【Purpose】We elucidated the efficacy of preventive negative pressure wound therapy (NPWT) for lower gastrointestinal perforations with high incidence of surgical site infection (SSI). 【Subjects and Methods】We investigated 35 cases of lower gastrointestinal perforation or penetration in our hospital from April 2012 to August 2016. We divided the cases into two groups by whether preventive NPWT was performed or not. We evaluated the incidence of SSI, the days until the wound closure and discharge. 【Results】Among of 35 cases, NPWT as preventive measures (preventive NPWT group) comprised 9 cases (26%), the other cases (not preventive NPWT group)comprised 26 cases (74%). There were no significant differences in the following background characteristics, such as patient factors (sex, age, etc.), operative factors (degree of contamination in peritoneal cavity, operation time, etc.). One case of SSI occurred in the preventive NPWT group and 13 cases in the not preventive NPWT group, which pointed to a significantly low rate in the preventive NPWT group (P<0.05). There were no significant differences in the days until the wound closure and discharge. 【Conclusions】Preventive NPWT may be able to reduce the incidence of SSI.

With an aim to clarify reliable preoperative evaluation factors regarding reversibility of intestinal ischemia associated with an incarcerated groin hernia, we investigated cases of incarcerated groin hernia in our department. 【Methods】To enable a comparative study, 20 patients who underwent an emergency operation for incarcerated groin hernia were divided into the following 2 groups by their bowel resection approach: the resection group (n=8) and the non-resection group (n=12). 【Results】 Three items were found to be significantly different between the two groups: time from onset to hospital visit, serum CRP level, and CT value of the contents of incarcerated intestine. Logistic regression analysis revealed that the CT value of the contents of the incarcerated intestine was the only significant independent factor. The cut off value calculated using a receiver operating characteristic curve of CT values of the contents of the incarcerated intestine was 20 HU, with a sensitivity of 62.5% and a specificity of 91.7%. 【Conclusion】The CT value of the contents of an incarcerated intestine can be used to determine whether intestinal ischemia is reversible or not. It can also be a useful index as an auxiliary diagnosis when performing manual reduction or determining whether enterectomy should be performed during surgery.

【Background】Laparoscopic appendectomy (LA) for acute appendicitis is feasible, because of easy access to the vermiform appendix and irrigation of the peritoneal cavity. However some patients need to switch from LA to open surgery due to severe local inflammation. In this study, we assessed cases of acute appendicitis in which conversion from laparoscopic to open surgery was required. 【Method】We retrospectively analyzed 203 patients who underwent surgery for acute appendicitis at Shin-Yurigaoka General Hospital from January 2013 to September 2016. 【Result】One hundred seventy-three patients received LA, (age 42.2±19.4 (mean±SD) years, 94 male). Of these, 6 patients (age 65.8±13.7 years, 4 male) needed conversion to open surgery. Reasons for conversion were hemorrhage from an artery of the mesoappendix in one, and severe inflammation of the cecum in 5 patients. Preoperative computed tomography (CT) revealed ascites in 5 patients. Pathological diagnoses were gangrenous appendicitis in three, and phlegmonous appendicitis, carcinoma in adenoma and mucinous adenocarcinoma in one patient each. Surgical site infection developed in one patient, and no patient needed reoperation. 【Conclusion】Detection of ascites in preoperative CT is a significant predictor of the necessity for conversion from laparoscopic to open surgery. Severe local inflammation may be a risk factor of concomitant malignancy of the appendix.

