A male in the 70’s with Parkinson’s disease underwent percutaneous endoscopic gastrostomy （PEG） using the introducer method. Following needle puncture, massive intragastric bleeding was observed, and surgical rescue was initiated. The patient remained hypotensive despite fluid resuscitation. Resuscitative endovascular balloon occlusion of the aorta （REBOA） was deployed in Zone 1, achieving partial hemodynamic stabilization. Contrast-enhanced CT revealed active extravasation from the abdominal aorta. Emergency laparotomy identified a small damage of the abdominal aorta, which was successfully sutured. Gastric wall injuries were also repaired, and a feeding tube was reinserted. Postoperatively, the patient received intensive care, including transfusion of 12 units of red blood cells and 6 units of fresh frozen plasma. He recovered steadily and was discharged on hospital day 114. To our knowledge, this is the first reported case of aortic injury during PEG in Japan. This case highlights the importance of surgical preparedness in invasive procedures involving frail patients.

Background: Traumatic pancreatic injury is rare, and consensus on the management of main pancreatic duct （MPD） injury remains lacking. We reviewed our institution’s cases and propose a treatment strategy. Methods: We retrospectively reviewed cases of traumatic pancreatic injury treated at our hospital between January 2004 and March 2024. Results: Thirteen patients were identified: 5 with AAST Grade ≥III and 8 with grade ≤II injuries. Surgical indication was determined by the presence of intra-abdominal injury and/or shock on admission. Of note, two hemodynamically stable patients with isolated grade IV MPD injuries underwent nonoperative management using endoscopic naso-pancreatic drainage （ENPD） and had favorable outcomes without surgery. Conclusion: While emergent surgery is necessary in patients with intra-abdominal injury or shock, selected cases of high-grade pancreatic injury with MPD disruption may be managed nonoperatively with ENPD when vital signs are stable.

　Our facility has been implementing an Acute Care Surgery （ACS） system since 2022. We report our experience of developing an ACS system through interdisciplinary collaboration, cooperation with other departments, and education for ER nurses from the nurse manager's perspective. A working group was established to manage the ER operating room. ACS concept was shared among all department heads, including the nursing head. Simultaneously, we procured the necessary items, managed costs, established a massive transfusion protocol, and conducted repeated simulations. ER nurses were encouraged to participate in in-hospital training, with acute care surgeons and public simulation courses. Collaborations with various experts such as physicians, nurses, laboratory technicians, and administrative staff was necessary to establish a safe and effective ACS system. Moreover, understanding the roles of each staff member and clarifying responsibilities were crucial to ensure a smooth ACS implementation.

　A 71-year-old man presented to our hospital with sudden-onset abdominal pain and was initially managed conservatively. However, he returned the following day due to persistent vomiting. Contrast-enhanced abdominal CT revealed median arcuate ligament syndrome （MALS） with rupture of a pancreaticoduodenal arterial arcade, resulting in a retroperitoneal hematoma. Although he remained hemodynamically stable, the hematoma caused duodenal obstruction due to external compression and wall edema. As the obstruction did not resolve with nasogastric decompression, the patient underwent laparoscopic gastrojejunostomy on hospital day 29. His postoperative course was uneventful.

Purpose: To clarify appropriate treatment, we investigated cases of gangrenous cholecystitis (GC) in our institution. Methods: This single-center retrospective study included patients who underwent cholecystectomy for acute cholecystitis between 2016 and 2022. We divided the 116 cases into the GC and non-GC groups, and in the GC groups, we additionally divided laparoscopic/laparotomic, or total/subtotal cholecystectomy groups. The groups were compared with in the viewpoints of some clinical factors including complications, and timing of cholecystectomy. Results: The GC group (n=84) had significantly cases with tachycardia and hypotension on admission than the non-GC group (n=57). Limiting in the GC group, in subtotal and laparotomic cholecystectomy groups, the rate of the severity and postoperative complication was significantly high. Early timing (within 24 hours of arrival to the hospital) cholecystectomy tended to have a higher risk of postoperative complication. Conclusion: The present results indicate that cautious medical plans for cases of GC having high risk would be required to emergency physicians. For cases of GC, the physicians cautiously should decide necessity of preoperative treatment, method of intraabdominal approach, and protective treatment for postoperative complication after subtotal cholecystectomy.

We looked back on the 10 years of acute care surgery 〈ACS） at our department and discussed what type of ACS is required in facilities in regional cities. In our department, the emergency and critical care unit started in 2012, which required major changes in the surgical emergency treatment system. At the regional level, we focused on maintaining the existing emergency system, and we established a system in which severe injuries and trauma cases were concentrated in our department. At the facility level, ACS team was formed with existing surgeons to facilitate trauma care and actively intervene in trauma care. In addition, to maintain the team, we improved the on-call system and implemented complete division of labor in perioperative management. At the individual level, we performed daily surgical tasks with a specialty to maintain surgical skills and motivation. In addition, we made efforts to encourage young surgeons and residents to intervene in the practice in order to foster the Acute care surgeons. In this way, we believe that ACS in regional cities can be established by maintaining the existing emergency system and having existing surgeons create a system that is suited to the facilities.

