We report herein on a review of 34 patients with spontaneous rupture of the esophagus treated in our department, which include 22 cases of the extra-mediastinal rupture type and 12 cases of the intra-mediastinal rupture type. We clinically analyzed the cases with reference to the diagnosis, treatment strategy and treatment outcome. The onset of the rupture was after vomiting in all the cases. Most of the patients were complaining of chest and back pain. The ratio of the correct diagnosis was 55.9％ and the median time to diagnose after the onset was 11 (4-168) hours. The most common perforation site was the left-lower thoracic esophagus (85.3％). The median perforation size was 3 (1-8) cm longitudinally, and the perforation size of the extra-mediastinal rupture type was statistically significantly longer. In the 12 cases of the intra-mediastinal rupture type, we performed surgical treatment in 6 cases, and conservative treatment in 6 cases. In the 22 cases of the extra-mediastinal rupture type, we performed surgical treatment in 21 cases, and conservative treatment in 1 case, which was transferred from another hospital after a certain interval. As for surgical treatment, direct closure alone of the perforation site with a left thoracotomy was performed in 10 cases, direct closure of the perforation site with a gastric fundic patch via the transhiatal approach was performed in 15 cases, and esophagectomy with cervical esophagostomy followed by secondary reconstruction was performed in 2 cases. The outcome of the intra-mediastinal rupture type was satisfactory in all cases. The emergency operations for the extra-mediastinal rupture type were associated with complications such as anastomotic leakage, pyothorax and as on in 9 cases (33.3%) with a mortality rate of 3.7% (only 1 case of post-operative death). To prevent post-operative pyothorax and mediastinal abscess, the drainage tubes in the posterior space of the left diaphragm and the left side of the thoracic descending aorta were regarded necessary in addition to the conventional thoracic drainage tube. Early appropriate diagnosis and choice of the treatment strategy for spontaneous esophageal rupture are thought to be important to achieve satisfactory results.

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Objective：Abdominal infection is a major cause of sepsis, and it can be severe, particularly when caused by lower gastrointestinal tract perforation. Multidisciplinary treatment including an operative procedure is indispensable for the survival of the patient. Materials and Methods：21 patients with a colorectal perforation underwent emergency surgery in our hospital from April 2010 to August 2013. We examined the validity of the surgical procedure and perioperative management including PMX-DHP. Results：Hartman's procedure was performed in 18 patients, in 2 severe cases of whom abbreviated surgery was undertaken. The average score of the Acute Physiology And Chronic Health Evaluation (APACHE) Ⅱ was 21.7 points, the 28-day survival rate was 95％ and the standardized mortality ratio was 0.11. Early Goal-Directed Therapy(EGDT) was achieved for all patients and direct hemoperfusion with polymyxin-B immobilized fiber(PMX-DHP) was induced for 8 patients with improvement in hemodynamics being confirmed in all patients. Conclusion：Our strategy for dealing with colorectal perforation contributes to the improvement of a high survival rate and the validity of our approach has been shown.

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As compared to acute appendicitis, which is quite common, diverticulum of the appendix is a relatively rare disease. In many cases, diverticulum of the appendix is correctly diagnosed during surgery after an initial diagnosis of appendicitis. We compared 14 patients (7.3%) who exhibited diverticulum of the appendix with 177 patients (92.7%) who did not from a total of 191 patients who underwent surgery following the diagnosis of acute appendicitis over a 2-year period from January 2012 to December 2013. We statistically compared the background, findings upon arrival at hospital, maximum diameter of the appendix, perforation rate, and number of days in hospital of these patients, and found that the perforation rate was significantly higher in patients with diverticulum of the appendix. These results suggested a risk of perforation even in cases of appendicitis with mild inflammation. Advances in diagnostic imaging have made preoperative diagnosis of diverticulum of the appendix via computed tomography possible at least to some extent. If findings suggestive of diverticulum of the appendix are observed, because of the high risk of perforation, surgical treatment should be considered even if the appendicitis is deemed mild.