Superior mesenteric artery occlusion is a critical disease with a high mortality rate. In this study, we retrospectively investigated the surgical outcome of patients with superior mesenteric artery occlusion. Twelve consecutive patients who underwent surgical treatment for superior mesenteric artery occlusion were reviewed. Four patients were men and eight patients were women, with a mean age of 74.5 years. Underlying disease included atrial fibrillation in eight, chronic renal failure on hemodialysis in six, and heart valve disease in five. Three patients developed occlusion at the root of the superior mesenteric artery (type A) , and the remaining nine patients developed occlusion at the periphery (type B). Eight patients (including type A: two, type B: six) underwent embolectomy, and consequently, five patients of type B could avoid bowel resection. The postoperative mortality rate was 25%. The serum lactate level of the bowel resection group was significantly higher than that of the no resection group (P=0.007). The mortality group showed a tendency toward lower PLT, higher AST, higher LDH, and higher CPK levels than the survival group, but there was no statistical significance. Our results suggest that high lactate level may serve as a clinical indicator for intestinal necrosis in patients with superior mesenteric artery occlusion.

A 49-year-old man underwent upper gastrointestinal series during a medical checkup in April 2016. From the night of the examination day he had abdominal pain, and visited our hospital on the next day. He was found to have peritoneal irritation and an elevated inflammatory response in blood tests. Abdominal CT showed that barium had collected inside a part of the small intestine with leakage of barium into the abdominal cavity. An emergency operation was performed with a diagnosis of gastrointestinal perforation. Laparotomy demonstrated perforation of the Meckel’s diverticulum located 50 cm oral from the terminal ileum. Partial resection of the small intestine including Meckel’s diverticulum was performed. Pathological examination showed inflammatory cell infiltration into the submucosa of Meckel’s diverticulum, with no evidence of ectopic mucosa. The perforation of the diverticulum in our case was thought to be caused by inflammation triggered by chemical stimulation from the barium.

A 65-year-old man was admitted to our hospital for acute severe epigastralgia. He was diagnosed as having superior mesenteric artery (SMA) occlusion based on the findings of an enhanced abdominal computed tomography (CT) scan. We performed endovascular treatment on the patient, and thereafter started close observation in the intensive care unit. After 18h, the patient developed acute pyrexia. We immediately performed an enhanced CT scan, which showed a necrotic lesion in the cecum. An emergency operation was performed, which confirmed diffuse ischemic changes in the cecal wall. Ileocecal resection and tube ileostomy were performed as an initial surgery. After 72h, the patient underwent ileostomy as a secondary surgery. Finally, he was discharged from the hospital 42 days after the secondary surgery. As endovascular treatment for acute SMA occlusion has a limitation in preventing bowel ischemia, close observation of the patient after the treatment is essential. When bowel ischemia occurs during the observation, a second-look surgery is effective to confirm the progression of the ischemia.

Endometriosis is a rare cause of intestinal obstruction. Herein, we report on a patient with intestinal obstruction secondary to endometriosis, diagnosed preoperatively based on her medical history and imaging findings, which was successfully resolved with laparoscopic surgery. A 38-year-old woman with an 18-year history of endometriosis had undergone excision of bilateral ovarian chocolate cysts at age 22. At age 37, she experienced two episodes of menstrual cycle-associated intestinal obstruction, treated with oral medication. One year after the last episode, she presented to our emergency outpatient clinic with abdominal pain and nausea. Intestinal obstruction was again diagnosed. On day10 of admission, laparoscopic surgery was performed for intestinal obstruction secondary to endometriosis. Intraoperatively, the patient was found to have adhesions between a left ovarian chocolate cyst and the ileum as well as intestinal endometriosis involving the ileum proximal to the adhesion site. Both lesions were possible causes of intestinal obstruction and were thus partially resected. The patient showed a favorable course and was discharged on postoperative day 5. Since it is thought that the indication of laparoscopic surgery may increase for the same disease from now on, we report this case with a review of the relevant literature.

