At our hospital, between April 2012 and end-December 2016, 74 patients underwent cholecystectomy for gallstones after a waiting period. We compared the clinical data of the 12 patients who developed acute cholangitis/cholecystitis while standing by for cholecystectomy (Group A) with those of the 62 patients who did not (Group B). We investigated the risk factors for the development of acute cholangitis/cholecystitis and surgical complications in the entire patient population. Significant differences in the number of cases with a previous history of acute grade 2 or 3 cholecystitis prior to the operation were observed between Group A and Group B. In regard to the laboratory data, the preoperative WBC count, serum CRP, and serum creatinine were significantly increased, and the serum albumin was significantly decreased in Group A as compared to Group B. In imaging studies, gallbladder wall thickening (≧5mm) and abscess were seen significantly more frequently in Group A as compared to Group B. Furthermore, investigation of the surgical outcomes revealed a higher conversion rate to open surgery, higher amount of blood loss, and higher rate of postoperative complications in Group A as compared to Group B. Our results suggest that a previous history of severe cholecystitis is a risk factor for the development of acute cholangitis/cholecystitis in patients standing by for surgery and for the development of surgical complications.

The incidence of colonic diverticular bleeding (CDB) is gradually increasing, because of an aging society and increasing usage of anticoagulants and nonsteroidal anti-inflammatory drugs (NSAIDs). Herein, we examined the present status, including the characteristics, diagnosis, therapy and prognosis of CDB. In this study, we enrolled 501 patients from 10 facilities who filled out our questionnaire. Of the 501, 304 (60.1％) were 70 years of age or over, and 320 (63.9％) were male；244 patients (48.7％)had hypertension, and 222 patients (44.3％) were taking anticoagulants or NSAIDs. Bleeding lesions were definitively diagnosed in 278 patients (55.8％) and mostly 164 lesions (32.7％) in the ascending colon, and the lesions were most frequently detected in the ascending colon (164 lesions [32.7％]). The diagnosis was made by colonoscopy in 426 patients (85.0％) and by computed tomography in 146 patients (29.1％). In all, 198 patients (39.8％) required hemostasis, and endoscopic clipping was performed in the majority. Difficulty in establishing hemostasis and rebleeding were encountered in 16.7％ of patients (33/198 patients). Some patients were treated by interventional radiology (IVR) techniques or surgery.

In December 2017, the Japanese Gastrointestinal Association, in collaboration with related academic societies, published a guideline for the management of colonic diverticulosis (diverticular bleeding, diverticulitis). Here, we summarize the key statements in the guideline that pertain to colonic diverticular bleeding. In Japan, the prevalence of colonic diverticulosis and the incidence rate of colonic diverticular bleeding have been increasing. Colonic diverticular bleeding ceases spontaneously in 70％-90％ cases, but the rate of re-bleeding is as high as 20％-40％. Colonoscopy, which is also useful for executing hemostatic procedures, is recommended as the first-line modality for the diagnosis of colorectal diverticular bleeding. In the endoscopic clipping method, as compared to direct placement of a hemoclip at the bleeding point, the rebleeding rate tends to be higher in the indirect placement, in which the bleeding diverticulum is closed with hemoclips in a zipper fashion. As compared to other hemostatic procedures, including endoscopic clipping, the transition rate to trans-arterial embolization or surgical operation is lower with diverticular ligation therapy, in which the bleeding diverticulum is mechanically ligated with a band or a plastic snare. In patients treated by the diverticular ligation method, a few cases with late-onset intestinal perforations have been reported. For prevention of rebleeding, withdrawal of NSAIDs and aspirin for primary prevention should be considered.

Recently, the incidence of diverticular hemorrhage has been gradually increasing owing to the increasing prevalence of diverticulosis and the increasingly widespread use of nonsteroidal anti-inflammatory agents. Moreover, diverticular hemorrhage develops without any premonitory symptoms, implying that urgent clinical management is needed. The usefulness of contrast CT, angiography, scintigraphy for gastrointestinal bleeding, barium impaction therapy, and colonoscopy is well established in the diagnosis and treatment of diverticular hemorrhage. However, since it is difficult to find the source of bleeding and establish hemostasis, recurrence sometimes occurs. By identifying the pivotal characteristics of the diagnostic and therapeutic methods and understanding the status of patients, optimal methods may be selected for the diagnosis and treatment of diverticular hemorrhage.

