Non-occlusive mesenteric ischemia (NOMI) is an acute mesenteric circulatory disorder that does not involve the organic occlusion of blood vessels and is associated with extremely high mortality. In 1974, Siegelman addressed angiographic criteria for the diagnosis of mesenteric vasospasm, which was gold standard for NOMI diagnosis. But the bowel ischemia diagnosis of objective examinations was improved for recent progress of multidetector-row computed tomography and ultrasonography. Therefore the new standard establishment of diagnosis of NOMI is expected. NOMI had no particular symptom, so this diagnosis was so late at severe conditions. If the patient was diagnosed for NOMI, the indication of intravenous vasodilative medication was performed for no symptom of peritonitis, and for peritonitis, surgery should be performed. Therefore construction of standardization and treatment new algorithm of the diagnosis of NOMI is desired.

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We investigated the prognostic factors for in-hospital death and the occurrence of organ dysfunction in 94 patients with colorectal perforation who underwent surgery between January 2002 and December 2012. Of the total, 11 patients died during hospitalization and 10 patients died of complications associated with the acute clinical state. Multivariate analysis revealed preoperative PT-INR of >1.5 as an independent adverse prognostic factor. The SOFA score was significantly higher in the non-survivor group than in the survivor group. A comparison of the SOFA parameters showed that the preoperative respiratory system, central nervous system (CNS) and renal system scores were significantly higher in the non-survivor group; furthermore, the postoperative respiratory system, cardiovascular system and CNS scores were also higher in this group. However, no significant differences were observed in the hepatobiliary or coagulation system scores between the groups. Also, there was no significant difference in the postoperative renal system score between the two groups, suggesting that treatment by CHDF was effective in patients with postoperative renal dysfunction. Colorectal perforation is often associated with poor outcomes; therefore, early detection of patients with a poor prognosis and prompt and appropriate treatment are critical.

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Although several studies on recombinant soluble human thrombomodulin (rhTM) have been reported, the safety/efficacy of rhTM for sepsis-associated disseminated intravascular coagulation (DIC) after emergency laparotomy remains controversial. We retrospectively reviewed the treatment and clinical characteristics of patients with sepsis-associated DIC who underwent emergency laparotomy between 2012 and 2014 at our institution. In all, 24 patients were treated with rhTM, while the remaining 19 were not. There were no significant differences in the background characteristics of the patients between the two groups, however, the APACHE Ⅱ score, admission rate to the intensive care unit, and respiratory utilization were higher in the cases treated with rhTM (p=0.02, p<0.001, and p=0.004, respectively). There was no significant association between rhTM use, mortality and complications including postoperative hemorrhage. The administration rate of fresh frozen plasma (FFP) was lower in the group that was treated with rhTM (p=0.02). This study demonstrates that rhTM may be used safely, even after emergency laparotomy, and may be associated with a reduced amount of FFP transfusion.

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Introduction: Detection of bowel ischemia before the development of necrosis is necessary for accurate diagnosis of bowel strangulation (BS). We developed a new method by which to detect bowel ischemia, which involves revision of the computed tomographic value of the small intestine according to that of the superior mesenteric vein to obtain the intestinal wall-superior mesenteric vein contrast enhancement ratio (IVCER). Methods: Twenty patients with BS and 24 patients with simple ileus (SI) underwent enhanced computed tomography. We compared the values of the IVCER between the patients with BS and those with SI. Results: The IVCER was significantly lower in the patients with BS than that in the patients with SI. The sensitivity and specificity of IVCER for accurate diagnosis of BS were 0.95 and 0.83, respectively. Conclusion: Determination of the IVCER allows for objective evaluation of bowel enhancement and can lead to an accurate diagnosis of BS.

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Recently, percutaneous transhepatic biliary drainage (PTBD) has been replaced by endoscopic biliary drainage (EBD) as the mainstream procedure for biliary drainage. Among the 136 cases of PTBD at our hospital during the last 6 years, the procedure was performed post bilioenteric reconstruction in 65 (47.8%) patients, for selective drainage of the peripheral intrahepatic bile ducts in 43 (31.6%) patients, and because of poor results obtained by endoscopic therapy in 28 (20.6%) patients. The current indications of PTBD converge with the contraindications for EBD, such as incomplete reaching for ampulla or peripheral bile ducts, or inefficiency of endoscopic therapy, and that will be more limited with the development of new endoscopic devices such as double-balloon endoscopes. Although under this situation, the clinical importance of PTBD is still remain because this procedure needs more reliability for individual patient compared with before. How to improve and maintain the crucial PTBD technique is an issue that needs to be resolved in the future.

