determining the treatment method for vascular injuries, it is essential to evaluate uncertain and quantitatively challenging factors related to the patient, physician, and the facility. Therefore, it is crucial to reflect on the clinical course of each case and discuss the most appropriate choice of treatment method.

Post-pancreatectomy hemorrhage (PPH) associated with pancreatic fistula has a high fatality rate and requires immediate management via interventional radiology. Transcatheter arterial embolization has been considered as the treatment of first choice for PPH, but liver abscess, liver failure, and intestinal necrosis due to insufficient blood flow to the peripheral organs may occur as complications after embolization. Recently, the usefulness of covered stenting for vascular injuries has been reported. However, there are no guidelines concerning the selection of and duration of treatment with antiplatelet agents for preventing stent occlusion. The safety of antiplatelet agents and their efficacy against stent occlusion and the long-term outcomes after stenting for PPH remain unknown. The main difference between stenting for acute coronary syndromes and carotid stenosis and stenting for PPH is the high risk of occurrence of bleeding and perivascular infection in the latter case. Use of antiplatelet agents should be carefully evaluated when stenting is performed in the presence of hemorrhage. Herein, we describe our experience in cases of stenting performed for PPH from the hepatic artery and the use of antiplatelet agents.

Tumor bleeding occurs in 6％ to 10％ of all malignant tumors. Tumor hemorrhage may not only delay treatment of the primary lesion, but also lead to a poor prognosis. Endoscopic hemostasis, which is often selected as the first-line treatment modality, has been reported to be associated with a high success rate. However, in patients who are not suitable candidates for endoscopic therapy, in a critical hemodynamic state, or with recurrent bleeding after endoscopic hemostasis, transcatheter arterial embolization (TAE) could be used as a reliable hemostatic measure. The advantage of TAE is its availability to a wide clinical spectrum of patients; it is performed under local anesthesia, so that it can be used in patients who are in poor general condition or in a critical hemodynamic state. Moreover, TAE can even be performed when there is no active bleeding, as empiric embolization. Successful hemostasis with TAE can be achieved with selection of the appropriate embolic material and finding the proper balance between the degree of devascularization and degree of maintenance of vascularity, depending on the tolerance for ischemia of each organ.

Rupture of visceral arterial aneurysms is extremely rare. The risk of rupture differs depending on the location of the aneurysm and the indications for prophylactic treatment also differ among patients. In recent years, cases of rupture due to segmental arterial mediolysis (SAM), an uncommon condition, have been increasingly reported. In most cases, transcatheter arterial embolization (TAE) is the treatment of first choice, and the optimal embolization method should be selected. Metallic coils are the most commonly used embolic material, but stentgrafts and histoacryl, a liquid embolic material, have recently begun to be covered by insurance for vascular injury. It would be desirable to develop more treatment options for ruptured arterial aneurysms.

Recently, Japanese, US, and European guidelines for the management of ruptured abdominal aortic aneurysms (RAAA) were revised as follows: “If it is anatomically feasible, endovascular abdominal repair (EVAR) is recommended as the treatment of first choice for RAAA.” However, there are some unresolved issues that could interfere with the improved prognosis expected with this treatment strategy, such as development of abdominal compartment syndrome. In this review, we identify the issues concerning EVAR for the treatment of RAAA, and describe the strategy employed for the management of RAAA at our facility.

A 70-year-old man visited our hospital with complaints of pneumaturia, fecaluria, and fever. He had undergone Hartmann’s procedure at the age of 59 under the diagnosis of colovesical fistula complicating sigmoid diverticulitis, followed by Hartmann’s reversal. Abdominal computed tomography showed multiple colonic diverticula, an abscess surrounding the colon, and gas in the bladder. Lower gastrointestinal endoscopy, cystoscopy, and enema X-ray radiography revealed a colovesical fistula and a colo-small bowel fistula, and surgery was performed. After the abscess cavity was opened, two fistulas were identified in the colon on the oral side of the previous anastomosis, and a fistula was also identified in the small intestine. The colovesical fistula had closed spontaneously. Hartmann’s procedure was performed by resecting a 12-cm segment of the colon including the fistula and the previous anastomosis. The small intestinal fistula was sutured and closed. Postoperatively, the patient developed surgical site infection and catheter-related bloodstream infection, but had a smooth recovery from both and was discharged on postoperative day 32. There was no recurrence until the follow-up conducted 2 years after the surgery. Recurrence of colovesical fistula complicating diverticulitis is rare after surgery, and we report this case with a review of the relevant literature.

