【Objective】 We report our experience of endoscopic transgastric drainage (ETGD) for patients with postoperative pancreatic fistula (POPF). 【Patients and Method】 Data of a total of 304 patients who underwent pancreatectomy at our department during the 6-year period from 2009 to 2014 were analyzed. Endoscopic ultrasonography (EUS)-guided ETGD was performed. A nasal drainage tube and internal drainage tube were inserted. 【Result】 Of the 304 patients, 57(18.8%) developed POPF classified as Grade B/C. In 17 of these 57 patients, puncture for fluid collection was performed after removal of the drainage catheter. ETGD was carried out in 5 patients, because the percutaneous puncture route could not be clearly identified. ETGD was performed after a median interval of 19 days after the operation and the patients resumed oral intake a mean of 11 days after the ETGD. There were no complications associated with the puncture. The patients were discharged from our hospital an average of 34 days after the ETGD. None of the patients showed relapse of the POPF. 【Conclusion】 ETGD for POPF after pancreatectomy can be performed safely. This treatment seems useful for POPF, especially in patients in whom percutaneous drainage proves difficult.

Between 2009 and 2013, 882 patients underwent hepatectomy at our hospital；of these, 16 patients (1.8%) required reoperation for postoperative abdominal hemorrhage. We reviewed our experience of performing reoperation for postoperative hemorrhage developing after hepatectomy by analyzing the data of these 16 cases. The underlying diseases in the patients who required reoperation were as follows：liver cirrhosis (LC) (n＝4), hilar cholangiocarcinoma (n＝3), hepatocellular carcinoma (HCC) with chronic hepatitis (CH) (n＝3), HCC with LC (n＝2), and ‘others’(n＝4). The surgical procedures included right hepatectomy (n＝4), left hepatectomy (n＝3), living donor liver transplantation (LDLT) with a left liver graft (n＝3), and ‘others’ (n＝6). Reconstruction of an artery, portal vein and/or IVC was needed in 7 patients (44%). Reoperation was performed within 24 hours of the development of hemorrhage in 12 patients (75%). The sites of hemorrhage after hepatectomy included the arteriovenous plexus of the hilar plate or paraglissonean pedicle (n＝4), hepatic vein (n＝4), artery (n＝3), “unknown”(n＝3), resected surface of the liver parenchyma, right adrenal vein(1 case each). The site of postoperative hemorrhage after hepatectomy was often the main vessel processing unit and its surroundings; therefore, to avoid postoperative hemorrhage, it is important to further improve the surgical technique.

Introduction: Since 2012, we have been placing self-expandable metallic stents (SEMS) as the initial treatment in patients with obstructive colorectal cancer, to avoid emergency operations. We report our experience of preoperative SEMS placement as a bridge to surgery in patients with obstructive colorectal cancer. Subjects and Method: We carried out preoperative stent placement in a total of 31 patients with obstructive colorectal cancer between March 2012 and December 2014. Results: These 31 patients, consisting of 16 male and 15 female patients (mean age, 68 years), were recruited for the present study. The success rate of stent placement was 100％ (31/31), but one accidental case occurred however, an accident occurred during the stent placement. Three complications were observed after stent placement, of which two were represented by perforations: however, there may have been no relationship between the stent placement and the perforations. The third complication was deviation of the stent, not associated with any symptoms: in this patient, the stent was replaced. The mean length of the bridge to surgery was 16 days. The rate of laparoscopic surgery was 67.7％ (21/31). Primary anastomosis was performed in 90.3％ (28/31), and there were no cases of suture failures. Conclusion: Preoperative placement of a SEMS makes it possible for laparoscopic surgery to be performed in patients with obstructive colorectal cancer, allowing minimally invasive therapy and thereby improving the patients’ quality of life.

