Postoperative delirium is one of the severe complications in elderly patients after surgery. We assessed the safety and effectiveness of a Chinese herbal medicine used as a suppository, formulated at our institute, for patients with postoperative delirium following gastrointestinal surgery. The diagnosis was made according to a score of ＜20 on the NEECHAM Confusion Scale (N scale). We prepared the suppository by mixing the Chinese herbal medicine yokukan-san, and Hosco H-15. Twenty-six patients (11.5%) out of a consecutive 227 patients were diagnosed as having delirium, and out of the 26, the suppository Yokukan-san was used in 23 cases. Among these 23 cases, 17(73.9%) recovered within 12 hours. In conclusion, use of Yokukan-san, a Chinese herbal medicine, as a suppository is safe and effective for patients with postoperative delirium developing after gastrointestinal surgery.

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Purpose: We evaluated potentially useful factors for the prediction of severe complications in patients with colorectal perforation, and examined their efficacy. Method: A total of 54 patients who underwent emergency abdominal operation for colorectal perforation were enrolled in this study. We evaluated the potential predictors of postoperative complications by classifying the patients according to the severity of the postoperative complications into a mild group and a severe group. Result: Univariate analysis revealed significant differences in the preoperative free perforation rate and feces ascites rate. We classified the patients according to the laparotomy findings as follows: Type Ⅰ: coating perforation＋non-fecal ascites; Type Ⅱ: coating perforation＋fecal ascites; Type Ⅲ: free perforation+fecal ascites. Multivariate analysis identified classification according to the laparotomy findings as an independent predictor of postoperative complications. The SIRS score, APACHE Ⅱ score, SOFA score and length of admission in the ICU after surgery were significantly higherin the Type Ⅲ cases than those in the Type Ⅰ and Type Ⅱ cases. The percentage of patients with serious complications was 19%/20%/59% in the Type Ⅰ/Ⅱ/Ⅲ cases. All three cases of hospital deaths had been categorized as Type Ⅲ according to the laparotomy findings. Conclusion: Classification according to the laparotomy findings was demonstrated to serve as an index of the disease severity in cases of colorectal perforation, and proved to be highly effective as a predictor of severe complications.

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Esophageal rupture, including Boerhaave syndrome, is a clinically rare entity, but requires prompt and adequate therapy, as it is associated with a high mortality rate. Early symptoms include abdominal pain, chest pain, back pain, dyspnea, and vomiting, none of which are specific symptoms. To accurately diagnose this condition in the early stage, it is vital to perform detailed investigation and to consider the possibility of esophageal rupture. Surgery is the main therapeutic approach, although conservative therapy is effective in some cases. The primary surgical technique for esophageal rupture is primary suture with fundic reinforcement, accompanied by T-tube drainage through the abdominal cavity. Thus far, we have encountered 10 patients with esophageal ruptures, including 7 patients with Boerhaave syndrome and 3 patients with a foreign body in the esophagus. Three patients received conservative therapy alone, seven patients underwent surgery, and one patient developed respiratory failure after surgery. Postoperatively, all patients recovered and were discharged from the hospital.

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Ten cases of esophageal rupture or perforation were reviewed. Nine cases were male and one case was female. The average age was 64 years. There were seven idiopathic esophageal perforations and two cases were caused by swallowing foreign bodies, a denture bridge or press through packaging (PTP). One case was perforation of a reconstructed gastric tube. The lower esophagus was the main site of perforation among the idiopathic esophageal perforations. The surgical approach for idiopathic esophageal perforations was trans-abdominal except in one case of re-perforation. In cases with perforation into the thoracic cavity, thoracic drainage or thoracotomy was performed. In the case of perforation by foreign bodies, when the site of the perforation was in the upper esophagus (the denture bridge), drainage was introduced from the neck. When the site of perforation was in the lower esophagus (PTP), drainage for the posterior mediastinum was introduced with the abdominal approach through the esophageal hiatus. For the cases of lower esophageal perforation or abscess formation after idiopathic-or foreign body-related esophageal perforation, the abdominal approach was considered useful owing to the appropriate drainage position, availability of the omentum for coverage, less invasive surgical stress, and easy access to the intestinal fistula for enteral feeding.

