It is sometimes difficult to diagnose acute appendicitis during pregnancy；moreover, appropriate treatment is required because premature delivery can occur due to the intraperitoneal contagion. Among the 25 pregnant women with appendicitis that we encountered during the 17-year period from 1998-2014, conservative treatment was undertaken in 9；of these, 2 who failed to respond to the conservative treatment required surgery appendectomy. In one of the patients, the baby was born prematurely. Appendectomy was conducted following the caesarean section in 2 of the 18 cases that underwent surgery. When the data were compared with those of the 184 cases of appendicitis not associated with pregnancy that received inpatient hospital care at our institute, no significant difference was observed in the number of days from symptom appearance to visiting the hospital, white blood cell count, serum CRP, body temperature, pulse, or the duration of treatment with antibiotics；on the other hand, the number of hospital days being significantly longer in the pregnant women with appendicitis. Delayed diagnosis/treatment of appendicitis during pregnancy is associated with a high risk of premature delivery, etc., and attention is required to determine the optimal methods for early diagnosis and prompt and appropriate treatment.

We attempted to identify factors that could predict the development of complications after emergency surgery in patients with acute cholecystitis. The medical records of 134 patients with acute cholecystitis who had undergone emergency surgery at our hospital between January 2010 and May 2014 were retrospectively reviewed. In all, 30 patients with complications were included in group A and 104 patients without complications were included in group B. The average length of hospital stay was 27.0 days in group A and 10.3 days in group B （P<0.001）. After performing a univariate analysis, a multivariate analysis was performed, which identified age ≥70 years (P=0.017), a past history of liver cirrhosis (P=0.031) and laparotomy (P=0.012) were independent risk factors for the development of postoperative complications. In patients ≥70 years of age, those with a past history of liver cirrhosis, and those with a history of having undergone laparotomy, it is particularly necessary to pay attention to the possible development of complications after emergency surgery for acute cholecystitis.

Superior mesenteric artery occlusion (SMA occlusion) is an uncommonly encountered abdominal emergency. We examined the data of 20 cases of SMA occlusion seen at our department between 1995 and 2012. The average age of the patients was 77 years (12 men, 8 women). Of the 20 patients, 19 (95%) had a past history of cardiovascular disease, and in 16 (80%), the diagnosis of SMA occlusion was made before the treatment. In regard to treatment, 16 patients underwent surgery, while 4 received thrombolytic therapy；1 patient required surgery after the thrombolytic therapy because of necrosis of the remaining bowel. There were 9 cases of in-hospital death (mortality rate：45%), including of 8 patients who had undergone surgery (mortality rate：50%), and 1 patient who had undergone thrombolytic therapy (mortality rate：25%). Second-look surgery was performed in 7 patients, of whom 2 required additional bowel resection and 1 died. On the other hand, in the 9 patients in whom no second-look surgery was performed, the mortality rate was high (78%) as compared to the group in which it was performed. In order to improve the prognosis of SMA occlusion, it is important to ensure that a second-look surgery is performed.

Objective: To evaluate whether the prognostic scoring system is appropriate for colonic diverticular perforation as well as colonic perforation of other etiologies. The scoring system for colonic diverticular perforation was also evaluated. 【Methods】 We retrospectively evaluated the data of 81 consecutive cases of colonic perforation at our institution. Patient information, laboratory results, perioperative information, and the Prognostic Scoring System data were compared between the 27 cases of diverticular perforation and 54 cases of colonic perforation of other etiologies. The data were also compared between the living and deceased surviving and non-surviving patients with diverticular perforation. 【Results】A statistically significant difference between the group with diverticular perforation and that with colonic perforation of other etiologies was observed only in the interval from onset to the hospital visit. Between the surviving and non-surviving patients with diverticular perforation, statistically significant differences were observed in the data on preoperative organ disorders, Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM), and the Mannheim peritonitis index. 【Conclusion】 The prognostic scoring system is applicable and useful for the evaluation of patients with colonic diverticular perforation in addition to those with colonic perforation of other etiologies.

