This retrospective study was conducted to examine the prognosis of surgery in patients with colorectal perforations. From January 2006 to August 2013, we encountered 32 cases of colorectal perforation in which an emergency operation was performed. 24 patients survived and 8 patients died during the perioperative periods. Almost all the causes of the perforations were diverticulitis and colorectal cancers. When the perforations occurred as free perforations, they were related to high mortality. The non-survivors were older compared to the survivors, and there were significantly high values found in a univariate analysis with the APACHE II and SOFA scores. In a multivariate analysis, the APACHE Ⅱ score was also selected as an independent predictive factor of the prognosis (OR: 1.679 (1.102-2.558), p=0.016). The pan-peritonitis caused by colorectal perforations is relatively common but life-threatening conditions. To save the patients, a useful evaluation system is required to assess their backgrounds and conditions, like the APACHE II score, and complete multimodality therapies must be performed.

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In this study, the relationship between serum lgG levels and the prognosis for colorectal perforations was examined. The subjects of this study were patients with generalized peritonitis due to colorectal perforations who were treated at our hospital between September 1st, 2011 and June 30th, 2013. Comparisons on the systemic inflammatory response syndrome (SIRS) period after surgery, duration of respirator use, and ICU duration were made between two groups of patients with normal IgG levels of 800 mg/dL or more and with hypo-lgG levels of less than 800 mg/dL. There were 27 cases during the study period, out of which 18 had normal IgG levels and the remaining 9 had hypo-lgG levels. The SIRS period of the hypo-lgG group was longer compared to the normal IgG group (12.9±14.2 days vs. 6.4±9.1 days). In addition, the hypo-lgG group had a longer duration of respirator use (8.1±7.0 days vs. 2.0±2.8 days), which resulted in prolonged ICU duration compared to the normal IgG group (14.4±13.1 days vs. 5.7±4.5 days). Hypo-lgG levels prior to surgery for colorectal perforation were associated with severe conditions. Thus, our results suggest improvement of the prognosis can be achieved by compensating for the IgG levels.

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We evaluated the usefulness of laparoscopic appendectomy (LA) compared to open appendectomy (OA) for acute appendicitis. From January 2010 to August 2013, 272 patients underwent appendectomy either by LA (140) or OA (132). The mean operation time was significantly longer in the LA group (83.0±3.1 min) than /OA group (66.1±2.7 min；P=0.002). The mean blood loss was less with LA (10.9±2.8 mL) compared to OA (32.7±7.5 mL；P=0.006). There was no significant difference in the hospital stay between LA (4.5±2.4 days) and OA (7.7±7.3 days). There was no significant difference in the incident rate of postoperative complications between LA (overall 8.6%; wound infection, 3.6%; postoperative intra-abdominal abscess, 5.0%) and OA (overall 10.6%; wound infection, 2.3%; postoperative intra-abdominal abscess, 5.3%, and postoperative ileus, 2.3%). However, postoperative ileus was less with LA (0%) compared with OA (2.3%); P=0.04). Overall, although LA requires a longer operation time than OA, LA may be more useful than OA.

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From 46 patients with bile duct cancer examined at our hospital during the 6-and-a-half yearperiod between January 2008 and June 2014, we compiled 25 cases of patients with accompanying acute cholangitis and conducted a study on drainage for acute cholangitis caused by malignant biliary obstruction. Eighteen of the 25 patients were diagnosed as having bile duct cancer at the initial examination and 7 were diagnosed as having choledocholithiasis, cholecystitis, or lower bile duct obstruction alone. Six of the 25 patients underwent radical surgery after drainage；the remaining 19 patients had unresectable cancer, in only 4 of whom the cancer was diagnosed as unresectable at the initial examination. After drainage, 12 patients experienced stent dysfunction such as obstruction or displacement, and the stent had to be replaced repeatedly during the course of treatment for some patients. As with normal cholangitis, it is basic practice to treat acute cholangitis caused by bile duct cancer with drainage as soon as possible when the cholangitis is moderate or severe. It is also necessary to select the appropriate method of drainage after determining whether the cancer is resectable and estimating the prognosis if it is unresectable.