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Background and Aims: Despite recent advances in treatment strategies, the management of esophageal perforation is still problematic and controversial. The purpose of the present study was to evaluate and compare the clinical data, treatment methods, and outcomes of patients with an esophageal perforation according to the systemic condition of each patient on arrival to the hospital. Subjects and Methods: Ten patients were treated for an esophageal perforation between 2004 and 2013. Based on the each patient’s pretreatment status, the patients were divided into two groups (shock and non-shock groups) and their clinical findings, treatment methods, and outcomes were compared. Results: The numbers of patients in the shock and non-shock groups were three and seven, respectively. The treatment procedures included conservative therapy in three non-shock patients, primary surgical repair in four non-shock patients, and conservative treatment with minor surgical approaches or stenting in three shock patients. The mortality rate was 0%. Conclusions: Tailoring the treatment strategy to the systemic condition of patients with an esophageal perforation is important. In particular, patients with shock should be treated conservatively with minor surgical approaches, including temporary stent insertion.

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【Background】 Historically, spontaneous esophageal rupture has been associated with high mortality. Improvements in diagnosis and critical care may lead to lower mortality rates. However, delay in treatment of more than 24 hours after rupture can result in significant morbidity. 【Material and Methods】 A retrospective review was performed of patients diagnosed as having a spontaneous esophageal rupture admitted to our institute from 2006 to 2014. Descriptive statistics showed the background characteristics of the subjects. 【Results】 There were 14 subjects, 13 male and 1 female. Demographic characteristics were as follows；Age 63 [IQR：57-68] yr, time to operation 9.5 [7.8-13.3] hours, left side 92.8%.Median length of hospital stay was 17.5 [IQR：15.8-29.3] days, rate of postoperative leakage was 14.2% (2 cases), and overall mortality in our hospital was 0%. Fundic serosal patching was undertaken in 3 complex cases and all of them had a good outcome. 【Discussion】 Thal and Hatafuku showed cases of spontaneous esophageal rupture treated with an onlay fundic patch, and it is widely used for treatment of achalasia of the esophagus. 【Conclusion】 The fundic serosal patch procedure may be useful for late and complicated repair of esophageal ruptures.

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We performed a retrospective clinical review of 11 patients surgically treated for esophageal perforation at our hospital. There were 5 iatrogenic perforations, 3 malignant perforations, 2 spontaneous perforations and one traumatic perforation. In the surgical treatment of benign esophageal perforations, 5 patients underwent primary closure, one patient underwent primary closure with an omental patch, one patient underwent partial esophageal resection and one patient underwent video assisted thoracoscopic drainage. In the surgical treatment of malignant esophageal perforations, one patient underwent thoracotomy for drainage and esophageal stenting (self-expanding metallic stent) was performed, one patient underwent thoracic tube drainage and underwent subtotal esophagectomy and reconstruction using a gastric tube, and one patient underwent naso-gastiric tube drainage and underwent an esophageal bypass using a gastric tube. As for the post-operative complications, anastomotic leakage occurred in 2 patients, pyothorax occurred in 1 patient, wound infection occurred in 1 patient, and the hospital mortality was 0%. The etiologies of esophageal perforation and the conditions of patients varied extensively, therefore the treatment of esophageal perforations should be selected appropriately according to each individual patient.

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Purpose：To evaluate the diagnosis, treatment and outcome of esophageal rupture/perforation in our department. Patients and Methods：From 2003 to 2013, the patients consisted of fifteen cases of esophageal rupture/perforation (4 patients with spontaneous perforation and 11 patients with idiopathic rupture). Results: Among the 4 cases of spontaneous esophageal perforation, 2 cases of the intra-mediastinal rupture type underwent conservative treatment, and surgery was performed in 2 cases of the extra-mediastinal rupture type. Nine cases of idiopathic esophageal rupture (endoscopic dilation for esophageal achalasia and esophageal stricture, endoscopy for retrograde cholangiopancreatography, endoscopic guide tube for the pharynx, endoscopic submucosal dissection for esophageal cancer) were related to endoscopic procedures, and these cases were treated conservatively. Esophageal ruptures at the level of the implanted aortic stent-graft in 2 patients were the extra-mediastinal rupture type. Surgery was performed in these cases, but one patient died due to sepsis from mediastinitis. Conclusion: Regardless of spontaneous perforation or idiopathic rupture, cases of the intra-mediastinal rupture type have a high curative rate with appropriate drainage. However, a review of the treatment strategy is necessary for the extra-mediastinal rupture type cases, because assessment of the optimum diagnostic and therapeutic methods is currently in progress.

