We diagnose, judge the severity of, and treat acute cholangitis according to the “‘Japanese Guidelines for the management of acute cholangitis and cholecystitis’”. The indication of emergency drainage of the common bile duct (CBD) is determined by the response to initial conservative treatment for moderate cases. Two hundred two cases of acute cholangitis (AC) due to CBD stones were analyzed retrospectively. The severity of AC patient cases at the time of admission was as follows：28.2% were mild, 62.4% were moderate, and 9.4％ were severe. Emergency drainage in the moderate cases showed a significant difference between the cases with 2 or less criteria of moderate cholangitis and those with 3 or more (28.9% and 58.3%, respectively; p<0.05.) All of the severe cases underwent emergency drainage except the cases that were diagnosed as severe using only the criterion of bacteremia. We performed lithotomy as the initial therapy for half of the cases that underwent emergency drainage. The survival rate was 98.5％. Our recommendation is that emergency drainage is necessary for severe cases of AC except for 1) those with only bacteremia and 2）those with 3 or more criteria of moderate cholangitis.

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Objective: The characteristics of liver injuries treated using interventional radiology (IVR) were examined. Subjects and Methods: The characteristics of cases with liver injuries that were treated at this hospital using transcatheter arterial embolization (TAE) for acute-phase bleeding and IVR for late-phase complications between April 1, 2007, and September 30, 2012, were retrospectively reviewed. Results: Of the 43 patients with liver injuries who were treated during the study period, 1, 16, 2, 20 and 4 patients had trauma grades of Ⅰa, Ⅰb, Ⅱ, Ⅲa, and Ⅲb, respectively. Nine patients underwent TAE for the control of acute-phase bleeding. One patient with unstable hemodynamics after TAE underwent surgery for a concurrent inferior vena cava injury. Death during the acute phase occurred in 2 patients whose probability of survival was less than 0.5. As for the late-phase complications, ultrasound-guided percutaneous drainage was performed in 2 patients with biloma, surgery was performed after ultrasound-guided percutaneous drainage in 2 patients with bile leakage, percutaneous drainage was performed in 1 patient with a hepatic abscess, and TAE was performed in 1 patient with a pseudoaneurysm. Conclusion: IVR for the treatment of liver injuries was effective for controlling acute-phase arterial bleeding in patients with a stable hemodynamic status and for the treatment of late-phase complications such as bilomas, hepatic abscesses, and pseudoaneurysms.

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Purpose: The prognostic factors and features of colorectal perforation in the elderly are still unclear. Therefore, we investigated the risk factors and features affecting hospital mortality in elderly patients with colorectal perforation. Patients and Methods: The subjects were 128 patients who underwent surgery for colorectal perforation, and they were divided into two groups; over 70 years of age (n=58) and under 70 (n=70). We analyzed the clinical factors and performed univariate and multivariate analyses to clarify the risk factors affecting hospital mortality using logistic regression analysis. Results: There was no significant statistical difference, except for the operative time between the two groups. The frequency of perioperative severe sepsis/septic shock and SOFA score at 1st postoperative day (POD) was significantly higher in the elderly group than in the non-elderly group. Age (p=0.04), ASA (p=0.02), more than 24 hours from onset to surgery (p=0.02), Hinchey stage IV (p=0.01), and preoperative septic shock (p<0.01) were selected by the univariate analysis and tested with a multivariate analysis. The results of which identified an age of 70 years or more (odds ratio 4.00, 95% CI: 1.26-12.66, p=0.03), along with ASA3 or more, more than 24 hours from onset to surgery and preoperative septic shock as independent prognostic factor. Conclusion: In the elderly, intensive perioperative management is necessary and it should be noted that the age itself is a prognostic factor.

