Subjects and methods：The characteristics of patients with SMA occlusion in this hospital between October 1, 2005 and September 30, 2012 were investigated retrospectively. Results: There were 10 cases of SMA occlusion, of which 4 were treated with interventional radiology (IVR), 2 required additional enterectomy after IVR treatment, and 4 were treated with enterectomy. The time from the onset to diagnosis was significantly shorter (6.8 hours vs. 29.1 hours, p<0.05) and the serum CRP significantly lower (0.5mg/dL vs. 13.9mg/dL, p<0.05) in the IVR group which showed improvement in response to the treatment (n=2) than in the intestinal necrosis group (n=8). The cutoff values of the two parameters were 2 hours and 0.2mg/dL, respectively. There were no abnormal findings on abdominal CT in the IVR group. Conclusion: IVR is considered as a worthwhile initial treatment modality in cases of SMA occlusion when the interval from onset to diagnosis is under 2 hours, the serum CRP is ≤0.2mg/dL, and abdominal CT reveals no abnormalities.

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The well-known “deadly triad” is too late with regard to determination of the necessity for damage control surgery (DCS) in abdominal traumatic emergencies and this determination should be made preoperatively. In 2008, we established a system in our emergency department aimed at reducing the time from admission to surgery for hemorrhagic shock patients. Laparotomy for trauma patients before introduction of the system was compared with after the introduction. The emergency department handled 11 cases (35.5%) before introduction and 32 cases (466.7%) after introduction, with time from admission to surgery being significantly reduced to 62.6±63.4 min from 120.2±138.0 min. Postoperative survival rates in the emergency department before and after introduction of the system were respectively 27.3％ and 43.2％ (NS) and survival rates in the operation room were 55.0% and 100% (p<0.05), respectively, showing a significant difference. Abdominal injury surgery (DCS) for controlling hemostasis is believed to improve the survival rate and reduce the time from admission to surgery.

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[Background] Afferent loop obstruction is a rare and occasionally fatal complication after gastrectomy with Billroth-IIor Roux-en Y reconstruction. [Patients and method] We examined the clinical features of 10 cases experienced in our institution between May 1993 and December 2010. [Results] The patients comprised nine males and one female, with an average age of 65.9 yr (47-83 yr). Eighty percent of the patients were diagnosed preoperatively based on the characteristic findings seen on computed tomography. This disease developed regardless of the period from surgery. An operation was performed in 7 cases (70%). Perforation and pancreatitis were observed in 1 case each, and the perforation patient died of multiple organ failure (MOF) after surgery in hospital. [Conclusion] Afferent loop obstruction leads to a fatal outcome when severe pancreatitis or perforation and necrosis of the afferent loop occur, so early diagnosis and treatment after its onset are important to improve the outcome.

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During emergency surgery for incarcerated femoral hernia, strangulation of the intestine may often occur. We retrospectively reviewed the clinical characteristics of patients who were diagnosed as having an incarcerated femoral hernia between 2000 and 2011 in Tsuyama Chuo hospital. There were 105 cases of femoral hernia, and incarceration was associated with 62% of the cases (65 patients). Emergency surgery was performed on 47 cases. The average age of the 47 patients was 76 years (25 to 96 years). Bowel resection was performed in 38% of the cases (18 patients). Tension-free hernia repair with the use of a mesh was performed in 53% of the cases (25 patients). In comparison with inguinal hernias encountered between 2000 and 2011, there were 1433 cases of inguinal hernia, and incarceration was associated with 12% of the cases (169 patients). Emergency surgery was performed on 71 cases. Bowel resection was performed in 5.6% of the cases (4 patients). Thus it was confirmed that femoral hernias were more frequently associated with incarceration and strangulation of the intestine.