We conducted a review of the data of 39 patients were diagnosed as having colonic diverticular bleeding between July 2010 and December 2017 at our emergency and critical care center. The patients consisted of 28 males and 11 females, with an average age of 66.3 years. We investigated whether dynamic computed tomography (CT) on arrival at the hospital, prior to colonoscopy, is helpful to identify and treat colonic diverticular bleeding. Dynamic CT had been performed on arrival in 33 of the 36 patients (n=33). The identification rate of the source of colonic diverticular bleeding by first colonoscopy was 83％ in the extravasation group (n=12) and 43％ in the non-extravasation group (n=21). We treated 21 patients by endoscopic hemostasis, 12 patients by conservative therapy, 4 patients by interventional radiology (IVR) procedures, and 2 patients by surgery. To identify and treat colonic diverticular bleeding by colonoscopy, performance of dynamic CT in the patient on arrival, prior to colonoscopy, is recommended. In patients with frequent rebleeds after conservative therapy or endoscopic hemostasis, IVR procedures or surgical therapy should be considered.

The incidence of colonic diverticulosis has been increasing in Japan because of westernization of the dietary habits and aging of the population. Along with this trend, the incidence of colonic diverticular bleeding has also been increasing. In general, the modality of first choice for emergency hemostasis in cases of colonic diverticular bleeding is endoscopic hemostasis; if this is unsuccessful, arterial embolization may be selected, with surgery as the last resort. It is desirable to identify the source of bleeding by endoscopy or CT before surgery, to avoid total colectomy. Colon diverticulosis is a benign disease, so we propose to consider the usefulness of laparoscopic surgery and the possibility of preventive surgery in a future study.

The incidence of lower gastrointestinal bleeding, which can be caused by a variety of underlying diseases such as colorectal diverticula, angiodysplasia, colitis, colon cancer, etc., increases with advancing age. Among the causes of lower gastrointestinal bleeding, colorectal diverticular bleeding is the most frequent, and its incidence is increasing in Japan. Presumably, the use of NSAIDS, steroids and antiplatelet drugs is spurring the increase in the incidence of diverticular bleeding. Although the severity ranges from minor to life-threatening, the bleeding often ceases spontaneously with conservative treatment alone, without the need for any special treatment. In cases of severe bleeding, hemostasis has been accomplished by endoscopic and interventional radiology (IVR) procedures. Both treatments have their own advantages and disadvantages merits and demerits. In this study, we propose to investigate investigated? the outcome of IVR procedures for lower gastrointestinal bleeding at our hospital and report the results, with some bibliographic considerations.

Appendicitis in cases with an abnormal position of the appendix and barium appendicitis are difficult to diagnose. A 48-year-old man was brought to our hospital by ambulance for lower abdominal pain developing a day after he underwent an upper gastrointestinal barium study. Computed tomography showed a right-sided sigmoid colon, with the ascending colon shifted towards the midline of the abdomen, and extraintestinal gas. The patient was initially diagnosed as having gastrointestinal perforation due to intestinal malrotation, and emergency laparotomy was performed. Intraoperative examination revealed a perforated appendix. The ascending colon, ileocecum, and the entire small intestine had herniated through the hernia orifice located behind the inferior mesenteric vein. Finally, the patient was diagnosed as having barium appendicitis, mesenterium commune, and left paraduodenal hernia. Left paraduodenal hernia with mesenterium commune is rare, and preoperative diagnosis is extremely difficult due to artifacts created by barium. The positional relation between the inferior mesenteric vein and gastrointestinal tract may help in the diagnosis of left paraduodenal hernia with mesenterium commune. Computed tomography with coronal imaging may be useful for the diagnosis of barium appendicitis.

A 44-year-old man presented to our hospital with a 1-day history of progressively worsening abdominal pain. He had eaten a heavy meal the previous night. Abdominal computed tomography showed a large amount of intra-abdominal fluid and extravasation of contrast medium from an artery of the greater omentum in the left upper abdomen. The patient was diagnosed as having intra-abdominal hemorrhage caused by bleeding from the greater omentum and emergency operation was performed. Since the patient was hemodynamically stable and the site of bleeding was confirmed, laparoscopic surgery was performed. Intraoperative examination revealed bleeding from the omental branch of the left gastroepiploic artery, and partial resection of the omentum including the left gastroepiploic vessels was performed. The postoperative course was uneventful, and the patient was discharged on the 6th postoperative day. Histopathological examination of the resected specimen showed no abnormal findings, such as neoplasms and aneurysms. Based on histopathological findings and absence of a history of trauma, the final diagnosis was idiopathic omental bleeding.