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We examined 62 cases of non-traumatic perforation of the small intestine which we experienced in our department from April 2009 to March 2014. Etiologies of the perforation were incarcerated hernia in 15 cases (24%), intestinal neoplasms in 9 cases (15%), adhesive intestinal obstruction in 9 cases (15%), Crohn’s disease in 8 cases (13%), iatrogenic and idiopathic perforation in 4 cases each and an intestinal ulcer in 3 cases. In only 5 cases (8.1%) was it possible to make a correct diagnosis of perforation of the small intestine before surgery and there were 6 cases (9.7%) who died during hospitalization. Perforation associated with the incarcerated hernia was common in older women. Perforation due to Crohn's disease was associated with a younger age at onset, but many postoperative complications including intraperitoneal abscess and wound infection were observed. In neoplastic perforation, the mortality rate within three months after surgery was as high as 60%. In addition, there were 4 patients who died of benign disease and they had severe preoperative comorbidities such as liver cirrhosis and renal failure. Although it is extremely difficult for us to diagnose non-traumatic perforations of small intestine, it is imperative that we do not miss the appropriate timing for the operation. However postoperative complications were observed in more than half of these cases. In cases with neoplastic perforation and those with severe comorbidities, the prognosis is poor.

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We investigated the validity of the transabdominal preperitoneal laparoscopic hernia repair(TAPP) for incarcerated and strangulated groin hernias in adult patients. Intestinal tract perforation and colonic strangulation are contraindications for tension-free repair including TAPP. There were 32 adult incarcerated and strangulated groin hernia patients from August 2010 to July 2013. There were 18 men and 14 women with an average age of 74.7 years (range 39-89). In the groin hernia classification of the Japan Hernia Society, there were 15 cases of type I (indirect hernia), one case of type Ⅱ (direct hernia) and 16 cases of type Ⅲ (femoral hernia). For the operative procedure, 16 cases were treated with TAPP, 12 cases with the anterior approach (5 with UHS repair, 4 with tissue to tissue repair, and 3 with Mesh Plug repair), and four cases with another approach. In the case of the TAPP approach, there was significantly less bleeding and shorter postoperative hospitalization. Two cases of seroma, two cases of pneumonia and one case of ileus accounted for the postoperative complications of TAPP, but there was no mesh infection and no recurrence. TAPP was a valid procedure for the incarcerated and strangulated groin hernia patients without intestinal tract perforation and the colonic strangulation.

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In a 52-year-old man presenting with the chief complaint of right abdominal pain, abdominal computed tomography showed pneumoretroperitoneum and slight fluid retention in the region from the back of the caudal pancreatic head to that around the right kidney. Upper gastrointestinal tract endoscopy showed redness, adhesive pus, and purulent fluid discharge from a diverticular wall around the papilla of Vater. Duodenography showed contrast medium leakage from the diverticulum into the retroperitoneal space. Based on these findings, the patient was diagnosed as having a retroperitoneal abscess caused by duodenal diverticular perforation. Since the white blood cell count was elevated to 20340/mm3, surgery was also considered. However, we selected conservative therapy with duodenal drainage and antibiotic administration, considering the risk for complications such as biliary injuries and stenosis and the small size of the abscess cavity. The symptoms gradually improved, and duodenography performed on hospital day 10 showed no leakage of contrast from the diverticulum. The patient resumed eating on day 14 and was discharged from the hospital on day 18. His clinical course has since been uneventful, and there has been no evidence of recurrence for over five years. We report this case of duodenal diverticular perforation that was managed conservatively, along with a review of the literature.

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We report two cases of traumatic rectal perforation caused by insertion of a foreign body as a sexual practice. A 64-year-old man often inserted the end of a hose into his anus during masturbation. After one such incident, the man experienced protracted abdominal pain and was rushed to a local clinic and then transported by ambulance to our hospital. Traumatic rectal perforation was diagnosed, and emergency surgery was performed. A 75-year-old man, during partner sex, had a sausage inserted into his anus. The sausage was never eliminated, and abdominal pain developed；he visited a local clinic and was referred to our hospital. Rectal perforation was discovered, and emergency surgery was performed. To our knowledge this is the 7th reported case of traumatic rectal perforation due to transanal insertion of a foreign object during sexual activity.

