【Purpose】We investigated the cases of emergency surgery performed at our Department of Inflammatory Bowel Disease (IBD) Surgery. 【Patients】The department of IBD surgery was inaugurated at our hospital in April 2014. Since then until March 2017, we have undertaken surgery for 1,094 cases Of these, 197 (18.0％) were cases of emergency surgery, and were enrolled for this study. 【Results】1) Target diseases: We treated 102 patients with ulcerative colitis (UC), 63 with Crohn’s disease (CD), and 9 with Behcet’s disease. 2) UC cases: There were 73 cases (71.6％) of UC exacerbation and 29 (28.4％) cases of postoperative complications. In regard to the emergency surgical procedures performed for the cases of exacerbation, total colectomy, ileal J-pouch anal (canal) anastomosis, and ileostomy accounted for the majority. 3) CD cases: There were 47 (74.6％) cases of exacerbation and 16 (25.4％) cases of postoperative complications. In patients with exacerbation of the primary disease, intestinal lesions were noted in 31 (66.0％) cases and anal lesions in 16 (34.0％) cases. 【Conclusion】The frequency of emergency surgeries performed at the department of IBD surgery was high (18.0％).

Developing a peritoneal abscess or subcutaneous emphysema associated with colon cancer is a rare but lethal complication. We report herein on a case with sigmoid colon cancer associated with abscess formation attached to the retroperitoneum that developed into emphysema from the retroperitoneum to the abdominal and chest wall. A 52-year-old male with left lower abdominal pain and chillness was admitted to our hospital. An abdominal computed tomographic scan showed sigmoid cancer in contact with retroperitoneum. Emphysema was also observed in the retroperitoneal cavity which had spread to the abdominal and chest wall. We diagnosed sigmoid colon cancer complicated with a penetrating peritoneal abscess and then performed emergency surgery. When colon cancer penetrates to the retroperitoneum, retroperitoneal emphysema spreads through the esophageal hiatus to the mediastinum, and uncommonly develops to subcutaneous emphysema of the abdominal or chest wall. This patient played golf the day before admission. Thus we supposed that the swing motion of golf play led to rupture of the penetrating peritoneal abscess and developed into subcutaneous emphysema from the abdominal to the chest wall.

An 88-year-old man, who had a medical history of distal gastrectomy and Billroth-I reconstruction for a stomach ulcer at the age of 48 year old, was admitted to our hospital with sudden vomiting and abdominal pain. Contrast-enhanced CT scan revealed a whirl sign and ascites accumulation. We performed an emergency operation under the diagnosis of a strangulated ileus. The small intestine had twisted clockwise around the superior mesenteric artery with a milky white ascites discharge. The twisted small intestine and mesentery changed to milky white, but there was no finding of necrosis on the twisted intestine. The triglyceride level in the ascites was 1,192mg/dL and the patient was diagnosed as having a volvulus of the small intestine with chylous ascites. Strangulated ileus with chylous ascites is a rare disease and is often reported to occur after upper gastrointestinal surgery. It is considered that the weight loss after surgery and anatomical change after reconstruction may trigger a strangulated ileus with chylous ascites.

We report herein on a case of delayed small intestinal stenosis following blunt abdominal trauma treated with laparoscopy-assisted surgery. A 64-year-old male was transferred to our hospital due to a traffic accident. He was diagnosed as having a mediastinal hematoma caused by an internal thoracic arterial injury, rib fracture, with pulmonary and abdominal contusion. An emergency arterial embolization and mediastinal drainage operation were performed. Three weeks later, he experienced abdominal pain. CT revealed local stenosis of the small intestine. He was diagnosed as having ileus. A long tube was inserted and the patient underwent laparoscopic assisted adhesiolysis and small intestinal resection on the 29th day. Intraluminal stenosis of the ileum at 20cm proximal from the ileocecum was detected, and this portion was resected. The stenosis was caused by a direct small intestinal injury not by circulatory impairment. Almost all cases of stenosis of the small intestine are irreversible. We found laparoscopy to be useful in diagnosis and treatment when post-traumatic intestinal stenosis could not be definitively identified.