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We report herein on the outcomes of endoscopic transpapillary biliary drainage and the effectiveness of the rendezvous method applied for cases in which transpapillary drainage proved difficult. The rendezvous method was performed with the combination of the transpapillary and transhepatic routes. There were 315 initial papilla cases in which bile duct intubation or drainage was needed from February, 2009 until August, 2013. Deep intubation of the bile duct and drainage was adopted for 17 impotent patients. Ten patients underwent precut papillotomy, seven patients underwent percutaneous transhepatic drainage and in all cases the reduction of jaundice was noted without complications. The rendezvous method was performed in 4 cases：a case in which indwelling of the percutaneous SEMS (guide wire) was difficult; a case of internal drainage; a case in which repeated transpapillary treatment was needed; and a case of PTBD dislocation. The rendezvous method, which combines the transpapillary and transhepatic routes, was not limited to only malignant disorders, but could also be performed for benign disease, and it seemed to be a clinically useful method.

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Bile duct strictures may occur as a postoperative complication caused by cholangitis and liver dysfunction due to cholestasis. Postoperative bile stricture has been reported to be related to the patients’prognosis. In addition to surgical biliary drainage performed from time immemorial, percutaneous trans-hepatic drainage (PTBD) has also been performed. In recent years, endoscopic biliary drainage is becoming the procedure of first choice for the diagnosis and treatment of bile duct strictures. However, in some cases in who’s not only takes the reconstruction of the digestive tract, but also other major or minor operation induced the adhesion or the status of vagotomy. The method of endoscopic biliary drainage (EBD) is difficult and may also prove dangerous. Since the 1990s, the combined percutaneous and endoscopic approach (CPE) for internal biliary drainage has been used in cases with unsuccessful drainage following the use of either approach alone. Because this method requires proficiency in both the endoscopic and percutaneous techniques, it is difficult to establish as the procedure of first choice for biliary drainage, but it is extremely useful as a last resort for difficult-to-treat cases even after laparotomic open surgery. In this paper, we describe the historical evolution of these procedures, and outline the specific methods and the required technique of CPE.

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Between 2006 and 2013, we performed X-ray-guided percutaneous transhepatic biliary drainage (PTBD) in five patients with non-dilated intrahepatic bile duct (diameter less than 1 mm) . The endoscopic approach was difficult in these patients due to their past history of gastric/duodenal surgery (anastomotic leakage after total gastrectomy, n＝3; cholangitis after total gastrectomy, n=1；anastomotic leakage after partial duodenal resection, n＝1). The patients were placed in the supine position, and a puncture was made between the right 7th and 8th ribs, 3 cm lateral to the bottom line of the 11th thoracic vertebrae (right transthoracic approach). This procedure was performed with local anesthesia under X-ray guidance. A contrast agent was injected to identify the intrahepatic bile duct, followed by careful insertion of a 0.018-inch guidewire. A two-step Seldinger technique was then used to place the 7-Fr PTBD catheter. The biliary drainage catheter was placed successfully in all the patients, with effective reduction of the serum total bilirubin. X-ray-guided PTBD can be performed safely in patients with a non-dilated bile duct in whom the endoscopic approach is difficult.

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While endoscopic biliary drainage has been widely applied for the treatment of pancreatobiliary diseases in patients with normal anatomy, it has been quite a challenge to perform conventional ERCP in patients with altered gastrointestinal anatomy. As a result, many patients with altered gastrointestinal anatomy are referred for percutaneous interventions, which are associated with a higher rate of complications than endoscopic therapy. The recent development of the short-type double balloon enteroscope (DBE) has enabled more practical use of diagnostic and therapeutic ERCP and completion accomplishment of biliary drainage. We summarize the usefulness of endoscopic biliary drainage using the short-type DBE.