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A 71-year-old male with no past medical history of laparotomy visited our hospital with the chief compliant of abdominal pain. Based on a thorough examination, the patient was diagnosed as having a strangulation ileus and underwent an emergency laparotomy. Intraoperatively, a 7-cm tubular structure with a saccular tip was identified at 50cm cephalad from the terminal ileum on the side opposite the mesentery. It had adhered to the small intestinal mesentery in that region, and the ileum had become incarcerated in the resulting space. An approximately 100cm section of necrotizing small intestine was resected. On pathological examination, the tubular structure with the saccular tip was a true diverticulum, and the patient was diagnosed as having Meckel's diverticulum. Intestinal obstruction is known as a Meckel's diverticulum-induced complication, but it is rarely caused by incarceration of an internal hernia induced by adhesion of Meckel’s diverticulum to the small intestinal mesentery. In addition, its development in the elderly may be rare because the incidence of Meckel’s diverticulum-induced complications decreases with aging. It should be kept in mind that Meckel’s diverticulum may be a causative factor of strangulation ileus in patients with no past medical history of laparotomy, even in the elderly.

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A 55-year-old man who had undergone esophagectomy for esophageal cancer 4 years previously visited the emergency room complaining of severe epigastralgia. He had taken proton pump inhibitors for a gastric tube ulcer. Redness of the skin was seen on his precordium, and a computed tomography scan detected subcutaneous emphysema around the sternum. He was diagnosed as having a gastric tube ulcer that had penetrated through to the chest wall, and he underwent an emergency operation. Specifically, debridement and direct closure of the gastric tube with an omental patch were performed. The patient's postoperative course was good, and he was discharged on the 16th day after the operation. The locations of penetrating peptic gastric tube ulcers vary according to the reconstructive route. Penetrating gastric tube ulcers can occur as a potentially lethal complication during the follow-up period after esophagectomy. Therefore, when such ulcers are diagnosed, surgical treatment should be performed.

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A 8-year-old boy was referred to our hospital with abdominal pain and vomiting. As he was diagnosed as having enterocolitis, he was admitted to our hospital and received conservative treatment. The next day, physical examinations revealed progressive abdominal tenderness with muscle guarding and rebound tenderness. Computed tomography scan revealed a dilated small intestine and a fluid-filled cystic lesion with air in the right lower quadrant. An emergency laparotomy was performed with a suspected strangulation ileus. A Meckel's diverticulum, 10cm×2.5cm in size, was found on the ileum about 80cm proximal to the Bauhin's valve. It was twisted about 180° counterclockwise at its neck and was necrotized. A diverticulectomy was performed. No postoperative complications occurred and the patient was discharged on the 8th day after the operation. Torsion is a rare complication of Meckel’s diverticulum in childhood, and we found reports of only 11 cases in Japan. Those diverticula were also large, greater than 6cm in length, and had narrow necks. In our case, we thought that the ileus was the result of torsion of Meckel's diverticulum, associated with peritoneal inflammation.

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An 80-years-old female who had a history of dementia and depression was admitted to hospital complaining of hematemesis and fever. The CT scan showed foreign bodies in the stomach and perforation of the gastrointestinal tract. The patient was observed under conservative therapy her general state improved. A gastrofiberscopic examination revealed a large quantity of disposable latex gloves in the stomach, but it was impossible to remove these gloves under the fiberscope. Therefore, these gloves were extracted by laparotomy and a small gastrotomy under general anesthesia. The patient was able to take a meal after 7 days post operation and discharge from hospital. This case suggests that medical materials should not be left lying around the bedside of patients, especially in the case of the psychotic elderly.