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Preoperative decompression can improve the short-term postoperative outcome in patients with colon cancer with cancer-associated obstruction. However, despite the performance of preoperative decompression, cancer-associated obstruction may hinder early recovery of gastrointestinal motility. In this study, we compared the postoperative gastrointestinal motility between patients with a cancer-associated obstruction that was released preoperatively and patients without any cancer-associated obstruction. This was a single-center, retrospective, observational study. We evaluated patients who underwent resection and primary anastomosis of the colon. The decompression group comprised 17 patients who underwent preoperative decompression, and the unobstructed group comprised 83 patients. All patients ingested one Sitzmarks® capsule 2 hours before surgery. Postoperative intestinal motility was radiologically assessed by counting the number of residual markers on abdominal radiographs taken on postoperative days 1, 3, and 5. The numbers of residual markers in the small intestine were significantly lower in the unobstructed group than in the decompression group on postoperative day 1 (p=0.008), day 3 (p=0.005), and day 5 (p=0.0005). Our data indicate the possibility of delayed recovery of postoperative gastrointestinal motility in patients with an obstruction despite having undergone preoperative decompression. This delayed recovery may lead to postoperative complications and extend the length of the hospital stay.

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We examined retrospectively 57 consecutive patients who underwent emergency angiography for gastrointestinal bleeding over a 24-month period. Of the 57 patients, 25 had upper GI bleeding (UGIB), and 32 had lower GI bleeding (LGIB). Patients who underwent transcatheter arterial embolization (TAE) for UGIB were uncontrollable with fiberscopy or were hemodynamically unstable patients. TAE for UGIB had a high technical success rate (100%) and clinical success rate (87.5%). Of 32 LGIB patients, 6 had no visible bleeding points on angiography, so we did not perform TAE. A technical success was achieved in 25 of 26 LGIB (96.2%) where bleeding was successfully stopped. There was one complication of TAE for GIB, by catheter manipulation which resulted in intimal dissection of the inferior mesenteric artery, but hemostasis was obtained and surgery was not required. TAE for GIB has a high success rate and safely achieves hemostasis.

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Endoscopic hemostasis for bleeding gastric ulcer is achieved with some local injection method, thermal coagulation, or mechanical clipping. The use of hemostatic forceps has increased with the widespread use of endoscopic submucosal dissection (ESD) to control upper gastrointestinal bleeding. However, there are few reports on the use of hemostatic forceps to control bleeding gastric peptic ulcers. We have had experience using an endoscope with a water-jet function and by setting the tip of the transparent hood over the site of interest, we were able to check the bleeding point easily.We first of all injected hypertonic saline-epinephrine (HSE) around the exposed vessels of the hemorrhagic gastric ulcer. Next hemostatic forceps were applied, with a narrow opening angle, a small cup and blunt blades to make pinpoint holding of the target lesion possible. We then used high-frequency hemostatic forceps for the exposed vessels of the hemorrhagic gastric ulcer. The power level of the equipment was set at 80 W, and the endoscopist coagulated the exposed and bleeding vessels. This soft coagulation process was repeated until hemostasis was confirmed. We concluded that endoscopic hemostasis using high-frequency hemostatic forceps for bleeding gastric ulcer was a safe and effective method.

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The efficacy and safety of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA-TAE) for Forrest I gastroduodenal ulcer bleeding were evaluated from the experience of 26 patients who underwent NBCA-TAE. Shock indices prior to and immediately after NBCA-TAE were compared to determine changes in hemodynamics. Days to Forrest type Ⅲ, as assessed by follow-up endoscopy, was used as an indicator of the healing process. Immediate hemostasis was achieved in all the patients, and the shock index significantly (p<0.001) improved from before (1.09±0.088) to immediately after NBCA-TAE (0.68±0.031). Sequential mucosal healing processes were observed in all the patients, and the number of days to Forrest type Ⅲ was 9.0±3.8. NBCA-TAE is an effective and safe method for the control of gastroduodenal ulcer bleeding, in terms of contribution to hemodynamics and healing process of the gastroduodenal mucosa. However, understanding the behavior of NBCA within the circulation and adequate administration techniques are necessary.