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This study investigated the diagnosis and treatment of patients with incarcerated groin hernias who underwent surgery in our hospital. Of the 182 cases of groin hernias in our hospital from January 2008 to February 2013, we operated on 22 (12.1%) hernias that were incarcerated. These incarcerated hernias included 7 indirect inguinal hernias, 9 femoral hernias, and 6 obturator hernias. Eighteen of these cases were diagnosed as hernia incarceration at the time of the first visit. Seven cases underwent manipulative or spontaneous reduction and chose elective surgery, and 11 cases required immediate operations. Four other cases were not initially diagnosed as incarcerated hernias due to the lack of attention to the inguinal region. Instead, they were diagnosed as ileus of unknown origin, which we reinforced with hyperbaric oxygen (HBO). The technique used in the 11 elective surgeries and 7 immediate operations was the Kugel method. When a patient having an acute abdominal hernia was examined, we kept hernia incarceration in mind and considered it important to check the neighborhood of the inguinal region with a physical view or CT imaging.

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Acute superior mesenteric artery (SMA) embolisms are rare and are associated with a high mortality rate. Extensive enterectomy could have detrimental effects on the nutritional status of patients. Ten patients who underwent surgery for acute SMA embolisms from 2006 to 2012 were reviewed (6 men, 4 women; mean age: 73years, range: 51-82). Abdominal multidetector row computed tomography (MDCT) scan imaging indicated an acute SMA embolism in 9 patients. All patients underwent open abdominal surgery, while 7 patients underwent embolectomy. No patient died of SMA-related thrombosis as a result of embolism formation. Eight patients who underwent extensive enterectomy showed no alteration in their nutritional status. MDCT was useful in early-stage diagnosis, and extensive surgery was an effective treatment strategy.

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Purpose: The study aimed to compare laparoscopic appendectomy (LA) with open appendectomy (OA) in children. Method: From January, 2007 to June, 2010, 130 children underwent OA and from July, 2007 to December, 2010, 121 children underwent LA for acute appendicitis. There were no cases of LA that required conversion to OA. Data collection included WBC, CRP, operative time, hospital stay, resumption of diet, postoperative complications (wound infection, intraabdominal abscess and ileus), and duration of intravenous antibiotic administration. Result: The operative time in the LA group (82.1±34.2 minutes) was longer than that in the OA group (58.4±27.5 minutes) (p<0.001). The hospital stay, resumption of diet and postoperative complications were not different between the LA and OA groups. Conclusion: LA for children was as safe and effective as OA, although the operative time for LA was longer than OA.

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Inguinal hernias are one of the most common reasons a primary care patient may need referral for surgical intervention. The patient's history and a physical examination are usually sufficient to make the diagnosis, but in case of incarcerated hernias, urgent computed tomography (CT) is very usefull for make the diagnosis. We always choose coronal scan view including upper abdomen to both femoral area. After the diagnosis of incarcerated hernia has been made, an emergency operation is performed using laparoscopy. Laparoscopy is very useful for verifying the condition of the intestine and the type of the hernia (including contralatetal hernia) and in the choice of the appropriate procedure. A remarkable reduction in morbidity and mortality can be achieved through an earlier referral to the hospital, quick preoperative workup, and performing emergency surgery.

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Background: We have been performing laparoscopic transabdominal preperitoneal inguinal hernioplasty for groin hernia at our institution from 1995 to 2012. Recently we adopted the laparoscopic approach in case of non-reducible groin hernia. Methods: A total of 61 patients who were diagnosed as incarcerated hernias were retrospectively analyzed. Results: We experienced 61 cases of non-reducible or strangulated groin hernia. In 15 cases manipulation was performed and the patients were offered early planed surgery. A total of 45 patients underwent emergency surgery for incarcerated/strangulated groin hernias. The patients consisted of 31 males and 30 females, with a median age of 73.9 years. Thirty-two cases were inguinal hernias, and 29 femoral hernias. In 11 cases laparoscopic surgery was conducted and the anterior approach was performed in 34. Conclusions: Laparoscopic guidance for the judgment of the viability of the contents of a hernia is more useful compared with preoperative enhanced CT. Laparoscopic reduction and repair of incarcerated inguinal hernia was useful and safe.