An 80-year-old woman complaining of abdominal pain was admitted to our hospital. Physical examination revealed a tender, fist-sized, movable mass in the right lower quadrant of the abdomen. Blood tests revealed elevated levels of inflammatory markers. Abdominal ultrasound and computed tomography showed an enlarged gallbladder with no continuity between the gallbladder neck and the cystic duct, and an elevated tumor was detected inside the gallbladder. Emergency surgery was performed under a preoperative diagnosis of gallbladder torsion and gallbladder tumor. Intraoperatively, we observed gallbladder torsion, with the gallbladder showing an approximately 270° clockwise rotation around its neck. The torsion was carefully fixed, and open cholecystectomy was performed. Macroscopic findings of the resected specimen were necrotic changes associated with ischemia in the gallbladder mucosa and a 30-mm tumor lesion, and histopathology revealed a papillary growth pattern of the tumor. The postoperative histological diagnosis was pStage I gallbladder cancer. Herein, we report a case of gallbladder torsion associated with gallbladder cancer encountered by us. In the diagnosis and treatment of gallbladder torsion suspected as being secondary to gallbladder cancer, the possibility of other complications such as gallbladder necrosis and biliary and carcinomatous peritonitis due to perforation must also be considered.

We report a case of cholecystoduodenal fistula presenting with gallstone ileus that was successfully treated by T-tube duodenostomy. A 75-year-old woman visited our emergency room with the chief complaint of vomiting. Abdominal plain CT showed bowel obstruction caused by a gallstone measuring 45×25mm in size in the small intestine. Abdominal contrast-enhanced CT showed a cholecystoduodenal fistula. Thus, the patient was diagnosed as having gallstone ileus caused by a cholecystoduodenal fistula. Since the bowel obstruction did not improve with conservative therapy, a one-stage surgery consisting of enterolithotomy, cholecystectomy and fistulectomy was performed. Because the duodenal defect with chronic inflammation could not be closed by suture or with an omental patch, a T-tube duodenostomy was performed. Thereafter, the patient was discharged without any postoperative complications. T-tube duodenostomy is a simple and effective procedure for cases of cholecystoduodenal fistula with severe inflammation of the fistula.

A 79-year-old female patient was admitted to our hospital with acute abdominal pain. Her medical history included diagnosis of adrenal tumor. Abdominal contrast-enhanced computed tomography (CT) showed massive adrenal? hemorrhage with intratumoral bleeding. She was diagnosed as having rupture of the left adrenal gland tumor. Her vital signs were stable, and she was afebrile. For control of the hemorrhage, we performed therapeutic embolization of the left superior and middle suprarenal arteries. She was discharged on the 9^th hospital day. Four months after the interventional radiology (IVR) procedure?, we performed laparoscopic adrenalectomy for the adrenal tumor. The resected tumor measured 3.0×5.2×3.0 cm in size. The final histopathological diagnosis was adrenal cortical adenoma. There are few reports of explosion rupture? spontaneous rupture? of an adrenal cortical adenoma. We successfully treated a case of spontaneous rupture of an adrenal cortical adenoma with massive hemorrhage by a combination of IVR procedure and laparoscopic surgery.

Internal herniation through a defect of the broad ligament of the uterus is very rare, and without adequate knowledge of the disease, the diagnosis could be delayed. We report a case of internal herniation of the intestine through an abnormal defect in the broad ligament of the uterus. A 32-year-old woman who had undergone a Cesarian section three years ago was admitted to our hospital with the complaints of abdominal pain and vomiting. Abdominal computed tomography (CT) showed wall edema of the segment of the small intestine in the pelvic cavity. The patient exhibited no other symptoms of ileus, and was therefore treated conservatively. The symptoms were not relieved, and a repeat CT on the following day revealed looping of the intestine and ascites, necessitating emergency surgery. Intraoperatively, dilated small intestinal loops were found within the pelvic cavity, and an abnormal defect was noted in the left broad ligament, with herniation of a 50-cm-long segment of the ileum through this defect. Since the intestinal loops showed evidence of necrosis, we performed partial resection of the involved intestine and sutured the defect. Since surgery is often required for broad ligament hernia, this condition should be borne in mind in the diagnosis of internal herniation in women.