A 46-year-old woman, who had received a living-donor renal transplant from her husband in September 2006, developed back pain in November 2015. Computed tomography (CT) revealed a retroperitoneal mass, which was diagnosed as extreme swelling of the para-aortic lymph nodes. Post-transplant lymphoproliferative disorder (PTLD) was suspected. In January 2016, the patient underwent a lymph node biopsy, which confirmed PTLD. Seven days later, she was admitted to our hospital with severe abdominal pain and vomiting. CT revealed further growth of the retroperitoneal mass, distension and edema of a segment of the jejunum, and ascites. We diagnosed edematous paralytic ileus resulting from acutely increased size of the retroperitoneal mass. The patient was hospitalized and received chemotherapy on the same day. On the fifth day of hospitalization, CT revealed recovery of the jejunum and slightly decreased tumor size. After that, the patient received six cycles of an R-CHOP regimen. She achieved complete remission 5 months later with no recurrence of PTLD. This very rare case of PTLD with secondary paralytic ileus was successfully treated with rapid chemotherapy. It is important to consider pathophysiological conditions in patients with PTLD and to treat promptly with chemotherapy based on the patient’s condition.

A 70-year-old woman who had chronic hypersensitivity, pneumonitis and Myasthenia Gravis had been taking prednisolone for a long time. Four years previously, she had undergone Hartmann surgery and descending colostomy because of perforation with a diverticulum in the sigmoid colon. Six months later, a double transverse colostomy was performed because of severe abscess formation around the descending colostomy. She was admitted to our hospital with left upper abdominal pain. The abdominal CT showed diverticulitis in the descending colostomy and free air under the left diaphragm. We diagnosed perforation and generalized peritonitis in the colon, and performed an emergency operation. A 5mm perforation had occurred in a diverticulum in the mesentery contralateral to the descending colon located between two stomas. Resection of the descending colon, and a descending colostomy closure were performed. As the reason for the perforation in this case, weakening of the descending colon wall was the potential cause because of the patients having taken prednisolone for a long time. Furthermore, feces passing through the transvers colostomy and flowing into the stenosed descending colon caused increasing pressure in the descending colon and this perforation. It was a very rare case of the perforation in the colon located between two stomas.

Case report: A 75-year-old man was transferred to our hospital with vomiting and disturbance of consciousness. Abdominal contrast-enhanced computed tomography revealed dilatation of the small intestine and poor contrast in the distal ileum. He was diagnosed as having strangulation ileus, and emergency surgery was performed. At 2m distal to the Treitz ligament, the small intestine was coiled around the other intestine and had strangled it. The color of the small intestine recovered following removal of the strangulation. However, an area of poor blood flow, 1cm in length, in the strangulated intestine and several dark spots in the serosa of its proximal dilated intestine were observed. The recovery of blood flow was insufficient despite warming the intestine with hot water. Thus, we performed indocyanine green fluorography. It revealed a contrast-enhanced effect from the vasa recta to the microvessels of the poor blood flow area. Seromusclar suture repair of the poor blood flow area was performed to avoid intestinal resection. After the operation, the patient required intensive care because of aspiration pneumonia. However, late-onset intestinal perforation did not occur, and he was discharged from the hospital 112 days after surgery.

This empirical report presents a rare case of complications post gastrostomy. A woman, eighty-six years old, underwent percutaneous endoscopic gastrostomy four years previously following a cerebral infarction. Recently, she had experienced repeated episodes in which her gastrostomy tube spontaneously dislocated due to abdominal pressure. Finally, her gastrostomy tube fell out and her stomach prolapsed outside her body during a coughing spell, requiring her to be taken to our hospital. The herniated stomach was exposed through the abdominal wall, and the mucosa was tinged slightly dark-red. This led us to suspect ischemia, but this was not supported by the computed tomography findings. Difficulties with manual reduction led us to perform emergency surgery. The prolapsed stomach was incarcerated in the herniated stomach itself. An incision was made in part of the abdominal wall, and then the incarceration was eliminated and the hernia repaired. The serosal color did not suggest any ischemic problem. Primary closure without gastrectomy was performed at the defect site, and the gastrostomy was rebuilt. It was possible for the patient to resume parenteral nutrition based on her good postoperative course. To the best of our knowledge, this is the first report of gastric prolapse as a complication following percutaneous endoscopic gastrostomy. We must consider the possibility of gastric prolapse in patients who experience spontaneous dislocation of a gastrostomy tube.