We analyzed the clinical data of 345 cases of acute abdomen in the elderly. The patients were all>80 years old and were hospitalized between April 2012 and March 2014. The comorbidities recorded among these patients were as follows：diabetes, 17.7%；hypertension, 60.6%；heart disease, 42.6%；respiratory disease, 13.6%；kidney disease, 9.3%；dementia, 27.0%. Among the patients who underwent operations, the operation times were longer and the bleeding was more severe in patients with respiratory diseases than in those without respiratory diseases. In all, 37 (37.0%) of the patients who underwent operations (OC group) and 35 (12.9%) of those who did not undergo any operation (NOC group) developed complications. Three cases (4.1%) of the OC group and 18 (6.6%) cases of the NOC group died at the hospital. Among all cases, 79.6% were discharged from the hospital. In the OC group, 17 cases had strangulation ileus, 14 had perforated bowel, and 10 had hiatus hernia. Careful postoperative care is essential in the OC group, as this group is at a high risk of complications. In the NOC group, 84 cases had bowel bleeding, 58 had cholangitis, adhesional ileus and others. Considering these findings, we would like to emphasize that physicians should be aware of the comorbidities and postoperative quality of life when managing patients>80 years old presenting with acute abdomen, especially while selecting cases for surgery.

Our hospital guidelines for the treatment of acute cholangitis (AC) are based on the Updated Tokyo Guidelines. We carry out emergency drainage for patients classified as having severe AC, drainage within 24 hours for patients classified as having moderate AC, and undertake conservative treatment for patients classified as having mild AC. If a case of mild AC is upgraded in severity at the time of the reevaluation, we perform drainage. We retrospectively analyzed the data of 145 patients who were diagnosed as having AC from April 2013 to August 2015, to evaluate the validity of our hospital guidelines for the treatment of AC during this period. The severity distribution of AC in our study patients was as follows：severe in 9.0%, moderately severe in 46.9%, and mild in 44.1%. The success rates of endoscopic biliary drainage in the severe and moderately severe AC cases were 92.3% and 100%, respectively. In one case of severe AC in which drainage by endoscopic retrograde cholangiopancreatography proved difficult, the drainage was accomplished by percutaneous transhepatic cholangio drainage. The average times to drainage in the patients with severe and moderate AC were 3.4 hours and 10.6 hours, respectively. The AC severity was upgraded to moderately severe at the time of the reevaluation in 10.9%(7/67) of cases initially classified as having mild AC, however, in all of these cases, endoscopic biliary drainage was accomplished and was associated with improvement. There were no cases of death attributable to worsening of the severity of AC. We concluded that the timings for biliary drainage in AC cases of varying severities specified in our hospital? guidelines are appropriate.

Antiplatelet therapy after coronary stent implantation is essential to prevent stent thrombosis. Drug-eluting stents (DES), which are reported to prevent restenosis, have become the preferred stents in patients undergoing percutaneous coronary intervention. Current guidelines recommend that dual antiplatelet therapy with aspirin and a thienopyridine should be administered for at least 12 months after implantation of a DES, followed by single antiplatelet therapy with aspirin for life. If antiplatelet therapy must be interrupted for any surgical procedure, aspirin and/or thienopyridine should be withdrawn 7 to 14 days before the procedure. Anticoagulant drugs are used mainly for patients with atrial fibrillation to prevent ischemic stroke. Although in the past, warfarin was the only available oral anticoagulant, novel oral anticoagulants (NOAC) are increasingly becoming available as alternate agents. The short half-life of the NOAC coupled with their rapid onset/offset of action should allow for a shorter period of drug cessation prior to surgical procedures. Since patients receiving antithrombotic drugs have diverse backgrounds, good cooperation must be ensured among specialists involved in the treatment of a case for assessing the risk of hemorrhage (or thrombosis) should antithrombotic therapy be continued (or withdrawn).