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I examined the treatment strategy in our Institution for large intestine diverticulum bleeding and 141 cases were diagnosed in the period from April, 2008 until December, 2012. Endoscopic hemostasis, IVR, barium filling and surgical treatment comprise a variety of approaches in the treatment of large intestinal diverticulum bleeding. As for the endoscopy enforcement rate, 92.10% (130/141 cases); inner; was 16.9% of art of endoscopic hemostasis enforcement rate （22/130 cases）. The success rate for hemostasis was 68.1% (15/22 cases), for TAE, it was 9.2% (13/141 cases), and as for the IVR approach, the success rate was 100% (10/10 cases). There was a rebleeding case in the Osakashi Securities Exchange as well as a diverticulum bleeding case, too, and we found it hard to stop the bleeding in our Institution. A total of nine rebleeding cases were recognized. Large intestinal diverticula often occur frequently, with each treatment method having its own good points and bad points, but rebleeding is possible no matter what treatment approach is chosen. It is therefore necessary to be prepared to be able to apply an alternative approach any time that rebleeding occurs.

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Aim: To examine a cohort of diverticular hemorrhage cases in the colon, diagnosed with endoscopy and/or angiography. Materials and methods: My primary approach was to diagnose the source of bleeding using a transparent suction hood inverted over the diverticula during colonoscopy. In cases with profuse bleeding I attempted to diagnose the diverticular hemorrhage using angiography. I examined the results of diagnosis, the success rate of hemostasis and complications in 172 cases. Results: I used angiography in 3 cases with profuse bleeding. In 2 out of 3 cases I found signs of active bleeding and performed arterial embolization using micro-coils. Including the one case where angiography failed, in 170 cases, I used colonoscopy to attempt to diagnose the bleeding source. Diagnosis was successful in 139 cases and unsuccessful in 31 cases. Endoscopic hemostasis was performed in 124 cases. The hemorrhage was effectively stopped in 107 cases but reoccurred in 17 cases. After re-attempting hemostasis, in 5 cases it was successful but 12 cases showed persistent hemorrhage. For the persistent hemorrhage cases, I used IVR and was successful in all 14 instances. Iatrogenic symptoms in the persistent hemorrhage group included 4 cases of peritonitis and 1 case of colonic perforation. Conclusions: Accurate diagnosis using transparent hood colonoscopy is crucial to achieve effective hemostasis of colonic diverticula. IVR is also effective when endoscopic hemostasis fails or in cases with profuse bleeding but the operator must take care regarding major complications.

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We summarized 61 cases of colon diverticular bleeding, and examined the usefulness of interventional radiology (IVR). The 17 cases that underwent IVR were significantly more severe than non-IVR cases, but there was no significant difference in the frequency of re-bleeding. We succeeded in achieving hemostasis in all 17 cases. The embolic material in 8 cases was gelatin sponge and microcoils in 9 cases. Regarding the site of embolization, in 9 cases it was the vasa recta, and the marginal artery in 8 cases. As for complications, we experienced one case of colon necrosis which required surgery, two cases of localized peritonitis, one case of re-bleeding, and one case of acute renal failure. IVR for diverticular bleeding is effective, and it is possible to avoid emergency surgery even under conditions of hemodynamic instability. However, serious complications can occur such as colon necrosis or localized peritonitis. Selection of the site of embolization and the embolic material must be carried out carefully.

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Ischemic enteritis of the small intestine is relatively rare, and we report herein on a rare case of a small intestinal stricture resulting from ischemic enteritis. A 76-year old man was admitted to the hospital with ileus syndrome. He had a medical history of cerebral infarction, hypertension, and hepatitis C infections. Plain abdominal X-ray showed the niveau sign in the small intestine. Abdominal CT scan demonstrated a small bowel obstruction due to local wall thickening in the small intestine. His symptoms disappeared with conservative treatment, but abdominal fullness recurred repeatedly. We judged that the conservative treatment was difficult, and surgery was performed. Intraoperatively, segmental stenosis of the small intestine was found about 15 cm long and about 180 cm distant from the Treitz ligament. The patient underwent resection of the small intestine. Microscopic examination revealed an ulcer with inflammatory cell infiltration, thickness and fibrosis in the submucosal layer. He was diagnosed as having ischemic enteritis.