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We retrospectively investigated 104 patients who were admitted to Showa University Hospital from November 2002 through June 2012 and underwent continuous hemodiafiltration (CHDF) for severe acute pancreatitis (SAP) (median age, 56 years; 78 male and 26 female patients). The median Japanese prognostic factor score was 4 points. Three patients were consistent with Grade 1, 74 were Grade 2 and 27 were Grade 3 in enhanced CT Grading. We started CHDF from the second day of the acute pancreatitis, and performed hemodialysis for 5 days (median). Early organ dysfunction rate was 86.5% (renal dysfunction rate: 23.1%), and the mortality rate was 15.4%. Significant improvement in the severity of acute pancreatitis, inflammation and complications rate were achieved with CHDF. On the other hand, there was no significant difference between the mortality rate when CHDF was started before the second day and after the third day during acute pancreatitis. A randomized controlled trial is necessary to prove the usefulness of CHDF for SAP.

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The diagnostic criteria for acute cholangitis and cholecystitis in Tokyo Guidelines 2007 (TG07) were established as an international standard. However, the necessity to revise them was shown by the validity assessment of TG07 diagnostic criteria on the basis of a retrospective analysis of patients collected from multiple institutions. Based on these results from the multicenter analysis, new updated diagnostic criteria were developed in 2013, (TG13). The TG07 diagnostic criteria for acute cholangitis had not enough sensitivity for those used to assess a life-threating disease. Due to the inappropriate combination of their diagnostic items, the guidelines were re-sorted according to 3 categories：cholestasis, inflammation and biliary manifestations. The validity assessment by the multicenter analysis showed that the TG07 diagnostic criteria for acute cholecystitis had a good diagnostic capacity. However, they involved a definitive diagnosis which did not require confirmation by imaging, so the expression of a definitive diagnosis was ambiguous and the TG07 were therefore unsuitable for clinical use. The definition of a definitive diagnosis was altered. In addition, another multicenter analysis showed that the TG13 diagnostic criteria had a better diagnostic capacity, and they were more suitable for clinical use.

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Over five years have passed since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07). Many differences have been reported between the Japanese Evidenced-Based Guidelines for acute cholangitis and cholecystitis (JGL) and TG07. Acute cholangitis: To revise JGL & TG07, we examined factors reported as predictive values of a poor prognosis among patients with acute cholangitis and factors associated with the need for urgent and early biliary drainage. To judge moderate cases on admission, 5 new factors, i.e. leukocytosis, high fever, age>75 years, hyperbilirubinemia, and hypoalbuminemia, were set for moderate criteria (Grade II) in TG13. The revised Tokyo Guidelines suggested adequate factors for severity assessment criteria to perform urgent and early biliary drainage for acute cholangitis patients with appropriate timing. Acute cholecystitis：The TG07 severity assessment criteria for acute cholecystitis did not have consequential problems that required major revision of the structures. Therefore, TG 13 severity grading for acute cholecystitis acceded to the concept of TG07. In summary TG13 presents more sophisticated severity grading systems. These criteria allow early diagnosis and early grading of severity. TG13 is clinically useful in the management of acute cholangitis and cholecystitis.

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In the diagnostic strategy of acute cholecystitis, ultrasound examination should be considered as the first choice of imaging modality for its non-invasiveness. Although the major sonographic findings of acute cholecystitis have not changed compared with those in the Tokyo Guidelines 2007 (TG07), each finding has become more clearly and precisely demonstrated by virtue of the improvement of the sonographic equipment, which has enabled us to change all the sonographic figures to new images in the Tokyo Guidelines 2013 (TG13). Also in TG13, we have put emphasis on the gall bladder swelling, wall thickening, calculi, debris, as well as sonographic Murphy's sign, as the reliable and reproducible findings regardless of the performance of the equipment used. Ultrasound is also useful for the assessment of the severity of cholecystitis. Pericholecystic fluid, intraluminal flap, and intraluminal/intramural gas are the major findings suggesting more severe cases of cholecystitis. In addition, ultrasound can be an effective modality to rule out other diseases mimicking acute cholecystitis, such as duodenal ulcer and pleuritis. On the other hand, the sonographic diagnosis of acute cholangitis is not always easy. Although the bile duct dilatation, stone impaction and tumor are the findings suggesting bile duct obstruction, they do not necessarily indicate coexisting inflammation. The wall thickening of the bile duct and intraluminal debris are more suggestive, while demonstrating these findings depends on the patients' condition, the examiner's skill, and the performance of the sonographic equipment.