A 70-year-old woman complained of acute abdominal pain and was referred to the emergency room. On physical examination, the abdomen was distended and abdominal muscle guarding was present. Abdominal computed tomography demonstrated a high-density foreign body in the small bowel, intestinal dilatation extending to that location, and a small amount of free air. We diagnosed it as perforation peritonitis because of the foreign body, and an emergency laparotomy was performed. During surgery, a tiny small bowel perforation located 160 cm on the oral side of the terminal ileum was observed and a hard foreign body could be felt within the lumen. It was approximately 3 cm in length and had a sharp pointed end. We performed a partial resection of a 5-cm segment of the small bowel containing the foreign body. After the surgery, the foreign body turned out to be a jujube seed. The postoperative course was favorable, and she was discharged on the eighth postoperative day. So far only three cases of intestinal perforation because of a seed have been reported in Japan, and this was the first to be caused by a jujube seed. It is very important to take the dietary history of a patient into consideration.

An 81-year-old woman who had a right upper abdominal pain and mass went to a local hospital. A subcutaneous hematoma was suspected because she had been taking anticoagulant medicine. However, the abdominal mass gradually enlarged and became swollen. Therefore, she was referred to our hospital for further examination and treatment. Abdominal contrast-enhanced CT scan showed no evidence of extravasation, however the swelling of the mass gradually increased. The adnominal wall mass was drained. Intraoperative findings revealed that the abdominal wall mass consisted of an abscess and a thin piece of fish bone was extracted, furthermore, there was no sign of communication between the abscess and the abdominal cavity. After surgery, her persistent pain and inflammation improved steadily. An abdominal wall abscess due to a fish bone is rare, and in most reports has been treated with laparotomy or laparoscopic operation. We report herein on our experience with the difficult diagnosis of an abdominal wall abscess caused by a fish bone cured with only lavage and drainage procedure, with a discussion of the relevant literature.

【Case 1】 A 77-year-old woman with dementia was admitted to our hospital complaining of abdominal pain and vomiting. We performed an operation because we suspected intussusception or foreign body impaction of the small intestine based on a computed tomography (CT) scan. A shiitake mushroom, 7cm in diameter and retaining its original form, was found in the ileum about 150cm proximal from the cecum. 【Case 2】 A 59-year-old man was admitted to our hospital complaining of abdominal pain. We diagnosed food-induced ileus due to a shiitake mushroom based on his dietary history and CT scan. Because there were no findings suggesting ischemia and necrosis of the small intestine, a long tube was inserted for conservative treatment, and after that, his symptoms improved. There were eighteen previous cases in which Shiitake mushrooms caused food-induced ileus in Japan. Referring to the past and present cases, CT images and the dietary history of the patients are important for diagnosis, and it is necessary to consider the size of the mushrooms and laparotomy history of the patients in the treatment strategy.

The most frequent complication of a diverticular colon is diverticulitis. Colon diverticulitis occasionally leads to abscess or fistula formation, and drainage of the abscess or an operation is needed. We have experienced a case of a right inguinal and paracolic abscess following diverticulitis of the ascending colon. The patient was an 82-year-old male who was admitted to our hospital because of acute exacerbation of pulmonary fibrosis. During the course of the treatment with steroids, fever, right flank pain and right inguinal pain were seen. Computed tomography and ultrasonography showed a right inguinal subcutaneous abscess and a right paracolic abscess. Each abscess was treated with only percutaneous drainage and conservative treatment with antibiotics. We have to evaluate precisely any abscess and fistula following colon diverticulitis and perform appropriate treatment.

An 88-year-old woman complained of sudden abdominal pain and vomiting, but was observed because the symptom improved after defecation. On the following morning, she experienced obnubilation and cold sweat. Hypoglycemia was suspected by her home doctor and glucose injection improved her consciousness. She was transferred to our hospital in vital shock, and her abdomen was remarkably distended. Abdominal CT suggested massive ascites with free air, and her consciousness deteriorated. She underwent an emergency laparotomy with the diagnosis of gastrointestinal perforation and septic shock. On laparotomy, massive ascites with food debris was found and a 5cm perforation of the posterior wall of the upper body of the stomach was noted with extensive necrosis. She underwent a partial gastrectomy, peritoneal lavage and drainage. Postoperatively, despite intensive care, she could not recover from the state of shock, and died on the 8th hospital day with progressive disseminated intravascular coagulation (DIC). Spontaneous rupture of the stomach in adults is rare, with a dismal prognosis.