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The aim of this study was to evaluate the factors affecting the treatment of incarcerated inguinal hernia. We reviewed 63 patients from January 2004 to October 2013 who were diagnosed as having an incarcerated hernia. We allocated these patients into three groups：one group included the patients who required resection of the intestine, another included the patients who required surgical operation, but did not undergo resection of the intestine, and the other group included the patients who underwent elective surgery. The patients who required resection of the intestine experienced more severe local pain. There were no differences in the blood test findings among the three groups. Ascites was seen more often in the patients who required resection of the intestine than those who underwent elective surgery. If incarcerated hernia patients exhibit strong local pain and ascites, it is highly likely that strangulation of the intestine is occurring.

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Femoral hernias represent a surgical disease frequently associated with bowel incarceration and necessitating emergency surgery. Between January 2003 and September 2011, in our institution, we retrospectively reviewed the clinical characteristics of 47 patients diagnosed as having a femoral hernia. Among the 42 patients (89%) with small bowel incarceration, bowel resection was performed in 21 (44%). The time from onset to surgery was significantly longer (p=0.01), and obstructive bowel symptoms were more frequent (p=0.01), in the patients who underwent resection. The overall mortality rate was 8.5% (4 patients). The time from onset to surgery and values of TP, CPK and CRP were significantly different between the patients who recovered and those who did not. Multivariate analysis showed a high CPK to be an independent prognostic factor (p=0.0409). The time elapsing from onset of symptoms to surgery and CPK level are considered to be important prognostic factors in patients with incarcerated femoral hernias. Early diagnosis and early treatment are therefore necessary in such patients.

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Groin hernia and obturator hernia are diseases which can cause ileus and peritonitis by incarcerated and strangulated hernias. It seems that the number of the groin and obturator hernias will increase from now on in members of the increasingly greying society. However, there is no consensus as to the operative method and use of mesh in the operation for incarcerated hernia, because of problems associated with ileus and intestinal resection. We report herein on 6 cases in which the Kugel method was used in emergency hernia operations in our department. In 4 cases of femoral hernias and one case of an obturator hernia, the average age of the patients was 85.3 years old (78 to 94 years old), the operation time was an average of 76.6 minutes (69 to 167 minutes), the amount of bleeding was an average of 5.5 g (3 to 10 g), and duration of the postoperative hospital days was an average of 11.2 days (6 to 17 days). Even for elderly patients, the Kugel method was less invasive, and could be performed safely. Our results suggested that the Kugel method appeared to be useful in emergency operations for groin and obturator hernias.

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[Introduction] We reviewed the results of operative procedures in patients with incarcerated groin hernia and those who underwent intestinal resection for hernial content necrosis. [Methods] We analyzed the results of operative procedures in the 18 patients who underwent intestinal resection for hernial content necrosis in our department in the period from January 2004 to October 2013. We chose to use the tension-free method using mesh insertion in cases other than abcesses, perforation and colectomy in patients with incarcerated groin hernia among those who underwent intestinal resection. [Results] Of 18 patients who underwent intestinal resection, 11 underwent repair surgery with the tension-free method (Kugel method: 7 cases, Mesh plug method: 4 cases) and 7 with the conventional method. In those who received tension-free repair surgery, no infections associated with mesh insertion were observed. Five patients underwent intestinal resection from different skin incisions, except for the groin area. [Conclusions] We concluded that the mesh insertion approach can be performed safely in patients with incarcerated groin hernia for which intestinal resection is performed due to necrosis of the hernial contents, provided that there is no abcess or intestinal perforation, and colon resection is not required.

