【Background】 The number of foreign patients presenting to our hospital increased 10-fold in four years. 【Purpose】We elucidated the characteristics and problems of medical care regarding cases of acute abdomen in foreign patients.【Subjects and Method】 We investigated 132 foreign patients who received medical care in our hospital from April 2012 to March 2016. 【Result】 Chinese patients accounted for 29％. The most common reason was injury and the second was abdominal symptoms in 27 patients. The number of hospitalized patients caused by abdominal symptoms was 10. We revealed several problems such as difficulty in communication, unpaid medical bills, consideration of religious customs and the place where they hoped to receive treatment. 【Discussion】 Our hospital is not authorized by the Japan Medical Service Accreditation for International Patients (JMIP) and we often have trouble with communication in Chinese patients who only speak the Chinese language. In order to make a precise diagnosis of acute abdominal symptoms in foreign patients, we should employ a medical interpreter and prepare a manual immediately, and we must facilitate the cooperation with authorized hospitals by the JMIP.

Our institution possesses both emergency and critical care centers and a broad maternal-child medical care center, and so we are actively accepting seriously ill pregnant patients and nursing them at our emergency center, and from admission onward their treatment is carried out by a team of professionals from both the emergency and obstetric departments. Furthermore, the same team provides early response treatment for cases of critical obstetric hemorrhage in the hospital. Between April 2013 and September 2016, 52 pregnant or postpartum patients were treated at the emergency center, and of these, 29 were patients admitted to this hospital from other hospitals. There were 24 patients who underwent hemostatic interventions at the emergency center （of these, 20 cases involved IVR） and 3 who underwent emergency caesarean sections （of these, 2 cases were perimortem caesarean sections）. In this treatment system, true teamwork is essential which is not easy to build. Because of the need for a common workplace language and common understanding, routine off-the-job training is also indispensable. Through this kind of collaboration, we are working toward the elimination of preventable perinatal deaths.

Our hospital is a core hospital with 540 beds and an emergency medical center, which is in the Kohoku area, Shiga prefecture. Our hospital’s center is operated by not only full-time staff but also staff who are working as part-timers. In order to reduce incidents in such a mixed team, it is important not only to brush-up on technical skills but also to improve non-technical skills.

We established the Department of Regional General Medicine (RGM), not acting contrary to a “specialty” or “organ or system specific” department, but intended to attach importance to “geographic region specific” and “intra-regional conclusion.”Furthermore, we supported patients who want to live, to undergo cure and care and to die in their region. Though we are members of the Department of RGM, we simultaneously belong to the Departments of Internal Medicine or Surgery and primarily work as internists or surgeons. We discuss the medical and non-medical condition of all patients who have been admitted to the Departments of Internal Medicine and Surgery in the RGM conference held every working day morning under the same and common intention and interest, and control the patients’ information. Of 307 patients in the past one year who underwent primary care by internists of the Department of RGM and who were admitted to our hospital, 10 patients were transferred to the Department of Surgery/RGM. There were no incidents nor accidents in the treatments and explanation concerning these treatments to the patients and their relatives, no mistake in information control among various medical staff and non-medical co-workers. Of 297 patients who were not transferred to the Department of Surgery, 35 patients died, all of whom were thought not to be require any help from a surgeon. Through the daily morning RGM conference under the same and common intention and interest, we could established safe and conclusive treatment for our patients.

The safety climate in the aviation field is advanced and universal, with a systematic education system for safety methods well established. On the contrary, there is no standardized method of investigation, documentation, and dissemination for safety in the field of medicine, which depends on every single person or organization under the present circumstances. To maintain optimal performance in medicine requires focusing on non-technical skills involved in decision-making, team building and maintenance, workload management, situational awareness management, and communication, which are considered crucial in the aviation field. Although evidence is scarce, we consider non-technical skills a promising tool for a culture change in the field of medicine as well. We need to learn from our past accidents and incidents. Sharing the cause of an accident is the first step toward preventing a similar incident from occurring again. The Japan Medical Safety Research Organization was established recently to act as an accident prevention system in the field of medicine. The same mechanism in the aviation sector is known as the Japan Transport Safety Board (JTSB), and it has already long been in place. Aviation and medicine have many features in common. Safety is paramount in both fields. The field of medicine can consider the option of a quick way to enhance the safety climate of the profession by learning from its counterpart in aviation.