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We present herein a rare case of a patient who experienced delayed stenosis of the jejunum after abdominal injury. A 58-year-old man, who had suffered abdominal injury in a traffic accident, developed a bowel obstruction 10 days later. We initially treated this patient conservatively with an ileus tube, but he did not improve. Therefore, we performed laparoscopic surgery 10 days after the ileus tube had been inserted. During laparoscopy, stenosis was identified in the jejunum at 150 cm aboral to the ligament of Treitz. Partial resections of the jejunum were performed. In patients with delayed bowel obstruction after abdominal injury, it is necessary to recognize the possibility of irreversible bowel stenosis. If the location of the small intestinal stenosis can be diagnosed, we suggest that it can be treated with laparoscopic surgery.

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An 88-year-old man presented complaining of abdominal distention. His scrotum was the size of an infant's head. An abdominal computed tomography scan showed intestinal loops in the left scrotum, which had caused bowel obstruction. An incarcerated left inguinal hernia was diagnosed. The size of the scrotum was reduced with manual reduction, but complete reduction was impossible. On day following admission, surgery was performed. The ileocecum was herniated and incarcerated in the left scrotum. Bowel resection was not performed because the intestine showed no evidence of necrosis. A left inguinal hernioplasty was performed using Lichtenstein’s procedure. The patient was discharged on postoperative day 13. A left-sided herniation of the ileocecum is rare, and so far only 5 cases have been reported in Japan.

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A 54-year-old woman was examined at an emergency outpatient clinic for intermittent pain in the upper-left side of the abdomen that had begun 7 hours before admission. An abdominal computed tomography examination showed distension of the splenic flexure of the transverse colon and presence of the whirl sign, prompting a diagnosis of transverse colon volvulus. An emergency colonoscopy showed black necrotic changes on the intestinal mucosal surface. To avoid the risk of perforation, emergency surgery was performed without attempting endoscopic repositioning. Abdominal findings showed that the splenic flexure of the transverse colon had rotated 270° counterclockwise when observed from the caudal end of the body. The splenic flexure was the point of obstruction. Necrosis was not observed in any of the layers of the colon；therefore, repositioning was performed without intestinal resection. Most cases of colon volvulus occur in the sigmoid colon, and only a few occur in the transverse colon. Herein, we describe our experience with a relatively rare case of transverse colon volvulus that was diagnosed preoperatively by computed tomography examination and the affected colon was restored without surgical resection.

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A 91-year-old woman was referred to our hospital for repeated small bowel obstruction. CT showed dilated intestinal loops and a bubbly mass, 3.5cm in diameter, in the small bowel. Fluorography using the ileus tube revealed a filling defect in the small bowel. The patient was diagnosed as having a small bowel obstruction caused by impaction of undigested food residue. Conservative treatment with an ileus tube showed no improvement. We performed dissolution therapy with Coca-Cola administration through the ileus tube. 100 mL of Coca-Cola was infused through the ileus tube, every 1 hour, 5 times a day. The 5 days dissolution therapy resolved the small bowel obstruction. Dissolution therapy with Coca-Cola may be useful in patients with food-induced small bowel obstruction resistant to conservative treatment with an ileus tube. It should be especially considered elderly patients to avoid surgical removal.

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A 69-year-old man visited our hospital with abdominal pain. Signs of peritoneal irritation were recognized all over the abdomen, and enhanced computed tomography demonstrated a piece of metal in the transverse colon and dilatation of the right side colon. An emergency laparotomy was performed under the diagnosis of perforation of the colon. Intraoperatively, a partial denture was found in the transverse colon and the clasp had penetrated the total intestinal wall. A right hemicolectomy was therefore performed. The patient's postoperative course was uneventful and he was discharged on the 16th postoperative day.