A 55-year-old woman presented with acute pain from around the umbilicus to the right lower abdomen. A CT scan showed the entire appendix was swollen, so we diagnosed acute appendicitis. We performed an emergency operation laparoscopically. The swollen appendix had adhered to the cecum. Ascites was discolored, and feces had adhered to the cecum wall after resecting the appendix. We diagnosed acute appenditis caused by cecum perforation, and performed an ileocecal resection. We diagnosed idiopathic cecum perforation by macroscopic and pathological findings from the excised specimen. In appendectomy we have to observe the cecum after resecting the appendix. It is possible that laparoscopic surgery is helpful to grasp any intraoperative change.

We experienced a case of strangulation obstruction caused by the right ureter as a cord-like structure. A 60-year-old female patient was diagnosed as having malignant melanoma of the vagina. She underwent total vaginectomy, extended hysterectomy and pelvic/inguinal lymph node dissection by gynecologists at our hospital. One and a half months later, the patient visited our emergency department with upper abdominal pain. Abdominal computed tomography suggested strangulation obstruction, and an emergency surgery was performed. Intraoperative findings revealed necrosis of the ileum, in which the necrotic region was approximately 30cm long, caused by strangulation by a cord-like structure on the anterior surface of the pelvis. The cord-like structure was first cut to release the strangulation, the necrotic portion of the intestine was resected and an anastomosis was performed. Finally, it turned out that the cord-like structure was the right ureter, therefore urinary tract reconstruction was carried out. We should be aware of the possibility that strangulation obstruction might be caused by a ureter when we examine the patient with strangulated obstruction who had previously undergone extended pelvic lymph node dissection.

A 52-year-old female experiencing abdominal pain presented to our hospital with a history of laparoscopic surgery for cholecystolithiasis and conservative therapy for small bowel obstruction. Her vital signs were normal; she had tenderness in the lower abdomen. Abdominal contrast computed tomography revealed massive ascites and a small bowel obstruction with caliber change. An emergency operation was performed under the suspected diagnosis of a strangulated small bowel obstruction. Massive ascites were observed. A 60×40 mm Meckel’s diverticulum was found on the ileum, approximately 50 cm proximal to the terminal ileum, with adhesion to the ileal mesentery on the anal side. It was assumed that the diverticulum had twisted with the ileum on the anal side. The diagnosis was small bowel obstruction caused by torsion of Meckel’s diverticulum. Partial resection of the ileum including the Meckel’s diverticulum was performed. Small bowel obstruction caused by the torsion of Meckel’s diverticulum is rare with a 0.3％-1.2％ occurrence rate. We report herein on our experience of a case of small bowel obstruction caused by the torsion of Meckel’s diverticulum and present a review of the relevant literature.

Mesenteric injuries caused by blunt abdominal trauma are relatively rare. However, blunt abdominal trauma sometimes causes peritoneal and abdominal visceral injuries. We have to make a diagnosis carefully in patients that have suffered such trauma. The above-mentioned injuries are often caused by high-energy trauma, such as falls and traffic accidents. In this case, we laparoscopically diagnosed intraperitoneal bleeding caused by a bull attack and performed hemostasis. A 54-year-old male was attacked by a bull at a stock farm. As a result, he suffered thoracicoabdominal pain and dyspnea. He was taken to our hospital. A computed tomography scan showed intraperitoneal bleeding, and a mesenteric injury was suspected. We performed a laparoscopic operation. The patient exhibited a good postoperative course. He was discharged on postoperative day 9. We experienced a case in which traumatic intraperitoneal bleeding was caused by a bull and was diagnosed laparoscopically. We report on our experience together with a review of the relevant literature.