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【Background】The treatments of malignant biliary and duodenal obstruction include surgical therapy or endoscopic therapy, and radiological intervention. Recently, double stenting, involving combined placement of a biliary stent (BS) and a duodenal stent (DS), has been reported as a low-invasive treatment. The appropriate therapy must be selected taking into consideration the patient’s prognosis, the timing of the duodenal obstruction, and the stenosis site. [Results] In all 16 patients, endoscopic double stenting (EDS) was performed safely with no early complications. The median DuS and BS patency period from the completion of the EDS were 40 days and 46 days. Furthermore, in the present study, we used two biliary drainage methods, ERCP and EUS-guided biliary drainage (EUS-BD). There were no differences in the success rate, complication rate, or the stent patency between the two methods. [Conclusion] EDS by ERCP and EUS-BD conducted in the present study was feasible and useful for the treatment of malignant biliary and duodenal obstruction.

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Purpose: We investigated whether endoscopic nasobiliary drainage (ENBD) is superior to endoscopic biliary stenting (EBS) in pancreaticoduodenectomy (PD) patients. Subjects and Methods: The outcomes of ENBD and EBS were compared in 97 subjects who underwent PD. (Comparison 1) Comparison of the interval to jaundice reduction and the proportion of subjects requiring additional treatment based on the method of the primary drainage (ENBD or EBS). (Comparison 2) Comparison of the incidences of postoperative complications (surgical site infection, pancreatic fistula, etc.) between the groups treated by ENBD and EBS. Results: (Comparison 1) In those with jaundice only, with total serum bilirubin levels of ≥5 mg/dL, ENBD and EBS were performed in 49 and 25 subjects, respectively. The mean interval until jaundice reduction was 12.8 days （median 9 days） in the ENBD group and 18.1 days （median 18 days） in the EBS group (p=0.036, 0.049). Additional treatment was needed in 2 patients of the ENBD group (4.1%) due to natural deviation, and 18 patients of the EBS group (72.0%) due to cholangitis or poor jaundice reduction (p＜0.01). (Comparison 2) The numbers of subjects who underwent ENBD and EBS just before surgery were 56 and 39, respectively, including those requiring tube placement due to severe pancreatic ductal stenosis despite having a serum bilirubin level of ＜5 mg/dL. The incidences of postoperative surgical site infection, pancreatic fistula and infectious complications were 23.2, 17.9 and 39.3% in the ENBD group, and 20.5, 15.4 and 33.3% in the EBS group, respectively (N. S.). Discussion and Conclusions：As for the postoperative complications, no significant differences were was observed between the two groups treated by ENBD and EBS just before surgery. However, as to the interval to jaundice reduction or the necessity of additional treatment, the results were superior in the ENBD as compared to those in the EBS group. Our results suggest that ENBD is superior to EBS for primary jaundice reduction before PD.

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Preoperative biliary drainage (PBD) has been conventionally performed in patients with obstructive jaundice prior to pancreaticoduodenectomy (PD). However, recently, there have been some reports suggesting that PBD might be associated with an increased incidence of postoperative morbidities. It has been argued that PBD induces biliary infection and consequently leads to infectious morbidities such as wound infection. In addition, some reports have suggested that preoperative biliary infection is associated with a risk of pancreatic fistula formation, which can be a life-threatening complication. Therefore, perioperative infection control measures, such as administration of a broad-spectrum antifungal agent, may be necessary to prevent postoperative morbidities in patients undergoing PBD prior to PD. In this report, we review the merits and demerits of PBD before PD and the associations between preoperative biliary infections and postoperative morbidities, including pancreatic fistula formation.

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A case of hemorrhage from a ruptured pancreatic pseudocyst that was caused by the performance of endoscopic ultrasonography (EUS) and which was treated by an emergency operation is presented in this report. A 43-year-old man with a long history of alcohol abuse was referred to us because of a cyst in the pancreatic tail. The patient had initially been treated conservatively under the presumed diagnosis of a pancreatic pseudocyst associated with alcoholic chronic pancreatitis. However, he was admitted to our hospital because of enlargement of the pancreatic cyst. We performed EUS to observe the cyst before drainage. During the EUS procedure, the patient complained of abrupt onset of abdominal pain and lapsed into shock. Enhanced CT showed rapid enlargement of the cyst and fluid collection in the peritoneal cavity. Emergency laparotomy was performed under the suspicion of intraperitoneal hemorrhage from the ruptured pancreatic pseudocyst. The intraoperative findings confirmed that the pancreatic pseudocyst had ruptured, resulting in the occurrence of massive ascites with hemorrhage. Distal pancreatectomy and splenectomy were performed. Intraabdominal bleeding caused by rupture of a pancreatic pseudocyst is a relatively rare complication. It is possible that the intraperitoneal hemorrhage from the ruptured pancreatic pseudocyst was caused during the EUS procedure performed in this case.