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Data of 14 cases of esophageal perforation treated between 2001 and 2013 were analyzed. The perforation was iatrogenic in three cases and idiopathic in the remaining 11; all the patients survived. The diagnosis of iatrogenic perforation was made during the treatment for the original condition. Most of the cases were treated conservatively immediately after onset, while only one case needed thoracic and mediastinal drainage because of bacteria-negative pleural effusion. Among the patients with idiopathic perforation, trans-thoracic direct repair was performed in 8 cases and T-tube drainage in the 2 cases respiratory failure. Only one case needed trans-abdominal mediastinal drainage. Leakage occurred in 3 cases; contributory factors included a delay of more than 16 hours from onset to surgery and the lack of reinforcement. In 2 of the cases, pyothrax without leakage occurred on the ruptured side, presumably caused by insufficient cleansing or ineffective drainage. In 3 cases, pyothrax occurred on the opposite side to the rupture, considered to be caused by a delay in the drainage of effusion. The essential points that must be ensured for successful treatment of thoracic esophageal perforation are massive cleansing and effective drainage of the contaminated pleural and mediastinal cavities, along with appropriate surgical repair of the perforated esophagus whose damage is impairing with time.

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In order to save patients with a spontaneous esophageal rupture, adequate management and treatment in the acute phase are required. Out of 29 patients with a spontaneous esophageal rupture admitted to our hospital over the past 30 years, 6 patients fell into tension pyopneumothorax, from whom 2 patients died due to cardiopulmonary arrest on arrival. In 19 patients who were able to undergo treatment for esophageal rupture over the past 13 years, 7 patients underwent a thoracotomy approach (thoracotomy group), 7 patients underwent a laparotomy approach, and 5 patients received conservative treatment (non-thoracotomy group). Nine patients received CT-guided drainage and one patient underwent thoracoscope-guided drainage and lavage. In the thoracotomy group (n=7) compared with non-thoracotomy group (n=12), PaO2/FiO2 was 214±83 vs. 278±143(p=0.2); shock occurred in 100% vs. 58% (p=0.46); pneumonia was seen in 14% vs. 33% (p=0.37); 2.7±2.9 vs. 13.9±19.6 days of respiratory supports (p=0.08); 12.6±7.3 vs. 26.4±19.4 days were needed in the ICU: (p=0.09); and the mortality rate was 1/7 vs. 0/12. The laparotomy approach is less invasive compared with the thoracotomy approach, because of a tendency to shorten time and to reduce intraoperative bleeding volume. We need to choose the treatment appropriate for the respiratory and circulatory conditions of patient in the acute phase.

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The application of glue is an established treatment for fistulas. We consider that the alpha-cyanoacrylate monomer (α-CA) is ideal for glue embolization in the case of intractable esophageal fistulas, because α-CA glue spreads faster and thus creates a bond more rapidly than the other polymer glues. However, there have been few reports of successful fistula closure using α-CA glue. We herein present four cases with intractable esophageal fistulas that were successfully treated with endoscopic injection of α-CA. One patient developed an aortoesophageal fistula due to a traffic accident. Two patients developed anastomotic leakage after esophagectomy for esophageal cancer. The other patient experienced perforation of a colon conduit after esophagectomy for esophageal cancer. In the image-guided therapy suite, a mixture of α-CA and lipiodol at a ratio of 0.3 to 1.7 mL was endoscopically injected through the fistula using a dispersion tube and a 2.5 mL glue syringe. We repeated this procedure every one or two weeks until the fistula was closed. In all four patients, esophageal fistulas were successfully closed with endoscopic injection of α-CA. This method is a feasible and safe procedure that may be effective for the treatment of non-healing esophageal fistulas.

