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Background Transcatheter arterial embolization (TAE) is the first-line nonsurgical treatment for severe blunt liver injury in patients, whereas operative management (OM) is recommended for hemodynamically unstable patients. This study investigated the comparative efficacy of TAE in hemodynamically unstable patients who responded to initial infusion therapy. Methods This retrospective study enrolled patients with severe blunt liver injuries, which were of grades III–V according to the American Association for the Surgery of Trauma Organ Injury Scale (OIS). Patients who responded to initial infusion therapy underwent computed tomography to determine the treatment plan. A shock index > 1, despite undergoing initial infusion therapy, was defined as hemodynamic instability. We compared the clinical outcomes and mortality rates between patients who received OM and those who underwent TAE. Results Sixty-two patients were included (eight and 54 who underwent OM and TAE, respectively; mean injury severity score, 26.6). The overall in-hospital mortality rate was 6% (13% OM vs. 6% TAE, p = 0.50), and the hemodynamic instability was 35% (88% OM vs. 28% TAE, p p = 0.05) and massive blood transfusion (OR, 7.25; p = 0.01); OIS grades IV–V were predictors of complications (OR, 6.61; p Conclusions TAE in hemodynamically unstable patients who responded to initial infusion therapy to some extent has acceptable in-hospital mortality and clinical failure rates. Hemodynamic instability and OIS, but not treatment choice, affected the clinical outcomes.

BACKGROUND Nonocclusive mesenteric ischemia (NOMI) causes intestinal necrosis due to irreversible ischemia of the intestinal tract. The authors evaluated the incidence of NOMI in patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysms, and they present the clinical characteristics and describe the outcomes to emphasize the importance of recognizing NOMI. OBSERVATIONS Overall, 7 of 276 consecutive patients with SAH developed NOMI. Their average age was 71 years, and 5 patients were men. Hunt and Kosnik grades were as follows: grade II, 2 patients; grade III, 3 patients; grade IV, 1 patient; and grade V, 1 patient. Fisher grades were as follows: grade 1, 1 patient; grade 2, 1 patient; and grade 3, 5 patients. Three patients were treated with endovascular coiling, 3 with microsurgical clipping, and 1 with conservative management. Five patients had abdominal symptoms prior to the confirmed diagnosis of NOMI. Four patients fell into shock. Two patients required emergent laparotomy followed by second-look surgery. Four patients could be managed conservatively. The overall mortality of patients with NOMI complication was 29% (2 of 7 cases). LESSONS NOMI had a high mortality rate. Neurosurgeons should recognize that NOMI can occur as a fatal complication after SAH.

Introduction Falls from6 meters have been shown to cause multiple traumas and serious injuries. However, especially among fall survivors who were transported to trauma centers, the relationship between falling distance and trauma severity remains unclear. This study aimed to investigate the relationship between falling distance and trauma severity among fall injury survivors who were transported to a trauma center and clarify the characteristics of trauma among survivors of falls from high places from an orthopedic surgeon's perspective. Methods We retrospectively reviewed the medical records of 65 fall injury survivors who were transported to a trauma center for falling distance; whether the fall was a suicide attempt; abdominal, chest, and head trauma; the numbers of upper-limb, lower-limb, and spinal vertebral fractures; McCormack load-sharing classification score; unstable pelvic fracture; Frankel classification; injury severity score (ISS); and duration of intensive care unit (ICU) and hospital stay. We evaluated the correlations between falling distance and the other factors and compared all factors between those falling6 meters and those falling6 meters. Results Falling distance was weakly positively correlated with durations of ICU and hospital stay. The percentage of cases that were suicide attempts, the number of lower-limb fractures, the McCormack load-sharing classification score, and the durations of ICU and hospital stay were significantly higher among those falling from6 meters than among those falling from6 meters. Conversely, there were no significant differences in abdominal trauma, chest trauma, head trauma, number of upper-limb fractures, number of vertebral fractures, unstable pelvic fracture, or Frankel classification between the two groups. Conclusion The findings indicate that falling from a higher distance may increase lower-limb and vertebral fracture severity and may lead to longer ICU and hospital stays among fall injury survivors who are transported to trauma centers.