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In the diagnostic imaging sections of 1st edition of the clinical practice guideline for acute cholangitis and cholecystitis published in 2005 and the Tokyo Guideline for the management of acute cholangitis and cholecystitis in 2007, the findings of bile duct expansion, bile duct stenosis and calculus are referred to as representative findings. However, while these changes may cause cholangitis, they do not always represent direct imaging evidence of cholangitis. Therefore, the old guideline mentions that it is difficult to diagnose acute cholangitis by imaging diagnosis, because the existence of bile infection cannot be determined from the imaging findings alone. In the revised guideline, the usefulness of dynamic CT in the imaging diagnosis of acute cholangitis is emphasized. That is, in patients with acute cholangitis, a temporary uneven deep staining is frequently observed in the arterial phase of dynamic CT for the liver；furthermore, this deep staining disappears with improvement of the cholangitis. Dynamic CT is also useful for the imaging diagnosis of acute cholecystitis；transient deep staining of the pericholecystic hepatic parenchyma observed in the arterial phase is a useful finding for the diagnosis of acute cholecystitis.

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Early laparoscopic cholecystectomy is the first-line treatment in patients with mild acute cholecystitis. However, in patients with moderate acute cholecystitis, early gallbladder drainage is required because moderate cholecystitis is often accompanied by severe local inflammation which may cause bile duct injury and other serious complications. In non-responders to initial treatment, gallbladder drainage is a salvage therapy for acute cholecystitis in patients who satisfy the following conditions: (1)Severity assessment is moderate or severe; (2)Surgical high-risk; (3)Refusing surgery; (4)Early surgery is not available in a local medical facility.

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TG07 describes the techniques and clinical results of surgical drainage, percutaneous transhepatic biliary drainage and endoscopic transpapillary drainage (biliary stenting and nasobiliary drainage) for the treatment of acute cholangitis. In TG13, which was published last year, special drainage techniques, including balloon enteroscopy-assisted biliary drainage and endoscopic ultrasonography-guided biliary drainage, are introduced in addition to the standard drainage techniques. In regard to the standard techniques of transpapillary biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP), not only traditional contrast medium-guided cannulation, but also wire-guided cannulation and its clinical performance is introduced. TG13 covers the management of acute cholangitis more comprehensively as compared to TG07. Furthermore, supplementary videos are provided to help the readers better understand these techniques, which is a first for academic guidelines. TG13 is “easy to understand,” not only for phycisians, but also other health-care professionals.

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The Tokyo Guidelines 2013 (TG 13), the international practice guidelines for acute cholangitis and cholecystitis, have been published and made available free of charge since 2013. Since 2007 when the first version of the Tokyo Guidelines 2007 was released, related clinical practice guidelines such as the Surviving Sepsis Campaign 2008 and 2012, and antimicrobial therapy for complicated intra-abdominal infections by the Infectious Diseases Society of America 2010 have been developed and published. In revising the Tokyo Guidelines 2007, these relevant guidelines were taken into account for clinical practitioners, and integrated into TG 13. In addition, several problems and aspects needed to be further considered. First, the antimicrobial susceptibility pattern (or local antibiogram) varied from place to place, and locally adapted practical antimicrobial recommendations were required. Second, there is a question if blood cultures would change outcomes among patients with acute cholangitis and cholecystitis. Third, what is the optimal duration of antimicrobial therapy for acute cholangitis and cholecystitis? Fourth, who should be treated empirically for Enterococci? Fifth, who should be treated for anaerobes? Lastly, what is the optimal prophylactic antimicrobial agent for elective endoscopic retrograde cholangiopancreatography? For continuous development, TG 13 should be revised in the near future to further integrate new clinical findings and should be validated in clinical practice.