Implementing a nutrition protocol for a team of medical specialists working in the ICU to define the indications, goals, and methods to evaluate the efficacy of enteral and parenteral nutrition has been demonstrated to improve patient outcome. In the ICU of Chiba University Hospital, a group of specialists including doctors, nurses, dieticians, physiotherapists, and biomedical engineers have gathered to form a nutrition team. The team is in charge of updating and disseminating the nutrition protocol, and implementing tools such as the nutrition evaluation form, nutrition rounds, and enteral nutrition algorithm for nurses, to ensure adherence to the protocol. These efforts have contributed to achieving early start and fulfillment of nutrition in the ICU patients. The team approach has contributed to reducing nutrition related incidents and accidents by promoting close communication between the specialists to provide safe and adequate nutrition to patients of various backgrounds and pathologies.

A 53-year-old woman was admitted to the hospital with a one-month history of abdominal pain and diarrhea. The laboratory findings were normal. Abdominal computed tomography showed an intussusception in the terminal ileum and we performed emergency surgery. Laparotomy revealed an intussusception over a 10 cm length caused by an elastic soft tumor at the ileum about 20 cm proximal to the ileocecal valve. After reduction of the intussusception, partial resection of the small intestine was performed. The tumor was 90×30×35 mm and had bulged into the lumen of the small intestine. Histological features were consistent with a neurofibroma and immunohistochemistry was negative for KIT and DOG1. We report herein on a rare case of neurofibroma in the small intestine with intussusception, together with a review of the literature.

There are various types of surgical treatment for adult intestinal malrotation. We present two cases of adult intestinal malrotation that were treated surgically with intestinal tacking. Case 1: A 43-year-old man presented to our hospital with abdominal pain. A computed tomography (CT) scan suggested a midgut vovulus so he was taken to surgery. The patient had a midgut volvulus caused by intestinal malrotation. We corrected the volvulus and tacked the intestine. The patient was discharged on the 10th postoperative day. Case 2: A 73-year-old man had recurrent abdominal pain for 30 years. An abdominal CT scan revealed a midgut volvulus, which surgical exploration showed to have been caused by an intestinal malrotation. We tacked the intestine, similar to Case 1. The patient was discharged on the 8th postoperative day. Intestinal tacking has generally fallen out of favor for cases of adult intestinal malrotation, due to complications such as ileus and herniation. However, we continue to successfully perform this technique and we describe it herein along with a literature review.

We report herein on an adult case of idiopathic intussusception treated using single incision laparoscopy-assisted jejunum segmental resection. A 46-year-old woman who had repeated abdominal pain was referred to our department because abdominal enhanced computed tomography revealed she had an intussusception. We performed single incision laparoscopy-assisted jejunum segmental resection due to repeated intussusception at the same point. The resected specimen showed no tumor. We diagnosed the condition as an idiopathic intussusception. An adult case of idiopathic intussusception is very rare. In such cases, minimally invasive laparascopic surgery can be considered.

We report herein on a case of delayed splenic rupture. A 17-year-old man was transferred to our hospital with trauma following a traffic accident. Computed tomography (CT) revealed a splenic injury (TypeⅠb according to the classification of splenic injury by the Japanese Association for the Surgery of Trauma) and left ilium fracture. Since his vital signs were stable, the patient had been treated conservatively and remained event-free. However, he complained of left lower abdominal pain on the 3rd day of hospitalization. CT scan revealed a rupture of the spleen and hemoperitoneum. Transcatheter arterial embolization (TAE) was performed, but as the hemorrhage could not be controlled, an emergency laparotomy and splenectomy were performed. The postoperative course was uneventful and the patient was discharged on the 22nd postoperative day. Because conservative therapy is insufficient in some cases, including TAE like this case, preparations for emergency surgery must be always considered.

A 51-year-old male patient presented to the emergency room with sudden lower abdominal pain. Although tenderness was observed over the lower abdomen, he exhibited no signs of peritoneal irritation, and abdominal CT showed a thickened and dilated small intestinal wall and a small amount of ascites in Douglas’s pouch. When a CT scan was performed again for follow-up examination of aggravated abdominal pain, 6 hours after admission to the hospital, increased ascites and intraperitoneal free gas were confirmed. The patient was diagnosed as having perforation of the digestive tract, for which emergency surgery was performed 6 hours after admission. An approximately 6-mm, clear, perforated site was confirmed in the jejunum, approx. 20 cm distal to the Treitz ligament, and partial excision of the small intestine was performed, including the perforated site. The excised specimen showed no abnormal findings, except for a punched-out perforated site. The histopathological findings showed a small intestinal wall with full-thickness rupture, but no granulation or fibrosis, and thus it was diagnosed as idiopathic small intestinal perforation. The outcome was favorable, and the patient was discharged from the hospital on postoperative day 10. Since it is not possible to observe abnormalities other than abdominal pain in the early phase of small intestinal perforation, careful follow-up observation and reexamination should be performed for unexplained abdominal pain.