We conducted a retrospective analysis of the clinicopathological findings, operative procedures, complications and prognosis in patients with perforated colorectal cancer. From January 2000 to December 2013, we performed surgery for 21 cases of perforated colorectal cancer. The mean age was 76 years (50-100 years). Perforation was observed at the tumor site in 12 cases, and proximal to the tumor-affected site in tumor in 9 cases. The perforation was labeled as a free perforation in 12 cases. Histologically, the disease was diagnosed as stage Ⅱ in 7 cases, stage Ⅲ in 9 cases, and stage Ⅳ in 5 cases. Tumor resection was performed in 18 cases, including 15 who underwent lymph node dissection (D2 or D3), and 3 who underwent palliative colostomy. The mortality rate was 4.8％, and the morbidity rate was 47.6％. The 5-year disease-specific survival rate was 75％. Recurrence occurred in 4 cases, and manifested as liver metastases in 3 cases, lung metastases in 2 cases, peritoneal dissemination in 1 case, and bone metastasis in 1 case. Therefore, it is believed that radical surgery with lymph node dissection contributes to improved prognosis in patients with perforated colorectal cancer, provided the patients can tolerate the operation.

We encountered three cases of gallstone ileus. All the patients came to our hospital with the complaints of abdominal pain and vomiting. Case 1: A 78-year-old man visited another hospital with abdominal symptoms. Abdominal CT revealed intestinal ileus caused by a gallstone and the patient was transferred to our hospital. We performed enterolithotomy alone for this patient. Case 2: A 69-year-old man visited our emergency room with the complaints of abdominal pain and vomiting and was found to have a cholecysto-duodenal fistula. CT revealed evidence of gallstone ileus. We treated this patient by enterolithotomy. After discharge, a careful examination on an outpatient basis revealed that the patient had a gallbladder carcinoma. Case 3: A 57-year-old woman complaining of vomiting and intermittent abdominal pain was referred to our hospital. CT revealed gallstone ileus, with one gallstone in the ileum and another in the gallbladder. We removed the gallstone in the ileum alone by laparotomy. On the 6th post admission day, the patient developed a recurrent gallstone ileus, and we undertook the same operation again.

A 72-year-old male patient who had undergone distal gastrectomy for gastric cancer after endoscopic submucosal dissection returned to our hospital with the complaints of fever and vomiting. Contrast-enhanced CT revealed intraperitoneal abdominal free air and an abscess. The diagnosis of major anastomotic failure was made, although a postoperative radiographic contrast study revealed no evidence of leakage. We performed transnasal drainage. Due to intermittent aspiration via the drainage tube, the abscess decreased in size and the patient resumed oral intake. He was discharged from the hospital after 47 days of admission. In many cases of major anastomotic failure, invasive surgical treatment is selected. However, we have reported a case of anastomotic failure that was successfully treated by a transnasal drainage tube without recourse to any invasive surgical procedure.

Herein, we report the case of a patient with sigmoid colon perforation who presented with pneumomediastinum and subcutaneous emphysema. An 88-year-old man was admitted to our hospital with a few days' history of abdominal distension and constipation. Chest-abdominal CT showed a tumor in the sigmoid colon, massive pneumoretroperitoneum, pneumomediastinum, and bilateral neck subcutaneous emphysema. Considering a preoperative diagnosis of peritonitis secondary to perforation of the sigmoid colon, we performed emergency surgery. Intraoperative observation revealed a perforation in the mesenteric side of the sigmoid colon. We performed Hartmann's operation with washing and drainage of the retroperitoneal space. The patient had a good postoperative course and was discharged from the hospital on the 48th postoperative day. Only 12 cases of colorectal perforation presenting with pneumomediastinum have been reported in Japan. We report a case of sigmoid colon perforation which presented with different types of emphysema air trapping.

A 92-year-old woman was admitted to our hospital with a diagnosis of intestinal obstruction. Abdominal CT showed a small-bowel loop incarcerated between the left pectineus muscle and left external obturator muscle. Under the diagnosis of intestinal obstruction due to incarceration of a left obturator hernia, surgery was performed using the laparoscopic approach. Intra operative observation showed a small bowel loop incarcerated in the left obturator foramen. The incarcerated small bowel segment was pushed out by the water pressure method, consisting of injection of normal saline through a Foley catheter^®. Since no irreversible changes were observed in the incarcerated small bowel loop, the hernial orifice was closed with a mesh sheet. The postoperative course was uneventful, and the patient was discharged on the 12th postoperative day. With the advances in the techniques of laparoscopic surgery, the laparoscopic approach has been increasingly adopted for the treatment of obturator hernia. We report a case of successful reduction of the strangulated intestinal segment using the water pressure method.