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An item regarding the surgical treatment and the timing for acute cholecystitis is updated in the present Tokyo Guidelines 2013 because optimal surgical treatment for each grade of severity is necessary. Mild acute cholecystitis: Early laparoscopic cholecystectomy is the preferred procedure. Moderate acute cholecystitis: Early laparoscopic or open cholecystectomy (within 72 hours after the onset of acute cholecystitis) is generally required, however, if patients have severe local inflammation, early gallbladder drainage is indicated. Severe acute cholecystitis: Urgent management of organ dysfunction and management of severe local inflammation by gallbladder drainage should be carried out. Delayed elective cholecystectomy should be performed. The most extreme bile duct injury is a vasculobiliary injury involving the major hepatic artery and portal vein with an incidence of approximately 2%. Such an extreme vasculobiliary injury is more likely to occur when fundus-down cholecystectomy is attempted in the presence of severe inflammation of the gallbladder, usually after the conversion from laparoscopic to open cholecystectomy.

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In the Tokyo guidelines for the Management of Acute Cholangitis and Acute Cholecystitis 2013 (hereinafter referred to as TG13), the flow charts are also revised. The TG13 flow charts recommend blood culture and bile culture. In the flow chart for the management of cholangitis, it is stated that treatment to remove the cause should be undertaken simultaneously with biliary drainage in patients with mild cholangitis caused by common bile duct stones. In the flow chart for the management of acute cholecystitis, laparoscopic cholecystectomy is recommended as the first-line treatment, except in patients with moderate cholecystitis associated with serious local inflammation such as biliary peritonitis who need an urgent surgical operation. The mobile application of TG13 is a digest of TG13 including the diagnostic criteria, the criteria for severity assessment, flow charts, bundles and figures and tables for antimicrobial therapy. With the upgrade of this application, it has become possible for users to transmit new information, making the application an important tool for use of the guideline in the future.

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In recent years, bundles that define mandatory items or procedures to be performed in clinical practice have been increasingly used in guidelines. Observance of bundles enables improvement of the prognosis of the target diseases, as well as helps in the preparation of guidelines. There were no bundles adopted in the Tokyo Guidelines 2007, whereas the updated Tokyo Guidelines 2013 (TG13) has adopted this useful tool. Critical parts of the bundles in TG13 include those related to the diagnostic process, severity assessment, transfer of patients if necessary, therapeutic approach, and time course. Their observance should improve the prognosis of acute cholangitis and cholecystitis. In regard to the TG13 management bundles, further clinical research (for example, international multicenter prospective trials) needs to be conducted to evaluate the effectiveness and outcomes of the bundles. It is also expected that the present report will lead to evidence construction and contribute to further updating of the Tokyo Guidelines.

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We report herein on a case of acute cholecystitis with an unruptured cystic artery aneurysm. A 41-year-old female was admitted because of right upper quadrant pain. Her blood test showed leukocytosis and her CT showed enlargement of the gall bladder and wall thickening. CT also showed a 9 mm round mass in the neck of the gall bladder. We thought that it was a cystic artery aneurysm and feared rupture of the aneurysm intraoperatively so we primary treated her with percutaneous transhepatic gallbladder drainage (PTGBD). One month later the cystic aneurysm had not disappeared so we treated it with angiography and embolization of the cystic artery aneurysm, whereafter we performed a laparoscopic cholecystectomy. After inflammation of gall bladder had improved, we were able to complete treatment safely.