Stroke is one of the most important diseases that must be prevented in Japan, where there has been a robust increase in the number of aged people, and where the opportunities for initiating stroke patients on antithrombotic therapy are also increasing. Antithrombotic therapy consists of thrombolytic therapy, antiplatelet therapy, and anticoagulant therapy. In order to reduce the risk of intravenous thrombolysis with rt-PA, it is important to start the treatment promptly in compliance with the recommended protocols. Dual antiplatelet therapy should be avoided in patients with microbleeds on MRI-T2* images. In patients with a non-valvar atrial fibrillation, non-vitamin K antagonist oral anticoagulant therapy is advisable. It is important to tailor antithrombotic therapy to individual needs, taking into account the clinical background of each patient and also the ethnic characteristics of the Japanese people. In the event of serious complications such as intracranial hemorrhage or gastrointestinal bleeding, it is important to determine whether to continue the antithrombotic therapy or not. In order to assess the risks and benefits of the treatment objectively, clinically available indicators and scoring systems need to be developed.

Background: Endoscopic procedures beyond a simple biopsy were started in January 2013, in accordance with the guidelines for gastroenterological endoscopy in patients on antithrombotic therapy (issued in July 2012). Patients and Methods: Between January 2013 and October 2014, 730 patients on oral antithrombotic therapy underwent endoscopy (upper gastrointestinal endoscopy, 431 patients; lower gastrointestinal endoscopy, 299 patients). Of these 730 patients, the post-endoscopic rate of significant bleeding was investigated in 216 patients who underwent endoscopic procedures beyond a simple biopsy. Results: The average age was 74.1 years, and the male-to-female ratio was 2:1. The post-endoscopy bleeding rate was 0% (0/165) in patients who underwent biopsy, 0% (0/17) in patients who underwent endoscopic mucosal resection (EMR), and 30% (3/10) in patients who underwent endoscopic submucosal dissection (ESD). The post-endoscopy bleeding rate after gastric ESD was significantly higher in the patient group on oral antithrombotic medications than in that not taking such medications (P<0.0001). There were no cases of thromboembolism. Conclusion: Clinicians should be cautious when performing endoscopic procedures beyond a simple biopsy, in compliance with the above guidelines, as the rate of post-ESD bleeding is high in patients taking oral antithrombotic medications, including those who have been restarted on antithrombotic treatment.

Recently, the number of patients with neurovascular and/or cardiovascular diseases taking antithrombogenic drugs has increased because of aging of the population. The Clinical Endoscopic Guidelines for patients taking antithrombogenic therapy published by the Japan Gastroenterological Endoscopy Society (JGES) was revised in 2012. The new guideline was subdivided according to the types of antithrombogenic drugs. In the setting of emergent pancreatobiliary endoscopic treatment, biliary drainage is basically the most prioritized. In patients who are taking anticoagrant drugs or chenopyridine derivative, however, it may be impossible to choose a precut sphincterotomy even for cases with difficult cannulation, which must be one of the significant remaining issues.

Antiplatelet therapy (AT) is necessary for in patients undergoing vascular interventional radiology (IVR). Especially for patients undergoing vascular IVR using stent, AT is needed not only during the periprocedural period, but also for life after the periprocedural period. However, some of these patients require suspension of AT if a need for surgery or biopsy arises, and some studies have reported that ischemic events may occur after cessation or modification of the AT in patients who have undergone vascular IVR. Therefore, physicians ordering suspension of AT require enough understanding of the risk of cessation of AT and on how to suspend AT without increasing the risk of ischemic events. In this article, we document not only standard AT administration, but also update evidence on the administration of AT in patients who have undergone vascular IVR.

【Background】The aim of this study was to evaluate the outcome of emergent cholecystectomy in patients with acute cholecystitis on antithrombotic therapy (AT), and to determine the risk factors for intraoperative hemorrhage.【Patients and Methods】From January 2007 to August 2014, 257 patients underwent emergent cholecystectomy at our institution; out of these, 64 patients were receiving AT, while the remaining 193 patients were not. We evaluated the influence of AT on the intraoperative blood loss. 【Results】Only hospital stay was significant longer in the patient group on AT(P=0.030). The intraoperative blood loss and need for quantum of transfusion were not significantly different between the AT and non-AT groups. Multivariate analysis failed to identify AT as a significant risk factor for intraoperative blood loss of more than 50ml. None of the patients developed any hemorrhage or thrombotic complications.【Conclusion】Emergent cholecystectomy appears to be feasible in patients on AT.