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A 70-year-old woman with myelodysplastic syndrome (MDS) had been followed for 10 years； the woman had refractory cytopenia with multilineage dysplasia and ring sideroblasts (RCMD)） and had been diagnosed as having intermediate-risk (Int 1) MDS according to the International Prognostic Scoring System (IPSS). On February 11, 2012, the woman was seen for right lower abdominal pain, and was diagnosed as having gangrenous appendicitis. The platelet count was decreased to 1.4×104/μL, therefore, conservative treatment was selected. She was kept nil by mouth and treated with meropenem 1.5 g/day. This resulted in alleviation of her symptoms, and the patient was discharged after 10 days of hospitalization. Three months later, the patient was transfused with platelets, and a laparoscopic appendectomy was performed. Pathology revealed appendicitis catarrhalis. Interval appendectomy allows preparation time for platelet transfusion, and was found to be a suitable approach to treat acute appendicitis in our patient with MDS with a marked decrease of the platelet count.

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An 82-year-old woman who had been receiving treatment with a proton pump inhibitor for reflux esophagitis was admitted to our hospital for sudden respiratory symptoms. She lapsed into shock at the outpatient department and was admitted to the intensive care unit. She was diagnosed as having acute respiratory distress syndrome due to aspiration pneumonia and received intensive treatment. After recovery, a barium swallow, upper gastrointestinal endoscopy and abdominal computed tomography revealed a type Ⅲ hiatal hernia as the presumable cause of the reflux aspiration pneumonia. Laparoscopic anti-reflux surgery was performed. The postoperative course was excellent and the patient was discharged on postoperative day 5. In Japan, laparoscopic anti-reflux surgery is not commonly performed, especially in older people and high-risk patients. However, some of these patients are good candidates for surgery because the procedure can prevent reflux and the associated complication of aspiration pneumonia. In our patient, we performed the operation soon after she recovered from pneumonia. The prompt treatment shortened her hospital stay and enabled early rehabilitation.

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In June 2013, a 55-year-old man was admitted to our hospital with emesis and diarrhea. He had a history of chronic pancreatitis and had previously undergone extensive gastrectomy for gastric ulcer. Blood biochemical examination and abdominal computed tomography (CT) revealed acute exacerbation of chronic pancreatitis and disseminated intravascular coagulation, which necessitated intensive treatment. Abdominal CT and endoscopic retrograde pancreatography performed due to inflammatory exacerbation on day 6 after admission revealed an infected pancreatic pseudocyst with pancreatic duct disruption. An endoscopic nasopancreatic drainage (ENPD) tube was inserted into the pseudocyst, after which the patient’s condition improved rapidly. Decannulation following improvement resulted in a relapse of inflammatory exacerbation；therefore, the ENPD tube was re-inserted and elective surgery was performed. Operative findings showed the infected pancreatic pseudocyst between the gastric remnant and the pancreas, which caused severe adhesion between these two organs. Therefore, total resection of the gastric remnant, distal pancreatectomy and splenectomy were performed. The patient’s postoperative course was uneventful and he was discharged on postoperative day 19.

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In January 2014, a 75-year-old female who had been diagnosed as having multiple myeloma presented with a sore throat. A plain x-ray of the chest revealed intraperitoneal free air. Abdominal contrast-enhanced CT showed evidence of pneumatosis along a broad extent of the small intestinal wall, and the patient was diagnosed as having pneumatosis cystoides intestinalis. Because she had no abdominal tenderness, conservative treatment was selected. Six days after admission, a repeat contrast-enhanced abdominal CT showed complete disappearance of the intraperitoneal free air and the pneumatosis. She was discharged from the hospital eleven days after admission. In some cases of PCI with intraperitoneal free air, emergency surgery might be required for suspected perforation of the digestive tract. However, in the cases without peritoneal signs, a careful decision should be made about the need for surgery, because the condition is potentially curable by conservative management.