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A 54-year-old man, in whom situs inversus totalis had been present from early childhood, was admitted with a fever and left lower quadrant pain. An enlarged appendix with a fecalith in the left lower quadrant was revealed on plain abdominal CT scan imaging. Acute appendicitis with situs inversus totalis was diagnosed, and an emergency operation was determined. Single-incision laparoscopic surgery was performed using a multi-channel port (LAP PROTECTORTM), which was inserted through a 2.0 cm umbilical incision. Three trocars were placed in the multi-channel port. Situs inversus totalis is a rare anomaly (incidence 1: 5,000 to 1: 10,000) characterized by the complete inversion of all abdominal and thoracic organs. Due to the abnormal anatomical location, diagnosis may be difficult and great care must be taken during surgery. Laparoscopic surgery for patients with this anomaly is a useful method, which can allow minimal invasive observation of the abdominal cavity and diagnosis is easily converted to treatment. It is also superior in terms of the cosmetic result if single incision surgery can be performed completely as in this case, because the need for any additional ports is assessed after observation of the focus status.

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A 78-year-old woman with ischemic colitis and diverticulitis of the colon had undergone a hysterectomy and salpingo-oophorectomy for bilateral pyosalpinx. On postoperative day 7, the patient complained of pyrexia, and a CT scan showed pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema. However, no rebound tenderness and muscular defence was observed on the physiological examination. Recto-sigmoid perforation was diagnosed on colon fiberoscopy and Gastrografin contrast enema examination. An emergency operation for recto-sigmoid perforation and pneumomediastinum was performed. The intraoperative findings revealed that perforation was present in the mesenteric side of the recto-sigmoid colon with necrotic tissue. The abscess formation was confirmed in the retroperitoneal space of the ascending colon around the right renal fascia. The emphysema had spread from the mesentery of the small intestine, transverse mesocolon, and lesser omentum to the mediastinum via an esophageal hiatus. We performed Hartmann’s operation with washing and drainage of the retroperitoneal space of the ascending colon to the mediastinum. The postoperative course was uneventful, and the patient was discharged from our hospital on the 36th postoperative day.

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Portal venous gas (PVG) occurs from various causes such as ischemia, inflammation and dilatation of the digestive system. PVG has been considered as having a poor prognostic condition requiring urgent operation, but on the other hand, many cases of PVG that recover without surgery have been increasingly reported. We report herein on two cases of PVG which were successfully treated with conservative management. Case 1. A 63-year-old male was referred because of epigastralgia. An enhanced CT scan revealed hepatic portal venous gas extended to superior mesenteric vein, pneumatosis intestinalis and stenosis of the celiac, superior and inferior mesenteric arteries with poor enhancement of each area of perfusion. He was diagnosed as having wide and segmental intestinal ischemia. Case 2. A 93-year-old female was transferred to our hospital because of vomiting and epigastralgia. An enhanced CT scan revealed PVG and pneumatosis and poor enhancement of the duodenum. Allowing for their general conditions and ages, they were both treated with conservative management. Both patients recovered and were discharged.

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A 76-year-old female consulted her general practitioner with a chief complaint of abdominal pain, and she was diagnosed as having severe acute pancreatitis. She received conservative treatment, however, her clinical conditions got worse, and she was brought to our hospital. The prognostic signs were positive for five parameters and the CT grade was judged to be grade 2. Abdominal CT showed the presence of free air in the mesocolon transversum. Emergency surgery was performed, because the patient had general peritonitis and disseminated intravascular coagulation (DIC). Although fat necrosis was found in the mesocolon transversum due to colonic penetration, there was no necrotic finding in the transverse colon. Ileostomy and drainage were therefore carried out. Although colonic perforation and colonic stenosis were demonstrated, these complications were improved by conservative treatment, and the patient was discharged from our hospital 155 days after the operation. The colonic stenosis had improved 1 year after the operation, and she is doing well with comfortable activities of daily life.

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We report herein on a patient who underwent emergency surgery twice with rectal perforation and necrosis of the stoma due to polyarteritis nodosa. A-62-year old female was hospitalized for neuropathy and had been treated with steroid pulse therapy. The day after the steroid pulse therapy had ended, she complained about sudden lower abdominal pain, and was diagnosed as having a rectal perforation. Hartmann’s operation was therefore performed. We thought that the perforation was originally caused by the steroid therapy, but according to the histological examination, it was caused by polyarteritis nodosa. Therefore, due to the necrosis of the stoma from which the lesion might have ranged, another surgery was performed, 20 days after the first surgery. We resected the left colon, and recreated the colostomy in the right side of transverse colon. Two and a half years have passed since the surgery and this patient is still currently alive.