Early diagnosis and appropriate treatment of superior mesenteric artery (SMA) embolism remains a clinical challenge. Early revascularization, whether by the endovascular or surgical approach, holds the key to the best outcome. A 75-year-old man with permanent atrial fibrillation, diabetes mellitus and hypertension was admitted to our hospital with a history of acute abdominal pain. Enhanced CT revealed SMA embolism. We attempted endovascular therapy first, and succeeded in complete revascularization without any complications. Per-catheter thrombectomy (aspiration of the thrombus) is a promising option for the treatment of SMA embolism.

A case of an extensive idiopathic retroperitoneal abscess is presented. A 64-year-old man visited our hospital complaining of vomiting and fever. Abdominal contrast-enhanced computed tomography (CT) revealed the presence of retroperitoneal emphysema and a retroperitoneal abscess that extended bilaterally. The patient was initially treated conservatively, however, the retroperitoneal emphysema and abscess appeared to deteriorate. Percutaneous drainage of the abscess was performed, but the effect was insufficient. Therefore, laparotomy was performed for drainage. The cause of the retroperitoneal abscess was unclear. The patient was diagnosed as having an extensive idiopathic retroperitoneal abscess. After further antibiotic administration and drainage treatment, the patient was discharged from the hospital after four months of hospitalization.

A 79-year-old female was admitted with a history of acute-onset epigastralgia that began 2 days after she ate salmon. The serum CRP and peripheral-blood white blood cell count were markedly elevated. An MDCT scan revealed a linear high-density object causing perforation of the distal part of the duodenum. Laparotomy was performed, which revealed an edematous duodenal wall adjacent to the ligament of Treitz. Dissection of the oral portion of duodenum was performed；a fish bone, 3cm in length, was found protruding from the duodenal wall, which was readily removed, and the perforated duodenal wall sutured. The postoperative course was uneventful. The patient was discharged 10 days after the surgery. Perforation of the duodenum adjacent to the ligament of Treitz caused by an ingested fish bone is a rare occurrence. Urgent MDCT was helpful in the diagnosis and in the decision to perform emergency laparotomy. We believe that prompt surgical removal of the fish bone is necessary in such cases of duodenal perforation, before further complications such as punctures of the liver and/or pancreas develop.

When it was swallowed a foreign bodies accidentally, it is understood that if they are passed through gastric pylorus, it will have no trouble generally. Foreign bodies that are accidentally swallowed are generally expected to pass through the gastric pylorus and eventually extruded through the anus, and do not usually give rise to problems. We report the case of an old woman with dementia who accidentally swallowed a flexible plastic ball and developed small intestinal obstruction caused by the ball. Case：A 77-year-old woman with severe dementia was brought to the emergency department of our hospital with continuous vomiting. Gastrointestinal endoscopy revealed a foreign body in the 3rd part of the duodenum, which could, however, not be removed. After 3 days of observation, when the patient’s condition deteriorated, emergency surgery was performed. Intraoperatively, a flexible plastic ball was palpable in the jejunum, which was removed, without any need for intestinal resection. The postoperative course was uneventful and the patient was discharged. From the findings in this case, we believe that flexible plastic things should be carefully followed after they cross the pyloric ring. Moreover, considering the progressive aging of the society, accidental ingestion will be important problem in the elderly as well as in children.

A 56-year-old woman with ulcerative colitis was diagnosed as having superior mesenteric vein (SMV) thrombosis. Although extensive thrombus formation was seen in the SMV and portal vein, the patient only complained of mild abdominal pain. The patient was initiated on continuous heparin infusion. She developed persistent high-grade fever, and abdominal computed tomography revealed localized ileal edema, suggestive of intestinal necrosis. Therefore, partial resection of the ileum was performed 8 days after admission. Heparinization was restarted immediately after the operation. Four days later, thrombocytopenia was noted. Hence, argatroban was administered immediately for suspected heparin-induced thrombocytopenia (HIT), and the heparin infusion was withheld. The platelet count started to increase from day 5 after the discontinuation of heparin. HIT type Ⅱ was diagnosed based on the detection of HIT IgG. Herein, we report a case of HIT developing during anticoagulant treatment for SMV thrombosis.