We report a new technique of biliary interventional radiology (IVR) for the treatment of intractable bile leakage approached from the fistula of the intraabdominal drainage route. A 72-year-old man was diagnosed as having hepatolithiasis and underwent a right anterior sectionectomy. After hepatectomy, a refractory intractable biliary fistula of the branch of the posterior segment was revealed. Since it was difficult to approach by either the percutaneous transhepatic or endoscopic transpapillary route, a biliary drainage tube was cannulated temporarily from the fistula of the intraabdominal drainage route and an internal fistula of the transected bile duct was successfully created under endoscopy. Bile leakage is one of the serious complications after hepatectomy and there is no standard treatment because of the potential clinical diversity. Our new technique of biliary IVR should be considered for the treatment of refractory intractable bile leakage because of its less invasive characteristics and simplicity.

A 64-year-old man whose medical history included psychogenetic disorder and Parkinson’s disease was referred to our hospital because of abdominal pain, vomitus and fever. Physical examination revealed abdominal defence. Plain abdominal X-ray examination showed a giant colonic gas shadow in the whole lower abdomen. Plain abdominal CT showed extension of the sigmoid colon. Therefore we diagnosed sigmoid volvulus and performed emergency surgery. Intraoperative findings revealed the existence of not only sigmoid volvulus but also cecal volvulus, so we performed Hartmann’s operation and ileocecal resection. The patient recovered once, but ileus recurred times, and 66 days after surgery, he died. Sigmoid volvulus complicated by cecal volvulus is very rare, and to the best of our knowledge no case has been reported in which both diseases occurred and the patient underwent the operation for them simultaneously. Both diseases often occur in elderly patients whose ADL has weakened. Abdominal X-ray and CT are effective for a diagnosis. Intestinal necrosis often occurs, and urgent diagnosis and treatment are required.

A 70-year-old male visited another hospital due to abdominal pain persisting for 1 month. Abdominal computed tomography (CT) revealed a linear high-attenuation structure (5cm) protruding from the lumen through the wall of the sigmoid colon. He was diagnosed as having colon penetration by a foreign body, and was referred to our hospital. There was only mild lower left abdominal tenderness. Blood tests showed no increase in inflammatory markers. Therefore, emergency surgery was considered unnecessary. Colonoscopy revealed a toothpick with both ends piercing the wall of the sigmoid colon. The toothpick was removed using grasping forceps. His subsequent course was favorable, and he was discharged on hospital day 3. He was unaware that he had accidentally ingested a toothpick. In Japan, gastrointestinal perforation/penetration by a fish bone has often been reported, but colorectal perforation/penetration by an accidentally ingested toothpick has been relatively rare. In addition, there have been only 4 reported patients who underwent colonoscopic removal of a toothpick. We report this patient along with a brief review of the literature.

Laparoscopic sigmoidectomy was performed for sigmoid colon cancer in a 66-year-old man. Oral intake was started on postoperative day (POD) 3, but he presented with fever and abdominal pain on POD 6. CT scan revealed thickness and edema of the ileal wall and no sign of anastomotic leakage. Thus, he was diagnosed as having colitis or local peritonitis, and antibiotics therapy was initiated. However, his symptoms did not improve, and a CT scan on POD 13 revealed multiple abscesses in the abdominal cavity. Drainage of a large abscess in the right lower abdomen was performed. His symptoms improved, but his fever spiked and abdominal pain relapsed on POD 19. A CT scan showed extensive increase in the density of mesenteric fat in spite of a decrease in abdominal abscesses, suggesting mesenteric panniculitis. Steroid therapy with prednisolone 50mg daily was initiated on POD 23, and his symptoms alleviated rapidly. Doses of prednisolone were gradually decreased, and the patient was discharged on POD 45.