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A 66-year-old man was admitted to our hospital with left upper abdominal pain. He had a history of treatment for hepatocellular carcinoma. Computed tomography revealed a large abdominal tumor adjacent to the left liver lobe. We suspected a rupture of the hepatocellular carcinoma and performed emergency tumorectomy, including partial hepatectomy of the left liver lobe, partial gastrectomy, and partial resection of the abdominal wall. A sarcomatous tumor was suspected from the intraoperative frozen section. Macroscopically, the resected tumor measured 28×23×20 mm and weighed 3,790g. The histological diagnosis was pleomorphic spindle cell sarcoma. The tumor was negative for all epithelium tumor markers except for vimentin. The final diagnosis was sarcomatoid hepatocellular carcinoma. On the 49th postoperative day, the patient died of disseminated peritoneal disease. Most sarcomatoid hepatocellular carcinoma progress rapidly, and the prognosis is poor. Surgical resection is the only effective treatment. We report herein on a case of sarcomatoid hepatocellular carcinoma with a review of the relevant literature.

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We report herein on a case of small intestine volvulus due to a paraduodenal hernia in which patient’s life was saved with an emergency operation. A 20-year old man visited a local hospital with abdominal pain and vomiting. The next day, with fresh bloody stools and worsening of his symptom, he was ambulanced to our hospital in shock. He had abdominal fullness and the peritoneal irritation sign, Computed tomography showed a dilated small intestinal and accumulation of ascetic fluid. We diagnosed strangulated ileus and performed emergency surgery. Intraoperatively, the small intestine had intruded by 100cm via the peritoneal aperture on the right side of Treitz's ligament, and from hernia sac, a 130-cm length of the small intestine with volvulus was necrotic. After release of the ileus, the intestinal blood supply was not restored, so we performed massive resection of the small intestine and surgically closed the hernia orifice. Postoperatively, the patient had paralytic ileus which was resolved by conservative procedure. He was discharged from our hospital 14-days after surgery.

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An 80-year-old woman presented with nausea and upper abdominal pain which had its onset one month previously after eating a pacific cod; she did not have any other abnormal findings. A computed tomography (CT) scan and ultrasonography (US) revealed an intra-abdominal abscess. Imaging identified a high density or high-echogenic linear object surrounded by an abscess adjacent to the gastric antrum, suggesting gastric perforation by a fishbone. Despite a laparotomy, the fishbone was not found in the abscess cavity intraoperative US was then performed in order to locate the fishbone in the posterior wall of the stomach. The anterior gastric wall was opened to remove the fishbone, which was buried in the posterior wall. Thus, intraoperative US can be used to locate foreign objects that are detectable with US.

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A 73 year-old-man underwent laparoscopic nephrectomy for a right renal cell carcinoma. The postoperative course was uneventful and he was discharged. However, he suffered abdominal fullness on the 10th day after surgery. The abdominal enhanced CT examination showed duodenal stenosis due to a hematoma after the rupture of an anterior inferior pancreaticoduodenal artery aneurysm. Transcatheter arterial embolization (TAE) was performed using microcoils. The arterial aneurysm was thought to be caused by the surgical procedure in addition to the development of pancreaticoduodenal artery on the basis of the median arcuate ligament compression syndrome. Duodenal stenosis persisted even after shrinkage of the hematoma. However, duodenal stenosis improved on the 50th day after surgery with conservative treatment. Although TAE is the first choice for the treatment of pancreaticoduodenal artery aneurysms, it is necessary to consider the complication of duodenal stenosis after TAE.

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A 76-year-old man receiving immunosuppressive therapy for a skin disease had disseminated intravascular coagulation (DIC) caused by a pulmonary infection. He was transferred to our department under the diagnosis of perforation following bleeding from a gastric ulcer. Abdominal computed tomography revealed not only abdominal free air but also widespread subcutaneous emphysema and retroperitoneal emphysema. On the other hand, the patient had no abdominal symptoms and a laboratory examination indicated a minor inflammatory response. Based on these findings, we chose conservative therapy with a diagnosis of intramesenteric perforation of the colon. However, lower abdominal pain gradually appeared 5 days after starting conservative therapy and an emergency operation was therefore performed. On laparotomy, a perforation was present in the mesenteric side of the colon. Hartmann’s operation was performed with resection of the perforated sigmoid colon. Histopathological and immunohistochemical examination revealed perforation due to cytomegalovirus infection. The patient’s general condition improved gradually with intensive care, and finally he was able to be discharged. Although cytomegalovirus infection is often seen in patients receiving immunosuppressive therapy, gastrointestinal perforation due to cytomegalovirus infection is rare.