A 61-year-old man who had undergone a right nephrectomy 7 years earlier for a right renal cell carcinoma was under clinical follow-up at the urology department of our hospital. In the history of present illness, the patient was admitted to our hospital's emergency department complaining of acute upper abdominal pain. CT was performed, because physical examination revealed tenderness in the epigastric region；the plain CT revealed a high-density region, believed to be caused by bleeding, in the gallbladder region and contrast-enhanced CT revealed early-phase staining of a tumor measuring 14mm in diameter. The patient was diagnosed as having bleeding from a gallbladder tumor. Open cholecystectomy was performed to treat the hemorrhagic gallbladder tumor. The resected gallbladder contained a dark red fluid composed of coagulated blood mixed with bile and a gallbladder tumor measuring 18mm in diameter. The tumor base could not be determined by the naked eye. Histopathological findings were consistent with a metastasis of clear cell carcinoma, which had been diagnosed in the past. We report this case here, because gallbladder metastases from renal cell carcinoma are hypervascular tumors and can therefore cause acute abdominal conditions such as biliary obstruction due to gallbladder bleeding or acute cholecystitis.

A 36-year-old pregnant woman with no previous history of laparotomy was admitted to our hospital for abdominal pain and vomiting in the 22nd week of pregnancy. Enhanced computed tomography revealed a closed loop with the beak sign in the right upper abdomen and a small amount of ascites. The patient was strongly suspected as having strangulated small bowel obstruction, and an emergency surgery was performed despite the pregnancy, since a cardiotocogram showed a reassuring fetal status. On laparotomy, a defect measuring approximately 25 mm in diameter was found in the mesentery of the transverse colon, and a part of the ileum (20 cm in length) was found to be incarcerated in this defect. The surgical diagnosis was transverse mesocolic hernia. The incarcerated segment of the ileum was reduced by traction. Since no ischemic injuries were observed in the ileum, no bowel resection was performed, and the defect in the transverse mesocolon was repaired by suturing. The postoperative courses of both the mother and fetus were uneventful, and the patient was discharged 15 days after the surgery.

We report a case of laparoscopic interval appendectomy in a patient with appendiceal endometriosis presenting as an appendiceal mass. A 38-year-old woman presented to us with a 7-day history of persistent lower abdominal pain. Physical examination revealed tenderness in the lower abdomen. Abdominal CT showed an appendiceal mass with small calcifications. Serum tumor marker levels were within their respective normal ranges. The patient was diagnosed as having acute appendicitis with an appendiceal mass. Conservative antibiotic therapy resulted in shrinkage of the appendiceal mass. Then, we performed laparoscopic interval appendectomy. During the operation, an enlargement and a bent structure at the tip of the appendix were seen. Histological examination revealed ectopic endometrial tissue in the serosal and muscle layer of the appendix. This disease is rare, but the possibility of appendiceal endometriosis must be borne in mind in women of the reproductive age group presenting with lower abdominal pain. Furthermore, it is considered to be important to search for ectopic endometriosis at other sites after making a definitive diagnosis of appendiceal endometriosis.

Obstructive shock is a clinical condition requiring quick diagnosis and treatment. However, it is not known whether the abdominal compartment syndrome (ACS) can cause obstructive shock. A 79-year-old man complaining of abdominal pain was brought to our hospital by ambulance; his respiratory status was poor and blood pressure was low. Physical examination revealed abdominal distention, and computed tomography showed marked dilatation of the small intestine and collapse of the inferior vena cava. The patient was diagnosed as having ACS associated with intestinal obstruction; decompressive laparotomy was performed in the emergency room, after which his breathing and blood pressure dramatically improved. No necrosis of any intestinal segment was observed. Adhesion was determined as the cause of the intestinal obstruction. ACS refers to a sustained increase of the intra-abdominal pressure, resulting in obstructive shock. In that case, ACS meeds decompressive laparotomy. The ACS was treated by decompressive laparotomy. However, intra-abdominal pressure measurement is difficult after a sudden change of the patient's condition, complicating the diagnosis. Moreover, intra-abdominal pressure is not measured in approximately half of the patients with ACS in Japan. Therefore, the appropriate time for laparotomy should be determined by measuring the intra-abdominal pressure regularly in patients at risk of development of ACS.