We report herein on a case of spontaneous pneumoperitoneum. A 94-year old woman was referred to our hospital for workup and treatment of subdiaphragmic free gas which was incidentally found on a chest X-ray taken at a local hospital. She had no signs of peritonitis, no abdominal pain, and no fever. No abnormal values were found on laboratory examination, and a computed tomography scan revealed no significant findings other than free gas. Spontaneous pneumoperitoneum was suspected, and she was admitted to our hospital for careful follow up. Gastrointestinal contrast radiography and upper gastrointestinal endoscopy were performed on days 3 and 4, respectively, but no remarkable findings were detected. She was discharged on day 8 without morbidity. Free air in the abdominal cavity is an important finding which indicates gastrointestinal perforation and the need for immediate surgical intervention. However, although rare, it is necessary to consider spontaneous pneumoperitoneum as one of the differential diagnoses, when there are no signs of peritonitis. In such cases, physical evaluation is crucial to avoid unnecessary surgery.

The development of medical imaging technologies has improved the clinical diagnostic accuracy of gallbladder torsion with some typical findings. It is however still difficult to diagnose preoperatively in some cases. We report herein on a case of gallbladder torsion in an elderly woman whose preoperative diagnosis were moderate acute cholecystitis and review the clinical aspect of gallbladder torsion. A 90-year-old female was admitted to our hospital with a 2-day history of right abdominal pain. Clinical examination revealed tenderness in the right upper and lower quadrant area with a palpable round mass. Abdominal US and CT showed a distended, thick-walled gallbladder with gallstones, common bile duct stones and pericholecystic fluid. From these findings, we made the diagnosis of moderate acute cholecystitis and performed a laparoscopic cholecystectomy. Intra-operatively, the gallbladder that was necrotic and gangrenous had undergone a 360-degree anti-clockwise torsion. The postoperative course was favorable. Since some clinical and imaging findings are the same in acute cholecystitis and gall bladder torsion, it is important to have knowledge of the typical findings of gallbladder torsion and to make a preoperative diagnosos.

A 70-year-old man was admitted for abdominal pain and diarrhea. An abdominal CT scan showed a large fecal mass in the sigmoid colon with thinning of the wall and a little ascites in the pelvic space. An intestinal obstruction associated with colorectal cancer was suspected because the serum CEA level was elevated to 42.4ng/mL. Conservation therapy was started after symptoms were relieved followed defecation. Five days later, colorectal endoscopy showed severe inflammation and necrosis of the sigmoid colon and rectum, so an emergency operation was performed. Laparotomy showed necrosis of the sigmoid colon and rectum but no tumor was found and we performed Hartmann’s operation. The serum CEA level normalized to 1.8ng/mL on the 18th postoperative day and the patient was discharged on the 28th postoperative day. In the case of acute abdomen with an elevated serum CEA level, it is necessary to consider not only malignant disease but also ischemic colitis.

A 22-year-old man visited the emergency department of our hospital with abdominal pain and high fever. He had rebound tenderness in the left hypochondrium. A blood examination revealed an increased inflammatory response, and an abdominal computed tomography scan showed a cystic lesion near the ligament of Treitz. After admission, the symptoms gradually improved. However, the cystic lesion showed enlargement, leading to hydronephrosis, and surgical resection of the lesion was considered. However, complications were judged likely to develop, and conservative treatment was continued, leading to shrinkage of the lesion. Later, the cystic lesion in the mesojejunum was resected for a definitive diagnosis. The lesion was conclusively diagnosed as a mesenteric pseudocyst after histopathological examination. A mesenteric cyst is rare in patients in Japan, and there are few reports of pseudocysts in adults. With the use of a laparoscopic procedure, the operation could be performed without any damage to the mesenteric vessels and surrounding organs.

