【Background】 Today, the cornerstone of treatment for traumatic liver injury is non-operative management (NOM). This study clarified the treatment outcomes of traumatic liver injury in the NOM era. 【Method】In this multicenter study, we retrospectively analyzed the data of patients with traumatic liver injury seen from January 2010 to December 2015. 【Results】 There were 239 patients (age 39.6±23.2 years; 55 males) from 16 centers. The severity of the liver injury was classified according to the Japanese Association for the Surgery of Trauma, as Ⅰa：Ⅰb：Ⅱ：Ⅲa：Ⅲb in 38：101：24：23：53 patients. The most frequent cause was traffic injury. The first selected treatment was damage control surgery (DCS) in 11 patients, transcatheter arterial embolization (TAE) in 32 patients, and conservative treatment in 196 patients. Nine patients who initially received conservative treatment subsequently underwent TAE (n＝2), endoscopic retrograde biliary drainage (n＝1), or surgery (n＝6), and six patients who initially received interventional radiology subsequently underwent surgery. The mortality rate was 7.9％ (n＝19; death from bleeding in 8 patients and from critical injury of other organ (s) in 11 patients). The rate of late complications was 2.5％. 【Conclusion】This study clarified the treatment outcomes of traumatic liver injury in the NOM era.

Surgical site infection (SSI) developing after lower gastrointestinal tract perforation surgery can lead to prolonged hospital stay and increase medical expenses. Recently, the effectiveness of preventive negative-pressure wound therapy (NPWT) for preventing SSI has been studied. At our department, we performed primary wound closure in 63 cases undergoing lower gastrointestinal tract perforation surgery, and the incidence rate of SSI was 21 cases (33.3％). Considering this high incidence rate, we introduced preventive NPWT and performed primary wound closure for 8 cases from January 2018 to August 2018. Of these 8 cases, only 1 developed SSI, indicating that performing preventive NPWT in cases undergoing lower gastrointestinal tract perforation surgery may be effective for preventing SSI. Hence, the selection criteria and management method necessary for performing preventive NPWT should be investigated.

An 8-year-old girl fell and hit the left side of her chest on a log at a recreational facility. She was transported to our hospital by ambulance complaining of pain on the left side of her chest. Contrast-enhanced abdominal computed tomography (CT) indicated type Ⅲb splenic injury, as defined by the Japanese Association for the Surgery of Trauma Spleen Damage Classification 2008, and intra-abdominal hemorrhage. No external leakage of contrast medium was noted, and the hemodynamics was stable; therefore, we selected non-operative management (NOM). The hemodynamics remained stable throughout the patient’s hospitalization. Follow-up abdominal CT on the 7^th hospital day showed splenic pseudo-aneurysms as evidence of splenic injury. Transcatheter arterial embolization was performed, and the patient was discharged on the 12^th hospital day, with a two-month exercise restriction. The developmental mechanism and natural course of splenic pseudoaneurysms remain unclear; thus, continued accumulation of splenic trauma cases is necessary.

A 77-year-old woman was admitted to our hospital with a history of fever, abdominal pain, and disturbance of consciousness. She had a past medical history of having undergone total hysterectomy followed by radiation therapy 23 years earlier . Physical examination revealed signs of peritoneal irritation and a plain CT of the abdomen showed a large amount of ascites and a small amount of free air. We diagnosed the patient as having panperitonitis caused by gastrointestinal perforation, and performed emergency operation. Intraoperative exploration revealed purulent ascites, but no perforation in the gastrointestinal tract; however, a perforation was found on the top of the urinary bladder. We finally made the diagnosis of spontaneous rupture of the urinary bladder caused by radiation, repaired the defect and covered it with omentum. We discharged the patient from our hospital with an indwelling urinary catheter. This case serves to underscore the importance of bearing in mind the possibility of spontaneous rupture of an abdominal organ in patients with a past medical history of radiation therapy who present with abdominal pain. It is also important to carefully monitor the urinary symptoms in patients who have undergone radiation therapy for the region, for early diagnosis of rupture of urinary bladder.