The subject was an 83-year-old man who visited our emergency room with the chief complaint of swelling accompanied by pain in the right inguinal region. Swelling and redness of the size of a fist were observed in the region extending from the right inguinal region to the scrotum. CT revealed a strangulated right inguinal hernia with findings suggestive of intestinal ischemia, and emergency surgery was performed. The vermiform appendix had prolapsed from the cecum into the hernia sac, with abscess formation found in the scrotum. In addition to using the inguinal approach, we also made a longitudinal incision in the scrotum in order to remove excise the abscess together with its capsule, after which the cecum was resected and radical hernia surgery was performed. Although the precise course of development is unknown, hernia incarceration of the cecum is believed to have occurred concurrently with appendicitis, followed by perforation and abscess formation in the hernia sac. The patient made good clinical progress and was discharged on the 8th postoperative day. Although cases of Amyand’s hernia, in which the vermiform appendix prolapses into the hernia sac, have been reported, it is uncommon to encounter cases in which appendicitis and abscess formation occur in the hernia sac, as in our present case reported here. We report this case, with some discussion of the pertinent literature.

A 63-year-old man with a 10-year history of left inguinal hernia visited our hospital with the chief complaint of diarrhea. Abdominal CT revealed a left inguinal hernia, circumferential wall thickening of the sigmoid colon segment within the hernia sac, and dilatation of the descending colon. The patient was diagnosed as having strangulated inguinal hernia and emergency surgery was performed. Intraoperatively, volvulus of the sigmoid colon, which contained a cancer lesion, was noted within the hernia sac. Sigmoid colon resection with D1 lymph node dissection and single-barrel colostomy (Hartmann method) was performed, along with hernioplasty without a mesh (Bassini method). Histological findings revealed the diagnosis of well-differentiated adenocarcinoma of the sigmoid colon with no lymph node metastasis.

Small intestinal Dieulafoy’s lesion is a relatively rare disease and is often known to cause major bleeding ; herein, we report a case in which we carried out resection of a small-intestinal Dieulafoy’s lesion. The patient was a 60-year-old woman who was hospitalized for massive melena. Abdominal contrast CT showed extravasation in the jejunum and a double-balloon enteroscopy revealed a 10-mm pulsatile submucosal tumor-like elevation in the small intestine, which we diagnosed as the bleeding source. Because endoscopic hemostasis was impossible, partial resection of the jejunum was performed. Histopathological findings showed dilated arteries in the submucosal layer and lesioned arteries with arterial lesions? based on which we made the diagnosis of Dieulafoy’s lesion.

We report the case of a patient with intussusception secondary to ileal endometriosis. A 30-year-old woman presented to our hospital with abdominal pain and vomiting. Abdominal computed tomography showed the pseudo-kidney sign in the right ileocecal area, based on which we diagnosed intussusception, and performed emergency surgery. We found the intussusception located 30cm proximal to the ileocecal valve and performed a manual reduction using the Hutchinson procedure. We found a tumor in the ileum, which we removed by resection. Histopathological findings revealed the diagnosis of endometriosis of the ileum. We believe this was a very rare case of intussusception caused by ileal endometriosis, and present the case here with a review of the literature.

We encountered a case of traumatic renal arteriovenous fistula and report the treatment results here, as patients with this condition are rare in Japan. The patient was a 90-year-old woman who fell into a sub-floor storage compartment and received medical attention for a left rib fracture at a local clinic. Shortly thereafter, she developed hematuria, and at the subsequent visit to the clinic, she presented with tachycardia and hypotension and was immediately transferred to our hospital by ambulance. A contrast-enhanced abdominal CT revealed injury to the left kidney, determined as type Ⅲb according to the 2008 classification system for renal injury by the Japanese Association for the Surgery of Trauma. At that time, early detection of the renal vein in the images? was also observed. We suspected that the patient had developed a traumatic renal arteriovenous fistula, which we then confirmed by renal arteriography. Transcatheter arterial embolization (TAE) was performed to occlude the fistula, after which the hematuria gradually resolved. The patient was transferred to the urology department 10 days after the initial trauma. TAE is an established treatment method for renal trauma, and this case corroborates the evidence that TAE can be performed safely even in cases with complicating renal arteriovenous fistula.