An 82-year-old man was admitted to our hospital for the treatment of skin ulcers and osteomyelitis. While hospitalized, he developed abdominal distension and dyspnea. Clinical examination led to the diagnosis of strangulated bowel obstruction due to a right diaphragmatic hernia, and emergency surgery was performed. As the patient gave a history of right traumatic hemopneumothorax and multiple rib fractures and liver injury resulting from a fall 18 years previously, he was considered as having traumatic diaphragmatic hernia. Intraoperative exploration revealed incarceration of the transverse colon in the thoracic cavity following herniation through the defect in the diaphragm. The incarcerated bowel was retracted into the abdominal cavity and the necrotic segment was resected, followed by end-to-end intestinal anastomosis two days later. Postoperatively, the patient developed complications such as pneumonia and wound dehiscence, and the treatment time was prolonged. Because traumatic diaphragmatic hernia can develop late after injury, a detailed history of trauma and risk factors must be obtained. In addition, early intervention is important because organ resection may be required.

Herein, we present a successfully treated case of a patient with sepsis due to stercoral rectal perforation, with concomitant novel corona virus disease (COVID-19). A 79-year-old woman visited an advanced emergency hospital with complaints of abdominal pain and fever. However, it was in the initial phase of the COVID-19 outbreak, hospitals were overwhelmed, and she could not undergo surgery. She was referred to our regional hospital for appropriate therapy, including palliative care. At first, we attempted to stabilize her general condition by conservative, but intensive treatments. Next, she was released from intentional isolation according to the Japanese guideline for COVID-19 treatment. Finally, we created a colostomy by the laparoscopic approach. She was discharged from our hospital in accordance with the Japanese guideline for hospital discharge, although her postoperative course, including prolonged fever, added confusion to making clinical decisions. In the COVID-19 pandemic era, the aspects of safety, feasibility and concerns in relation to surgical treatments have been discussed, especially in patients suffering from COVID-19 concomitantly with other infectious diseases. Real-time monitoring, e.g., by repeated rapid antigen tests, could be a valuable tool for determining the optimal timing for surgical treatments.

Recently, non-operative management (NOM) has become the standard of care for solid organ injuries following blunt abdominal trauma in hemodynamically stable pediatric patients. However, the management strategies for high-grade pancreatic injuries with pancreatic duct injury in children need to be thoroughly investigated. We retrospectively reviewed the management and outcomes in three pediatric cases of pancreatic injury, including pancreatic duct injury, at our hospital between 2015 and 2020. The average age of the patients was 9.7 (range: 5-14) years and all were boys presenting with isolated blunt pancreatic injury. While the severity of the injury was diagnosed mainly by abdominal CT, ERP was performed in one case, and MRCP in two cases. NOM was selected in all cases, ERP with ductal stenting was performed in one case, and percutaneous ascites drainage in two cases. At least two cases developed pancreatic pseudocysts, which resolved spontaneously in both cases. NOM could be a feasible option for high-grade pancreatic injuries in selected pediatric patients. Data on the success rate of NOM and long-term outcomes of organ-preserving treatment are still scarce; therefore, further studies are required.

A 90-year-old female patient was transported to our hospital with a history of consciousness disorder. Abdominal CT showed acute cholecystitis, intraabdominal free air confined to the pelvic cavity, mesenteric emphysema, air around the uterus and ovaries, and retroperitoneal emphysema. Emergency laparotomy was carried out under the diagnosis of lower gastrointestinal perforation. Intraoperative examination showed necrotic changes of the gallbladder, but no perforation of the intestine. We performed cholecystectomy. After the surgery, the patient developed septic shock and disseminated intravascular coagulation, but could eventually be discharged from the hospital 36 days after the surgery. Clostridium perfringens, a gas-producing bacterium, was detected in cultures of bile fluid specimens collected intraoperatively. Postoperative histopathology revealed emphysematous changes in the walls of the gallbladder. There are only a few reported cases of emphysematous cholecystitis with extraluminal air confined to the pelvic cavity.