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A 66-year-old woman was referred to our center for examination of a huge abdominal mass. Computed tomography (CT) revealed a 10 cm tumor extending into the pelvic cavity from the abdominal cavity. Although surgery was indicated from the CT findings that suggested a malignant lesion, such as a gastrointestinal stromal tumor (GIST), she did not consent to the procedure and was therefore placed under observation. However, 51 days after the initial examination, she was admitted to the emergency department due to loss of consciousness caused by septic shock. Because no improvement was seen with conservative treatment with vasopressors and antibiotics, she underwent a tumorectomy with concurrent resection of the small intestine, appendix, and sigmoid colon. Her postoperative course was good, and the patient was discharged on postoperative day 17. We report herein on the features and course of this rare case of GIST of the small intestine accompanied by septic shock and discuss the relevant literature.

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We report herein on the case of an 82-year-old man who had recovered from diarrhea and high fever but complained only of appetite loss at the first examination. CT imaging revealed a localized subphrenic abscess and the laboratory test indicated leucocytosis. His symptoms were not severe, and therefore, he was scheduled to undergo another examination on the next day and left. However, 9 hours later, the patient developed sudden chills at home. He was transferred to our emergency room complaining only of an unusual sensation in the abdomen, but had no abdominal tenderness or muscular defense. He was in shock because his systolic blood pressure and heart rate were 85 mmHg and 93/min, respectively. New laboratory test results indicated leucopenia. Another CT scan revealed that the localized subphrenic abscess had ruptured into the abdominal cavity. An emergency laparotomy was performed and the postoperative course was uneventful. Rupture of a completely localized abscess is rare, and subphrenic abscesses have mainly been reported to rupture into the thoracic cavity. However, the possibility of rupture into the abdominal cavity should also be considered in patients with subphrenic abscesses and rapid drainage should be performed immediately after the abscess is diagnosed.

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A 23-year-old man visited the hospital with the complaint of right lower abdominal pain. Contrast-enhanced abdominal computed tomography revealed a structure comprised of concentric layers of low and high signal intensity areas in the right abdomen, consistent with a diagnosis of intussusception. Emergency surgery was performed laparoscopically. The ileum was identified as invaginating the ascending colon. Because the tip of the intussusceptum reached the hepatic flexure, laparoscopic reduction was difficult to achieve. Through an approximately 9-cm midline incision in the upper abdomen, one hand was inserted into the peritoneal cavity, and the oral side of the invaginating intestine was gently pushed outward from the anal side and thereby reduced. Intraoperative palpation and inspection showed no organic disease in the ileocecal area. Six weeks after the operation, no organic lesion that might have caused intussusception was found on colonoscopy. Thus, idiopathic intussusception was diagnosed. If the absence of organic disease is confirmed after reduction, idiopathic intussusception does not require further treatment and is a good indication for laparoscopic surgery.

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A 40-year-old man visited our hospital with an abdominal injury. Abdominal CT and US showed intra abdominal bleeding and a 10 cm hepatic tumor. The patient was diagnosed as having hemoperitoneum caused by rupture of the hepatic tumor. After two sessions of transcatheter arterial embolization of the hepatic artery, tumor bleeding was stopped and the patient's vital signs were stabilized. Two years later after embolization, hepatic resection was performed. The histological diagnosis was cavernous hemangioma.

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We report herein on a case of ileus due to a trichobezoar or “hairball”. A 12-year-old girl was admitted for abdominal pain and vomiting starting 5 days previously, and was found on abdominal X-ray imaging to have intestinal dilation unresolved by long intestinal tube insertion. Computed tomography (CT), ultrasonography (US), and other results suggesting intussusception necessitated surgery for ileus. The apparent cause were two trichobezoars found in the ileum 100 cm from Bauhin's valve, one 10×3 cm and the other 8×3 cm. They were removed, and the girl's postoperative course was uneventful. Trichobezoars are usually attributable to trichotillomania or trichophagia necessitating psychiatric treatment, and careful follow-up is essential to decrease or prevent recurrence.