Incarcerated umbilical hernias in adults are sometimes associated with poor outcomes, because of comorbidities such as liver cirrhosis and severe obesity. We report four adult cases of incarcerated umbilical hernia. The patients ranged in age from 54 to 92 years (median 63.5). The male-to-female ratio was 3: 1. The body mass index ranged from 20.3 to 27.4 (median 24.1). Three out of the four patients had a history of liver cirrhosis. All the patients were treated by surgery under general anesthesia. Suture repair was performed in two, patients and mesh repair in the remaining two. Only one patient needed resection for a strangulated segment of the small intestine. Two of the four patients needed ventilatory support after the surgery. The length of hospital stay was 8 to 37 days (median 13). None of the patients died or developed recurrence of the hernia. The two patients who had liver cirrhosis needed ventilatory support after the surgery despite having been in a good condition preoperatively. Surgery under local anesthesia can be considered in umbilical hernia patients who are high-risk cases for general anesthesia.

A 47-year-old woman with developmental disabilities was brought to us with a history of having swallowed a sewing needle a week earlier. She had previously undergone four laparotomies for similar reasons. There were no symptoms or signs of peritonitis. A plain X-ray of the abdomen confirmed the foreign body, and abdominal CT revealed 16 needles in the abdomen. Several of the needles were extra-luminal, but there was no apparent ascites or free air. The patient declined surgical treatment, and was treated conservatively in the hope that the needles would be discharged naturally. No adverse symptoms or signs were evident until the patient was transferred elsewhere for treatment of the intellectual impairment on day 17. Subsequently, she has remained free of signs or symptoms for two years. The number of needles that were confirmed on the abdominal radiographic images has decreased, while the number that had migrated out of the lumen remain fixed. Natural excretion of foreign bodies can take a long time and sewing needles might be relatively less likely to cause intraperitoneal infections. Patients with fixed, inorganic foreign bodies could be conservatively managed if they remain asymptomatic.

We report a rare case of a 73-year-old woman with delayed traumatic incarcerated diaphragmatic hernia. The patient presented with severe epigastralgia. She had sustained traumatic injury of the right shoulder in a fall and undergone operation for repair of a rotator cuff tear 9 months earlier. Contrast-enhanced computed tomography revealed dilated intestinal loops, intestinal prolapse into the thorax, the closed loop sign and defect of contrast in the prolapsed intestine. Based on the findings, we diagnosed the patient as having incarcerated diaphragmatic hernia and undertook emergency surgery. Intraoperatively, some cracks were found in the right diaphragm, which seemed to be weakened. The diaphragm was injured and the ileum had prolapsed into the thorax through a defect in the diaphragm which was about 3 cm×3 cm in size. The prolapsed ileum was resected as it was found to be necrotic, and the defect in the diaphragm was sutured directly. After the operation, the patient made good progress.

A 57-year-old man was admitted to our hospital with a history of right lower abdominal pain. Abdominal contrast-enhanced CT revealed closed loop obstruction of the small intestine dorsal to the cecum, and emergency laparotomy was performed. Intraoperatively, incarceration of the ileum into the 2cm-orifice of the retrocecal fossa was identified. With the diagnosis of intestinal obstruction caused by retrocecal hernia, the incarcerated ileum was released, without any need to perform intestinal resection. In addition, the orifice was opened widely. The patient was discharged on postoperative day 8 without complications. Retrocecal hernia is a relatively rare entity that frequently requires emergency operation because of strangulated intestinal obstruction. We report a case herein, with a review of the literature.