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We report herein on a case of acute appendicitis due to appendiceal metastasis from small-cell lung carcinoma (SCLC). A 68-year-old man received chemotherapy for SCLC (T2N2M0stageⅢA) and was under follow-up at our hospital. He was admitted to our emergency room with the chief complaint of right lower quadrant pain. Physical examination showed mild tenderness and tenderness was seen over Mcburney’s point. Abdominal plane CT revealed swelling of the appendix, and we made the diagnosis of acute appendicitis. Conservative therapy was attempted due to the weakness of the rebound tenderness and muscle guarding. Six days later, abdominal tenderness had increased and rebound tenderness was noted. An operation was performed under a diagnosis of perforated appendicitis or peritonitis. Intraoperative findings revealed a tumor at the tip of the appendix and the appendix itself was found to be perforated with retroperitoneal abscesses. We performed an appendectomy and drainage was carried out. The postoperative histopathological diagnosis was appendiceal metastasis from SCLC. The patient died from brain metastasis 3 months after the final surgery despite systemic chemotherapy.

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A 70-year-old man was admitted to our hospital because of loss of consciousness. He was a chronic user of an NSAID, and also complained of epigastralgia and melena. He was in a pre-shock state and upper gastrointestinal bleeding was suspected. After admission he had massive hematemesis and went into shock. Emergency endoscopy revealed a giant ulcer with active bleeding high on the posterior wall of the stomach. The bleeding could not be controlled with endoscopic hemostasis and an emergency laparotomy was performed which confirmed that the gastric ulcer had penetrated the pancreas and the splenic artery, with massive bleeding. A total gastrectomy with distal pancreatectomy was performed and the patient was rescued. Invasion of gastric ulcers into the splenic artery is very rare. Because it soon leads to massive bleeding and a potential fatal outcome, immediate treatment including surgery is important.

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A 66-year-old male with a history of alcoholism presented with abdominal pain. His systolic blood pressure fell to 50 mmHg during computed tomography (CT). The CT revealed chronic pancreatitis with calcification and a large hematoma measuring 10 cm in diameter extending from the pancreatic body to the greater curvature of the stomach. Angiography was performed, as rupture of a splenic pseudoaneurysm was suspected as the cause of the hemorrhagic shock. Angiography revealed that the source of the bleeding was at the origin of the posterior gastric artery pseudoaneurysm from the splenic artery. We successfully embolized the splenic artery. However, the blood pressure fell again 6 hours later. Therefore, an emergency laparotomy was performed to control the bleeding. The operative findings included a fist-sized hematoma around the posterior gastric wall. Even after distal pancreatectomy and splenectomy, the bleeding from the posterior gastric wall persisted, and was controlled only after a fundectomy was performed. While performing an emergency operation for a ruptured posterior gastric artery pseudoaneurysm due to chronic pancreatitis, a gastrectomy could be an important component of the operative procedure to control bleeding from the gastric wall.

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A 76-year-old man who had undergone right hemi-colectomy under the diagnosis of ascending colon cancer and malrotation was consulted to our department due to abdominal pain and abdominal fullness. He had low grade fever, tenderness and rebound pain of the lower abdomen, but no defence. Laboratory tests showed no acidosis or coagulation disorders. Abdominal CT scan showed extension of the small intestine and fluid collection based on which a diagnosis of adhesive intestinal obstruction was made. Conservative treatment was performed, however, surgical intervention was considered because of worsening symptoms. Under the diagnosis of internal hernia caused by an abdominal cocoon, membrane resection was performed. The postoperative course was uneventful. We report herein on a rare case of internal hernia caused by an abdominal cocoon.