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A 35-year-old female who was diagnosed with threatened premature delivery by a local physician and treated with oral medications from the 31st week of pregnancy was admitted to our hospital for exacerbation of abdominal pain and vomiting on the 3rd day of the 35th week of pregnancy. CT showed enlargement of the small intestine and ascites. Since strangulated ileus was strongly suspected, emergency surgery was performed on the 6th day of the 35th week of pregnancy. After performing a Caesarean section, the occluded segment of the small intestine was explored and a part of the small intestine was found to be incarcerated in the intersigmoid fossa. We completed the surgery without resection of the small intestine, because there were no necrotic changes. The postoperative course was uneventful and both the mother and the baby were discharged on the 8th postoperative day. Here, we report our experience of a case of intersigmoid hernia diagnosed during pregnancy.

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A 72-year-old man presenting with sudden left-sided abdominal pain and watery stools was found by abdominal computed tomography to have extra-intestinal gas and inflammation of the adipose tissue corresponding to the descending colon. Under a suspected diagnosis of a colonic penetration, emergency diagnostic laparoscopy was performed. As the splenic flexure of the colon was found to penetrate into the mesentery, a segmental colonic resection including the penetrating lesion was performed laparoscopically. With the macroscopic finding of two longitudinal mucosal ulcerations and the microscopic finding of a thickened subepithelial collagen band, the patient was diagnosed as having collagenous colitis. The patient gave a history of treatment with oral lansoprazole for 5 months, and proton pump inhibitors are well-recognized as being among the possible causes of collagenous colitis. Administration of lansoprazole was stopped, and the patient has had no abdominal pain or watery stools until date, 6 months after the surgery.

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A 64-year-old woman was transferred to our hospital with injuries sustained in a car crash. Abdominal enhanced CT revealed intra─abdominal hemorrhage and extravasation of contrast medium in the pancreatic head region. The patient was in shock. An emergency laparotomy revealed portal vein injury. We attempted to repair the injured portal vein, however, the repaired vein was narrow and weak. Therefore, we finally ligated the portal vein. The postoperative course was good and the patient was discharged from the hospital on the 36th postoperative day. While portal vein injury is rare, it is associated with a high mortality rate. To decrease the mortality, it is important to control the bleeding rapidly.

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A 49-year-old man visited our hospital with severe abdominal pain of sudden onset. Abdominal contrast-enhanced computed tomography revealed intussusception of the transverse colon. Surgery was performed because the remarkable thickening of the wall of the ascending colon observed on CT was suspected as a sign of malignancy. On closer observation, however, worms that appeared to be anisakis worms, were confirmed on the surface of the mucosa at the site of formation of the inflammatory tumor. Histopathological examination of the resected specimen confirmed the diagnosis of anisakiasis.

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A 56-year-old man presented with epigastric pain. He had a medical history of cerebellar infarction and type 2 diabetes mellitus. An enhanced abdominal CT scan revealed a giant splenic artery aneurysm (50 mm) and situs inversus totalis, and the patient was admitted to our hospital. We selected open abdominal surgery because of the aneurysm size and location. Very strong and extensive adhesions were noted between the aneurysm and the pancreas. Since we considered that resection of the aneurysm would be associated with a very high risk of postoperative pancreatic fistula, we performed ligation of the splenic artery aneurysm and splenectomy. No complications were seen during or after the operation, and the patient was discharged from the hospital on the 22nd postoperative day. Giant splenic artery aneurysms are very rare, and there is no surgical case report of a splenic artery aneurysm occurring in a patient with situs inversus totalis. We report this case with a report of the literature.

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Colonoscopy is widely used for the diagnosis and treatment of colorectal lesions. Although iatrogenic perforation of the colon is rare, it can be fatal. With the recent improvements in laparoscopic surgical devices and techniques, laparoscopic repair of colonic perforations is now feasible, provided adequate bowel preparation is performed. Here, we present 3 cases of iatrogenic colonic perforation, who were successfully treated by laparoscopic surgery. The mean operative time was 139 minutes, the mean fasting period was 3.3 days, and the mean postoperative hospitalization period was 8 days. There were no cases of operative morbidity or mortality. Laparoscopic repair is a feasible and effective treatment for iatrogenic colonic perforation.