A 57-year-old woman and hepatitis C carrier had undergone eradication of Helicobacter pylori. She was transported to our hospital by ambulance with hematemesis and tarry stool in April 2015. She was diagnosed as having a hemorrhagic duodenal ulcer, and endoscopic hemostasis was performed. Primary hemostasis was achieved and conservative treatment was performed. During this treatment, rebleeding occurred which caused hemorrhagic shock on day 7 after admission, and emergency surgery was performed. Based on intraoperative findings, a pancreaticoduodenectomy (PD) was performed, and the patient was discharged 39 days after surgery. A limited operation tends to be selected for surgical treatment of a benign ulcer, but our case suggests that an extended operation aimed at total resection of the ulcer should be considered for some patients.

An 89-year-old woman was admitted to our hospital with lower abdominal pain and vomiting. She was diagnosed as having radiation enterocolitis, based on abdominal X-ray and computed tomography findings. She had a past history of a total hysterectomy followed by radiation therapy more than 27 years perviously. On hospital day 3, she developed a high fever and lower abdominal pain. Abdominal computed tomography revealed the balloon of the urethral catheter was outside the bladder. She was diagnosed as having intraperitoneal bladder perforation caused by the indwelling urethral catheter. Since abdominal pain with rebound tenderness was localized and gastrointestinal perforation could be ruled out, conservative treatment with urinary drainage and antibacterial chemotherapy was given, and her condition improved. Examination of the bladder using a cystoscope was performed, and she was diagnosed as having radiation cystitis. When we see a patient with acute abdomen who is fitted with an indwelling urethral catheter, bladder perforation could be a differential diagnosis.

A 68-year-old man with fever was diagnosed as having a liver abscess and sepsis. Two days after admission, disseminated intravascular coagulation (DIC) occurred with portal vein(PV) thrombosis and anticoagulant therapy was started. On the 11th day, he had hemobilia and gastrointestinal bleeding with a hepatic pseudoaneurysm, and he underwent a coil embolization. His condition improved following conservative therapy and he was transferred to another hospital on the 47th day after his arrival. According to the 9 reported cases of PV thrombosis with liver abscess in Japan, 6 cases (67％) had stem PV thrombosis and 3 cases (33％) had superior mesenteric vein(SMV) thrombosis which might be associated with a fatal prognosis, but all cases were alive. A serious liver abscess can cause PV thrombosis. PV thrombosis with liver abscess can be saved with multimodal therapy for comorbidity even if intestinal necrosis with SMV thrombosis has not occurred.

A man in his seventies was receiving chemotherapy for head and neck cancer. From the tenth day of the course he started to suffer from delayed gastric emptying which was treated by inserting a nasogastric tube. Ten days later, he suddenly developed severe dyspnea. The CT showed left-sided pyothorax, and drainage by a thoracic tube was initiated. Two days after, food residues were observed in the drainage bottle. Gastric endoscopy showed multiple ulcers at the fundus, and the contrast study revealed an intrathoracic leakage of the contrast agent. Suspecting a gastropleural fistula caused by a perforated gastric ulcer, we performed an emergency operation. Suture closure of the fistula and drainage of the left thorax were done.

A 75-year-old man with a history of a distal gastrectomy for gastric cancer two years previously presented with severe abdominal pain on the fifth day after starting a new chemotherapy regimen with paclitaxel plus ramucirumab due to the recurrence of peritonitis carcinomatosa. We diagnosed the patient as having panperitonitis due to a gastric perforation because a CT scan showed a thinning of the stomach anterior wall near the site of the gastro-jejunostomy anastomosis and presence of ascites and free air. Based on these findings an emergency operation was indicated. The intra-operative findings showed the omentum to be resected, the hepatic round ligament had become extremely short and the small bowel demonstrated adhesion due to inflammation. The perforation was repaired with a flap from the parietal peritoneum. The patient’s postoperative course was uneventful. We therefore consider the parietal peritoneum to be a useful alternative when the omentum, hepatic round ligament and small bowel are not available for the treatment of a perforation.

