Background：Although prophylactic drainage after surgery for peritonitis has been reported to have little efficacy, surgeons in Japan have conventionally undertaken it. We carried out this study to investigate the usefulness of prophylactic drainage insertion following laparoscopic surgery for perforated gastroduodenal ulcer. Method: Between January 2010 and September 2014, 49 patients underwent laparoscopic surgery for perforated gastroduodenal ulcer at our hospital. A postoperative drain was inserted in 24 patients (group D), while it was not in the remaining 25 (group ND). We compared patient characteristics and postoperative outcomes between the two groups. Results：There were no significant intergroup differences in the patient characteristics. However, the average postoperative hospital stay duration was significantly shorter in group ND (9.6±2.9 days) than in group D (12.4±5 days; p=0.02). Furthermore, there were no significant intergroup differences in the incidence of postoperative complications (group D: 3 cases, group ND: 0 cases). Conclusion: The results of this study indicate that there is no need for prophylactic drainage following laparoscopic surgery for perforated gastroduodenal ulcer.

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We examined the validity of the strategy of neoadjuvant chemotherapy (NAC) for obstructive rectal cancer. Focusing on 55 cases of obstructive rectal cancer diagnosed between 2000 and 2012, we examined and compared the treatment results between the NAC group (15 cases) and the non-NAC group (40 cases). In the NAC group, L-OHP was administered in 93% and L-OHP with bevacizumab in 86% of patients. The response rate to NAC was 73.4% and there were no cases of PD. In addition, the antitumor effect of the treatment led to significant shrinkage of the tumor and a large number of cases with improvement of the N grade to N0 in the NAC group. The rate of R0 was 100% in the NAC group, and 82.5% in the non-NAC group, and there were no cases requiring total pelvic exenteration. There was no significant difference in the incidence of postoperative complication or reoperation between the two groups. There was no difference in the 3-year local recurrence-free survival rate, 3-year recurrence free rate, or 3-year survival rate between the two groups. Therefore, our findings suggested that the use of NAC for obstructive rectal cancer is an effective treatment strategy in terms of reducing the disease stage and is equivalent in terms of the safety.

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Between January 2007 and May 2014, we encountered 18 cases of patients who had swallowed button batteries, two of which were lithium batteries. In both of the latter cases, severe complications, such as mediastinitis and tracheoesophageal fistula were observed. Coin-shaped lithium batteries are large enough to lodge easily in the esophagus. Moreover, since they can also generate a high electric potential, they are capable of causing chemical injury in the esophagus. For these reasons, it is recommended that coin-shaped lithium batteries lodged in the esophagus be removed as soon as possible, and the patients should be followed up by endoscopic examination to promptly detect the development of any complications. It is also important to educate people regarding the risks associated with swallowing of these batteries.

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Early diagnosis and assessment of operability are required in the treatment of strangulated obstruction. This study was designed to clarify the diagnostic accuracy and treatment outcome in patients with strangulated intestinal obstruction mainly diagnosed by computed tomography (CT). The subjects were 263 patients diagnosed as having bowel obstruction without malignant tumor or hernia between 2008 and 2013. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the diagnostic accuracy of strangulated intestinal obstruction were 83.7%, 98.6%, 95.8%, 93.2% and 96.3%, respectively. Although many of the clinical and radiological findings reported in the literature are not observed in the early stages of strangulated intestinal obstruction, the accuracy of the CT findings is especially high, with a reported sensitivity of 95.9% and specificity of 92.5%. Only one patient died of sepsis after emergency operation in our study. For early diagnosis of strangulated intestinal obstruction, identification of distinctive findings such as the closed─loop sign and mesenteric changes on the CT are important.