Introduction:In July 2016, a mass-casualty stabbing attack took place at a facility for disabled persons located in Sagamihara City (Kanagawa Prefecture, Japan). The attack resulted in 45 casualties, including 19 deaths. The study hospital dispatched physicians to the field and admitted multiple casualties. This report aimed to review the physicians’ experiences and to provide insights for the formulation of response measures for similar incidents in the future.Report:This incident involved 30 emergency teams and 12 fire department teams, including those from neighboring fire departments. Five physicians from three medical institutions, including the study hospital, entered the field. The Simple Triage and Rapid Treatment (START) method was used on the field. The final field triage category count was: 20 red, four yellow, two green, and 19 black tags. All the casualties (n = 26) except for the 19 black tag casualties were transported to one of six neighboring medical institutions.The median age of the transported casualties was 41 years (interquartile range [IQR] = 35.5 – 42.0). Three casualties (21.4%) were in hemorrhagic shock on arrival at the hospital. Twelve patients had multiple cervical stab wounds (median four wounds; IQR = 3.75 – 6.0). A total of 91.7% of these stab wounds were in mid-neck Zone II region. Of the 12 patients with cervical stab wounds, four (33.3%) required emergency surgery, and the rest were sutured on an out-patient basis. One patient had already been sutured on the field. All patients requiring emergency surgery had deep wounds, including those of the carotid vein, thyroid gland, nerves, and the trachea. Eight of the casualties were hospitalized at the study institution. Five of them were admitted to the intensive care unit. There were no deaths among the casualties transported to the hospitals.Conclusion:Regional core disaster medical hospitals must take on a central role, particularly in the case of local disasters. Horizontal communication and interactions should be reinforced by devising protocols and conducting joint training for effective inter-department collaborations on the field.Maruhashi, T, Takeuchi, I, Hattori, J, Kataoka, Y, Asari, Y. The Tsukui (Japan) Yamayuri-en facility stabbing mass-casualty incident. Prehosp Disaster Med. 2019;34(2):203–208

Background Boerhaave's syndrome has a high mortality rate due to respiratory failure, septic shock, and multiple organ failure. We had previously carried out primary repair with laparotomy and postoperative computed tomography-guided drainage for mediastinal abscess and empyema. However, this treatment prolonged mechanical ventilator days and length of intensive care unit stay. Therefore, we decided to carry out primary repair with laparotomy and add lavage and drainage using video-assisted thoracoscopic surgery. Methods From April 2004 to September 2018, 18 patients with Boerhaave's syndrome were treated; 6 patients treated conservatively were excluded. Thus, 12 patients who underwent surgical treatment were divided into the computed tomography-guided drainage group (D group) (6 patients) and the lavage and drainage using video-assisted thoracoscopic surgery group (VATS group) (6 patients), and the two groups were retrospectively compared. Results The VATS group had significantly longer operation time than the D group {359 [328, 387] vs. 220 [155, 235] min, P=0.004}, but the ventilator-free days (VFDs) were significantly extended {24 [21, 24] vs. 10 [0, 17] days, P=0.02}, and the length of intensive care unit stay was significantly shortened {14 [8, 14] vs. 35 [29, 55] days, P=0.01}. Conclusions Lavage and drainage using video-assisted thoracoscopic surgery is an effective surgical method for Boerhaave's syndrome.