Purpose: In this study, we carried out a retrospective evaluation of the safety of open cholecystectomy in patients with acute cholecystitis receiving antithrombotic therapy. Method: Between January 2007 and December 2015, 305 patients underwent open cholecystectomy for acute cholecystitis at our hospital. Of the 305 patients, 75 patients were receiving antithrombotic therapy(AT group), while the remaining 230 patients were not receiving antithrombotic therapy(non-AT group). The patient backgrounds and surgical outcomes were comparatively evaluated between the two groups. Results: The average age in the AT group was significantly higher than that in the non-AT group (74.5 vs. 68.0; P<0.01). There was no significant difference in the operation time, intraoperative blood loss, frequency of postoperative complications or hospital stay between the two groups. Conclusion: Open cholecystectomy for acute cholecystitis can be safely performed in patients receiving antithrombotic therapy.

We report a case of laparoscopic repair of an internal hernia through a defect of the broad ligament of the uterus associated with small obstruction. A 58-year-old woman presented to us with a history of continuous lower abdominal pain persisting for several days. Abdominal CT revealed herniation of the small bowel through a defect in the left broad ligament. After ensuring appropriate bowel decompression by introduction of a long naso-intestinal tube, we selected the laparoscopic approach for repair. Relief from the bowel obstruction was obtained without excision of the small intestine, and the defect was completely repaired by laparoscopic suturing. The postoperative recovery was uneventful and the patient was discharged within a few days. Internal herniation through a defect of the broad ligament of the uterus is a rare condition. However, if some characteristic CT findings are borne in mind, it is possible to make a definitive diagnosis preoperatively. Laparoscopic surgery is technically feasible and is considered to be an effective approach for internal hernias, such as hiatal hernia of herniation through a defect in the broad ligament of the uterus, under the condition of sufficient intestinal decompression by introduction of a long naso-intestinal tube.

Laparoscopic (assisted) appendectomy is not yet generally used in pregnant patients and the operative procedure is not yet standardized. We present three cases of pregnant women in whom laparoscopic appendectomy was performed.Case1: A 31-year-old woman at 22 weeks of gestation. The 12-mm camera port was placed 1 finger width above the umbilicus. The 5-mm trocar was inserted into the right flank region and the appendix was grasped directly with the forceps. The incision was then extended to 3cm and extracorporeal appendectomy was performed. Case 2: A 40-year-old woman at 30 weeks of gestation. The 12-mm camera port was placed 5cm above the umbilicus. The 5-mm ports were placed in the right hypochondriac and suprapubic regions. The suprapubic port was close to the uterus. Therefore, attention was reguired to preventing contact with the uterus. Case 3: A 30-year-old woman at 25 weeks of gestation. The 12-mm camera port was placed 5cm above the umbilicus. The 5-mm ports were placed in the right hypochondriac region and in the right lower quadrant of the abdomen. The operation was completed successfully without any contact with the uterus. We consider that the location of the ports in Case 3 can be deemed as the standard.

A 59-year-old man sustained bodily injury by a jet of air from an industrial air compressor directed accidentally at his anal region. He visited the emergency department of our hospital with the complaints of persistent abdominal distention and pain. Perforation of the lower digestive tract was suspected, because plain chest and abdominal radiographs, as well as abdominal computed tomography, showed a large amount of free air in the abdominal cavity. We performed semi-urgent surgery, as his abdominal symptoms were mild at the time of the initial diagnosis. A longitudinal lacerated wound measuring approximately 3 cm in length was found in the rectal anterior wall of the cephalad site at approximately 5 cm from the at a site approximately 5 cm cephalad to the abducted peritoneum. Leakage of stool was observed in the wound area. Hartmann's procedure was performed for segmental resection of the damaged large intestine and construction of an artificial anus. His postoperative progress was favorable and he was discharged on the 14th day after the procedure. The sigmoid colon is the most commonly reported site of intestinal perforation caused by compressed air；cases of multiple perforations and perforation at distant sites have also been reported. In this case, a perforating tear was found in the rectum. It is important to carefully localize the site of perforation across the entire lower digestive tract, a common site for barotrauma, taking into account the status of the intestinal tract, including the presence of stools and diverticula.