The patient was a 69-year-old man who presented to our emergency room with the complaints of hematemesis and bloody stool. He was hospitalized and blood examination in the emergency ward revealed anemia (Hb 9.3g/dL). Contrast-enhanced computed tomography revealed an aneurysm of the gastro-duodenal artery in the arterial phase measuring 65x45 mm in size. Abdominal angiography revealed extravasation of contrast medium into the duodenum, suggestive of rupture of the aneurysm. Therefore, emergency transcatheter arterial coil embolization was performed. However, the aneurysm re-ruptured on the same day, and repeat arterial embolization was performed, which yielded successful hemostasis. Considering the risk of late rupture of the aneurysm, we performed elective pancreatoduodenectomy on day 8 of hospitalization. Rupture of a gastroduodenal artery aneurysm could be fatal. We conclude that achievement of hemostasis by emergent interventional radiology followed by surgery at an appropriate time could be the best strategy for successfully managing rupture of a gastroduodenal artery aneurysm.

A man in his 40s presented to a previous hospital with the complaint of abdominal pain, and was transferred to our hospital with a diagnosis of intussusception. Since abdominal contrast-enhanced CT revealed intussusception associated with a tumor of the small intestine, we performed emergency surgery via a laparoscopic approach through a median incision. An about 1-meter long segment of the small intestine containing the tumor was resected, followed by end-to-end anastomosis. The postoperative course was uneventful, and the patient was discharged from the hospital 10 days after the operation. Postoperative histopathology revealed a hamartomatous polyp, which was diagnosed as a Peutz-Jeghers polyp. Herein, we report a rare case of adult intussusception caused by a Peutz-Jeghers polyp.

Two patients were admitted to Ageo Central General Hospital for refractory pleural effusion. Case 1, a 53-year-old man with alcoholic cirrhosis and ascites, presented with respiratory distress. A plain chest radiograph showed massive right pleural. Since administration of albumin and diuretics did not improve his condition, thoracoscopy and laparoscopy were performed, which revealed a fistula in the diaphragm; the defect in the diaphragm was sealed using a tissue adhesive sheet (TacoSeal^Ⓡ︎), polyglycolic acid sheet (PGA) (Neover Sheet^Ⓡ︎), and fibrin glue (Veriplast P^Ⓡ︎). Case 2 was a 67-year-old female patient with HCV hepatitis. Thoracic drainage was performed to relieve the pleural effusion-related respiratory discomfort. Suspecting pleuroperitoneal communication, the chest cavity was closed as in the first case. Both patients were discharged without postoperative complications. The minimally invasive laparoscopic and thoracoscopic approach is useful for the treatment of pleuroperitoneal communication. When suturing poses a challenge, reinforcement with tissue adhesive sheets may be a useful option.

A 79-year-old woman with chronic renal failure and atrial fibrillation presented to our hospital complaining of acute abdominal pain. Abdominal CT revealed a common bile duct stone. Because of renal dysfunction, we did not use contrast medium. However, the following day, the patient’s consciousness disturbance and abdominal pain worsened. Therefore, we performed abdominal contrast-enhanced CT under sodium bicarbonate solution administration to prevent contrast-induced nephropathy, which revealed thrombus occlusion of the superior mesenteric artery (SMA) and poor contrast enhancement of the small intestine wall. The patient was diagnosed as having acute SMA occlusion, and resection of a 410-cm segment of the small bowel was performed. Although she developed short bowel syndrome postoperatively, her life was successfully saved, and her renal function was preserved. In cases of atrial fibrillation presenting with acute abdomen, it is important to perform contrast-enhanced CT for accurate evaluation of the possibility of SMA.