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A 77-year-old man was diagnosed as having mantle cell lymphoma (MCL). R-CHOP therapy was administered, and complete remission was achieved. Three years later, the patient was admitted to our hospital with abdominal pain and vomiting. Because CT showed intussusception of the ileocecal region, emergency operation was performed； the laparotomy showed ileoileocolic intussusception, and multiple protruding lesions could be sporadically palpated in the small intestine. The ileocolic intussusception was reduced by the Hutchinson maneuver, however, since the ileoileal intussusception could not be reduced, we performed ileocecal resection. Histopathological examination revealed the diagnosis of recurrent mantle cell lymphoma. Extranodal involvement is present in the majority of MCL patients, with a peculiar tendency for invasion of the gastrointestinal tract in the form of multiple lymphomatous polyposis (MLP). In a patient with a previous history of MCL presenting with intussusception, recurrence in the digestive tract should be considered and appropriate treatment must be administered promptly.

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We encountered a case of delayed bile leakage after laparoscopic cholecystectomy. A 39-year-old man was hospitalized due to gall bladder stones. We performed laparoscopic cholecystectomy and the patient was discharged after an uneventful postoperative course. On the 8th postoperative day, however, he presented with abdominal pain. Abdominal CT showed fluid collection around the dorsal area of the cystic duct, and bile leakage was suspected. On the 9th postoperative day, the fluid collection spread to the surface of the liver. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was performed, which showed bile leakage from the cystic duct. We diagnosed delayed bile leakage developing after laparoscopic cholecystectomy, and endoscopic nasobiliary drainage (ENBD) was performed. After 11 days, ENBD contrast radiography confirmed the absence of further leakage, and the ENBD tube was removed. We considered that bile leakage was caused by ultrasonically activated device and ENBD the useful therapy for bile leakage after laparoscopic cholecystectomy. Careful manipulation of devices is crucial during cholecystectomy.

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We report a case of strangulated ileus developing after inguinal hernioplasty carried out by the mesh plug method. An 85-year-old man was admitted to our institution for ileus. His past history included a left inguinal hernioplasty performed with a mesh plug, hypertension and cardiac arrhythmia. Abdominal CT revealed strangulated ileus, and emergency surgery was performed. The plug was attached to the pedicle of the sigmoid colon, causing ileus. Various prostheses are used nowadays for the treatment of inguinal hernia, which have been reported to sometimes be associated with complications. While surgical site infection, seroma, hematoma and chronic pain are commonly known complications, strangulated ileus is very rare. We report a case of strangulated ileus developing after inguinal hernioplasty, with some documents.

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I report a rare case of peritonitis caused by bile leakage. A 79-year-old woman underwent ileocecal resection for perforated appendicitis. Postoperatively, she developed sepsis due to a central venous catheter infection, but was discharged after the condition responded favorably to catheter removal. The CV tip culture grew MRSA. On the 5th day after discharge, the patient presented to our outpatient clinic with low back pain, abdominal pain and a low-grade fever. Abdominal computed tomography revealed acute cholecystitis with an abdominal wall abscess. Surgery was performed on the following day. At operation, a large volume of bilious ascites was observed in the peritoneal cavity, the gallbladder was necrotic, and its wall was thinned, although there was no obvious perforation. Therefore, cholecystectomy and intraperitoneal drainage were performed. Ascitic fluid culture grew MRSA. Postoperatively, the patient developed MRSA pneumonia, which resolved after vancomycin treatment. The low back pain persisted and further detailed examination revealed pyogenic spondylitis and discitis. Remission was achieved with conservative management, including rest to the affected part and administration of vancomycin and linezolid. Herein, I have reported a case of biliary peritonitis caused by bile leakage secondary to necrotic acalculous cholecystitis associated with MRSA sepsis.