Purpose To validate our previously designed transcatheter arterial embolization (TAE) technique for bilateral iliac arteries in unstable pelvic fractures, which is designed to also prevent gluteal necrosis and avoid vasopressors. Methods We retrospectively analyzed the data of patients with pelvic fractures who underwent our new TAE procedure to determine the incidence of subsequent gluteal necrosis. We also compared certain variables between patients who underwent TAE before 2005 using a different technique and developed gluteal necrosis and patients who underwent TAE in 2005 and onward using our technique. Gluteal necrosis was confirmed by a radiologist based on imaging findings. Results Seventy patients with pelvic fractures who underwent our TAE technique met the inclusion criteria (bilateral iliac arterial embolization and no embolic agent other than a gelatin sponge). Patients’ median age was 47.5 years, 33 were male, and 92.9% (65/70) had unstable fractures. Sixty-eight patients had severe multiple trauma. No patients developed gluteal necrosis following our TAE procedure and the overall survival rate was 82.9% (58/70). We found no statistically significant difference in procedure time between the previous and new technique, although the new procedure tended to be shorter. Furthermore, overall survival did not significantly differ between the groups. Multiple regression analysis revealed that TAE procedure time and external pelvic fracture fixation were independently related to gluteal necrosis. Conclusions Our non-selective bilateral iliac arterial embolization procedure involves arresting shock quickly, resulting in no post-procedure gluteal necrosis. The procedure involves cutting the gelatin sponge rather than “pumping” and avoids the use of vasopressors.

Case Alkaline ingestion frequently causes corrosive esophagitis but rarely causes lower digestive tract injury. In this case, a 79-year-old man accidentally drank kitchen detergent. After 3 h, lower abdominal pain occurred and gradually worsened. He was taking a proton pump inhibitor after proximal gastrectomy for gastric cancer. He had local tenderness in the left lower abdomen. Abdominal computed tomography showed expansion of the small intestine, thickening of the intestinal wall, and inflammatory changes. Upper gastrointestinal endoscopy showed no obvious injury to the esophagus or stomach. Outcome Conservative treatment with an ileus tube was undertaken for intestinal obstruction caused by alkaline ingestion. There were no complications, such as gastrointestinal perforation, and he was discharged on day 17. Conclusion Alkaline ingestion may cause injuries not only to the upper but also to the lower digestive tract in patients who are taking proton pump inhibitors or have had gastrectomy.

A 39-year-old male fell from a forklift and was urgently transported to our hospital. His vital signs were stable at the initial visit. Contrast imaging computed tomography (CT) showed extravasation (Ev) of contrast medium emigrating outside of the renal capsule and hematoma around the right kidney, and he was diagnosed with traumatic right renal injury, Grade IV laceration [American Association for the Surgery of Trauma classification]. When imaging the inferior renal artery branch extremity perfusing the area where Ev was found in the following blood vessel contrast imaging, obvious Ev was not found in the arterial phase; however, massively spreading Ev was found in the area adjacent to the renal laceration in the venous phase after taking a contrast image of the renal parenchyma. Thus, he was diagnosed with a renal vein branch injury. The transcatheter arterial embolization (TAE) was performed to the area, resulting in the disappearance of Ev.The effectiveness of TAE for renal injury has been established; however, it is only performed for arterial hemorrhage. TAE for venous injury has not previously been considered because a tamponade is supposedly effective for hemostasis of venous hemorrhage due to the anatomy surrounding Gerota's fasciae. This is an extremely rare case in which only venous injury was identified, without obvious arterial hemorrhage. Gerota's fasciae were broken and hemostasis treatment was required. Because the renal artery is the end artery, the venous hemorrhage was controlled with arterial embolization.In our case, renal vein branch injury was identified on CT and hemorrhage was terminated using TAE for the renal artery branch. TAE can be used as a non-operative management for the successful treatment of renal vein branch injury. Keywords: Non-operative management, Renal vein branch injury, Transcatheter arterial embolization, Venous hemorrhage

Acute superior mesenteric artery thrombosis is usually fatal; however, early intravascular treatment using a mechanical thrombectomy device can be an effective intervention. A 70-year-old man with atrial fibrillation presented with sudden abdominal pain; superior mesenteric artery thrombosis was confirmed using contrast-enhanced computed tomography. Thrombolysis, mechanical fragmentation, aspiration, and thrombectomy were successfully performed using the Trevo® XP ProVue stent retriever via a brachial approach, and intestinal necrosis was avoided. Thus, intravascular treatment of superior mesenteric artery thrombosis can be performed using a relatively low-profile catheter and a brachial artery approach, allowing the implementation of a multimodal interventional radiological approach tailored for individual cases.