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The transabdominal pre-peritoneal (TAPP) approach has been the first choice for adult inguinal hernias in our department since 2009. The TAPP technique offers the following advantages: 1. Diagnostic accuracy; 2. The bilateral groin can be checked and immediately repaired; 3. Relief of postoperative pain and wound discomfort; and 4. Earlier rehabilitation. We have expanded our indication to incarcerated cases with the advancement of our technical stability and safety. In our strategy for incarcerated inguinal hernias, we first verify the viability and peristalsis of the incarcerated bowel with enhanced computed tomography and abdominal ultrasonography followed by reduction. Even if reduction is possible, we perform surgery within 24 hours to avoid false reduction or late perforation. If reduction is impossible, we laparoscopically determine the viability of the incarcerated bowel segment based on color, peristalsis, and venous congestion When bowel resection is not required, TAPP is performed in the usual manner. If bowel resection is required or the bacterial contamination is suspected, we postpone TAPP for the prophylaxis against prosthesis infection. We experienced 14 cases (15 hernias: 1 direct, 12 indirect, 2 femoral) between 2009 and 2013. In 11 cases TAPP was simultaneously performed after laparoscopic observation confirming the viability of the incarcerated bowel segment. TAPP was performed in 2 cases within 24 hours after undergoing reduction and postponed TAPP was performed in the remaining cases because the incarcerated bowel was perforated by strangulation. No conversion to open surgery occurred. It can be considered that TAPP could offer benefits with reliable and minimally invasive therapy, not only for elective cases, but also incarcerated cases.

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We report herein on the case of a 32-year old female in whom situs inversus had been recognized since childhood. She came to the emergency room complaining of abdominal pain since the previous day. At the time of initial diagnosis, WBC and CRP were elevated and tumefaction, which was assumed to be associated with the appendix, was observed in the left lower abdominal quadrant on abdominal CT imaging. Acute appendicitis with situs inversus totalis was diagnosed and the patient was admitted to the hospital for conservative treatment. Improvement in the symptoms was observed, but following the patients request, a single incision laparoscopic appendectomy was carried out on the fourth day. Three days after surgery, the patient was discharged from the hospital with satisfactory progress. Single incision laparoscopic appendectomy is considered to allow intra─abdominal observation over a wide range, and the relative position of each organ could be easily understood. This method is considered to be safe and more cosmetic for acute appendicitis patients with situs inversus. The patient was discharged from the hospital with satisfactory progress. This method is considered to be safe and to produce better cosmetic results for acute appendicitis patients with situs inversus.

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A 27-year-old man with no medical history was brought to our emergency department with a sudden onset of severe upper abdominal pain. Following a moderate meal he had drunk about 500 mL of a sodium bicarbonate drink in one draft. Within 1 minute after drinking the bicarbonate, the patient had severe abdominal pain without nausea or retching. On admission, a computed tomography scan of the upper abdomen and a water-soluble contrast medium swallow showed retromediastinal emphysema and a extravasation of contrast medium from the gastric lesser curvature. Based on these findings, the diagnosis of gastric rupture was made and an emergency operation was performed 6 hours after onset. The patient was successfully treated by simple closure of the perforated stomach and was discharged in good condition 12 days after the operation. To the best of our knowledge, this is the first reported case of gastric rupture occurring after drinking an entire sodium bicarbonate drink in a single draft.

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A 76-year-old man with a history of appendectomy was treated with chemotherapy in the pulmonology department of our hospital for right lung cancer (carcinomatous pleurisy). He had abdominal pain, and CT examination showed ileus of the descending colon. We suspected an internal hernia and performed an emergency operation. The intraoperative findings revealed that an adherent band had strangulated the descending colon. There were no signs of ischemia, so only the band was resected. On day 4 post-surgery, the patient developed mild hypochondriac pain and left flank pain. Laboratory tests showed leukocytosis and elevated C-reactive protein (CRP) levels, and on day 6 post-surgery, CT examination showed perforation of the descending colon from which the strangulation had been previously removed, and gangrenous cholecystitis. We performed left hemicolectomy, transverse colostomy, intraperitoneal drainage, transverse colostomy and cholecystectomy, and the patient was discharged 49 days after reoperation. Strangulated ileus of the colon due to an adherent band is a rare case, and we report herein on such a case together with a review of the literature.