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Aim：The aim of this study was to clarify the risk factors for severe pancreatic fistula (PF) formation following radical gastrectomy. Patients and Methods：A total of 1,035 consecutive patients have undergone radical gastrectomy with suprapancreatic lymphadenectomy at our institution since 2007. Of these, the 56 patients (5.4%) who developed PF following radical gastrectomy were enrolled in this study. Cases classified as having Grade Ⅲb or more severe PF according to the Clavien-Dindo classification or with drainage for ≥50 days after the gastrectomy were defined as having severe PF. Results：Sixteen patients required hospitalization for ≥50 days and six patients had Grade Ⅲb or more severe PF. Univariate analysis identified body mass index (BMI) (p=0.005, <26.5 kg/m² vs. ≥26.5 kg/m²) and anastomotic leakage (p=0.007, present vs. absent) as being significantly correlated with the severity of PF. Multivariate analysis identified BMI (p=0.004; relative risk (RR), 8.65；95% confidence interval (CI), 1.96-37.4) and anastomotic leakage (p=0.013；RR, 6.12；95%CI, 1.66-78.3) as being independent risk factors for severe PF. Conclusion：High BMI and presence of anastomotic leakage are risk factors for severe PF formation following radical gastrectomy.

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Ruptured abdominal aortic aneurysms (rAAAs) have a very poor prognosis. Even with open surgical repair (OSR), the early mortality rates are still as high as at 40〜50%, and survival rates have not improved over the last 40 years with OSR. To achieve the improved survival rates associated with rAAA, it is important to introduce‘the endovascular aortic repair(EVAR)-first’protocol. Appropriate patients with rAAAs who are undergoing treatment in experienced vascular centers should be offered EVAR as the first choice.

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Although many reports from national datasets and systematic review suggest that emergency endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms(rAAAs) may be associated with better early clinical results than conventional open repair (OR), there was no significant difference among both in recent large randomized controlled trials. We have introduced a standardized protocol since 2010 because we believe that the results of EVARs can be through such strategies as a thorough multidisciplinary approach and teamwork. From January 2010 to December 2014, we performed 69 EVAR cases, the 30 day mortality rate of which was 24.5％. It showed a significant improvement over the 30 day mortality rate we achieved (43.3％) when we performed 30 OR cases for rAAAs before introducing the EVAR protocol in our institution. This article will focus on the early results of EVAR from our experience and consider the potential efficacy of EVAR.

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The shock index (SI), defined as the ratio of heart rate to systolic blood pressure, is a simple marker for the situation in emergency patients. This study is presented to determine whether the SI is a useful marker for patients with endovascular repair of ruptured abdominal aortic aneurysms (rEVAR). In 33 patients, rEVARs were performed as an emergency in our institution between April 2012 and March 2015. The SI was calculated just before putting the patients under anesthetic. Intraoperative immediate technical success was obtained in all cases. Eight patients died in our hospital after rEVAR, and 6 of these 8 patients who died within 30 days after rEVAR were diagnosed as having abdominal compartment syndrome (ACS). The SI of the patients with ACS and without ACS were 1.66±0.12 and 1.02±0.08, respectively (p<0.01). The SIs in the dead and surviving cases were 1.57±0.20 and 1.08＋±0.09, respectively (p＜0.01). To avoid patients with a high SI score falling into ACS, careful preparation of the procedure for leak control during rEVAR and decompression of the abdomen after rEVAR are considered necessary. The SI is concluded to be a simple and useful marker in patients with rEVAR.

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To improve the survival of an endovascular aneurysm repair in the case of ruptured abdominal aortic aneurysms, a protocol-based approach is important. Furthermore, there are several important technical aspects that include the choice of anesthesia, the percutaneous and femoral cut down approach, and the use of an aortic occlusion balloon.

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Although, endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysms is increasing, randomized controlled trials (RCTs) could not prove the superiority of EVAR in comparison to open surgical repair. To improve the surgical result of emergency EVARs, many problems must be solved. As CT scan is sometimes impossible to perform or there is not enough time to plan and select devices in an emergency EVAR, open conversion becomes necessary more frequently than an elective EVAR. In previous reports, open conversion was done in 2.6-14.0% of emergency EVARs. In our group, open conversion was done in 1.9% of emergency EVARs. Open conversion was performed due to persisting endoleakage, access difficulty and so on. As delay of open conversion may cause a fatal result, we need to avoid delaying decision to convert to open surgery.