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We report a rare case of acute peritonitis due to perforation of the Meckel’s diverticulum caused by a fish bone. A 34-year-old man visited our emergency room complaining of abdominal pain. Signs of peritoneal irritation were recognized in the lower abdomen. Abdominal enhanced CT revealed an abscess formation in the pelvis. A calcified foreign body was also recognized in the small intestine adjacent to the abscess. We diagnosed peritonitis caused by perforation of the small intestine by a foreign body and performed emergency surgery. Intraoperative findings revealed perforation of an ileal diverticulum by a fish bone. Partial resection of the ileal segment including the perforated diverticulum was performed. The histopathological diagnosis was perforation of a true diverticulum of the ileum compatible with the Meckel’s diverticulum.

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An 81-year-old man was admitted to our hospital with abdominal pain and protuberance. Abdominal CT revealed excessive dilation of the colon by feces and stenosis of the descending colon. Fiberoptic colonoscopy showed a tumor occupying the entire circumference of the descending colon. Based on the findings, a diagnosis of malignant bowel obstruction was made. While placement of a transanal tube was difficult, it allowed drainage of a large volume of saburra. The abdominal pain subsided after fasting, and a descending colectomy was performed on day 11 of hospitalization. Conservative management, including withholding of oral intake and intravenous hyperalimentation, was adopted for the duodenal obstruction from the 10th postoperative day. On postoperative day 32, the patient developed high fever, and severe sepsis caused by methicillin-resistant Staphylococcus aureus and Escherichia coli was diagnosed by blood culture. After treatment for the sepsis, the patient complained of back pain on postoperative day 62. CT and MRI revealed osteolysis of the 8-9th thoracic vertebra. The patient was diagnosed by percutaneous biopsy as having spondylitis caused by methicillin-resistant Staphylococcus aureus. At present, the patient continues to receive conservative treatment.

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Gallbladder injuries due to abdominal blunt trauma are rarely observed clinically because of the anatomical protection offered to the gall bladder. We encountered a case of gallbladder rupture with cholelithiasis merged with blunt multiple trauma. A 64-year-old woman was hit by a car, knocked to the ground, and run over from her foot to the stomach. She was found to have very low blood pressure at the accident site and was transported to our hospital by ambulance. Ultrasonography revealed an echo-free space around the spleen and in Morrison’s pouch. Enhanced CT showed injury of the left lobe of the liver, bloody ascites, and some gallstones in the gall bladder which showed irregular wall thickening. Based on the findings, we diagnosed hemorrhagic shock associated with liver and gallbladder injury and performed emergency surgery. Because the echo-free space on the FAST examination increased over time and portal vein injury was suspected from the CT findings, we performed left lateral segmentectomy and cholecystectomy. By the time the patient was discharged from the hospital after the operation, she had made satisfactory progress.

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A 66-year-old woman developed acute abdominal pain 2 days after undergoing upper gastrointestinal radiography. On the following day, she called for an ambulance as the abdominal pain had become more severe. At the emergency room, she went into cardiopulmonary arrest, but was resuscitated successfully. Abdominal computed tomography revealed free air and extravasation of barium into the abdominal cavity. Based on the findings, the patient was diagnosed as having barium peritonitis due to perforation of the gastrointestinal tract. She was transported to our hospital and emergency laparotomy was performed. Because perforation of the sigmoid colon was noted intraoperatively, we performed partial resection of the sigmoid colon, colostomy and peritoneal lavage. Postoperatively, the hemodynamics was unstable, however, the patient recovered from the septic shock with multidisciplinary treatment, including polymyxin B direct hemoperfusion. She was discharged 36 days after the operation without any neurological sequelae. In conclusion, barium peritonitis due to colorectal perforation is a rare, but severe complication of upper gastrointestinal radiography. We report a case of survival after cardiopulmonary arrest caused by barium peritonitis and discuss the clinical implications based on a review of literature.