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A 71-year-old man was admitted to our hospital because of right back pain. He had undergone laparoscopic cholecystectomy in 2008 at another hospital. Abdominal CT revealed an abscess in the right abdominal wall and just under the diaphragm. On the same day incision and drainage for abdominal wall abscess were performed and multiple stones, 3～5 mm in diameter, were removed through the surgical wound. Antibiotic therapy was performed for the subdiaphragmatic abscess without any effect. As echo and CT-guided drainage didn’t work well, incision and drainage were performed under general anesthesia. The same kind of multiple stones were removed through the incision. Calculus analysis revealed that the stones consisted of cholesterol. The postoperative course was satisfactory and the patient was discharged.

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A 44-year-old woman was brought to our hospital after suffering an abdominal contusion caused by a seat belt during a car accident. A seat belt mark and mild tenderness were observed on the lower abdomen, but no signs of rebound tenderness were seen. As no abnormalities were found on computed tomography (CT), the patient was followed at home, but the patient returned to our hospital two days after sustaining the injury due to exacerbation of the chest pain. As free intraperitoneal gas was seen on both plain chest x-ray and CT, the patient was referred to our department and surgery was performed. Laparoscopic observation revealed a 5 mm perforation (type Ⅱa under the Gastrointestinal Tract Injury Classification of the Japanese Association for the Surgery of Trauma) in the jejunum. An interrupted suture was placed on the injury site. The patient was discharged on postoperative day 9.

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A 72-year-old female suffered acute abdominal pain and underwent computed tomography at a local clinic. The CT scan identified a retroperitoneal and colon mesenteric hematoma, a pancreaticoduodenal artery aneurysm in the hematoma, and no extravasation of contrast medium. The patient was sent to our hospital emergency department by ambulance. An emergency abdominal angiography was performed and showed a ruptured aneurysm originating from the inferior pancreaticoduodenal artery. Catheter embolization was performed from the superior mesenteric artery with micro-coils and the postoperative condition was stable. On arrival, the patient had a fever and C-reactive protein was high in the first set of laboratory data. Hemoculture was positive for Streptococcus anginosus which is part of the normal oral flora, and a carbapenem antibiotic was quickly administered. The patient had had submaxillary swelling and referred pain for three months, therefore we thought that a submaxillary abscess which was associated with a decayed tooth had caused the infectious aneurysm. The patient then suffered from duodenal stenosis due to a hematoma, so long-term fasting, insertion of a gastric tube and total parenteral nutrition was required. We report herein on a rare case of a pancreaticoduodenal artery aneurysm rupture suspected as having been caused by infection from a decayed tooth.

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An 84-year-old man with a cerebral infarction, atrial fibrillation and type 2 diabetes mellitus was admitted to the hospital because of anemia. The patient had undergone a thoracoscopic esophagectomy with retrosternal gastric tube reconstruction for advanced thoracic esophageal cancer. On postoperative day (POD) 2, urine volume decreased due to a renal function disturbance and continuous hemodiafiltration was performed from POD 2 to POD 3. On POD 4, the patient complained of mild abdominal pain, and an abdominal X-ray examination led us to suspect post-surgical paralytic ileus. However, the patient developed metabolic acidosis on the 5th POD. A CT scan showed hepatic portal venous gas in the left lobe of the liver and pneumatosis cystoides intestinalis in the wall of the small intestine. We performed an emergency operation. The operative findings showed a considerable length of non-continuous ischemic bowel of approximately 90 cm from ileum end, and the necrotic bowel was resected. However, since no pulse defect of the superior and inferior mesenteric artery was observed, the pathological findings revealed non-occlusive mesenteric ischemia. In spite of multidisciplinary therapy in intensive care unit, the patient could not recover from his state of shock and died from multiple organ failure.