Object To evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma. Patients and methods The records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group). Results Thirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n = 12), thoracotomy (n = 1), craniotomy (n = 1), and haemostasis of the lower extremities (n = 1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n = 12), endovascular stent or stent-graft placement (n = 2), and embolisation of a portal vein by laparotomy (n = 2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72] min vs. 355 [SD 169] min; p = 0.007). The mortality were 15 (95% CI 2–45) % in the intraoperative IVR group vs. 36 (95% CI 22–51) % in the control group. Conclusion Hybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.

Early reperfusion by percutaneous coronary intervention (PCI) is the current standard therapy for ST-elevation myocardial infarction (STEMI). To achieve better prognoses for these patients, reducing the door-to-balloon time is essential. As we reported previously, the Kitasato University Hospital Doctor Car (DC), an ambulance with a physician on board, is equipped with a novel mobile cloud 12-lead ECG system. Between September 2011 and August 2013, there were 260 emergency dispatches of our Doctor Car, of which 55 were for suspected acute myocardial infarction with chest pain and cold sweat. Among these 55 calls, 32 patients received emergent PCI due to STEMI (DC Group). We compared their data with those of 76 STEMI patients who were transported directly to our hospital by ambulance around the same period (Non-DC Group). There were no differences in patient age, gender, underlying diseases, or Killip classification between the two groups. The door-to-balloon time in the DC group was 56.1 ± 13.7 minutes and 74.0 ± 14.1 minutes in the Non-DC Group (P < 0.0001). Maximum levels of CPK were 2899 ± 308 and 2876 ± 269 IU/L (P = 0.703), and those of CK-MB were 292 ± 360 and 295 ± 284 ng/mL (P = 0.423), respectively, in the 2 groups. The Doctor Car system with the Mobile Cloud ECG was useful for reducing the door-to-balloon time.

Background The resuscitative endovascular balloon occlusion of the aorta, because of its efficacy and feasibility, has been widely used in treating patients with severe torso trauma. However, complications developing around the site proximal to the occlusion by resuscitative endovascular balloon occlusion of the aorta have almost never been studied. Case presentation A 50-year-old Japanese woman fell from a height of approximately 10 m. At initial arrival, her respiratory rate was 24 breaths/minute, her blood oxygen saturation was 95% under 10 L/minute oxygenation, her pulse rate was 90 beats per minute, and her blood pressure was 180/120 mmHg. Mild lung contusion, hemopneumothorax, unstable pelvic fracture, and retroperitoneal bleeding with extravasation of contrast media were observed in initial computed tomography. As her vital signs had deteriorated during computed tomography, a 7-French aortic occlusion catheter (RESCUE BALLOON®, Tokai Medical Products, Aichi, Japan) was inserted and inflated for aortic occlusion at the first lumbar vertebra level and transcatheter arterial embolization was performed for the pelvic fracture. Her bilateral internal iliac arteries were embolized with a gelatin sponge; however, the embolized sites presented recanalization as coagulopathy appeared. Her bilateral internal iliac arteries were re-embolized by n-butyl-2-cyanoacrylate. The balloon was deflated 18 minutes later. After embolization, repeat computed tomography was performed and a massive hemothorax, which had not been captured on arrival, had appeared in her left pleural cavity. Thoracotomy hemostasis was performed and a hemothorax of approximately 2500 ml was aspirated to search for the source of bleeding. However, clear active bleeding was not captured; resuscitative endovascular balloon occlusion of the aorta may have been the cause of the increased bleeding of the thoracic injury at the proximal site of the aorta occlusion. Conclusions It is necessary to note that the use of resuscitative endovascular balloon occlusion of the aorta may increase bleeding in sites proximal to occlusions, even in the case of minor injuries without active bleeding at the initial diagnosis.