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An 85-year-old woman was brought into our hospital because of melena. An upper gastrointestinal endoscopy was performed, which however did not reveal the origin of the bleeding. The patient gradually went into hemorrhagic shock, and contrast-enhanced computed tomography (CT) was performed. Extravasation of the contrast medium was observed in the fourth portion of the duodenum；therefore, we performed transcatheter arterial embolization with coils, and hemostasis was achieved. As a few hours later, the abdominal distension increased and CT revealed rebleeding and perforation, we performed emergency surgery. Thereafter, no bleeding was noted from the duodenal diverticula in the fourth portion of the duodenum, however, bleeding was noted from a diverticulum in the third portion of the duodenum；therefore, we reefed the diverticulum. Twelve days after the surgery, a blood examination revealed rapidly progressing anemia. Moreover, a repeat upper gastrointestinal endoscopy showed exposed blood vessels in the diverticula of the fourth portion of the duodenum. Therefore, we conducted endoscopic clipping, which was successful, and the patient has not had rebleeding until date. In conclusion, surgery and embolization are useful treatment options for diverticular bleeding, depending on the location of the diverticulum and the hemodynamic status.

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Fulminant Streptococcus pyogenes infection (FSPI) presents with a wide range of severe manifestations and is associated with a high mortality. However, pelvic inflammatory disease (PID) has not been reported previously as an initial presentation of FSPI. Herein, we report a case of FSPI who presented with PID as the initial manifestation. A-58-year-old woman was diagnosed as having PID by a physician and transferred to our hospital. The laboratory findings at the first presentation to our hospital revealed evidence of severe infection (WBC 18,800/μL, CRP 51.5mg/dL) and acute renal failure. The only significant finding on CT was a small volume of ascites. Exploratory laparotomy revealed severe inflammation of the pelvic organs. In light of the laparotomy findings and the exacerbated sepsis state, we suspected FSPI, and performed retroperitoneal evacuation and initiated the patient on continuous hemodiafiltration. However, the patient deteriorated, developed multiple organ failure, and died 43 hours after hospitalization. Subsequently, Streptococcus pyogenes was cultured from the vagina and retroperitoneum. This case emphasizes the need for clinicians to be aware of severe PID as a possible initial manifestation of FSPI, which carries an unfavorable prognosis.

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A 74-year-old male who underwent S8 subsegmentectomy of the liver for recurrent hepatocellular carcinoma developed fever on postoperative day (POD) 7. The fever persisted despite administration of antibiotics；as abdominal computed tomography (CT) revealed findings suggestive of a possible abscess, percutaneous drainage was performed on POD 14. The following day, the patient developed acute melena. Colonoscopy revealed multiple small ulcers at the terminal ileum. Conservative treatment proved ineffective, and the melena worsened on POD 24. Enhanced CT demonstrated extravasation in the jejunum, and emergency angiographic examination was performed. Arterial angiography revealed extravasation from the first branch of the jejunal artery, therefore, transarterial embolization was performed, which effectively stopped the intestinal bleeding. Thereafter, neither ischemia of the intestine nor rebleeding occurred, and the patient was discharged on POD 51. Enhanced CT and angiographic examination were useful to identify the site of the gastrointestinal bleeding, and the results in the present patient suggested that arterial embolization might be effective for the treatment of hemorrhagic small intestinal ulcers.

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Case 1 was an 80-year-old male who was brought to our institution by ambulance because of a hemorrhagic duodenal ulcer. Endoscopic treatment failed because of the poor field of vision. Computed tomography showed bleeding from the gastroduodenal artery, and an angiographic examination was performed. The bleeding was successfully controlled by transcatheter arterial embolization (TAE). Case 2 was a 57-year-old female. Although her hemorrhagic duodenal ulcer had been treated by endoscopic techniques three times, the bleeding recurred. During the fourth episode of bleeding, she lapsed into shock. Computed tomography showed the gastroduodenal artery located in the ulcer bed；TAE was performed, which successfully stopped the bleeding. Surgery or TAE should be performed in difficult cases with duodenal ulcers in order to ensure hemostasis. In some cases, TAE may be an easier, faster and safer method as compared to surgery. TAE is now considered the first-line therapy for massive UGI bleeding, and MDCT may help in the selection of the appropriate treatment method.