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A 71-year-old woman was admitted to our hospital with fever, chills, and vomiting. Abdominal enhanced CT showed wall thickening of the colon at the splenic flexure and an ambiguous nodule that is continuous from the colon to the spleen. Direct invasion of the spleen by colon cancer with secondary splenic abscess formation was suspected. We planned to perform the surgery after infection control by antibiotics. However, since the patient developed hypotension at 48 hours after admission, emergency surgery was performed under the suspicion of rupture of the splenic abscess.Left hemicolectomy, splenectomy and transverse colon colostomy were performed. The postoperative course was uneventful and the patient was discharged on postoperative day 28. Splenic abscess associated with colon cancer is a rare clinical entity. In these cases, we must be aware of the possibility of extension of the splenic abscess and peritonitis occurring within a short period of time. Prompt surgical treatment as soon as possible after the diagnosis is necessary.

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We sometimes encounter internal hernia, but sigmoid mesocolic hernia is very rare in adults. A 96-year-old woman was brought to our hospital for sudden onset of vomiting and severe abdominal pain. Her lower abdomen was distended and tender to palpation, and a small mass was palpable in the LLQ. Abdominal CT revealed dilated loops of the small intestine with air fluid levels, the whirl sign was positive, and ascitic fluid accumulation was noted in the lt. pelvis. Emergency operation was performed based on the clinical suspicion of strangulation obstruction. Laparotomy revealed a 30-cm long segment of necrotic small intestine protruding from an abnormal opening in the sigmoid mesentery. Therefore, under the diagnosis of sigmoid mesocolic hernia with strangulation, the necrotic segment of the small intestine was resected and the defect in the mesentery was closed. Despite intensive care, however, the patient died of aspiration pneumonia on day 46 after the operation.

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A 69-year-old woman presented with an abdominal bruise after a car accident. CT performed at arrival and three hours after the incident suggested liver injury. CT performed seven days after the injury showed fluid collection in theright retroperitoneum. Both the findings on Drip Infusion Cholecystocholangiography-CT and retroperitoneal cavity puncture drainage revealed bile duct injury. Twenty days after the injury，duodenal perforation occurred，and an emergency operation was performed. We performed pancreaticoduodenectomy because the damage had spread to thepapilla Vater. Development of traumatic duodenal injury and bile duct injury seven days after injury is extremely rare. However, this case highlights the need to bear in mind the possibility that patients with a history of blunt abdominal injury may develop late-onset symptoms.

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The patient was an 86-year-old woman who was under treatment with an α-glucosidase inhibitor for diabetes. She was transferred to another hospital because of decreased level of consciousness. Because abdominal CT revealed intra-abdominal free air, she was admitted to our hospital, where she was clinically diagnosed as having hyperosmolar nonketotic acidosis and perforation of the gastrointestinal tract. Therefore, exploratory surgery was performed；the laparotomy revealed intramural emphysema in the small intestine, but no perforation of the gastrointestinal tract. Based on the operative findings, pneumatosis cystoides intestinalis associated with intra-abdominal free air was diagnosed. We suspected that the α-glucosidase inhibitor may have contributed to the development of the pneumatosis cystoides intestinalis, and discontinued the medicine. The patient was discharged on the 31st postoperative day. Pneumatosis cystoides intestinalis associated with intra-abdominal free air that may be causatively related to the use of an α-glucosidase inhibitor is comparatively rare, and so far only 15 cases, including our case, have been reported in Japan. In addition, such a patient presenting with impaired consciousness has never been reported.

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A 71-year-old woman with acute abdomen was referred to our hospital. Acute generalized peritonitis and gastrointestinal perforation were diagnosed based on the findings on abdominal examination and computed tomography (CT), and emergency surgery was performed. The peritoneal cavity was found to be contaminated with feces, and a 1-cm-diameter perforation of a diverticulum in the rectosigmoid colon was detected. Widespread ischemia, extending from the small intestine to the cecum, was also evident, and nonocclusive mesenteric ischemia was diagnosed. Hartmann’s procedure was carried out, and thereafter, we adopted open abdominal management to avoid massive resection of the small intestine. The wound was covered using a sterilized, commercially available polyethylene bag, which was sutured circumferentially to the surrounding skin to conclude the operation. Postoperatively, the patient remained on artificial ventilation；on a daily basis, the bottom of the polyethylene bag was freed and the entire small intestine was examined manually. On day 4, we determined that preservation of the intestine was feasible and closed the wound. The patient was discharged on day 41. After surgical procedures, open abdominal management solely by suturing a polyethylene bag is exceptionally simple, as it offers not only a clear view from outside, because the bag is transparent, but also allows repeated manual examinations of the entire intestine. Hence, this is an extremely useful technique.