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Laparoscopic cholecystectomy (LC) is now a standard procedure for benign cholecystic disease. However, severe complications that have not been associated with open surgery have been reported. We report herein on a case with subcapsular hematoma of the liver and AMI after LC. A 69 year-old-man was admitted with acute cholecystitis. He underwent LC. There was neither damage to the surface of the liver damage nor bleeding during the operation. After the operation, anemia and hepatic dysfunction progressed, and postoperative bleeding was suspected. CT showed a subcapsular hematoma of the hepatic right lobe and bleeding from the peripheral right hepatic artery. We tried to stop the bleeding via interventional radiology with vascular embolization. After embolization the blood data improved, but the patient had difficulty in breathing. In addition, cyanosis had developed. We diagnosed AMI with ECG and echocardiography and the patient underwent an emergency coronary artery bypass graft in the nearest cardiovascular center. In this case, it was assumed that the subcapsular hematoma was due to unnoticed liver damage through traction of the gallbladder. We report herein on a case with subcapsular hematoma of the liver following LC with a review of the literature.

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We report on a rare case of primary peritoneal carcinoma, causing intestinal obstruction, with difficulty. in diagnosis. A 71 year old woman who underwent a hysterectomy, left adnexectomy, and had recurrent episodes of ileus was admitted to our hospital with nausea and abdominal pain. CT scan showed small bowel dilatation, small amounts of ascites and calcified abdominopelvic nodules. She was diagnosed as having recurrence of adhesive intestinal obstruction, and. conservative treatment with long tube insertion was performed. However, her condition continued to deteriorate, therefore, we performed an operation 4 days later. Macroscopically, a mass was found extending from the ileum. and adhering strongly to the retroperitoneum. A partial jejunonectomy was carried out. After surgery, her general condition improved and she was discharged from our hospital on the 40th postoperative day. Histological examination showed the tumor was a peritoneal carcinoma, resembling serous papillary adenocarcinoma of the ovary. Because peritoneal dissemination existed on the side of the serosa, we diagnosed the condition as an intestinal obstruction caused by peritoneal carcinoma.

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We report herein on a case of intussusception due to recurrent malignant lymphoma of the small intestine. A 77-year-old man was diagnosed as having malignant lymphoma (diffuse large B-cell lymphoma) of the left ethmoidal sinus. R-CHOP therapy was performed, and the patient achieved complete remission. The patient was admitted to our hospital with lower abdominal pain and vomiting two years later. Computed tomography showed intussusception of the ileum. We performed an emergency laparotomy and partial resection of the small intestine. The specimen included a 7.0×4.5 cm tumor. Immunohistological examination demonstrated recurrent malignant lymphoma. Malignant lymphoma sometimes recurs in the small intestine and induces intussusception even if patients achieve complete remission. In this situation, it is desirable to perform early surgery with this disease in mind.

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A 63-year-old man consulted a doctor because of progressive left thigh pain and swelling, and was suspected as having thigh gas gangrene resulting from the penetration of the descending colon. He was transferred to our university hospital for extensive treatments. After admission he underwent an emergency drainage for abscesses from the retroperitoneum to the thigh. After the drainage, his inflammatory responses gradually improved. Subsequent colonoscopy revealed that the descending colon cancer had penetrated into the retroperitoneal space, so that laparoscopic left hemicolectomy was performed for a complete cure. This case showed us the importance of examining the lower gastrointestinal tract when encountering a nontraumatic example of gas gangrene especially in the thigh area. If local drainage could improve the patient's conditions, a highly definitive surgery could be selected, even by laparoscopy, as an alternative procedure to graded operations which are usually done in the acute phase.