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A 13-year-old boy with Cornelia de Lange syndrome was admitted with the chief complaints of nausea, diarrhea and fever. He had undergone fundoplication and gastrostomy for gastroesophageal reflux. After admission, his abdominal distension got worse and he underwent computed tomography, which showed pneumoperitoneum, mediastinal emphysema and subcutaneous emphysema. Surgical exploration disclosed no apparent causative findings such as any perforated portion. Afterwards he underwent an operation twice because of residual abscess and adhesional ileus. When he developed ileus, a decompression tube was inserted, which showed intestinal malrotation. We believe that the idiopathic pneumoperitoneum in our case seems to have been induced by intermittent volvulus of the small intestine. We report herein on a case in which we encountered difficulty in its treatment.

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We treated a 48-year-old woman who suffered from sudden severe abdominal pain due to a right paraduodenal hernia. She arrived at our hospital 2 hours after the onset of pain. Physical examination revealed anemia and the peritoneal sign on all 4 quadrants of the abdomen. Abdominal enhanced computed tomography revealed the absence of the horizontal part of the duodenum, “sac-like appearance”, and “SMV rotation sign”. Because of the typical computed tomographic findings, we entertained the preoperative diagnosis of a right paraduodenal hernia with volvulus, for which emergency laparotomy was performed. Upon entering the peritoneal cavity, necrosis of the small intestine was found not only in the sac at the right anterior pararenal extraperitoneal space but also outside the sac with a volvulus of 270°. We resected 260cm of the small intestine, which comprised 90cm of necrotic intestine in the paraduodenal hernia sac and 170cm outside the sac. Long-distance small intestinal necrosis was found not only in the sac at the right anterior pararenal extraperitoneal space (90cm) but outside the sac with the volvulus of 270°(170cm). This was resected leaving a remnant small intestine of 100cm. The hernia sac was suture-obliterated. Postoperatively the patient recovered rapidly without any complications or short bowel syndrome. We herein report on a rare case of paraduodenal hernia together with a review of the Japanese literature.

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We report herein on a case of intraabdominal hemorrhage from multiple liver tumors which metastasized from a primary gastric choriocarcinoma. An 83-year-old man with the complaint of intermittent left lower abdominal pain was seen in the hospital. Abdominal contrast enhanced CT demonstrated liver tumors at the left and right lateral segment, which were contrast-filled, resembling cavernous hemangiomas. The CT value of ascites around the liver and spleen was 100 Hounsfield units. An emergency operation was performed under the diagnosis of intraabdominal hemorrhage due to rupture of liver hemangiomas. Operative findings indicated that our diagnosis was correct and resection of the left lateral segment was performed. The resected specimen showed a cavernous tumor about 8 cm in diameter, which was histopathologically diagnosed as a choriocarcinoma. After surgery, upper esophagogastroduodenoscopy showed a type 2 gastric tumor and the biopsy specimen revealed primary gastric choriocarcinoma, a poorly-differentiated carcinoma including multinucleate atypical cells stained with hCG. Rebleeding from the liver tumor developed and was controlled with transarterial embolization (TAE). The patient died of rapidly-enlarging hepatic metastases 40 days after surgery.

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We report herein on case of a Spigelian hernia combined with a direct inguinal hernia. A 69-year-old man visited our hospital with the chief complaint of a left inguinal mass, which had been getting bigger since he noticed it 5 years previously. Abdominal ultrasonography showed two hernia orifices and the contents of the hernia sac, in one of which the small intestine was prolapsing on the cranial side, and the other was supposed to be fat tissue on the caudal side. With the diagnosis of combined direct and indirect inguinal hernia, elective surgery was conducted under local anesthesia. After the inguinal canal was cut open, we found the direct inguinal hernia prolapsing from the medial side of the inferior epigastric artery and vein, along with a Spigelian hernia prolapsing through the lacertus of the transverse abdominal muscles and internal oblique muscles. No indirect inguinal hernia was found. Mesh-plugs were inserted into both orifices. Spigelian hernias are not widely acknowledged due to their rareness, however, the associated morbidity is expected to increase with the aging of the population. Because the recurrence rate of Spigelian hernias after the surgery is low (0.7%), it is important for these hernias to be diagnosed and treated appropriately.