The first patient was a 64-year-old female who presented with abdominal pain. Abdominal CT revealed the diagnosis of left paraduodenal hernia. Hernia repair with laparoscopic surgery was performed on the day of admission. The second patient was a 67-year-old female who also presented with abdominal pain. CT revealed extension of the stomach, duodenum and proximal side of jejunum, based on which left paraduodenal hernia was suspected, and a nasal intestinal tube was inserted. The abdominal pain improved, however, contrast study under endoscopy via the endoscope? still showed incarceration of the small bowel. Therefore, laparoscopic surgery was performed three days after the contrast study. In many cases, left paraduodenal hernias are diagnosed before surgery, however, pure laparoscopic surgery for left paraduodenal hernia is not commonly performed in Japan. We believe that laparoscopic surgery is a less-invasive treatment for left paraduodenal hernias and report two cases of left paraduodenal hernia that were treated by pure laparoscopic surgery.

Retroperitoneal necrotizing fasciitis is a rarely encountered condition and is known to be associated with a high mortality rate, failing immediate and aggressive surgical management. Herein, we present a patient who underwent repeated surgical debridement and drainage under open abdomen management for early radical source control. A 60-year-old man with a history of diabetes mellitus and ulcerative colitis was transferred to our department because of disturbance of consciousness. On admission, he was diagnosed as having septic shock associated with retroperitoneal soft tissue infection caused by gas-forming bacteria, and presented with extensive emphysema in the abdomen and retroperitoneal space. At the time of laparotomy, the necrotic process extended from the left renal capsule to the retroperitoneum and mesentery. The patient was managed successfully by aggressive and repeated debridement under open abdomen management. On day 7, his abdomen was closed with a formal fascial suture, and he was transferred to a local hospital on day 78. In conclusion, in patients with retroperitoneal emphysema presenting with evidence of systemic inflammation, retroperitoneal necrotizing fasciitis should be considered, and open abdomen management may be a useful approach for aggressive radical source control in such cases.

A 3-year-old boy was referred to our hospital with a history of persistent bloody stools and progressive anemia. Neither upper gastrointestinal endoscopy nor total colonoscopy revealed the site of bleeding, therefore, we suspected that the bleeding was from the small intestine. Contrast-enhanced computed tomography (CT) revealed diverticulosis of the ileum with bleeding in the right upper abdomen. We diagnosed Meckel’s diverticulum and performed emergency partial resection of the ileum. Histopathological examination revealed Meckel’s diverticulitis with ectopic gastric mucosa and ulcer. Although it is difficult to diagnose Meckel’s diverticulum preoperatively，contrast-enhanced CT may be useful for the diagnosis in cases of Meckel’s diverticulum with bleeding.

The patient reported herein was a 68-year-old man with rectal cancer (Ra) (StageⅢa; cT3cN1cM0c) who presented with a type-2 tumor mass. He underwent low anterior resection (Lap-LAR) with D2 lymph node dissection. The Denonvilliers fascia was preserved. The rectum proximal to the tumor was so severely distended that two automatic suturing devices were required to excise resect the involved rectal segment. The patient started taking meals orally could resume oral intake on postoperative day 4, however, he developed pneumaturia on postoperative day 10. Abdominal CT revealed air bubbles in the seminal vesicles, suggestive of a rectovesical fistula. He was asked to abstain from oral intake and given total parenteral nutritional support and antibiotic therapy. Subsequently, the fistula began to close and the patient was discharged on postoperative day 32. Rectovesical fistula is a very rare complication after operation for rectal cancer. A search of the Japan Medical Abstracts Society and Pubmed to the best of our ability revealed only 14 case reports until date, including our case. It has been reported that this complication could occur from the 9^th to 60^th postoperative day (median 13.5 days) due to anastomotic leakage. Careful judgment of the need for surgery to treat this condition is recommended, as these fistulas frequently heal with conservative treatment alone.