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Ruptured abdominal aortic aneurysms (rAAAs) are still associated with significant morbidity and mortality. Recently some reports have documented the feasibility and effectiveness of an emergency endovascular aneurysm repair (eEVAR) of rAAAs. However the superiority of eEVAR to open repair remains controversial. We reviewed eleven cases of eEVAR for rAAAs performed in our hospital from August 2011 to January 2015. The mortality and incidence of bowel ischemia was 9.1%. During eEVAR, unstable systemic circulation, intra-abdominal hypertension, and interruption of the inferior mesenteric artery (IMA) and/or internal iliac artery (IIA) all have been implicated as potential risk factors for fatal bowel ischemia. In case of bowel ischemia, an early diagnosis and an appropriate surgical interventions are important. The establishment of methods of intraoperative evaluation of the mesenteric circulation and preservation of the IMA circulation should contribute to improve the results of eEVAR.

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Endovascular Abdominal Aortic Repair (EVAR) for ruptured abdominal aortic aneurysms (rAAAs) has gained acceptance as an alternative to open repair. However, it is still a difficult challenge for patients with unstable hemodynamic conditions. Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are common complications of EVAR for rAAAs that lead to high morbidity and mortality. ACS is an organ dysfunction caused by IAH. IAH is common in rAAA patients because of retroperitoneal hematoma and resultant fluid shifts from massive fluid resuscitation. ACS is diagnosed when there is an evidence of organ dysfunction and the IAP is greater than 20mmHg. Because of increased mortality, a decompression laparotomy is performed. Vacuum-assisted wound closure therapy is recommended because it can potentially decrease the concentration of the bacterial count, and manage third-space fluid. If a Type 2 endoleak is suspected, an additional surgical procedure will save a patient’s life. Appropriate management of ACS is critical in improving rAAA-associated mortality.

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In recent years, the relative benefits of endovascular repair (EVAR) for ruptured abdominal aortic aneurysms (RAAAs) compared with open surgical repair (OSR) have been demonstrated in several observational reports or larger national administrative database studies. However, disagreement still persists over which therapy is best, because all randomized controlled trials(RCTs) to date have not been able to prove the significant superiority of EVAR. Although there is no difference in the outcomes between EVAR and OSR, specifically 30-day mortality in the level I evidence, postoperative quality of life may be improved by EVAR treatment. At this moment, EVAR should be applied for the patients with a favorable anatomy. In contrast, patients who are found to be poor anatomic candidates for EVAR are likely best served with an expeditious OSR. More high quality RCTs comparing EVAR and OSR for the treatment of RAAA, especially focusing on aneurysm neck length or the anatomical applicability for EVAR, are needed in the future.

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Less invasive surgeries such as laparoscopic gastrectomy (LG) have been developed for the treatment of gastrointestinal malignancies. Internal hernia is a known complication of gastric bypass surgery and gastrectomy, especially when these surgeries are performed by the laparoscopic approach. We report three cases that were diagnosed as having internal hernia after LG with Roux-en-Y reconstruction for gastric cancer；all the three cases had been treated by the laparoscopic approach. Although the approach was converted to open surgery based on the suspicion of small intestinal perforation in one case, the other two cases were treated by laparoscopic surgery. By exploring the small intestine from the terminal ileum to the oral side, the small intestine can be successfully restored. Continuous closure of mesenteric defects and Petersen’s space are recommended to avoid the development of internal hernia after LG.

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Although conservative treatment is the treatment of first choice for pneumatosis cystoides intestinalis and portal venous gas induced by α-glucosidase inhibitor (αGI) use, it is essential to distinguish these diseases from those causing intestinal ischemia. In this case, mesenteric fat stranding of the lower ileum was detected by computed tomography (CT) during conservative treatment for portal venous gas and pneumatosis intestinalis, and was useful to distinguish these conditions from intestinal ischemia. Our patient was an 81-year-old woman who had been taking oral αGIs for diabetes mellitus. While hospitalized, she developed acute abdominal pain after defecation. She was transferred to our hospital because of portal venous gas, intestinal dilatation and pneumatosis intestinalis around the superior mesenteric vein detected by CT. Conservative therapy was initiated because there was no clinical evidence of peritoneal irritation or acidosis. CT performed 21 h after the onset revealed thickening of the lower ileum wall, mesenteric fat stranding, and ascites. Because peritoneocentesis revealed that the ascites was serous and the mesenteric fat stranding coincided with the area at which pneumatosis cystoides intestinalis associated with oral αGI use frequently occurs, we concluded that the present symptoms were caused by oral αGI ingestion. With continuation of conservative treatment, the symptoms (as revealed by CT) improved, and the patient was discharged after an uneventful clinical course.