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A 50-year-old woman was examined at our hospital after occurrence of abdominal pain and vomiting，and was initially diagnosed as having gastritis. Because of repeated vomiting that night，she was reexamined at our hospital and admitted for follow-up. The next day，she was referred to our department because of ileus. We observed tenderness and a high inflammatory response in the upper abdomen. Because of exacerbation of abdominal pain over time，we suspected a strangulated ileus and performed emergency surgery. Upon performing laparotomy，we observed that the tip of the appendix had adhered to the mesoileum in a loop shape and that an aboral ileal loop located 10 cm from the ileocecal valve was strangled for 10 cm. Upon releasing the strangulation，we performed an appendectomy without performing intestinal resection because of improved blood flow in the intestinal tract. Histopathological examination of the adhered portion of the appendiceal tip revealed acute catarrhal appendicitis. Although strangulated ileus is frequently encountered by surgeons in a clinical setting，it is rare for the appendix itself to be strangulated. Therefore，we report on this case along with a discussion of the relevant literature.

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We report herein on 2 cases of strangulated small bowel obstruction during pregnancy with literature review of 58 cases in Japan. Case 1: A 34-year-old woman in her 29th week of pregnancy visited our hospital with the chief complaints of acute abdominal pain and vomiting and was admitted with suspected small bowel obstruction due to fecal impaction. After admission, her symptoms increased and cardiotocography showed late deceleration. We therefore performed an emergency Caesarean section. Intraoperatively, necrotic small bowel was detected and resected. Case 2: A 39-year-old woman in her 38th week of pregnancy was transferred to our hospital with the chief complaint of acute abdominal pain. An abdominal CT showed small bowel dilation with the beak sign. We performed a Caesarean section under the definitive diagnosis of strangulated small bowel obstruction. As the strangulated bowel was not necrotic in this case, we did not perform resection.

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A 56-year-old woman visited our hospital with the chief complaint of abdominal pain following an umbilical injury. Computed tomography revealed a ruptured hepatic cyst. The following day, a chest X-ray showed hydrothorax, which was suspected because of the ruptured hepatic cyst. Based on these findings, thoracic drainage was performed. The chest fluid gradually disappeared after the drainage, and the drainage tube was removed on day 6 after admission. However, 2 days later, she complained of severe abdominal pain. An abdominal echo scan showed an infected hepatic cyst; therefore, percutaneous trans-hepatic drainage was performed and antibiotic therapy was initiated. The abscess gradually resolved, and she was discharged on day 42 after admission.

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A 49-year-old female presented with developed nausea, abdominal pain and distension. She had developed Wernicke’s encephalopathy at the age of 21 and was hospitalized with aspiration pneumonia twice. The superior mesenteric artery (SMA) syndrome was diagnosed 2 years ago and she was successfully treated conservatively. Despite the abdominal discomfort since the day before admission, she continued on an oral diet. Soon after the admission, she deteriorated rapidly with respiratory failure and went into shock. CT scan demonstrated free air over the right subphrenic space and a markedly dilatated stomach with stenosis in the third part of the duodenum. During an emergency laparotomy, the stomach was seen to be dilated and distended down to the pelvis, and the proximal 2/3 of stomach was necrotic. The upper part of the gastric body was paper-thin and showed a perforation 4 cm in diameter. We performed a proximal gastrectomy and set tube-esophagostomy and distal gastrostomy. She remained haemodynamically unstable and hypoxic throughout the intra-operative period. Despite intensive care, she died the following day. Gastric rupture based on the SMA syndrome is rare and there have been only 2 cases reported. An emergency operation is necessary for survival.