A 16-year-old male with congenital nephrogenic diabetes insipidus was diagnosed as having perforated appendicitis and panperitonitis and admitted for emergency surgery. His daily fluid intake was 10 liters. The operative diagnosis was gangrenous appendicitis, no perforation. After the operation, the patient was administered electrolytes every two hours. Maintenance fluid transfusion was undertaken at the rate of 80mL/hr. In addition, 5% dextrose equivalent for every two-hours' urine output was given for the replacement of free water loss. Postoperatively, no remarkable changes were observed in the serum electrolyte levels. Severe osmotic dehydration with potential neurologic sequelae can develop in congenital nephrogenic diabetes insipidus patients mainly infused with crystalloid fluids. The urine output and serum electrolyte levels must be closely monitored. Among the more favorable intravenous fluids is 5％ dextrose, and oral fluid intake should be resumed as soon as possible.

This was a 71-year-old man hospitalized for stroke, in whom an ileus tube was placed for the diagnosis of ileus made after he developed vomiting and abdominal distention. He responded to the conservative treatment, and since a careful examination revealed no organic lesions that could have caused the ileus, we diagnosed paralytic ileus caused by long-term ingestion of antipsychotic drugs. The ileus recurred eight days after the removal of the ileus tube, and the ileus tube was re-inserted. The following day, the drainage from the ileus tube became bloody, CT revealed evidence of bowel intussusception, and emergency surgery was performed. Intraoperatively, the patient was found to have an antegrade intussusception on the anal side of the jejunum, with the balloon of the ileus tube advancing 20 cm into the anal side of the jejunum by the ligament of Treitz. The intussusceptum had become necrotic and a 150-cm long segment of the jejunum was excised. No lesions were found in the excised specimen that could have caused the intussusception, and we made the diagnosis of bowel intussusception due to ileus tube detainment. We are reporting this case as a rare example of bowel intussusception caused by an ileus tube placed for paralytic ileus in a patient with no history of abdominal surgery.

The Fournier syndrome is a severe rapidly progressive necrotizing fasciitis of the perineum. We encountered a rectal cancer patient with Fournier gangrene. A 63-year-old man consulted our hospital for scrotal pain and swelling. Laboratory examination revealed that the WBC count (21900/mm3) and serum CRP level (45.6mg/dL) were elevated. Abdominal computed tomography showed wall thickening of the rectum and scrotum, and perirectal emphysema. We diagnosed the patient as having rectal cancer and Fournier gangrene. Emergency surgery was performed with debridement, lavage and drainage, and colostomy. From the 15th postoperative day, we attempted negative pressure wound therapy. Colonoscopic examination showed type 3 tumor in the lower rectum. On the 46th postoperative day, we performed laparoscopic Mile's operation (D2). Histopathology revealed a stage Ⅲ rectal cancer. The patient has discharged on the 122nd hospital day. It is considered very important to determine how a radical operation might be performed early in a rectal cancer patient with Fournier gangrene. The negative pressure closedown therapy was very effective for achieving an early operation in our case. Therefore, we report this case with a review of the literature.

A 35-year-old man was admitted to the hospital with a history of intermittent abdominal pain. Laboratory tests revealed slight increases of the white blood cell count and serum CRP. Abdominal computed tomography showed the target sign in the right lower abdomen and an ascending colon tumor, suggestive of intussusception. An ileo-colic intussusception was found at operation, with a tumor of the cecum. Ileocecal resection was performed after repositioning of the intussusceptum by the Hutchison technique. The postoperative course of the patient was uneventful. Histopathological examination of the resected specimen showed a lymphangioma of the cecum. Adult intussusception accounts for approximately 5％-10％ of all intussusceptions. Gastrointestinal lymphangioma is extremely rare, representing less than 0.1％ of all lymphangiomas. We reviewed the data of 33 patients with intussusception caused by intestinal lymphangioma, including the present patient, with a discussion of the Japanese literature.