A 67-year-old man presented with heel pain and fever, two months after a skin graft for a foot burn. He had a medical history of diabetes mellitus. Examination revealed necrosis and ulceration of the right heel, with laboratory findings showing renal dysfunction. Gram staining identified streptococci, and cultures confirmed group A β-hemolytic streptococcus and methicillin-resistant Staphylococcus aureus 〈MRSA）. Diagnosed with streptococcal toxic shock syndrome 〈STSS）, the patient was treated with piperacillin-tazobactam and daptomycin. Imaging revealed necrotizing soft tissue infections 〈NSTIs）, necessitating extensive surgical debridement, which exposed widespread necrosis of the calf and Achilles tendon. Postoperative care included intensive monitoring, circulatory support, and ventilation, leading to steady recovery. Daily wound irrigation and additional debridement facilitated healing, with laboratory markers normalizing by day 6. This case highlights the importance of early diagnosis, multidisciplinary management, and prompt surgical intervention for STSS and NSTIs to improve clinical outcomes.

Non-occlusive mesenteric ischemia （NOMI） is a disease that results in impaired intestinal blood flow without organic obstruction of the main trunk of mesenteric vessels. Despite improvements in diagnosis and surgical treatment, it remains an emergency condition with a high mortality rate. At our hospital, before 2021, the physician in charge individually decided the treatment plan and surgical procedure for NOMI, but after 2022, indocyanine green （ICG） fluorescence angiography, open abdominal management （OAM）, and second-look operation were standardized in all cases. With this strategy, after naked eye confirmation of an abnormal color of the intestinal tract, blood flow is evaluated using ICG fluorescence angiography, and the extent of resection is determined. A second-look operation is performed within 48 hours after OAM without anastomosis, during which ICG fluorescence angiography is also performed. These procedures support the surgeon in determining the extent of the resection required, and reduce the surgeon's mental stress. We would like to continue further studies to improve surgical outcomes and the prognosis of NOMI by accumulating cases in which these strategies are used.

A 70-year-old man came to our hospital with a chief complaint of abdominal pain. An abdominal contrast-enhanced computed tomography （CT） scan revealed extensive hepatic portal venous gas and a poor contrast area in the small intestine, and he underwent emergency surgery. The patient was diagnosed as having non-occlusive mesenteric ischemia （NOMI）. The patient underwent small bowel resection with indocyanine green （ICG） fluorescence imaging and open abdomen management but without anastomosis. In 2nd surgery, the patient underwent anastomosis with ICG fluorescence imaging. The patient was discharged home on the 14th day without postoperative complications. We report a case of a patient with NOMI who underwent an optimal bowel resection using planned two-stage surgery and ICG fluorescence imaging, and had a favorable outcome.

A 40-year-old woman injured in a traffic accident was initially transported to another hospital with critical vital signs. A contrast-enhanced CT scan revealed injuries to the pancreatic head, duodenum, and right kidney. She was transferred to our hospital for further management. She underwent pancreaticoduodenectomy and right nephrectomy. Intraoperatively, an inferior vena cava （IVC） injury was identified. Due to the difficulty in repair, the surgery was concluded with gauze packing. On postoperative day 5, she underwent placement of an IVC stent graft to control the bleeding. Effective hemostasis was achieved, and two days later, a reconstructive surgery was performed. She was discharged home on postoperative day 47. Both pancreatic head and IVC injuries can be fatal, it is crucial to determine treatment strategies based on the patient's overall condition and the severity of injuries.

We report the case of a 68-year-old man who experienced hemorrhagic shock due to a blunt-force left subclavian artery injury sustained during a fall accident. The patient was treated using our Hybrid Emergency Room System (HERS), which integrates the emergency room, CT, interventional radiology (IVR), and operating rooms, enabling seamless diagnostics and treatment. Contrast-enhanced CT revealed a left subclavian artery injury, left clavicle fracture, and extravasation. Hemostasis was achieved with a peripheral stent graft successfully placed using our HERS without complications. Subclavian artery injuries are rare and associated with high mortality rates. While surgical intervention is standard, endovascular treatments are increasingly preferred owing to the challenges and associated risks posed by surgical exposure. This case demonstrates the efficacy of prompt CT-guided endovascular treatment for injury characterization and resuscitation. Our approach underscores the advantages of the HERS in safe and effective management of complex trauma cases.