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A 64-year-old man came to our hospital regularly since undergoing right hemi-colectomy for colon cancer in 2005. A submucosal tumor 4 mm in diameter was first noticed at the fornix when he underwent upper endoscopy for screening in 2008 and its size had increased up to 7 mm in 2011. In December 2012, he was admitted to the emergency room in our hospital with the complaint of vomiting blood. Upper endoscopy found a ruptured sub-mucosal tumor with active bleeding at the fornix of the stomach. An emergency total gastrectomy was performed because of uncontrollable bleeding. Pathologic examination diagnosed the tumor as a gastrointestinal stromal tumor (GIST) with high risk. We report herein on a rare case of gastric GIST with rapid growth. Even if a sub-mucosal tumor of the stomach is less than 2 cm, the growth trend of the tumor should be followed up carefully.

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A 32-year-old man had received conservative treatment at another hospital six times because of intestinal obstruction caused by Meckel's diverticulum. He had refused any surgical procedures because he could not take any time off from his work. He visited our hospital with recurrent intestinal obstruction. He received conservative treatment and kept working. After that, when he finally could take time off from his work, a single port laparoscopic partial resection of the small intestine was performed. The post operative period was uneventful. After 5 days he was discharged and started working on the next day. The treatment, which has cosmetic advantages and could allow the patient to return to studies or the workplace early, is suitable for a young patient with intestinal obstruction caused by Meckel's diverticulum.

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A 71-year-old man visited a hospital with left inguinal pain and was diagnosed as having left inguinal hernia incarceration. He was transferred to our hospital for herniorrhaphy. Physical examination revealed diffuse peritonitis and enhanced computed tomography demonstrated a small amount of free air. An urgent laparotomy was performed for a gastrointestinal perforation. During surgery, a tumor was found in the sigmoid colon and the oral side of the tumor showed an ischemic change. Although we could not find the site of perforation, we considered the colon perforation for incarceration, therefore Hartmann’s procedure was used. Histological examination revealed the tumor to be a moderately differentiated adenocarcinoma with a thinning intestinal wall at the oral side of the tumor. The patient’s postoperative course was uneventful and he was discharged on the 17th postoperative day.

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A 72-year-old man presented to our hospital complaining of epigastric pain and vomiting. He had undergone descending aortic graft replacement and omentopexy for stent graft infection. Abdominal X-ray revealed a diaphragmatic hernia with prolapse of the stomach and transverse colon, which was confirmed on contrast CT. He underwent laparoscopic diaphragmatic hernia repair. The herniated viscera were easily returned to the peritoneal cavity. The hernia orifice was 4×5 cm in diameter, which was closed by direct suture. Care was taken not to overtighten the omental pedicle. We then fixed a 10×12 cm composite mesh to the diaphragm to cover the omental pedicle. The patient had an uneventful recovery and was discharged on postoperative day 5. He currently had no recurrence 1 year after surgery. Laparoscopic repair is less invasive and more effective for diaphragmatic hernia repair.

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Adult umbilical hernia is a relatively rare disease. Moreover the existence of this disease in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) is rare. We report herein on an emergency surgical case of an incarcerated adult umbilical hernia in a patient undergoing CAPD. The patient was a 40-year-old woman who had been undergoing CAPD for chronic renal failure. She was hospitalized as an emergency case because of suspected CAPD-associated peritonitis. On the day after admission, a painful mass was evident in the umbilical region. We undertook emergency surgery under the diagnosis of incarcerated umbilical hernia. The small bowel was observed in the hernia sac. Intestinal blood flow improved as soon as we loosened the hernia orifice, therefore the small bowel was preserved. Primary suture repair was performed. After surgery, the patient was discharged with an uneventful course. Renal functional reserve is decreased in CAPD patients, and it is easy to fall as a result the occurrence of serious complications. We believe that a quick diagnosis and early surgery are important in order to avoid postoperative complications.

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