A-51-year-old woman was transported to the emergency room of our hospital with a 1-week history of vomiting, diarrhea, and weakness. At admission, the patient was diagnosed as being in septic shock. A plain X-ray of the abdomen revealed intestinal edema and massive ascites. Intestinal necrosis was suspected, and emergency laparotomy was performed. The entire abdominal cavity was visualized, and approximately 2,000 mL of milky-white, purulent ascites was observed. No intestinal necrosis or intestinal perforation was noted, and only laparotomic drainage was performed. Streptococcus pyogenes (Group A) was detected in cultures of specimens of vaginal discharge, blood, and ascitic fluid. The patient underwent intensive treatment for septic shock, including dialysis, and the infection was controlled. Nonetheless, she developed muscle weakness and peripheral nervous disorders, and was diagnosed as having sepsis-induced critical illness polyneuropathy (CIP). Herein, we present a report of this case of pelvic peritonitis caused by fulminant group A Streptococci, together with a review of the literature. While the patient suffered from various serious symptoms, she recovered through operation, intensive care, and rehabilitation.

Rupture of a jejunal diverticulum is rare, and it is often difficult to diagnose preoperatively. A 68-year-old American man was admitted to our hospital complaining of epigastric pain. Blood examination showed evidence of severe inflammation. Physical examination revealed rebound tenderness in the upper abdomen, and equivocal muscle guarding. Abdominal computed tomography showed a 30-mm tumor-like lesion containing air in the middle of the lower abdomen with inflammatory change around it. This lesion was suspected to be connected to the small intestine. Because of the possibility of a perforated jejunal gastrointestinal stromal tumor (GIST), emergency surgery was performed. When an adhesion of the mesojejunum was peeled off, purulent discharge escaped. A perforated jejunal diverticulum was observed on the mesenteric side of the jejunum about 75 cm from the ligament of Treitz. Partial resection of an approximately 20-cm segment of the jejunum was performed. Three cellophane-like foreign bodies were identified in the perforated diverticulum in the resected specimen, and it was suspected that the foreign bodies could have caused the diverticular perforation. A case of jejunal diverticulum perforation suspected to be caused by a foreign body is described. This case reaffirms the importance of preoperative imaging.

The patient was a woman in her 50s who had undergone endoscopic resection of a polyp in the cecum. Four days after the procedure, she visited our hospital complaining of lower right abdominal pain, and physical examination revealed signs of peritoneal irritation. Abdominal CT showed inflammation in the polyp resection area, and one of the clips used during the procedure was detected in the appendix, without any evidence of inflammation. Although diagnosing the cause of the abdominal pain and selecting the appropriate treatment plan posed a challenge initially, appendectomy was performed after initial conservative treatment. This seems to be the first reported case of retention of an endoscopic clip in the appendix without evidence of inflammation. It was unclear if automatic passage from the appendix could be expected. Because the clip was relatively sharp and therefore a potential cause of perforation, we decided to perform appendectomy.

A 48-year-old man was brought to our hospital complaining of right lower abdominal pain. He was diagnosed as having an incarcerated right inguinal hernia, which was subsequently treated by hernia repair. Although the pain improved，the patient was admitted to our hospital because abdominal computed tomography (CT) revealed edema of the small intestine and a small amount of ascites. A repeat abdominal CT on the third postoperative day showed worsening of the small intestinal edema and increase in the amount of ascites, so we performed a review laparoscopy because of suspected peritonitis. The serosal injury noted on the mesenteric side of the ileum was considered to have possibly been caused during the repair of the incarcerated hernia, and we performed laparoscopic partial resection of the affected segment of the small intestine. As contamination of the abdominal cavity was mild, we used an anterior approach for the surgery. The patient showed a favorable clinical course and was discharged on the 10th postoperative day. Our case highlights the possibility of manual reduction of an inguinal hernia causing intestinal damage.