An 89-year-old male patient with a history of prior gastric surgery presented to our emergency department with the complaints of abdominal pain and severe back pain. A contrast-enhanced CT (CECT) showed strangulated small intestinal obstruction. In addition, the inferior vena cava (IVC) was obstructed because of extramural compression by the dilated small bowel, and the anterior internal vertebral venous plexus was dilated. Emergency surgery was performed, with subsequent improvement of the abdominal pain and back pain. On the 9th day after surgery, a repeat CECT revealed that the compression of the IVC and dilated anterior internal vertebral venous plexus were no longer evident. In this case, the dilated anterior internal vertebral venous plexus secondary to the IVC obstruction caused the compression of the spinal cord and nerve roots, and consequently the severe back pain.

Torsion of the gallbladder is not a commonly encountered condition in clinical practice. We operated on six patients with torsion of the gallbladder：laparoscopic cholecystectomy in two patients and open cholecystectomy in four. The patients with torsion of the gallbladder were more elderly and thinner as compared to those with acute cholecystitis who underwent cholecystectomy during the same period at our department. The symptoms of torsion of the gallbladder were non-specific. In regard to the preoperative diagnosis, abdominal CT with MPR (multiplanar reconstruction) was useful for the diagnosis. The condition warrants emergent cholecystectomy as treatment. Laparoscopic cholecystectomy can be safely performed because of the relative simplicity of the required surgical procedure for the disease.

A 57-year-old male was admitted to the hospital for the treatment of pharyngeal and esophageal cancer. Preoperative examination revealed a rectal carcinoid. Therefore, after the operation for the pharyngeal and esophageal cancer, the patient underwent transanal excision (TAE) for the rectal carcinoid. The TAE was a full-thickness excision, and the defect was repaired. Although there were no signs of peritoneal irritation after the TAE, the WBC count and serum CRP were elevated. Abdominal computed tomography (CT) revealed retroperitoneal emphysema with gas in the retroperitoneum and mesenterium. The patient was treated conservatively with antibiotics and nil by mouth. However, as the vital signs became unstable, colostomy was performed on postoperative day 3. The patient recovered uneventfully after the colostomy. While postoperative complications of TAE are rare as compared to open surgery, caution should be exercised against the possible development of complications such as retroperitoneal emphysema after TAE.

We report two cases of prolapse of the small intestine through a ruptured vagina after hysterectomy. Case 1, a 33-year-old woman, underwent laparoscopic hysterectomy for ovarian cancer. Two months later, she visited our hospital with lower abdominal pain after sexual intercourse. Since the small intestine was eviscerated from the vagina, we performed emergency laparotomy. The small intestine was reduced into the peritoneal cavity, and the dehiscent vaginal cuff was repaired. We also found mesenterium commune. Case 2, a 53-year-old woman, underwent abdominal hysterectomy for uterine fibroids. Two months later, she visited our hospital with lower abdominal pain after evacuation. Since the small intestine was eviscerated from the vagina, we performed emergency laparotomy. The small intestine was reduced into the peritoneal cavity, and the dehiscent vaginal cuff was repaired. We found mesenterium commune in this case as well. Prolapse of the small intestine through a ruptured vagina after hysterectomy is a rare complication. However, it could cause intestinal obstruction and ischemic necrosis. Therefore, the possibility of this complication should be carefully considered in patients presenting with lower abdominal pain after hysterectomy.

The patient was a 21-year-old man, who was admitted to our hospital with injuries sustained in a vehicular accident. CT examination on admission showed left diaphragmatic injury. His consciousness level was altered, and he needed to be intubated, although his respiratory and circulatory dynamics were stable. Emergent endoscope-assisted repair of the traumatic diaphragmatic injury was performed. A large 10-cm defect was found in the left diaphragm, and the stomach was strangulated. No other injuries were found in the thorax or abdomen. The postoperative course was uneventful, and the patient, with diffuse axonal injury, was transferred to a rehabilitation hospital on the 26th hospital day. The most frequently used emergent operative approach is open thoracotomy or laparotomy. Endoscopic repair is usually adopted for elective operation；endoscopic surgery also has cosmetic advantages. However, our experience in the patient reported herein suggests that it is possible to treat traumatic diaphragmatic injury safely by the endoscopic approach in the acute phase.