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In cases of fulminant hepatitis, the possibility of injury to other organs exists because of rapid deterioration of the patient’s condition. We present herein on 2 cases of fulminant hepatitis complicated by acute pancreatitis. The pathologies of the 2 cases included acute exacerbation of chronic hepatitis B and cryptogenic hepatitis. Both patients were candidates for liver transplantation because of the ineffectiveness of conservative therapy. However, neither patient could undergo surgery because of uncontrollable acute pancreatitis. For patients with fulminant hepatitis, the control of complications in other organs, including acute pancreatitis, is important. High-mobility group box-1 has been reported to participate in the pathophysiology of fulminant hepatitis and the severity of acute pancreatitis. Therefore, the involvement of high-mobility group box-1 characteristics is expected in such pathophysiologies.

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Villous adenomas of the large intestine are recognized as tumors with a high malignant potentiality that secrete large amounts of mucus containing electrolytes. We report herein on a case of rectal villous adenocarcinoma with electrolyte depletion syndrome. A 76-year-old man was admitted to the hospital with severe diarrhea, vomiting and loss of consciousness. Laboratory examination on admission showed decreased serum electrolytes <Na 122 mEq/L, K 2.6 mEq/L, Cl 65 mEq/L> and renal dysfunction <BUN 108.9 mEq/L, Cre 3.44m Eq/L> due to dehydration. Colonoscopy and computed tomography were performed for further evaluation of rectal mucous discharge. A villous tumor was revealed in the rectum below the peritoneal reflection. The patient was diagnosed as having electrolyte depletion syndrome, and underwent an abdominoperineal rectal resection. Histopathological findings revealed a 155×130 mm sized villous adenoma with well-differentiated adenocarcinoma. There has been no recurrence during an 8-year follow-up.

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A 65 year-old man was hospitalized due to lower abdominal pain. Abdominal computed tomography revealed a thickened appendix resembling bunches of grapes and opacity of fat tissue. An emergency operation was performed under the diagnosis of appendiceal diverticulitis. A portion of the appendix had perforated. We confirmed a perforation of diverticulum with contrast radiography and a pathological exam. Because the frequency of perforation in appendiceal diverticulitis has been estimated to be much higher than that in ordinary appendicitis, a symptomatic appendicitis with diverticulum and/or an appendiceal diverticulitis should be operated on regardless of the degree of inflammation. On the other hand, it is very difficult to diagnose appendiceal diverticulitis preoperatively. We herein report on a case with appendiceal diverticulitis diagnosed preoperatively with a review of the literature.

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We report herein on a rare case of panperitonitis caused by pyonephrosis in a 65─year old woman. She presented with abdominal pain at a local hospital where she was given a diagnosis of intestinal obstruction. Not having got any better after treatment using a long tube, she was referred to our hospital for further examination. Abdominal CT showed right pyonephrosis with coral calculus, a subcutaneous abscess at the right waist, and purulent ascites in the entire abdomen. We performed an emergency operation based on a diagnosis of panperitonitis. Operative findings showed heavy purulent ascites in the abdomen and great inflammation especially around the right kidney. We diagnosed her as having peritonitis due to pyonephrosis, and performed a right nephrectomy and drainage of the abdominal cavity.

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A 46-year-old man was admitted to our hospital's emergency department for rapid lower abdominal pain. Computed tomography (CT) showed localized small intestinal dilation at the dorsal of the mesocolon sigmoideum. We diagnosed the condition as ileus due to internal hernia involving the sigmoid mesocolon, and an emergency operation was performed. Intraabdominal reference with a laparoscope showed the incarcerated small intestine in a defect of the left lobe of the mesocolon sigmoideum, with impeded blood flow. After the incarcerated small intestine was reduced, the hernia orifice was sutured and closed. The incarcerated small intestine resection and functional end to end anastomosis was performed via a small laparotomy at the umbilicus. The postoperative course was uneventful. Though internal hernia involving the sigmoid mesocolon is one of the rare diseases encountered as an abdominal emergency, laparoscopic surgery might help in ensuring increased episodes of an uneventful course of treatment.

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