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We report two cases of gastrointestinal perforation caused by accidental ingestion of a press-through package （PTP）. Case 1：an 87-year-old woman who was suffering from epigastralgia. Abdominal CT revealed a high-density opacity, suspected to be a PTP, in the duodenum with surrounding free air. Under the diagnosis of duodenal perforation, upper gastrointestinal endoscopy was performed. The PTP in the duodenum was removed endoscopically, and a perforation was identified and clipped. Unfortunately, endoscopic treatment was unsuccessful. Partial resection of the duodenum and jejunum was performed on hospital day 48. Case 2：a 60-year-old woman visited his physician because of upper abdominal pain. CT showed intraabdominal free air, and the patient was transported to our hospital. The foreign body and region of perforation could not be detected on a repeat CT. At laparotomy, a perforation with partial exposure of a PTP was found in the ileum. The perforated portion of the ileum was surgically resected. Accidental ingestion of PTP should be kept in mind as a cause of gastrointestinal perforation. Abdominal CT imaging is useful for correct diagnosis of gastrointestinal perforation caused by PTP. It is noteworthy that the materials of PTP affect various features of CT imaging.

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A 65-year-old man who had been diagnosed as having hypopharyngeal and esophageal cancer was admitted to the hospital with the chief complaint of dysphagia. The patient received definitive chemoradiotherapy for the hypopharyngeal cancer, and the tumor showed complete response to the treatment. For the esophageal cancer, the patient was treated by right thoracic esophagectomy with gastric tube reconstruction through the intra-thoracic route. The thoracic duct was resected with the esophagus, and the stump of the residual thoracic duct was clipped above the diaphragm. On postoperative day （POD） 9, the chest drainage tube on the right side was removed and oral nutrition was started. However, bilateral pleural effusion was noted on POD 10. Then, chest drainage was performed again, and the drained fluid was milky and white, confirming the diagnosis of chylorrhea. Conservative therapy failed to reduce the chylorrhea. On POD 22, we decided to perform an emergency laparotomy. The lymphatic duct communication with the thoracic duct was detected on the aorta at the upper side of the pancreas, and the root of the lymphatic duct was ligated successfully. The postoperative course was uneventful and the chylorrhea was completely controlled. Then, on POD 12 after the emergency operation, after the patient resumed oral intake, the patient was discharged from the hospital.

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A 74-year-old woman who had undergone Miles' operation 23 years previously for rectal cancer was under periodic clinical examination. She visited our hospital with left-sided abdominal pain and vomiting. She had a knob-like swelling outside the stoma and CT revealed a parastomal hernia along with strangulated ileus. An emergency operation was performed. A part of the small intestine was incarcerated in the parastomal hernia sac and had become necrotic. Resection of the necrotic part and end-to-end anastomosis were performed while avoiding contamination to the extent possible. The orifice of the parastomal hernia was directly sutured and an artificial mesh was placed. She left the hospital without complications such as mesh infection after the operation.

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An 85-year-old female with no past history of trauma or blood dyscrasia or of treatment with anticoagulant drugs was transported to our emergency room from another hospital complaining of sudden left-sided abdominal pain. Laboratory examination showed a lower hemoglobin level as compared with that documented at the previous hospital. Enhanced computed tomography revealed a poorly enhancing tumorous lesion on the leftside of the transverse colon and extravasation into the peritoneal cavity. Free air was also detected within the peritoneal cavity. Consequently, an emergency laparotomy was performed for suspected perforation and hemorrhage secondary to the tumor in the transverse colon. The surgical findings revealed two intramural hematomas in the transverse colon, associated with partial disruption of the serosa and leakage of blood into the peritoneal cavity, although there was no evidence of contamination by digestive juice. Partial resection of the transverse colon and colostomy were performed. Histopathological examination showed the intramural hematoma not associated with vessel malformation, and a final diagnosis of idiopathic intramural hematoma in the transverse colon was made.