A 19-year-old man who had sustained injuries after falling accidentally from a height of 7 meters was brought to our critical care center. When he arrived at our center, he was lucid and his respiratory and circulatory statuses were stable. A whole-body CT revealed laceration of the lateral segment of the liver and active vascular contrast extravasation (AAST grade Ⅲ blunt liver injury), with fluid collection in the peritoneal cavity. Transcatheter arterial embolization (TAE) was performed for the hepatic injury, following which hemostasis was achieved. The patient developed high-grade fever on the 3rd hospital day, and a repeat abdominal CT revealed increased free air and a hematoma in the upper part of the abdomen. On the 4th hospital day, the patient’s abdominal pain worsened in severity and physical examination revealed signs of peritoneal irritation potentially suggestive of gastrointestinal perforation. Therefore, emergency laparotomy was performed. Since no damage to the abdominal hollow viscera was found, liver resection and drainage were performed. We speculate that in this case, the free air in the abdomen was found as a result of injury to the intrahepatic bile duct. Non-surgical pneumoperitoneum with biliary peritonitis, as in this case, is difficult to differentiate from perforation of the abdominal hollow viscera.

Afferent loop syndrome associated with remnant gastric cancer is extremely rare. A 72-year-old man who had undergone distal gastrectomy for a gastric ulcer 40 years earlier was admitted to the hospital complaining of nausea. Laboratory studies revealed hyperamylasemia, and abdominal CT showed a fluid-filled dilated afferent loop and mass lesion near the gastrojejunostomy. Emergency upper gastrointestinal endoscopic examination revealed a lesion suggestive of type 4 gastric cancer at the gastrojejunostomy. The afferent limb was obstructed due to the cancer, so that we could not insert a drainage tube into it. We diagnosed afferent loop syndrome associated with remnant gastric cancer, and performed percutaneous transhepatic gallbladder drainage(PTGBD); one week later, the drainage catheter was passed transpapillarily into the duodenum. The dilatation of the afferent loop improved, so that the patient was scheduled for an elective surgery for the remnant gastric cancer. PTGBD followed by elective surgery is one of the effective ways of treating afferent loop syndrome associated with remnant gastric cancer.

A 74-year-old man presented to our hospital complaining of back pain. He had previously undergone a descending aortic graft replacement and omentoplasty for an infected aneurysm. Abdominal plain radiography and computed tomography revealed a diaphragmatic hernia with prolapse of the stomach. The patient was placed under observation because he did not have any abdominal symptoms at the time. Three days after hospitalization, however, he started vomiting and was referred to the surgical department. He was diagnosed as having an incarcerated diaphragmatic hernia, and emergency laparotomy was performed. We found a dilated diaphragmatic aortic hiatus, with prolapse and incarceration of most of the stomach through the hiatus. We returned the herniated organ to the abdominal cavity and closed the diaphragmatic hernia hiatus. As the reason for the internal hernia in this case, it was considered that the stomach prolapsed into the left thorax through the aortic hiatus as it was retracted by the greater omentum surrounding the aortic graft. We should bear in mind the possibility of diaphragmatic hernia arising as a complication of omentoplasty.

A 43-year-old male patient visited our hospital with complaining of lower abdominal pain. Abdominal computed tomography revealed a swollen appendix with a fecalith. We diagnosed appendicitis, and performed laparoscopic appendectomy on the same day. The vermiform appendix was gangrenous, but showed no obvious tumor. However, postoperative histological examination revealed the presence of a goblet cell carcinoid (GCC) with subserosal invasion and lymphatic invasion. Considering the malignant features of the GCC and the possible risk of regional lymph node metastasis, we performed additional laparoscopic ileocecal resection with lymph node dissection. No residual tumor or lymph node metastasis was found in the additionally resected specimens. The postoperative course of the patient was uneventful. GCC is classified as a subtype of adenocarcinoma and has a high malignant potential, which is the reason we carried out additional resection, akin to the treatment of adenocarcinoma. We report this rare case of 2-stage laparoscopic surgery for GCC, with a review of the Japanese literature.