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A 77-year-old man was transferred to our hospital under the suspition of the invagination caused by a small bowel tumor. Abdominal CT revealed a partially enhancing jejunal tumor, which was the front of the invagination. An upper gastrointestinal series showed a well-designed and round filling defect in the upper jejunum, and enteroscopy revealed a submucosal tumor, 5cm in diameter, which showed good mobility, with a Delle at the top of the tumor. We finally performed laparotomy because of repeated ileus symptoms. The jejunum was invaginated by the tumor, and we performed partial resection of the jejunum after reduction of the invagination. The resected specimen showed a peduncular tumor, 3.5×2.5cm in size, and its cut surface was uniformly whitish and solid. Histopathological examination showed infiltration of the submucosa by inflammatory cells, predominantly myofibroblastic cells. Immunohistochemical analysis of the tumor showed positive staining for vimentin, and negative staining for SMA, CD34, desmin, and S-100 protein. Based on the findings, a final diagnosis of inflammatory myofibroblastic tumor（IMT）was made. Primary gastrointestinal tract IMT is a relatively rare disease, therefore, this case is reported here together with some bibliographical comments.

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An 87-year-old woman presented to our hospital with a history of fever and vomiting. Inflammatory markers were elevated, and abdominal computed tomography showed a low-density area behind the uterus and a ring-shaped pessary in the vagina inserted for preventing uterine prolapse. Since the intravaginal ring-shaped pessary was suspected as the cause of colpitis and pyometra in the patient, we attempted to extract it, but it proved to be difficult. Therefore, we cut the ring-shaped pessary with a fret saw and clippers used for cutting ribs and performed foreign body extraction from the vagina. We experienced one case that resected a ring-shaped pessary to the vaginal outside. We report our case with a review of the literature.

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An 82-year-old woman complaining of intense abdominal pain was brought to the hospital in shock and was immediately hospitalized. Abdominal CT revealed hemorrhagic ascites derived from rupture of hepatocellular carcinoma (HCC). Emergent angiography showed tumor staining in the lateral segment, and selective trancatheter arterial embolization (TAE) was performed to achieve hemostasis. The clinical course of the patient after the procedure was satisfactory, and the patient was discharged from the hospital. Without hepatectomy, the tumor size decreased, accompanied by a fall in the serum levels of tumor markers (AFP, PIVKA Ⅱ) during the observation period of 52 months. The patient survived for 67 months after the procedure. Emergent transcatheter arterial embolization (TAE) is the most effective and minimally invasive treatment for hemostasis for cases of ruptured hepatocellular carcinoma.

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We report herein on a case of an 8-year-old girl who was transferred to our hospital because of increasing abdominal pain over about a week. CT showed the dirty fat sign around the greater omentum. We diagnosed an omental infarction, and performed laparoscopy-assisted omental resection. Histological examination showed invasion of inflammatory cells, the growth of fibroblasts, and bleeding, and confirmed the diagnosis of omental infarction. This case was thus reported herein, together with some bibliographic comments.

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Incarceration of the appendix in a femoral hernia sac has rarely been reported. We report the case of a patient diagnosed as having femoral hernia with incarceration of the appendix vermiformis. A 75-year-old woman came to our hospital complaining of abdominal pain. Abdominal CT revealed findings were suggestive of a right femoral hernia with incarceration of the appendix in the hernia sac. We performed appendectomy and the direct Kugel patch procedure. The postoperative clinical course was good and the patient was discharged from the hospital three days after the surgery. Recently, CT which has become high-performance is able to discriminate even the contents of a hernia sac. When an abscess is detected in the hernia sac， use of a permanent prosthesis should be avoided from the point of view of the risk of surgical site infection. On the other hand, in cases of early operation and those without an abscess in the hernia sac, infectious complications are less likely to occur even when a permanent prosthesis is used.

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