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A 66-year-old male underwent sigmoidectomy and pancreatoduodenectomy for cancer of the colon and lower bile duct cancer. Five months postoperatively, he was hospitalized for hemorrhagic shock due to hematemesis and melena. Endoscopy revealed hemorrhage at the left intrahepatic bile duct on day 1, but angiography detected no aneurysm rupture. Embolization employing jelpart® was then performed, based on the examination findings. However, melena recurred on day 5, necessitating additional embolization with microcoils. He had been running a persistent high fever since admission to our hospital, and we thus conducted abdominal contrast-enhanced computed tomography. It showed a liver abscess in the left lobe. We performed a left hepatectomy. Careful observation and treatment should be followed with much care for the liver abscess, especially for patients who have undergone transcatheter arterial embolization after biliary tract reconstruction.

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A 94-year-old woman was admitted to the hospital with an incarcerated rectal prolapse. About 20 years previous to admission, she had undergone Thiersch’s procedure, but recently the rectal prolapse had relapsed. The patient attempted to reduce the prolapse manually, but was unsuccessful. On admission, a rectal prolapse, 10 cm in diameter was observed extra-anally, with a necrotic surface. CT scan revealed that the blood flow in the rectal wall had decreased, so we performed an emergency laparotomy (Hartmann's procedure). The patient was discharged from hospital on the 29th day after operation with a good postoperative course. This case demonstrated that we should pay attention to an incarcerated rectal prolapse after transanal surgery for rectal prolapse.

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A 51-year-old woman consulted a local physician because of left abdominal pain. Abdominal ultrasonography revealed an abdominal mass, and the patient was referred to our hospital. A fist-sized mass accompanied by tenderness was palpable in the left middle abdomen. Abdominal contrast-enhanced computed tomography showed a hypervascular mass about 8 cm in diameter, associated with intratumoral hemorrhage. The mass was contiguous with the jejunum. Abdominal magnetic resonance imaging suggested a gastrointestinal stromal tumor. Emergency surgery was performed for a preoperative diagnosis of bleeding from a small-bowel tumor. Laparoscopic surgery was begun, and the entire small intestine was examined, but no mass was found. The tumor （diameter, about 8 cm） in the transverse colon had grown in an extramural direction and protruded into the peritoneal cavity. The tumor was resected via a minilaparotomy. Under gross observation, the tumor was pedunculated and had a smooth surface. The cut surface showed hemorrhagic and cystic changes. Histopathologically, the mass arose from the muscularis, with proliferation of irregularly arranged spindle-shaped cells. The tumor was negative for c-kit and CD34 and positive for desmin, with an MIB-1 index of ≤5%. Leiomyoma was thus diagnosed. The patient recovered uneventfully and was discharged on the 10th hospital day.

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A 47-year-old male patient with Marfan syndrome was diagnosed as having a huge chronic expanding hematoma around a thoraco-abdominal aortic prosthesis seven years after aortic grafting for aortic dissection. He developed acute gastric distension and he was diagnosed as having acute gastric volvulus by an endoscopic examination after surgical removal of the hematoma. The volvulus was dissolved endoscopically, but it relapsed soon. The volvulus was finally resolved by surgical gastric wall fixation. Hyperextension of the stomach by the huge hematoma and fragile connective tissue associated with the Marfan syndrome were considered to be the causes of the gastric volvulus in the present case. We should bear in mind that Marfan syndrome patients could develop acute gastric volvulus.

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A 48-year-old man who had suffered abdominal trauma was transported to our emergency room by ambulance. On arrival, his vital signs suggested shock. He responded to initial infusion. Contrast enhanced computed tomography was performed. An intra-abdominal hemorrhage was diagnosed due to superior mesenteric artery (SMA) injury. The patient’s blood pressure decreased again, and emergency surgery was judged to be necessary. However, there was a delay before the operation could be performed. The root of the SMA was occluded with a balloon catheter, and then open hemostasis was performed. Extensive mesenteric injury involving the retroperitoneum and the SMA was noted. Hemostasis was achieved by suturing as soon as possible, and the portion of the intestinal tract with poor blood flow was resected. The wound was closed after gauze packing. Three days later, laparotomy was performed again for a colostomy. Ten months later, the patient underwent colostomy closure. With SMA occlusion, the hemorrhage noted before laparotomy was successfully controlled, and long-term placement was possible without reperfusion injury or ischemic injury of other organs. In addition, the minimum blood flow in the region of the SMA except for the injured area was considered to have been successfully maintained.