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A 76-year-old man had been admitted to a care facility with dementia and diabetes. The facility consulted our hospital because of suspected gastrointestinal perforation in the patient. Abdominal plain computed tomography (CT) showed the presence of a large amount of intra-abdominal free air. Evaluation of the abdominal findings was very difficult because of the patient’s dementia. We were not able to rule out gastrointestinal perforation. We performed intra-abdominal puncture and deaerated the intra-abdominal free air. These measures resulted in resolution of the abdominal pain in the patient. We diagnosed the patient as having pneumatosis cystoides intestinalis with intra-abdominal free air due to administration of an α-glucosidase inhibitor. He was managed by conservative therapy. There has been no recurrence for 18 months since the treatment. Pneumatosis cystoides intestinalis with intra-abdominal free air requires differentiation from gastrointestinal perforation. Abdominal reevaluation after deaeration via intra-abdominal puncture seems to have useful potential in patients with dementia and the mental disorders.

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A 67-year-old male patient visited our hospital with the complaint of lower abdominal pain. Clinical examination revealed the presence of fluid in the pelvic cavity and an intra-abdominal mass. Emergency surgery was performed for suspected intraperitoneal bleeding associated with rupture of tumor. Laparotomy revealed 300mL of hemorrhagic ascites in the abdominal cavity and an outer parietal tumor measuring 12.5 cm in diameter with a ruptured capsule in the jejunum approximately 10cm from the Treitz ligament, which was thought to be the source of the bleeding. Partial resection of the small bowel including the tumor was performed. Immunostaining revealed positive staining for CD 34 and c-kit, and intraperitoneal bleeding due to rupture of a GIST. Imatinib mesylate was given as adjuvant therapy, however, the drug was switched to sunitinib when peritoneal dissemination was confirmed 11 months after the surgery. The patient died 21 months after his initial surgery. Intraabdominal hemorrhage due to rupture of a giant GIST is rare. We report the case herein with a review of the relevant literature.

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Case 1：A 79-year-old female was admitted to our center with lower abdominal pain. Because abdominal computed tomography (CT) revealed a gas shadow in the uterine cavity with free air, she was diagnosed as having perforated pyometra, and total hysterectomy and bilateral adnexectomy was performed. Case 2: A 73-year-old female was admitted to another hospital because of bipolar hip arthroplasty. She developed septic shock after complaining of right lower quadrant abdominal pain, and was transferred to our center and diagnosed as having perforated pyometra based on the findings on abdominal CT of a gas shadow in the uterine cavity with free air and disruption of the uterine wall. Total hysterectomy and bilateral adnexectomy were performed. Gastrointestinal perforation was initially suspected because of panperitonitis with free air in both cases. However, a preoperative diagnosis of perforated pyometra could be made because the CT scans revealed gas in the uterine cavity with free air and disruption of the uterine wall. When these findings are present in elderly females with panperitonitis, it is possible to diagnose perforated pyometra preoperatively.

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A 51-year-old woman with a history of alcoholic chronic pancreatitis presented to our emergency department with epigastralgia. CT revealed the formation of an internal pancreatic fistula through the esophageal hiatus from the pancreatic pseudocyst containing a slightly high-density area in the pancreatic tail to a cystic lesion in the mediastinum. Based on these findings, we diagnosed the patient as having a mediastinal pancreatic pseudocyst accompanied by intracystic hemorrhage. Endoscopic retrograde cholangiopancreatography (ERCP) showed a communication between the pancreatic duct and the pancreatic pseudocyst. Endoscopic nasopancreatic drainage (ENPD) was performed. The mediastinal pancreatic pseudocyst gradually decreased in size and the patient improved. But we were concerned about the recurrence of the pancreatic pseudocyst, pancreatic pleural effusion and intracystic infection. Therefore, we performed distal pancreatectomy and opening and drainage of the cyst. Until now, two years since the operation, the patient has remained in good condition without recurrence. Mediastinal pancreatic pseudocyst is a rare complication of pancreatitis. Our case suggests that endoscopic transpapillary drainage is a useful treatment method for mediastinal pancreatic pseudocyst in patients showing communication between the pancreatic duct and pancreatic pseudocyst.