We report a case of trauma with delayed onset of traumatic diaphragmatic hernia with incarceration 6 days after the injury was sustained. A 90-year-old male fell while walking and bruised his left thorax. On day 6 after the injury, he lost his appetite, and on day 7, he began to experience acute difficulty in breathing. Chest X-ray and computed tomography led to the diagnosis of traumatic left diaphragmatic hernia, and emergency surgery was performed. The left diaphragm was ruptured near the central tendon, and most of the stomach, transverse colon, and greater omentum had herniated into the left thoracic cavity. The bowel loops were replaced in the abdominal cavity, no resection was required. The ruptured diaphragm was directly closed after a chest drainage tube was inserted through the intercostal space.

An 87-year-old woman visited the emergency department of Onomichi General Hospital complaining of acute right inguinal pain. Physical examination revealed no bulge in the right inguinal region or any evidence of peritoneal irritation. Laboratory data revealed slight elevation of the inflammatory marker levels. Abdominal contrast-enhanced computed tomography revealed incarcerated small intestinal loops between the right pectineus and external obturator muscles. Under the diagnosis of incarcerated right obturator hernia, emergency laparoscopic operation was performed. Intraoperative examination revealed no necrosis of the incarcerated small intestine. Therefore, in the same surgical session, we performed repair of the hernia via the inguinal approach, using the Kugel hernia patch. At the end of the operation, laparoscopic viewing confirmed that the inserted patch had been appropriately placed. The patient was discharged without any postoperative complications on day 7. Laparoscope-assisted surgery is a more beneficial and less invasive approach than laparotomy in cases of incarcerated hernia where there is no necrosis of the incarcerated intestine and the vital signs are stable.

We encountered a case of a spontaneous discharge of spilled gallstones six years after laparoscopic cholecystectomy. A 65-year-old man was admitted to our hospital with the complaints of right back pain and fever 15 months after cholecystectomy. Computed tomography (CT) revealed calcified foreign bodies within an abscess in Morisson’s fossa and the right subphrenic space. Drainage was scheduled, but the patient developed right lower lobe pneumonia. The operation was canceled and the patient was discharged from the hospital. However, 6 years after the cholecystectomy, the patient observed spontaneous discharge of the stones. CT showed that some stones had moved from Morisson’s fossa to the back and subcutaneous areas. The right subphrenic stones were stable. Spilled gallstones are associated with a small, but quantifiably real risk of a wide range of significant postoperative problems. Surgeons should take care not to injure the gallbladder and try to prevent the spillage of gallstones. Spontaneous discharge of spilled gallstones is very rare.

An 82-year-old woman visited our emergency department complaining of abdominal pain and vomiting. Abdominal CT revealed dilated small intestinal loops, however, the cause of the obstruction was not clear. Conservative medical management provided no relief from the symptoms. With the symptoms persisting, on the 3^rd day after admission, a long intestinal tube was inserted. On 6^th day after admission, contrast examination via the long tube revealed complete intestinal obstruction. The patient complained of lower abdominal pain, laboratory examination revealed elevation of the inflammatory marker levels, and emergency surgery was performed. Intraoperatively, the small intestine was found to be incarcerated into the broad ligament of the uterus. The herniated intestine was reduced by making an incision in the hernia orifice and the incarcerated segment of small intestine was resected, as it showed evidence of necrosis. A retrospective review of the CT images suggested that displacement of the uterus toward the left side, location of the obstruction close to the uterus, and extension of the broad ligament of the uterus are helpful findings for the diagnosis of intestinal herniation through the broad ligament of the uterus broad ligament hernia. The postoperative course was uneventful. We encountered a relatively rare case of hernia of the broad ligament of the uterus with characteristic CT findings.

A 73-year-old woman visited our hospital with a history of abdominal pain persisting from the previous day. Abdominal contrast-enhanced computed tomography showed dilatation of the transverse colon and a positive whirl sign, and we made the diagnosis of volvulus of the splenic flexure of the colon. Since we did not find any apparent signs of bowel necrosis, we attempted endoscopic reduction, but failed. The abdominal pain was relieved, but it recurred 8 hours later. Endoscopic reduction was attempted again, but failed again, and we placed a transanal ileus tube in the dilated colon. Computed tomography showed pneumatosis intestinalis of the splenic flexure of the colon and edema of the mesentery, therefore, we performed emergency surgery. The splenic flexure of the colon was? expanded and twisted about 180 degrees counterclockwise, but there was no evidence of bowel necrosis. We performed partial resection of the splenic flexure of the colon and a functional end-to-end anastomosis. Although there is no report of laparoscopic surgery performed for volvulus of the splenic flexure of the colon, we consider that the procedure can be performed safely for this condition.