A 63-year-old man was diagnosed with jugular venous suppurative thrombophlebitis after undergoing strangulation ileus surgery. His condition was not stabilized by therapy with antibiotics, heparin or other supportive treatments. Pulse-spray treatment (PST) was administered, following which, the patient was afebrile without symptoms and the laboratory data improved. There were no complications such as sustained sepsis, septic embolisms or pulmonary embolisms. This is a unique case report of the use of a pulse-spray catheter in the treatment of total occlusive jugular venous suppurative thrombophlebitis following the failure of medical therapy.

Background: Considerable parts of the myocardium fall into myocardial stunning just after reperfusion therapy for acute myocardial infarction (AMI). In the present study, the prediction of recovery from myocardial stunning by the change in the stroke volume (SV) with a Swan-Ganz catheter (Stroke Volume with Swan-Ganz, SGSV) just after reperfusion therapy was attempted. Methods: The study consisted of 35 consecutive patients transferred to the Emergency Center of Kitasato University Hospital with a first uncomplicated anteroseptal AMI. Primary percutaneus transluminal coronary angioplasty (primary PTCA) for left anterior descending artery (LAD) was performed in 32 patients. They were divided into a stroke volume-increasing group (SGSV-UP group) or decreasing group (SGSV-DOWN group) according to their SGSV change during the CCU stay. The ejection fraction (EF) and SV on left ventriculography (LVG) (EF on LVG, LVGEF; SV on LVG, LVGSV) in the acute and chronic phase (about 6-8 months later) were compared between the two groups. Results: Twenty four patients were classified into the SGSV-UP group and 8 patients into the SGSV-DOWN group. LVGEF increased significantly in the SGSV-UP group but not in the SGSV-DOWN group (from 40.8±8.5% to 54.1±9.1%, P=0.0022 vs. from 42.2±10.6% to 43.6±7.7%, N. S.). LVGSV changed similar to LVGEF. In the SGSV-UP group, the relationship between the change in LVGEF (Δ LVGEF) and SGSV (Δ SGSV) was revealed to be Δ LVGEF (%)=1.4+0.5 Δ SGSV (ml) (P=0.0082). Regional asvnergy was significantly reduced in the SGSV-UP group (P=0.034). Conclusion: The increase in SGSV just after reperfusion therapy for AMI was related to the recovery of LVGEF and LVGSV in the chronic-phase. This suggests that recovery from myocardial stunning begins just after reperfusion therapy for AMI.

Background: Major pelvic venous injuries secondary to blunt trauma can be a difficult problem in diagnosis and management This study aimed to elucidate the clinical significance of iliac vein injuries demonstrated by venography in patients with blunt pelvic injuries who remained unstable even after transcatheter arterial embolization (TAE). Methods: We reviewed the records of 72 patients with unstable pelvic fracture who presented with shock at our center after blunt trauma from 1999 through 2003. The average Injury Severity Score was 34.3 in this study population. Results: TAE was the first method of choice to control bleeding from pelvic fracture in 61 patients. Thirty-six patients recovered from shock after TAE. Eighteen of 25 who did not recover from shock died. In 11 of these 25, transfemoral venography with a balloon catheter was performed, revealing significant venous extravasation in 9: common iliac vein in 5, internal iliac vein in 3, and external iliac vein in 1. The average Injury Severity Score of patients with iliac vein injury was 45.8. Treatments for venous injuries were laparotomy for hemostasis (n = 1, survivors = 0), retroperitoneal gauze packing (n = 3, survivors = 1), and endovascular stent placement (n = 3, survivors = 3). Two patients suffered from cardiac arrest before treatment for venous injury. External fixations were performed after TAE according to fracture type. Conclusion: The iliac vein injury is the principal cause of hemorrhagic shock in some patients with unstable pelvic fractures after blunt trauma. Venography is useful for identifying iliac vein injuries.