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We report herein on our experience with an emergency single incision laparoscopic cholecystectomy (SILC) for acute cholecystitis (AC) in a patient with previous upper abdominal surgery (PUAS). The patient was a 62-year-old male who was admitted to our hospital due to acute cholecystitis. He had previously undergone abdominal surgeries of appendectomy and gastrectomy. He underwent an emergency SILC with the glove method. Three 5-mm ports were inserted into the peritoneal cavity through the glove. We used a hands-free retraction system, a flexible port and pre-bending forceps to retract or divide. After we had obtained the optimum operative field, the cystic artery was divided using laparoscopic coagulating shears and the cystic duct was also divided after clipping. The gallbladder was freed from the liver bed and retrieved through the umbilicus. The operation time was 132 min and the blood loss was 50mL. There were no perioperative complications. The patient was discharged on postoperative day 6 due to the remission of intra-abdominal inflammation. The SILC is a feasible and safe procedure even in a patient with AC and PUAS. Those conditions are not a contraindication for an SILC.

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A 62-year-old man was admitted to another hospital for right lower abdominal discomfort. Computed tomography (CT) showed intussusception, and he was transferred to our hospital. Our enhanced CT showed an ileocolic type intussusception with a 20-mm mass at the leading end. We performed a laparoscopic ileocecal resection. A 20-mm enterolith was incarcerated nearby the ileocecal valve. The patient’s postoperative course was uneventful, and he was discharged on the 11th postoperative day. Intussusception caused by an incarcerated enterolith is rare, and we report on our case with a discussion of the literature.

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A man in his 60s with a history of excessive alcohol consumption had experienced anorexia for 2 months. He presented with sudden lumboabdominal pain, shivering, vomiting, and a fever of 40℃. The presence of peritoneal irritation, swelling in the right inguinal region, and peripheral circulatory insufficiency suggested intestinal ischemia due to an incarcerated inguinal hernia. An emergency laparotomy revealed no apparent intestinal ischemia, but acute circulatory insufficiency due to sepsis was diagnosed after culture of the blood taken on admission yielded Aeromonas hydrophila. The infection route was unknown, but bacterial translocation from the intestine was suspected. The patient recovered and survived after treatment with antimicrobial agents for sepsis and intensive care with mechanical ventilation. He was immunocompromised by chronic hepatitis caused by the excessive alcohol consumption, along with the resulting anorexia. Because of this susceptibility of immunocompromised patients, in examining and treating patients with severe sepsis accompanied by acute abdomen we need to remember that A. hydrophila is a potential cause.

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A 42-year old man visited our emergency room with sudden epigastralgia and vomiting. Emergency laparoscopic surgery was performed, with a diagnosis of strangulated ileus due to left paraduodenal hernia based on the computed tomography imaging. On the left lateral side of the Treitz ligament, intrusion of the small intestine into a mesentery defect of the dorsal inferior mesenteric vein was observed together with dilation at the oral part of the intestine. The intrusion of the small intestine was pulled back into the abdominal cavity, and the hernia orifice sutured closed. The patient’s postoperative course was uneventful and he was discharged 18 days after the operation. No recurrence has been observed during the follow-up.