There are few reports on ingestion of cylindrical batteries. We report a case in which we endoscopically removed a number of ingested AA batteries. A 61-year-old man with a history of schizophrenia was referred to us from a psychiatric hospital, after he reported that he had“swallowed batteries.” Plain abdominal X-rays showed multiple radiopaque foreign bodies in the stomach. Emergency upper gastrointestinal endoscopy was performed and numerous AA batteries and multiple ulcers were noted in the stomach. We used a recovery net to collect a total of 11 batteries one-by-one. Two additional AA batteries were eliminated by defecation the following day. Prompt removal is required in case of ingestion of batteries as they can cause rapid chemical damage within a short period of time. Use of the recovery net was useful for removing the batteries in this case.

An 80-year-male patient with a pacemaker for sick sinus syndrome had undergone the Hartmann operation for idiopathic rectal perforation 8 years previously. In the present medical history, he developed left lower abdominal pain and had to be transported to our hospital by ambulance. Computed tomography （CT） revealed ascites, free air, and an iso-density area of extra in the vicinity of the ? colostomy, with a parastomal hernia. He was advised to undergo surgery for the parastomal hernia through the colostomy perforation. Emergency operation was performed. We resected the perforated bowel and constructed a transverse colostomy. The postoperative clinical course was nearly uneventful under intensive care, and the patient was discharged on day 40 of hospitalization. We present a case of colostomy perforation with a parastomal hernia and a review the literature.

We present two cases in which we performed laparoscopic appendectomy for acute appendicitis in the second trimester of pregnancy. The patients were a 19-year-old woman who was 16 weeks pregnant and a 33-year-old woman who was 25 weeks pregnant. Both patients presented with acute abdominal pain and were diagnosed as having acute appendicitis. We could perform the operation safely without any pressure on the uterus by devising a suitable port insertion position. The patients were able to get up and leave the hospital early without any complications. Both also delivered their babies without any problems. It is important for surgery during pregnancy to be safe and less invasive, so as to ensure early resumption of activities and easy pain control. There were still are few reports of laparoscopic appendectomy for appendicitis in pregnant patients in Japan. Laparoscopic appendectomy is useful if it can be performed safely with adoption of a suitable method/suitable port positions.

A 69-year-old man was admitted to the hospital with the chief complaint of lower abdominal pain. Abdominal computed tomography showed an abscess near the umbilicus, with the abscess communicating with the small intestine. Suspecting abscess formation in the omphalomesenteric duct remnant, laparoscopic surgery was performed. At 50 cm from the ileocecal junction, the ileum was divided into two lumens, one of them leading to the abscess. En-bloc resection of the omphalomesenteric duct remnant and the abscess was performed. Histopathological findings showed the abscess containing gastrointestinal smooth muscle tissue. Omphalomesenteric duct remnant is mostly seen in children, and rarely in adults. To the best of our knowledge, this is the first reported adult case of omphalomesenteric duct remnant with abscess formation in Japan, that was treated by laparoscopic surgery first case of abscess formation of an omphalomesenteric duct remnant in an adult.

A 53-year-old-man visited our hospital’s emergency center with a history of abdominal pain and fever. Abdominal examination revealed tenderness in the lower right abdominal. Computed tomography (CT) revealed an enlarged appendix, ascites, severe edema of the bowel wall and invagination of the intestine. We decided to perform surgery for an assumed diagnosis of acute appendicitis. However, we were concerned about the possible presence of an underlying malignant tumor, and therefore performed ileocecal resection (D3 lymphadenectomy) via a lower abdominal midline incision. The postoperative pathological diagnosis was cecal cancer (T4a, N0, M0; Stage Ⅱ). There are few case reports of appendicitis caused by a malignant tumor. In most adults, invagination of the intestine is caused by a malignant tumor. In the present case, we performed ileocecal resection due to the suspicion of acute appendicitis coexisting with a malignant tumor based on the CT findings. Malignant tumor should be suspected as a potential cause of appendicitis in patients showing invagination of the intestine on imaging.