Japanese Association for Acute Medicine and Japanese Association for The Surgery of Trauma developed JATEC (Japan Advanced Trauma Evaluation and Care) course as an off-the-job training to improve trauma care in Japan. In this course, the trauma patients undergo primary survey and secondary survey. FAST (focused assessment with sonography for trauma) is performed to detect hemoperitoneum during primary survey. In this article, we describe FAST in the evaluation and care for abdominal trauma. If the patient becomes hemodynamically unstable during the survey or the intraoperative period, we have to repeat primary survey and FAST.

症例は63歳の男性で, 膵頭部腫瘍に対して膵頭十二指腸切除術を施行した. 術後52日目に血小板数とヘモグロビン濃度の急激な減少を認めた. その翌日に突然, 痙攣が出現し昏睡状態に陥り, 左片麻痺を認めた. また発熱もみられるようになった. 最初, 脳梗塞と敗血症によるDICの診断で治療を進めていったが改善傾向はなかった. 血小板減少, 破砕赤血球を認める溶血性貧血, 原因不明の中枢神経症状, および発熱より血栓性血小板減少性紫斑病 (TTP) と診断した. 新鮮凍結血漿による血漿交換を行ったところ, 臨床症状は劇的に改善し始め, 計5回の血漿交換により完全寛解に至った. 本例は術後発症したTTPで原因は不明である. 退院後6か月間, 再発は認められていない. TTPに対しては, 正確な診断と早期の治療開始が救命に不可欠である.

近年,増加傾向にある気管支喘息発作による発作死患者の病態を知る目的で,気管支喘息により来院時心肺停止状態であった患者26人(心肺停止群)を,重症気管支喘息のため人工呼吸管理を必要とした患者25人(対照群)と比較し,背景因子や臨床経過,病態生理などの差異について検討した。両群間で性比,年齢,通院治療歴,大発作入院歴,24時間以内の緩解発作の既往などの背景因子に差は認められなかった。来院までの経過は,心肺停止群では通報時12人(46.2%)が意識清明であったにもかかわらず,救急隊現場到着時20人(76.9%)の患者が心肺停止状態となっていた。一方対照群では,来院時22人(88.0%)に意識障害を認めたが,全例血圧は維持されていた。気管内挿管時の動脈血ガス所見では,心肺停止群は高度の混合性アシドーシスであったのに対し,対照群は呼吸性アシドーシスのみであった。症状出現から人工呼吸開始までの時間および治療開始後,気管内挿管時のPaCO2が半減するまでの時間は,心肺停止群でそれぞれ106±31min, 132±34minで,対照群の322±62min, 591±173minに比べ,ともに有意に短時間であった(p

ICU入室重症患者の急性期の異化期において,早期グルタミン加経腸栄養の有用性を検討する目的で,臨床的なprospective studyを行った。ICU入室患者で急性期に経腸栄養を開始した21症例を3群に分けた。経腸栄養剤のみを投与した症例を対照群(n=7)とし,経腸栄養剤にグルタミンを標準体重あたり0.2g加え投与した症例をI群(n=7), 0.5g加え投与した症例をII群(n=7)とした。なおこの3群間での総投与熱量と窒素量は同一になるように調節した。I群,II群と対照群との間でAPACHE-II scoreに明らかな差は認めなかった。栄養評価の指標となる血清蛋白質(総蛋白,アルブミン,プレアルブミン,レチノール結合蛋白,トランスフェリン)のI群,II群の10日間の変化は,対照群と比較して明らかな差は示さなかった。しかし尿中3-メチルヒスチジン濃度の10日間の変化では,I群,II群とも対照群と比較して有意に減少していた(対照群:0.06±0.05mEq/gCr, I群:-0.03±0.03, p