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A 49-year-old woman without a history of laparotomy consulted a local physician for abdominal pain. She was referred to our hospital with a possible diagnosis of intestinal obstruction. Abdominal X-ray showed a niveau image in the small intestine and abdominal CT scan revealed a dilated small intestine, ascites in the pelvis and dilation of the small intestine with a closed loop at the dorsal surface of the sigmoid colon and the sigmoid mesocolon. An emergency operation was performed on the same day under the suspected diagnosis of an internal hernia associated with the sigmoid mesocolon. The patient was diagnosed as having an intersigmoid hernia because 210 cm of the small intestine from the terminal ileum was found incarcerated 5 cm into the intersigmoid fossa. After the incarcerated small intestine was reduced manually, the hernia orifice was closed without resection. The postoperative course was uneventful and she was discharged on the 8th postoperative day. Intersigmoid hernia is a very rare type of an internal hernia in which the intestine is incarcerated into the incomplete adhesive part between the sigmoid mesocolon and the retroperitoneum. An abdominal CT scan was effective for diagnosis, and the early diagnosis and surgical intervention were able avoid resection of intestine.

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A 63-year-old man with Stage IV gastric cancer (LD, Type3, T4b(Panc), N3b, M1(LYM), cStage IV) presented with massive hematemesis during his first chemotherapy with TS-1+CDDP. Though he underwent emergency upper endoscopy, bleeding from the gastric cancer could not be controlled. Diagnostic pre-embolization angiography was performed and extravasation from the upper superior pancreatic duodenum artery was identified. Transcatheter arterial embolization (TAE) was successfully performed with superselection of the active bleeding artery. The patient was able to undergo 14 courses of chemotherapy until he died of gastric cancer 18 months after the TAE. The emergency TAE successfully controlled the bleeding from the unresectable gastric cancer and contributed to extending patient's life prognosis.

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An 84-year-old woman with an 11-month history of hemodialysis, came to our emergency outpatient clinic suffering from abdominal pain and vomiting, and was admitted to our department. The patient underwent a computed tomography (CT) scan because her white blood count and CRP increased remarkably on the 2nd hospital day. CT scan showed lumps of feces in the transverse colon, intraabdominal free air and feces out of the lumen. An emergency surgery was performed based on the preoperative diagnosis of colon perforation. Since identification of the site of perforation was difficult, we performed diagnostic laparoscopy from an umbilical port prior to the laparotomy. The laparoscopy revealed leakage of feces from the transverse colon near the splenic flexure. We extended the incision to the upper abdomen and closed with sutures and performed a colostomy at the oral side. The postoperative course was uneventful, and the patient was transferred to another hospital on 93rd postoperative day. The diagnostic laparoscopy was useful to identify the site of perforation to avoid excess invasiveness of the surgery.

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A woman in her 40s had experienced chronic diarrhea and astriction since being a university student. In 2013, she visited our hospital due to swelling from undernutrition. She received treatment and medication for protein-losing enteropathy; however, her symptoms persisted. Abdominal CT showed a bowel obstruction due to thickening of the wall of the ileum, and we placed an indwelling ileus tube. The patient’s terminal ileum was subsequently found to have a 4-cm area of obstruction on a contrast study using the ileus tube and transanal double-balloon enteroscopy, so we suspected Crohn’s disease. She was unresponsive to conservative medical management, and we thus performed a laparoscopic partial intestinal resection. After the surgery, the patient convalesced gradually with nutritional care. Thereafter, she was diagnosed as having intestinal endometriosis, not Crohn’s disease, based on the pathological findings. We report herein on the case of this patient treated with laparoscopic intestinal resection and present a literature review.

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Early and preventive use of intra-aortic balloon occlusion (IABO) could improve hemodynamics and the total blood loss in cases of intraabdominal hemorrhage. We present herein on 2 cases. In case 1, a 59-year-old male with a traffic accident injury was conveyed by our hospital. Under a diagnosis of blunt injury-mediated intraabdominal hemorrhage, we planned to perform emergency surgery for hemostasis. With pre-operative IABO, we were able to maintain the patient's hemodynamics until complete hemostasis. In case 2, a 70-year-old female, another traffic accident victim, was conveyed by our hospital. She had intraabdominal hemorrhage from small bowel and mesenteric injuries. We used IABO before the surgery for the prevention of loss of blood pressure. In fact, the intraoperative bleeding had lowered her systemic pressure, but IABO improved the instability during surgery.

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