We report the case of a patient with a bezoar, in whom a retroperitoneal abscess developed secondary to duodenal perforation by the bezoar. An 80-year-old woman visited our hospital with about a 1-month history of fever and persistent anorexia. Abdominal CT revealed a retroperitoneal abscess and a sponge-like mass in the duodenum. Surgery was performed based on the diagnosis of retroperitoneal abscess secondary to duodenal perforation caused by the bezoar. The patient, however, eventually died of septic shock. Bezoars are concretions of foreign matter in the gastrointestinal tract that may rarely cause gastric ulcer or gastrointestinal obstruction. However, gastrointestinal perforation caused by a bezoar is rare. This case serves to emphasize that early treatment is important in patients diagnosed as having a bezoar, as the condition is associated with a risk of gastrointestinal perforation and sometimes fatal complications.

A 33-year-old man was transferred to our hospital with injuries sustained in a traffic accident. He suffered from hemorrhagic shock secondary to right renal injury and emergent nephrectomy was performed. Eighteen days after the operation, percutaneous drainage of a collection of abdominal fluid caused by bile leakage from the Luschka duct was performed. On day 27 after the operation, the serum total bilirubin level increased, and MRCP and ERC revealed severe stenosis of the distal bile duct. Thus, the patient was diagnosed as having traumatic bile duct stricture. By 16 days later, the serum total bilirubin decreased to the normal range, and ERC showed improvement of the stricture. The patient was discharged on postoperative day 79. In many cases, traumatic biliary stricture occurs secondary to rupture of the bile duct and the subsequent fibrotic process. However, transient edema of the bile duct wall was considered to be the cause of the stricture in our present case, because the stricture resolved with conservative (observation only) management.

A 27-year-old man with idiopathic thrombocytopenic purpura (ITP) was admitted to our hospital with a history of lower right abdominal pain and hematochezia. The patient was diagnosed as having ulcerative colitis (UC) by colonoscopy. He was initiated on conservative treatment, however, his condition proved to be treatment-resistant. In order to enhance the curability of UC and ITP, we performed laparoscopic-assisted total colectomy, ileal-anal anastomosis (IAA) and splenectomy. After the surgery, the blood platelet count rapidly increased. The postoperative course was favorable. We also present a review of the reported cases of UC with ITP in Japan.

Diaphragmatic hernia complicating pregnancy is rare and its coexistence with pancreatitis is even less common. Herein, we report the case of a 22-year-old primigravid female who presented with pancreatitis complicating Bochdalek hernia. The patient was transferred to our hospital from a neighborhood clinic at 32 weeks of gestation with the symptoms of nausea and abdominal pain and high serum amylase levels. Laboratory examinations and abdominal computed tomography revealed left diaphragmatic hernia and mild acute pancreatitis. We selected conservative management, For her 32 weeks of gestation and her overall condition was stable as the maternal and fetal conditions, as well as the overall general condition of the patient, were stable at 32 weeks of gestation and we expected fetal lung maturation. On day 2 of admission, she developed dyspnea. A plain chest X ray showed mediastinal shift to the right. Therefore, emergency surgery with diaphragmatic plasty and caesarian section were performed. After the operation, the patient’s respiratory condition recovered promptly and the serum amylase returned to normal range within 2 days. Her child The neonate also needed to be intubated because of neonatal respiratory distress syndrome. After treatment with pulmonary surfactant, however, the baby showed good recovery. Both the patient and her baby were discharged without any problems.

A 75-year-old female patient with no previous history of undergoing abdominal surgery visited our hospital complaining of abdominal pain since having her lunch. Enhanced computed tomography of the abdomen revealed a dilated segment of the small intestine posterior to the transverse colon and anterior to the duodenum. A diagnosis of internal hernia was made, and emergency laparotomy was performed. Laparotomy revealed a hernial orifice measuring 3 cm in diameter in the mesentery of the transverse colon, with a 15-cm segment of the jejunum incarcerated through it. As the incarcerated small intestine was not necrotic, the hernia orifice was repaired using a suture. Because transverse mesocolic hernia is rare, we report this case with some reference to the literature.