Background: In critically injured patients with multiple injuries and unstable pelvic fracture, late mortality almost invariably results from sepsis. Methods: We analyzed the clinical features of 11 patients with sepsis caused by soft tissue infections surrounding the fractured pelvis, of 830 patients with pelvic fracture after blunt trauma treated at our level I trauma center over the past 25 years. Soft tissue infection was defined as abscess formation in subcutaneous tissue or muscle diagnosed by computed tomography or an operation. Results: Mean injury severity score was 48, and mean systolic blood pressure on arrival was 66 mm Hg. All patients had multiple concomitant injuries and prolonged hemorrhagic shock. Open pelvic fracture was present in five patients. Mean blood transfusion volume within 24 hours was 12,611 mL. Intra-aortic balloon occlusion was performed in three patients and transcatheter angiographic embolization in nine patients. Embolic sites of transcatheter angiographic embolization were bilateral internal iliac arteries (n = 9), lumbar artery (n = 5), median sacral artery (n = 2), and circumflex femoral artery (n = 2). Infection sites included the gluteal (n = 11), femoral (n = 6), sacral (n = 4), lumbar (n = 4), anterior iliac (n = 2), inguinal (n = 1), and perineal (n = 1) regions. Necrotic changes of infected soft tissue were found in all patients. They underwent open drainage and daily debridement with pulsatile irrigation followed by intravenous antibiotics. All patients developed severe sepsis, five of whom subsequently died of multiple organ failure. Conclusions: In critically injured patients with multiple injuries and unstable pelvic fracture, peripelvic soft tissue infections occasionally cause sepsis. Peripelvic infections are often accompanied by necrotic changes and easily develop into severe sepsis or multiple organ failure. Identifying high-risk patients and early diagnosis with prompt surgical treatment are indispensable for the patients' survival.

Objective We evaluated the ability of endoscopic ultrasonography to predict likelihood of stricture formation in patients with corrosive esophagitis. Methods Consecutive patients with esophagitis resulting from alkaline or acid chemical ingestion (n = 11) were evaluated prospectively by endoscopic ultrasonography between hospital days 4 and 12. Findings for the most severe lesion were classified according to the appearance of the muscular layers: distinct muscular layers without thickening (grade 0); distinct muscular layers with thickening (grade I); obscured muscular layers with indistinct margins (grade II); and muscular layers that could not be differentiated (grade III). Findings were also classified according to whether apparent damage to muscular layers in the worst-appearing image involved part of the circumference (type a) or the whole circumference (type b). Implications of these findings for subsequent stricture formation were then evaluated. Results Stricture formation did not occur in patients with grade 0 or grade I images; transient stricture formation occurred in a patient showing grade IIa. Stricture requiring repeated bougie dilation occurred in a patient showing grade IIIb. Conclusions Endoscopic ultrasonographic images presumed to reflect the destruction of muscular layers (grades II to III), as opposed to only edema (grade I), may be associated with stricture formation. This modality can accurately visualize deep lesions in corrosive esophagitis, making it prognostically useful.

To investigate the efficacy of continuous regional arterial infusion (CRAI) of a protease inhibitor and antibiotic for severe acute pancreatitis (SAP) in patients admitted to an intensive care unit (ICU). A total of 51 patients with SAP requiring admission to an ICU were studied. The patients were divided into two groups: one received the protease inhibitor nafamostat mesylate and the antibiotic imipenem by continuous regional arterial infusion (CRAI group) and the other received protease inhibitors and antibiotics by intravenous infusion (non-CRAI group). To evaluate the therapeutic usefulness of CRAI of a protease inhibitor and antibiotic for SAP, the rate of surgery and the cumulative survival rate were compared between the non-CRAI group and the CRAI group. The rate of surgery was 32% in the non-CRAI group and 9% in the CRAI group (P = 0.08). Cumulative survival rates at 1, 6, and 12 months were 77.9%, 48.9%, and 48.9% in the non-CRAI group compared with 100.0%, 100.0%, and 87.1% in the CRAI group. Outcome was thus significantly better in the CRAI group than in the non-CRAI group (P = 0.002). CRAI of a protease inhibitor and antibiotic may decrease the need for surgical therapy and reduce mortality in patients with SAP.