A 72-year-old man was admitted to our hospital with appetite loss and vomiting. Gastroduodenal endoscopy and an enema study revealed an obstruction in the jejunum near the Treitz ligament. Contrast-enhanced computed tomography revealed a tumor in the jejunum. Preoperatively, the patient was diagnosed as having jejunal obstruction caused by jejunal cancer. The tumor originated in the jejunum at 5 cm distal from the Treitz ligament. We performed resection of the jejunum and anastomosis of the jejunum and duodenum. A histopathological study revealed a moderately differentiated tubular adenocarcinoma originating from a Heinrich type I aberrant pancreas in the jejunum. He received S-1 as adjuvant chemotherapy for 17 cycles. At present, 24 months after surgery, he is doing well without recurrence.

We report herein on two patients with an esophageal perforation and poor general condition successfully treated with T-tube drainage. Patient 1 was a 68-year-old man who presented with an intra-mediastinal esophageal rupture. He developed severe sepsis and underwent surgery 200 hours after the rupture onset. We performed T-tube drainage and deterging of the thoracic cavity. He was discharged 132 days after the onset of illness. Patient 2 was an 84-year-old man whose pulmonary condition was poor. He underwent T-tube drainage and deterging of the thoracic cavity 6 hours after the rupture onset. He was discharged 171 days after the onset of his illness. Drainage using a T-tube for esophageal perforation appears to be a minimally invasive and effective method for patients in any general condition.

Gastroscopy performed on a 66-year-old man in June 2015 revealed complete, circumferential, elevated mucosal hypertrophy of the antrum. He was referred to our hospital. Abdominal computed tomography revealed cystic lesions in the wall of the stomach. A gastric mucosal biopsy and endoscopic puncture aspiration cytology showed no malignant findings. The pancreatic type amylase and CA 19-9 levels were elevated in the cystic lesion. We suspected an ectopic pancreas causing pyloric stenosis. We scheduled surgery to treat the stenosis, but the cystic lesion grew rapidly and burst the day before surgery was scheduled. During surgery, we observed an old hematoma and hemorrhagic ascites in the abdominal cavity. We diagnosed rupture of the cystic lesion. Because there was a possibility of latent cancer in the ectopic pancreas, we performed a laparoscopy-assisted distal gastrectomy with lymph node dissection and washed the abdominal cavity. The pathological diagnosis was ectopic pancreas, Heinrich type Ⅱ. The patient made satisfactory progress. It is rare for an ectopic pancreas to cause pyloric stenosis and rupture with bleeding, as in our case. We should examine and treat carefully with emergency surgery in mind when an ectopic pancreas has a cystic lesion.

A 66-year-old man presented with a ruptured aneurysm of the posterior superior pancreaticoduodenal artery (PSPDA). He was admitted to our hospital with abdominal pain and vomiting. Angiography showed the PSPDA aneurysms were defined. We performed therapeutic coil embolization for the PSPDA aneurysms. Abdominal bloating and vomiting appeared on the ninth day after transarterial embolization (TAE), and an upper gastrointestinal examination revealed stenosis and transit obstruction associated with duodenal edema. A feeding tube was inserted and conservative treatment was continued. He developed fever and jaundice on the 27th day after TAE, diagnosed as acute cholangitis with blood test and abdominal contrast CT examination, and percutaneous transhepatic gallbladder drainage was performed. The cholangitis improved promptly. Duodenal narrowing slowly improved and the patient was discharged on day 52 after TAE. We believe that the historical and imagery diagnosis was segmental arterial mediolysis (SAM). After the angiogram the patient was complicated with delayed duodenal stenosis and cholangitis. This is a rare case with few previous reports. Additionally, TAE caused stenosis due to edema of the duodenum, it seems that if the edema reaches the papilla of Vater, biliary excretion disorder causes cholangitis.