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A 60-year-old female presented complaining of epigastric pain. Gastroscopy showed an ulcer in the gastric angle and a large amount of residue and anti-ulcer therapy was initiated, but the abdominal pain increased after 5 days. Abdominal CT revealed a dilated small intestine and food masses containing air. Laparotomy revealed a hard stone (4cm) including food fibers at 150cm oral from the ileum end which had caused simple obstructive ileus, and it was removed via an intestinal incision. On the 8 postoperative day, the abdominal pain recurred. Abdominal CT showed a dilated small intestine and food masses containing air. Laparotomy was performed again at 14 days after the first procedure. The small intestinal portion around the previous suture site was adherent, forming a mass, and there were 2 hard stones (4cm) at the anal side from the suture site. The small intestinal mass was resected. We suspected that the two food masses containing air in the stomach at the first CT had been discharged from the stomach. This was an instructive case in which an intestinal obstruction needed a repeat reoperation due to the discharge into the intestine of bezoars which had been left in the stomach.

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While incarcerated hernias of the intestine usually require emergency surgery, herein, we report a case of incarcerated internal hernia occurring through the broad ligament of the uterus that was successfully reduced by a rectal examination; the hernia was then repaired by elective surgery. A 53-year-old woman visited the emergency room complaining of left lower abdominal pain and nausea of acute onset that developed while she was jogging. An abdominal contrast-enhanced CT showed a closed incarcerated loop of the sigmoid colon around the caudal aspect of the left ligamentum teres uteri. Based on this finding, the patient was diagnosed as having internal herniation of the intestine through the broad ligament of the uterus. The incarcerated bowel was palpable by rectal digital examination, and could be reduced with some manipulation, which resulted in improvement of the clinical symptoms such as the lower abdominal pain and other symptoms of bowel obstruction Thus, we avoided emergency surgery and performed a laparoscopic repair electively. Two defects were found in the broad ligament of uterus, which were sutured and closed. In addition, the mesentery of the sigmoid colon showed a linear bruise, which was considered to be the location of the incarcerated bowel. The patient recovered without postoperative complications and was discharged on postoperative day 3.

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A 36-year-old male with no history of laparotomy and abdominal trauma was admitted to our hospital complaining of having abdominal pain and vomiting. The CT scan showed dilation of the small intestine and ascites, and an internal hernia was suspected. An emergency laparotomy was performed. Intraoperatively, about 10cm of the ileum was found to have penetrated through the greater and lesser omentum. The ileum was not strangulated or necrotized, therefore, intestinal resection was not performed. Internal hernias through the greater and lesser omentum are difficult to diagnose preoperatively. Therefore, in the case of ileus with no history of laparotomy, an internal hernia through the greater and lesser omentum should be considered and an early operation should be performed.

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A 62-year-old man underwent an abdominal transanal resection with a J-pouch anal anastomosis for lower rectal cancer and diverting loop ileostomy for postoperative vesicorectal fistula in the left lower abdomen 1 year previously. The patient was admitted to the hospital with abdominal pain and a prolapsed ileostomy which has occurred while he was playing tennis. The patient has devised a handmade device to protect the stomal pack. The prolapse was difficult to reduce and marked discoloration of the bowel wall was observed as bowel necrosis. An emergency laparotomy through a midline incision found a prolapsed double-barreled ileostomy complicated with an incarcerated intestinal loop. Intraoperative findings showed that the proximal small intestine had prolapsed at the double-barreled ileostomy. The strangulated small intestine was resected, and a new single-barreled ileostomy was constructed at the same site （left lower abdomen）. The resected specimen did not reveal the origin of the intussusceptions. Pressure from handmade device was suspected as the cause of the prolapse of the proximal side of the small intestine.

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Calcium Polystyrene Sulfonate (Argamate Jelly^®) is one of the cation-exchange resins which is used to treat hyperkalemia caused by chronic kidney failure. Constipation is well known as one of the major side effects, and as the agent acts directly on the intestinal tract, there has been a report of intestinal tract perforation. This is given as a potential side effect in the drug information leaflet in the packaging. We experienced 3 cases in which colon perforation occurred during internal use of the agent, and report on them herein. We describe the clinical course and the histopathological laboratory findings. In addition, we added some discussion based on the literature and considered a hypothesis of the mechanism which could lead to intestinal perforation during the internal use of Calcium Polystyrene Sulfonate.

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