A 70-year-old man, who had a feeling of fullness and nausea from that morning, visited our hospital due to vomiting at midnight. Plain abdominal CT demonstrated a severely dilatated stomach in the right side abdomen, duodenal bulbus in the left upper abdomen, and a normal position spleen. He was thus admitted under a diagnosis of acute gastric volvulus. Anasogastric tube was inserted, after which his symptoms disappered. An upper gastrointestinal radiographic examination was performed. At the start of the examination, his stomach was in the normal position, but during the examination, organo-axial torsion was seen again. On the following morning, the shape of the stomach was in the normal position on x-ray imaging, so he started taking food again. Three days later, he vomited again and gastric volvulus recurred. After nasogastric tube drainage, an upper gastroscopy was performed, but there were no abnormal findings. On lower digestive tract radiographic examination, the left side of the transverse colon was elongated, and located to the upper-anterior side of the stomach. Laxity of the gastrosplenic ligament and gastrocolic ligament was suspected. We made a diagnosis of acute organo-axial gastric volvulus with transverse colon elongation. We report herein on a case of acute organo-axial gastric volvulus with transverse colon elongation, succesfully treated with gastropexy and partial resection of the left side transverse colon.

A 53-year-old man with a 7-hour history of abdominal pain presented to the emergency room. On admission, he showed severe tenderness, rebound tenderness, and muscle guarding in the left side of the abdomen. Abdominal computed tomography (CT) revealed free air, ascites, and irregular wall thickness in the left side of the small intestine. Emergency surgery was performed after the patient was diagnosed as having a small intestinal perforation because of a tumor. During surgery, irregular wall thickness and perforation were observed in the small intestine. A resection of the small intestine was performed. The patient was diagnosed as having intestinal T-cell lymphoma and was discharged without complication. He underwent chemotherapy and autologous peripheral blood stem cell transplantation at another hospital. CT revealed complete remission. However, 4 years 2 months after the surgery, the tumor recurred at the lymph nodes of his neck. The patient died 4 years 6 months after the surgery, despite chemotherapy, because of lymphoma infiltration of the central nervous system and respiratory failure.

A 76-year-old woman was injured in a traffic accident and was diagnosed as having hemorrhagic shock due to injury to her diaphragm, liver, and kidney, and fractures of the pelvis, left femur, right tibia, and fibula. She was transported to our hospital where she underwent external fixation for her left femoral and pelvic fracture on day 1 and an open reduction and internal fixation for the pelvic fracture on day 7. Her general condition worsened on day 11 with leakage of fecal fluid from the pelvic drain. Following a laparotomy, we performed open abdominal management (OAM) with vacuum packing closure (VPC) under the diagnosis of a small intestinal perforation. On day 14, because of drainage failure, we changed from VPC to vacuum assisted closure （VAC）. Although we performed anastomosis of the intestinal tract on day 17, she underwent an ileostomy for postoperative suture failure on day 22. VAC was discontinued on day 53, and she was transferred on day 125. Drainage failure observed in cases of OAM necessitates changing from VPC to VAC.

We report herein on an unusual case of pyometra, an intrauterine pus collection, which presented as a strangulated inguinal hernia. An 88-year-old woman with a high fever and swelling of the right inguinal region went to her family physician who suspected the presence of a strangulated inguinal hernia and referred her to our hospital. Physical examination revealed right inguinal swelling with pain and redness, but no tenderness in the abdomen. Laboratory findings were unremarkable except an elevated level of C-reactive protein and an increased white blood cell count. Enhanced computerized tomography （CT） showed an abscess 6cm in diameter in the right pelvis and another which was 8cm in the right inguinal region. There was also communication between the two abscesses and a fistula in the retroperitoneum cavity. We made the diagnosis of a perforation of pyometra into the retroperitoneal cavity, which spread into the inguinal region. Drainage of both abscesses was conducted and bacteriological cultures were positive for Streptococcus constellatus. The post-drainage course was good, and the patient was discharged without the necessity for a hysterectomy.