We describe herein two patients for whom laparoscopic surgery combined with intraoperative colonoscopic examination was performed for ascending colon diverticular hemorrhage. Both patients were diagnosed as having hemorrhage of the colon using contrast-enhanced CT. For the first case, progressive anemia and the CT finding of bleeding were observed after colonoscopic temporary hemostasis. We performed surgery because of difficulty in identification of the bleeding site with repeated colonoscopic examination. For the second case, surgery was performed because of hemorrhage, again after temporary hemostasis by IVR. In both patients, intraoperative colonoscopic examination confirmed that no hemorrhage remained in the colon after laparoscopic resection. Intraoperative colonoscopic examination can be useful during laparoscopic surgery for diverticular hemorrhage of the colon.

The patient was a 67-year-old male. He presented with abdominal distention and pain during radiotherapy for a cutaneous angiosarcoma of the head at our dermatology department. An abdominal CT scan showed thickening of the ileum wall and dilatation of the proximal small bowel extending from the thickened section. He was diagnosed as having bowel obstruction. Conservative treatment was then performed with an intestinal tube ; however, he subsequently underwent surgery because no improvement was observed. Laparoscopic observation of the abdominal cavity revealed an approximately 5-cm, dark red tumor in the ileum with dilatation of the proximal small bowel. Thus, this site was considered to be the origin of obstruction. The small bowel was partially resected through a minilaparotomy. The patient was diagnosed as having small bowel metastasis from a cutaneous angiosarcoma of the head based on the results of the histopathological tests. Small bowel metastasis from angiosarcomas is rare ; thus, we report on our case along with a review of the relevant literature.

A 29-year-old man, who had had a communication problem due to severe mental retardation, presented with acute circulatory failure and abdominal distension. He was diagnosed as having bowel obstruction and was referred to our hospital. An enhanced abdominal CT scan revealed an intra-abdominal cystic lesion beneath the lower abdominal wall, a lot of ascites without intraabdominal free air, and broad bowel dilatation without obvious obstruction. Hypermucoviscous Klebsiella pneumoniae was detected in the cystic lesion following percutaneous drainage. His final diagnosis was an infected urachal cyst with disseminated peritonitis and paralytic ileus. Though antibacterial therapy had a limited effect, he was successfully treated with laparoscopic resection of the whole urachal remnant and intraabdominal drainage. When we come across infections due to hypermucoviscous K. pneumoniae, we have to recognize the difficulty of its treatment. Furthermore, we have to take into consideration not only conservative approaches with antibiotics and percutaneous drainage, but also aggressive approaches including abscess fenestration or resection of infected organs.

We describe herein the application of component separation to treat abdominal wall hernia accompanied by infection and perforation of the small intestine. A 61-year-old man was admitted to a hospital with right lateral abdominal pain that was diagnosed as ureteral lithiasis. During transurethral urinary calculi removal, the ureter was damaged, and the procedure was switched to a laparotomy. The abdominal wall was opened postoperatively, and an abdominal wall hernia was repaired using mesh. However, the small intestine adhered to the mesh and became perforated to form a skin fistula, and the patient was then referred to us. We initially attempted preserving treatment such as an indwelling intestinal tube, negative pressure wound therapy, pouching management etc., but these were unsuccessful. We decided that removal of the infected mesh was necessary, along with partial resection of the small intestine, mesh removal, and abdominal wall reconstruction using component separation. An 8 × 6-cm defect that was found in the abdominal wall could only be repaired using component separation. This technique seems useful for treating abdominal wall hernias with large fascial defects accompanied by infection.