A 44-year-old female visited our hospital complaining of abdominal pain and morning nausea. An abdominal CT revealed the “whirl sign” and marked dilatation of the bowel segment near the liver. The proximal bowel segment, namely, the terminal ileum, was dilated, while the distal bowel segment, namely, the ascending colon, was collapsed. Therefore, we diagnosed the patient as having cecal volvulus and carried out an emergency operation. We performed laparoscopic detorsion with three trocars and fixed the ascending colon to the peritoneum of the lateral abdominal wall with absorbable sutures. After the surgery, the patient’s symptoms rapidly resolved, and she was discharged on postoperative day 3. Until date, 3 years since the surgery, there has been no evidence of recurrence. Thus, our emergency laparoscopic technique may be a viable strategy for treating adult cecal volvulus.

We report a case of intussusception in an adult secondary to ascending colon cancer. A 77-year-old woman with ascending colon cancer was admitted to our hospital for elective surgery. At admission, she was detected to have intussusception, which was easily reduced by the endoscopic approach. A day before the surgery, the patient complained of abdominal pain of sudden onset and vomiting. Abdominal computed tomography revealed multiple the “concentric ring sign” and diffuse mesenteric edema, indicating tumor-induced intussusception. Emergency surgery was performed. The surgical findings indicated tumor-induced intussusception of the ascending colon without intestinal ischemia or perforation；therefore, right hemicolectomy was performed. Her postoperative course was uneventful, and the patient was discharged on postoperative day 17.

Laparoscopic surgery is performed for many cases of acute abdomen； however, its application to trauma cases is limited. We present our experiences of laparoscopic surgery in two cases of traumatic rectal injury. In the first, an 80-year-old man fell down on a back scratcher, called a magonote in Japan, and presented with injuries to the rectum, prostate and bladder. Emergency suturing of the rectal lacerated wound was performed, with compression to stop the bleeding. A diagnostic laparoscopy following the rectal repair revealed no peritoneal damage. A loop ileostomy was created for proximal diversion of the fecal stream without laparotomy. On the 128th postoperative day, after the rectovesical fistula had closed spontaneously, the ileostomy was closed. In the second case, a 79-year-old man presented to us with rectal injury caused by an enema. An emergency diagnostic laparoscopy revealed no intra-abdominal organ injuries. A sigmoid colostomy was created for proximal fecal diversion without laparotomy. The patient’s postoperative course was uneventful. The colostomy was closed on the 86th postoperative day. Laparoscopic surgery is useful in some cases of abdominal trauma, such as patients with traumatic rectal injuries, who can be safely managed by diagnostic laparoscopy and diverting colostomy without the need for a laparotomy.

A 42-year-old woman, who was under outpatient treatment for schizophrenia at another hospital, was transported to our hospital by ambulance 105 minutes after she stabbed herself in the abdomen with a knife. Contrast-enhanced computed tomography (CT) suggested damage to the pancreatic head and to the region of the gastrointestinal tract from the gastric antrum to the duodenum. Emergency laparotomy was performed 255 minutes after the injury, which revealed that the tip of the knife had penetrated the duodenal bulb and parenchyma of the upper border of the pancreatic head (width：approximately 5 mm) and reached the ventral aspect of the vertebral body； therefore, gastroduodenectomy including the perforated site of the gastrointestinal tract was performed, with closure of the pancreatic head by suturing. In Japan, patients with abdominal stab wounds are only infrequently encountered by surgeons. In our patient reported herein, the knife was still in place at presentation, making detailed preoperative assessment difficult. However, treatment by meticulous surgery resulted in a favorable course of the patient.