Intussusception in adults is said to be caused by organic lesions, and is most commonly attributed to malignant tumors. We report our experience of a case of appendiceal submucosal abscess that was difficult to distinguish from a malignant tumor. The case subject was an 18-year-old female who consulted our hospital for the chief complaint of epigastric pain, vomiting, and fever from several days earlier. Computed tomography (CT) revealed pseudo-kidney signs with ileocecal intussusception in the ascending colon. There were no clear tumors or abscesses observed. Intussusception was diagnosed, and emergency surgery was performed. Intraoperative findings revealed intussusception of the ileocecum region, cecum, and appendix, identified as cecal-colonic intussusception. Macroscopic findings revealed a neoplastic lesion in the cecum, with mesenteric lymph node swelling, and thus under the suspicion of cecal cancer, single-port laparoscopic ileocecal resection＋D2 lymph node dissection was performed. Histopathological findings led to the diagnosis of an appendiceal submucosal abscess. In Japan, there are 3 reported cases of adult intussusception caused by appendicitis. Although there are few reports of intussusception with appendiceal submucosal abscess, in adult onset intussusception presenting with signs of infection such as fever, diagnosis and treatment should be performed with an appendiceal submucosal abscess in mind.

A 79-year-old female was referred to our hospital under a diagnosis of small bowel obstruction (SBO) with severe epigastralgia. She also had dementia and had previously undergone surgery to insert a lumboperitoneal (L-P) shunt. Enhanced computed tomography could not confirm the location of the obstruction and ischemic lesions, but did identify a foreign body in the left side of the small intestine. Considering that it might be an intestinal tract perforation and thus vulnerable to central nerve infection through the L-P shunt, emergency surgery proceeded. However, we were unable to identify the cause of the SBO via laparoscopy, so an open laparotomy was prepared. Close examination of the abdominal cavity revealed an edematous and reddish small bowel with a foreign body and a lesion at the ileum. The lesion was opened, the foreign body was removed, and the lesion was repaired. The foreign body was identified as a press-through package (PTP). The postoperative course was uneventful without L-P shunt-related encephalopathy, and she was discharged on postoperative day 15. Several gastrointestinal perforations caused by PTP have been reported. Acute abdominal symptoms should be carefully assessed when patients already have a device placed in the abdominal cavity.

A 79-year-old man with a history of an open procedure for right hemicolectomy had been taking warfarin potassium for atrial fibrillations. He was seen for the chief complaint of sudden pain in the right hypochondriac region and abdominal computed tomography imaging revealed a swollen gallbladder with cervical calculi and a surrounding contrast effect indicating hemorrhage. He was diagnosed as having hemorrhagic cholecystitis with intraabdominal hemorrhage. In accordance with the 2013 Tokyo Guidelines for the management of acute cholangitis and cholecystitis, an emergency laparoscopic cholecystectomy was performed. Although a hematoma was found between the gallbladder and an adherent greater omentum, no perforation was seen in the gallbladder itself. Adhesions around the cervix of the gallbladder could be released and the cholecystectomy was completed under laparoscopy. We report on this case as an instance in which an emergency laparoscopic cholecystectomy could be done for hemorrhagic cholecystitis even under adverse conditions such as history of epigastrium laparotomy and anticoagulant therapy.

Recently, damage control surgery has found a wide application in a variety of situations. We report herein on a case of unrepairable traumatic gastrointestinal tract injury for which we applied damage control surgery. An 84-year-old man was transferred to our hospital with injuries sustained in a car crash. He had a previous medical history of surgical procedures including gastrectomy and hepatectomy. On arrival, the patient was in shock, and an abdominal enhanced computed tomography scan demonstrated intraperitoneal free air at the epigastric region. An emergency laparotomy was performed. On laparotomy, the Billroth-Ⅱ fashioned gastro-jejunal anastomosis was ruptured. Because of hemodynamic instability and unrepairable injury, we undertook damage control surgery without primary reconstruction. The ruptured anastomosis was transected and the distal stump of the remnant stomach was closed by suturing. The stump of the jejunum was constructed into external fistulas. After the operation, the patient slowly recovered under strict management of nutrition. After improvement of his condition, we performed a second-look operation for reconstruction of the gastrointestinal tract. In conclusion, damage control surgery is a feasible and successful approach for the management of at-risk and unstable patients.

Although laparoscopic appendectomy (LA) has been widely practiced in Japan as a safe and beneficial procedure for the treatment of acute appendicitis, LA in pregnancy still remains controversial especially in the case of complicated appendicitis. We experienced a case of laparoscopic appendectomy for the acute appendicitis in a patient in her 26th week of pregnancy. The chief complaint was right lower quadrant pain. Abdominal CT confirmed a swollen appendix without any sign of perforation including ascites or free air. We decided to perform laparoscopic surgery based on the wide field of vision, less invasion, cosmetic aspect, and early ambulation after surgery. Laparoscope revealed a perforated appendix and periappendicular abscess. Through careful and appropriate positioning of the trocar, we completed the operation safely. Although she temporarily developed signs suggesting threatened premature delivery during the perioperative period, she was delivered of a healthy baby in her 40th week without complications under obstetrical management. Although the indication of LA for complicated cases of appendicitis should be strictly considered, LA could be beneficial and safely performed also in pregnancy．