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Removal of a rectal foreign body requires open laparotomy if transanal extraction is unsuccessful. We report a case of transanal intrarectal foreign body extraction using an obstetrical vaginal speculum under caudal anesthesia. A 66-year-old man was admitted to our hospital with an intrarectal plastic bottle that he had inserted into his anus and later could not pull out without assistance. A plain computed tomography (CT) of the abdomen showed a foreign body in the rectum. Under caudal anesthesia, manual extraction was attempted, but the bottom of the plastic bottle was hidden by the rectal mucous membrane. We used a Yanagi vaginal speculum to softly compress the membrane, which facilitated safe removal of the inserted material. The foreign body was 16 cm in length and 6 cm in width. Caudal anesthesia is easy to perform at the emergency department, and the speculum that we used allows a good view of the rectal operating field.

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A 61-year-old man was admitted to hospital complaining of diarrhea. He was diagnosed as having lipoma of the sigmoid colon and referred to our hospital for resection. A day before visiting our hospital, the tumor prolapsed through the anus, which the patient reduced manually by himself. He complained of abdominal pain when he visited our hospital. We performed CT and diagnosed intussusception caused by the tumor. There was no evidence of obstruction or malignancy, and we performed endoscopic reduction. While waiting for the intestinal edema to resolve, the patient was maintained on only high-density liquid nutrition under hospitalization under close monitoring for a week. Then, we electively performed laparoscopy-assisted sigmoid colectomy. Microscopic findings showed proliferation of adipose cells in the submucosal layer. The tumor was diagnosed as a lipoma of the sigmoid colon.

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An 87-year-old man was admitted to our hospital with consciousness disturbance after a fall at home. Abdominal enhanced computed tomography demonstrated rupture of HCC in segment 6/7. Based on the presence of a right rib fracture, a diagnosis of traumatic rupture of hepatocellular carcinoma was established from the medical history. Although we tried to perform emergency angiography and transcatheter arterial embolization, we failed because of stenosis of the celiac artery secondary to arteriosclerosis. Therefore, we performed damage-control surgery by gauze packing, performed a 2^nd operation on day 4 after the first operation, and confirmed hemostasis from the hepatocellular carcinoma. Traumatic hepatocellular carcinoma is extremely rare, therefore, we report this case with a review of the literature.

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A 78-year-old female patient was admitted to our hospital with the chief complaint of hematemesis. She had liver cirrhosis, type C, and chronic renal failure. Upper gastrointestinal endoscopy was performed, which revealed bleeding from ruptured esophageal varices. The patient was therefore treated by endoscopic variceal ligation. Although her postoperative progress was good, bleeding from portal hypertensive gastropathy was observed on the 15th and 16th days, which was controlled by argon plasma coagulation therapy. Although it is comparatively rare, worsening of portal hypertensive gastropathy is a possible postoperative event after endoscopic variceal ligation for esophageal varices that can lead to hematemesis.

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A 79-year-old woman was admitted to our hospital because of loss of consciousness. The patient was in a shock state, and showed hypothermia, severe acidosis and blood coagulation disorder. CT was performed immediately, which suggested acute peritonitis due to sigmoid perforation. We decided to perform damage-control surgery （DCS） in the patient, and emergency operation was performed, which confirmed diffuse ischemic change and perforation of the sigmoid wall with massive fecal leakage. Since the pulsation of the inferior mesenteric artery and sigmoid artery could be well palpated, non-occlusive mesenteric ischemia (NOMI) was suggested as the main cause of bowel ischemia. Sigmoidectomy and tube colostomy were performed as the initial surgery. The patient showed signs of recovery after intensive care and underwent additional resection of the oral-side remnant colon and transverse colostomy as the secondary surgery. Finally, she was transferred to another hospital for rehabilitation training 44 days after the secondary surgery. The concept of DCS could contribute to a better prognosis of NOMI.