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An 18-year-old man with sudden left lower abdominal pain during evacuation was admitted to our hospital and he was diagnosed as having colitis of the descending colon. The pain got gradually worse after admission and a follow-up CT scan showed perforation of descending colon. An emergency operation was performed, suturing the perforation of the descending colon and constructing a transverse colostomy, but we could not find the cause of the perforation such as cancer or diverticulum. At the same time we noticed that, on touch alone, the serous membranes of the small bowel were easily injured. Following genetic testing, the patient was diagnosed as having the vessel type of Ehlers-Danlos syndrome (EDS). Stoma closure was performed 7 months after the operation. After that, paralytic ileus caused colon necrosis and re-perforation, and we constructed the ileostomy once again. On admission, many complications were seen due to EDS, such as separation of the wound and rupture of the stoma, but the patient has now returned to normal activities of daily living. We should discuss carefully about how to operate on gastrointestinal perforations and provide appropriate treatment after surgery for the patient.

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A 69-year old man who had undergone total gastrectomy for early gastric cancer with Roux-en-Y reconstruction 7 years previously was taken to hospital by ambulance with abdominal pain. An abdominal CT scan showed a dilated afferent loop, and the patient was diagnosed as having acute afferent loop syndrome. An emergency operation revealed a twisted afferent loop near the Treitz ligament and the rotation was restored by hand. Five months later, blood tests revealed elevated levels of hepatobiliary enzymes and an abdominal CT scan showed a dilated afferent loop again：the patient was therefore diagnosed as having chronic afferent loop syndrome. Percutaneous transhepatic cholangiodrainage (PTCD) was conducted, the PTCD catheter was passed to the duodenum one week later, and dilation of the afferent loop was improved. At the elective operation, stenosis of afferent loop was located near the anastomosis site, and partial resection of small intestine and side to side anastomosis between the afferent loop and distal intestine was performed. The postoperative course was mostly good and no relapse has occurred 2 years after PTCD and the operation. PTCD and an elective operation are one of the effective ways for treating afferent loop syndrome.

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A 37-year-old man with a 10-year history of atopic dermatitis used 14 kinds of Chinese herbal medicine and complained of abdominal pain and vomiting. Abdominal CT led to the suspicion of paralytic ileus due to idiopathic mesenteric phlebosclerosis (IMP). He was placed under conservative medical treatment and his symptoms were relieved, but he was re-hospitalized five days after discharge for recurrence of the symptoms. Abdominal CT also showed a large number of linear and granular calcifications along the colic wall from the cecum to the splenic flexure and the mesenteric vein. Total colonoscopic examination demonstrated a brown change in color from the cecum to the descending colon, and scattered ulcerations mainly on the transverse colon. Histopathological inspection led to a diagnosis of IMP. A laparoscopy-assisted extended right hemi-colectomy was performed, and the splenic flexure with good color and without edema was decided as the resection line. The patient remained well without preoperative symptoms at 36 months after the operation. The facts of this case suggest that withdrawal of the Chinese herbal medicine and decision on the excision range from intraoperative view were effective for the prevention of recurrence of the IMP.

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We report herein on the case of an 82-year-old man who complained of nausea and abdominal pain for 3 days before the first admission. Computed tomography (CT) revealed a food-induced small bowel obstruction. As the conservative therapy with placement of a long tube was unsuccessful, the mass was removed by resection of small intestine. Twenty days after his discharge, the patient was readmitted because of recurrence of the food-induced small bowel obstruction. Another mass was removed in the second surgery. Both masses were made of fiber, and we surmised that they were bezoars. When we reviewed the first CT scan, a mass with the same size and form as that removed in the second operation was identified in the stomach. Further detailed interview revealed that he had eaten persimmons 5 months before the first admission. To improve the continuous uncomfortable halitosis, he had also consumed Coca-cola for the first time in his life 5 days before his first admission. We surmised that each diospyrobezoar had fallen into the small bowel one after another because of the partial dissolution by Coca-cola.

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A-82-year-old woman was brought to the emergency department with shortness of breath and abdominal pain. The physical examination and abdominal CT scan showed perforation of the rectum diverticulum, so a laparoscopic anterior resection was performed immediately. As much preoperative preparation as possible and a careful operative procedure enable us to perform an emergency laparoscopic colectomy safely.

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