Background: Transcatheter arterial embolization (TAE) can cause gluteal skin and muscle necrosis. However, the ultimate and typical signs of gluteal necrosis resulting from TAE have not yet thoroughly been investigated. Methods: From January 1995 to December 2003, 165 pelvic fractures were managed with TAE to control retroperitoneal bleeding at our level 1 trauma center. From these, 12 patients suffered gluteal muscle and skin necrosis. We reviewed the medical records of these 12 patients for age, gender, fracture type, embolic sites, computed tomography (CT) findings, serum creatine kinase level, site of skin necrosis, time from injury to skin necrosis, treatment, and outcome. Results: All 12 patients underwent TAE of the bilateral internal iliac arteries with gelatin sponge slurries. One patient suffered from an infection of the gluteal muscle from an open fracture site. Five patients presented with signs of gluteal soft tissue injuries on admission. Of these, four had skin abrasions and three revealed fluid or air collection under the gluteal skin on CT. The remaining six patients showed no evidence of soft tissue injuries on admission, and the lesions appeared between 2 days and 7 days after their admission. In these six patients, low-density areas (LDAs) of gluteal muscle with a clear border on the CT were observed following the appearance of skin lesion. The skin necrosis was located in the center of either or both buttocks, and signs of ischemia were clearly demarcated from the adjacent normal tissue. Four of 12 patients died from sepsis, three of whom suffered from uncontrollable gluteal infections that had been pointed out as LDAs on the CT. Conclusions: In every patient with gluteal necrosis associated with pelvic fracture following TAE, initial traumatic contusion cannot be ruled out as contributing to the development of the necrosis. However, for patients who undergo TAE of the bilateral internal iliac artery and who show clear-border LDAs on CT, skin necrosis centered on the buttock, and the delayed appearance of a skin lesion, careful attention must be given in the event of an arterial obstruction due to TAE.

Background: In the treatment of patients with pancreatic injury, the focus of attention is usually on main ductal injuries. Methods: To develop a classification system for pancreatic ductal injuries, we retrospectively analyzed blunt pancreatic injuries in 40 patients. We assessed the relationships between findings on pancreatography (36 endoscopic retrograde procedures and 4 transduodenal procedures), the treatment modality, and the clinical course. Results: Patients with class 1 injuries (radiographically normal ducts, n = 13) could be treated nonsurgically without major complications. Patients with class 2 injuries (branch injuries, n = 7), in whom contrast medium from ductal branches did not leak from the pancreatic parenchyma (class 2a, n = 3), could be treated nonsurgically. Patients with leaks into the retroperitoneal space (class 2b, n = 4) required at least a drainage laparotomy. Patients with class 3 injuries (main duct injuries, n = 20), including two patients in whom conservative treatment resulted in severe complications, required laparotomy. Conclusion: This classification system for pancreatic ductal injuries may facilitate the selection of appropriate therapeutic modalities for patients with blunt pancreatic injury.

fac-(+)546-[Cr(L-ala)2(L-leu)]·1.5H2O and fac-(−)546-[Cr(D-ala)2(L-leu)]·1.5H2O were prepared by the method using an ethanol solution, with [Cr(L-leu)2(NCS)(OH2)](leu=leucinato) with L- or D-alanine used as the starting material respectively. Also, fac-[Cr(L- or D-ala)(L-leu)2]·2H2O was obtained from the filtrate, the standing temperatures were 5, 25, 40, and 55 °C. The optical purity of fac-(Λ)-[Cr(L- or D-ala)(L-leu)2]·2H2O increases with the rise in the standing temperature. In the case of DL-alanine, [Cr(L-ala)2(L-leu)]·1.5H2O and [Cr(D-ala)(L-leu)2]·2H2O were obtained during heating and from the filtrate respectively. By using this procedure, the possibility of the optical resolution of DL-alanine was shown.