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An 84 year-old woman with hypertension, rheumatoid arthritis and reflux esophagitis who was under treatment with, among other drugs, celecoxib and lansoprazole, was referred to our hospital in September 2012 for diagnostic evaluation and treatment of diarrhea and melena. Abdominal examination revealed both rebound tenderness and muscle guarding. Computed tomography revealed ischemic change of the colorectal wall along the long segment, with free air and abscess formation in the retroperitoneum surrounding the descending and sigmoid colon. Under the suspected diagnosis of acute generalized peritonitis secondary to colonic penetration into the retroperitoneum caused by ischemic colitis, we performed emergency surgery, namely, Hartmann’s operation. Histopathology revealed the diagnosis of collagenous colitis. The postoperative course was uneventful, and no relapse of the gastrointestinal hemorrhage was observed until the 12-month follow-up after the surgery in the absence of treatment with either celecoxib or lansoprazole.

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There are two complications of gastrolithiasis : ileus and gastric ulcer. We encountered a case of gastric ulcer perforation after surgery for small bowel obstruction by a bezoar with hepatic portal venous gas （HPVG）. A 72-year-old man was admitted to our hospital with abdominal pain. Physical examination revealed tenderness and muscle guarding. A blood examination revealed metabolic acidosis. CT showed HPVG and distended small bowel with pneumatosis. An emergency laparotomy was performed. The small intestine was obstructed by a foreign body 170cm anal to the Treitz ligament. We conducted partial resection of the lesion. The foreign body was dark brown in color and suspected to be a gastric bezoar. We also felt other foreign bodies and removed them via stomach incision. Panperitonitis occurred and reoperation was performed on postoperative day 12. A distal gastrectomy was performed because of gastric perforation. An additional bezoar was removed from the terminal ileum. When bezoar ileus is diagnosed, the possibility of gastric ulcer formation must be borne in mind, and careful examination should be performed for the presence of other bezoars and ulcer perforation during and after the operation.

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A 37-year- old man presented with acute-onset abdominal pain and nausea. He was referred to our hospital with the diagnosis of ileus. Abdominal computed tomography showed a positive closed loop sign of the small intestine. Since we suspected strangulated ileus caused by an internal hernia, emergency laparoscopic surgery was performed. Laparoscopy revealed ileus due to transomental herniation. About a 30-cm segment of the small intestine had herniated through a hiatus of the greater omentum. Because the herniated small intestine showed no dark red discoloration, it was not resected. After the herniation was laparoscopically released, the greater omentum was cut and the hiatus of the greater omentum was opened. We therefore conclude that laparoscopic surgery is useful for the diagnosis of ileus caused by transomental herniation.

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We report a case of traumatic main pancreatic duct injury treated by endoscopic pancreatic duct drainage. Case: A 21-year-old male injured in a traffic accident was transferred to our hospital. An abdominal CT scan showed severe pancreatic injury, and injury to the main pancreatic duct was also suspected. Endoscopic retrograde pancreatography confirmed main pancreatic duct disruption. Endoscopic nasopancreatic drainage (ENPD) was successfully performed. The patient was treated conservatively, and his clinical course was almost uneventful. The management was changed from ENPD to endoscopic pancreatic stenting on day 24, and the patient was discharged on day 49 after admission to the hospital. Discussion：Main pancreatic duct injury is usually considered as an indication for surgery, however, recent studies have reported success of non-operative management for traumatic pancreatic duct disruption, e.g., stenting. There is still only limited experience with endoscopic management of traumatic pancreatic injury, however, this approach is expected to play an important role in the non-operative management of pancreatic injury.

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We report 3 cases of umbilical urachal sinus that were successfully treated by laparoscopic resection. A 22-year-old man, a 25-year-old man and a 21-year-old man presented to our hospital with clinical evidence of omphalitis. In all three cases, abdominal CT showed the findings of omphalitis and umbilical urachal remnants. After conservative treatment with antibiotics and drainage, we performed laparoscopic surgery using three ports. The first port was inserted via a Mc burney incision. We poured saline colored with indigo carmine into the bladder to visualize the confluence of the urachus and the bladder. The bladder side of the urachal remnant was interrupted twice by an intracorporeal knot-tying technique. We removed the umbilical urachal remnant completely, followed by umbilical plasty. The postoperative course was uneventful in all three cases and the hospital stay ranged from 4-6 days after the operation. Laparoscopic resection of the umbilical urachal remnant is useful as a less-invasive and cosmetically beneficial technique.

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