A 68-year-old male patient visited our hospital complaining of right hypochondralgia and vomiting. The results of laboratory tests, abdominal ultrasonography and CT were consistent with the diagnosis of cholecystitis. The patient was admitted to the hospital for conservative management. On day 2 after admission, exacerbation of the cholecystitis was suspected and a percutaneous transhepatic gallbladder drainage (PTGBD) tube was inserted. The inflammatory reaction subsided within a few days, however, the volume of drainage from the PTGBD tube suddenly increased. Contrast medium injected into the PTGBD tube reached the pancreatic duct via the common bile duct and the amylase level in the PTGBD drainage fluid was elevated to 68600IU/L. Malfusion of the pancreaticobiliary ducts was suspected. Endoscopic ultrasonography revealed confluence of the common bile duct and pancreatic duct and incarceration of a cholelith in the common bile duct. A lithotomy was performed using endoscopic retrograde cholangiopancreatography; after this procedure, contrast medium injected into the PTGBD tube no longer reached the pancreatic duct and the amylase level in the PTGBD drainage fluid returned to the normal range. We concluded that the incarceration of the choledocholith in the common bile duct had caused regurgitation of pancreatic juice into the bile duct.

A 76-year-old female patient with von Recklinghausen disease was admitted to our hospital with a history of melena and anemia. She had suffered frequent episodes of melena and dizziness and received blood transfusion 14 times during the previous 4 years. Repeated upper/lower gastrointestinal endoscopies, capsule endoscopy and 99Tc scintigraphy failed to reveal any lesions in the gastrointestinal tract. While she was under observation, she developed another episode of melena. Abdominal CT revealed an enhancing mass in the abdomen measuring 40mm in diameter. On laparotomy, the tumor was found to be located at the jejunum about 50cm from the Treitz ligament. Partial resection of the small bowel was performed. The histopathological diagnosis was gastrointestinal stromal tumor (GIST) with a low risk rating. The melena subsided completely following the resection, and until now, 8 months since the surgery, there has been no evidence of relapse.

A 34-year-old woman with the complaint of abdominal pain was admitted to our hospital. Abdominal CT revealed findings suggestive of intussusception of the ileocecal portion of the intestine into the ascending colon. No tumor lesions were observed. Endoscopy revealed reddening of the surface of the leading part of the intussusception in the ascending colon. We considered that the intussusception was caused by inflammation or a submucosal tumor in the terminal ileum. We tried to reduce the intussusception by air insufflation via the endoscope, but were unsuccessful. Therefore, we performed emergency surgery, whereupon we discovered that the intussusception from the terminal ileum to the ascending colon had resolved itself. We observed no abnormal redness of the serosal surface of the ileum or colon. We found a cecal mass on palpation and performed an ileocecal resection. The tumor was diagnosed as a cavernous lymphangioma of the cecum. The patient's postoperative course was good and she was discharged on postoperative day 6. Laparoscopic observation alone is often inadequate to decide on the appropriate operative method. In particular, information is limited in emergency surgery, and careful consideration is required in choosing between emergency laparoscopic surgery and open surgery.

The patient was an 84-year-old woman who had undergone ileocecal resection and hernia repair for cecal carcinoma and right inguinal hernia two years earlier. One year after the operation, the inguinal hernia had recurred, however, because of the mild symptoms, the patient had been kept under observation alone a wait-and-watch policy had been adopted. In the history of present illness, as the hernia had remained incarcerated for a week and grown bigger, the patient was admitted to our hospital. Her right inguinal area had expanded, and contrast-enhanced abdominal CT revealed a tumor measuring 11cm in diameter with a high-density area. We performed emergency surgery under the tentative diagnosis of incarcerated inguinal hernia caused by a bleeding ovarian tumor. Right oophorectomy and hernia repair using PHS(Prolene Hernia System) were performed. On histopathological examination, the tumor cells were negative for CK7 and positive for CK20；on the basis of these findings, the tumor was diagnosed as an ovarian metastasis from the cecal cancer. To the best of our knowledge, based on an extensive search of the literature, this is the first case of incarcerated inguinal hernia caused by a metastatic ovarian cancer.