A 74-year-old woman visited another orthopedics hospital after falling over at home and was diagnosed as having a fractured right rib. The patient was instructed to rest at home with conservative treatment, but experienced gradual decline in her activities of daily living. Eighteen days after the fall, she was readmitted to the orthopedics hospital with difficulty in breathing. She underwent chest radiography, which revealed several abnormalities and was thus referred to the emergency department of our hospital, where she was diagnosed, based on chest X-ray findings, as having pleural effusion, blunt lung trauma, abnormal intestinal gas in the right intrathoracic area and left-sided deviation of the trachea. Computed tomography showed herniation of the small intestine into the right thoracic cavity. The patient was diagnosed as having a right traumatic diaphragmatic hernia and an immediate operation was performed. We found a 4-cm long tear in the right diaphragm. The small intestine was pulled back intraperitoneally and the diaphragmatic tear was sutured. She finally recovered and was discharged on the fifteenth hospital day.

An 83-year-old male with no past surgical history of the abdomen sought medical attention at a nearby clinic with the chief complaint of abdominal pain, which lead to a diagnosis of bowel obstruction and was referred to our hospital. An abdominal CT scan revealed that the diameter of the small intestine narrowed acutely in the right lower abdominal quadrant. Considering all possible causes, an internal hernia was suspected to be the primary cause of the bowel obstruction and an emergency operation was performed. Upon laparotomy, a part of the ilium was found to be incarcerated within the para-ascending colic fossa. The herniated ilium was restored and the hernia sac was opened. After careful inspection there was no necrosis of the ilium, thus no excision was performed. A case of internal hernia in the paracolic gutter of the ascending colon is rare. CT imaging features are therefore little known and can make the diagnosis challenging. After taking prior reported cases as well as our case into account, we would like to report that there were two interesting features on CT imaging (1. Incarcerated intestine was shown at the lateral and dorsal area of ascending colon; and 2. Displacement of the ascending colon toward the medial aspect) which could be important for the diagnosis of this situation.

We report herein on a case of mucinous cystadenocarcinoma （MCC） in the pancreas head associated with acute stomachache. A 87-year-old woman had been under physician observation for MCC. She came to our hospital due to an acute stomachache. CT showed that the MCC was growing fast. Fearing its impending rupture, we performed emergency surgery. The pathological findings showed MCC with ovarian-type stroma and positive staining for estrogen and progesterone receptors. The patient was discharged on postoperative day 31. Despite no adjuvant therapy, there has not been any relapse of the cancer three years after surgery.

We report herein on a rare case of a primary small intestinal volvulus in a 56-year-old male. The patient visited our hospital because of sudden abdominal pain. An enhanced computed tomography examination showed a closed loop of the small intestine. An emergency laparoscopic operation was performed under a diagnosis of strangulated obstruction. It was found that 50cm of the ileum had rotated 180° counter-clockwise. Laparoscopic repair avoided removal of the ileum. Since there no adhesion or tumors were found, primary volvulus of the small intestine was diagnosed. The postoperative course was uneventful, and the patient was discharged on the 6th day. This is a rare and difficult condition to diagnose preoperatively. Whilst it is normally characterized by a whirl sign on abdominal CT, and overeating and heavy exercise can play a role, our case was atypical at this point. Laparoscopic repair of a small intestinal volvulus is very rare in Japan. We consider that our laparoscopic technique was useful in the diagnosis and treatment of our case.

A 77-year-old man was brought to our hospital by ambulance with abdominal pain. Localized wall thickening of the terminal ileum was seen on abdominal computed tomography, from which distention was seen proximally and collapse distally. Following ileus tube insertion, infusion therapy was performed and the abdominal symptoms abated. An ileus tube contrast study performed on day 6 of hospitalization revealed localized stenosis in the lumen of the terminal ileum. Contrast agent passed well, so the ileus tube was removed and the patient started eating on day 8 of hospitalization. However, intestinal obstruction recurrence was seen and a small bowel resection was performed on day 12 of hospitalization. An ileal stenosis section was resected approximately 10 cm proximal from the ileocecal valve. The postoperative course was good, the patient started eating on postoperative day 3 and was discharged on postoperative day 9. The resected specimen contained only a single round undermining ulcer and lumen stenosis, with no specific histopathological findings. The cause was unclear from the patient’s medical history, medication history, and clinical presentation, and the lack of specific pathological findings. Furthermore, based on the gross image and other characteristics, the lesion was classified as a simple ulcer.