We report herein on two cases of gallstone ileus impacted in the duodenum. 【Patient 1】A 69-year-old woman was referred to our hospital evincing frequent vomiting. Abdominal CT revealed a cholecystoduodenal fistula and a gallstone impacted in the third part of the duodenum. Because her bowel obstruction could not be resolved with conservative therapy, a one-stage operation was performed in which the gallstone was moved to the ileum, and an incision was made in the ileum to extract the gallstone；this was followed by cholecystectomy, and fistula closure. 【Patient 2】A 69-year-old woman was referred to our hospital evincing symptoms of vomiting. She had a historical diagnosis of cholecystolithiasis in the past. Abdominal CT revealed a cholecystoduodenal fistula, with the gallstone impacted in the duodenal bulb. Three days after admission, a one-stage operation was performed, in which an incision was made in the fistula, and the gallstone was extracted through this incision；this was followed by cholecystectomy, closure of the fistula and gastrojejunostomy. These two patients showed good outcomes with a one-stage operations/procedures.

A man in his 60s was transferred to our emergency department for chest and abdominal bruises. He went horse riding after having a meal, and fell off the horse. His abdomen was rigid. Abdominal CT revealed free intraperitoneal gas, discontinuity in the anterior wall of the stomach, and occlusion of the left renal artery. Disseminated peritonitis due to traumatic gastric rupture was suspected, and emergency surgery was performed. Ascites in the peritoneal cavity was not clear, and there was a 5cm rupture from the anterior wall of the gastric body to the greater gastric curvature. This rupture was sutured and closed. Although the patient developed a perinephric abscess postoperatively, he recovered following drainage and was discharged 39 days after the surgery. While gastric ruptures are uncommon in abdominal injury, it occurs more frequently if a patient has a full stomach. Thus, a comprehensive medical consult should be performed to consider the possibility of gastric rupture for these cases.

Superior mesenteric arterial (SMA) embolisms have a poor-prognosis, and wide resection of the intestinal tract is often required due to intestinal necrosis that develops rapidly after the onset of the embolism. The case reported herein involved a 69-year-old male patient with a past history of untreated atrial fibrillation. He visited a physician with abdominal pain. Since a SMA embolism was suspected based on his CT findings, he was sent to the emergency room of our hospital approximately 5 hours after his visit with the physician. The abdominal wall was soft and did not exhibit a muscular response. Although the CT suggested a thrombus in the SMA main trunk, no findings to suggest intestinal necrosis were observed. We subsequently began thrombolysis treatment using an arterial infusion of a total of 720,000 urokinase units. After this treatment, we found a significant improvement in the size of the SMA, and the abdominal pain was completely ameliorated. The patient was discharged from the hospital on day 12 with a favorable prognosis, and no redevelopment of the SMA has occurred to date.

A 49-year-old man had undergone Direct Kugel repair for a right internal inguinal hernia 2 weeks previously. He displayed abdominal distension and was diagnosed as having an obstructive ileus derived from intestinal adhesion to the repaired right hernia site, and emergency laparoscopic surgery was performed. A defect was identified in the peritoneum of the right hernia site, where the small intestine had prolapsed into the preperitoneal cavity and strong adhesion with the mesh had occurred. The adherent parts were removed and the inguinal hernia was repaired again. As the small intestine and mesh could not be dissected, they were resected via a local laparotomy. Because the peritoneal injury during the first hernia repair operation may have triggered the defect, it is important to exfoliate the preperitoneal space carefully for prevention of such complications. Postoperative ileus after inguinal hernia repair is rare, but must be considered in the postoperative course, and an early diagnosis and surgical procedure are required when occurrence is suspected.

A 91-year-old woman consulted our hospital with abdominal distension. She was diagnosed as having a right obturator hernia with intestinal tract dilatation. Before the emergency operation, an ileus tube was inserted and decompression of the intestinal tract was achieved. After that laparoscopic surgery was performed safely. Obturator hernias often occur with intestinal dilatation in elderly women. Preoperative decompression via ileus tube insertion may provide a good intraperitoneal view, and contribute to the completion of laparoscopic surgery, which is considered to be minimally invasive.