We present a report of two patients with recurrent volvulus of the sigmoid colon who were treated by single-incision laparoscopy-assisted sigmoid colectomy after endoscopic decompression. (Case 1) A 74-year-old man presented to us with a history of abdominal pain. Based on the findings of physical examination, plain X-ray of the abdomen, and abdominal computed tomography (CT), the patient was diagnosed as having volvulus of the sigmoid colon. Endoscopic reduction was performed successfully. Subsequently, 6 and 11 months later, the patient presented to us again complaining of abdominal pain. Thereafter, based on the diagnosis of recurrent volvulus of the sigmoid colon, we performed single-incision laparoscopic-assisted sigmoid colectomy. The patient was discharged from the hospital 9 days after the operation, after an uneventful postoperative course. (Case 2) An 86-year-old woman presented to us complaining of abdominal pain. Based on the findings of physical examination, plain X-ray of the abdomen, and abdominal CT, she was diagnosed as having volvulus of the sigmoid colon. Endoscopic reduction was performed successfully. Subsequently the patient presented to us again 3 months later complaining of abdominal pain. Based on the diagnosis of recurrent volvulus of the sigmoid colon, we performed single-incision laparoscopic-assisted sigmoid colectomy. The patient was discharged from our hospital 13 days after the operation, after an uneventful postoperative course. Single-incision laparoscopy-assisted surgery for patients with recurrent volvulus of the sigmoid colon after endoscopic decompression is safe and feasible, and therefore, a valid therapeutic option.

A 13-year-old male patient was transported to our hospital complaining of abdominal pain that had first started during his early morning exercise, but had gotten worse after lunch. The abdomen was flat and soft, with localized tenderness in the upper navel. Abdominal contrast-enhanced computed tomography (CT) showed clockwise twisting of the bowel around the superior mesenteric artery. The patient was diagnosed as having intestinal torsion and underwent emergency laparoscopic surgery. Intraoperative exploration of the abdominal cavity revealed no fixation to the retroperitoneum from the cecum to the hepatic flexure, and twisting of the ascending colon. As reduction proved difficult under laparoscopic guidance, the procedure was completed after conversion to open surgery. Both the ascending colon and the small intestine were found to be twisted clockwise by 180 degrees. After the twisted intestine was released, no evidence of necrosis or perforation of the intestine or colon was apparent. The patient was finally diagnosed as having had volvulus caused by intestinal malrotation. The ascending colon and retroperitoneum were fixed. Volvulus caused by intestinal malrotation is rare in adolescence.

An 82-year-old woman was admitted with a history of lower abdominal discomfort, and was found to have a hen egg-sized tumor in the rectum. Abdominal CT showed intussusception of the sigmoid colon and a round shaped tumor in the rectum. Fiberoptic colonoscopy revealed a hen egg-sized elastic-hard, smooth-surfaced tumor projecting into the colonic lumen. Sigmoidectomy with D2 lymph node dissection was performed under a preoperative diagnosis of sigmoid colon submucosal tumor associated with intussusception. Histopathological examination of the resected specimen revealed a well-differentiated liposarcoma of the colon. The postoperative course was favorable and the patient was discharged on postoperative day 28. Liposarcoma arising from the large intestine is rather rare, and we report the case herein, with a review of the relevant literature.

A 48-year-old man was transferred to our emergency department with shock after sustaining injuries in a car collision accident. Abdominal CT performed after ensuring hemodynamic stability revealed traumatic abdominal wall hernia and emergency operation was performed. Intraoperative exploration revealed strangulation of a segment of the small intestine and mesentery. After ligation to control the bleeding and resection of the strangulated segment of the small intestine, the abdominal wall was closed directly. On day 5 after the operation, the patient developed delayed perforation of the ascending colon, and reoperation was performed. Thereafter, until the present, 14 months after the operation, the patient has shown no evidence of recurrence of the abdominal wall hernia. Direct closure is suitable for cases undergoing emergency repair of traumatic abdominal wall hernia, because of the possibility of delayed organ injuries.

Anastomotic hemorrhage is a rare complication. The role of endoscopic treatment for this complication has not yet been clarified, because endoscopy just after surgery is associated with an elevated risk of anastomotic leakage. We describe three cases of colonic anastomotic hemorrhage occurring just after surgery who were treated by an endoscopic approach. Case 1: A 74-yr old woman who underwent open colectomy for transverse colon cancer. Case 2: A 57-yr old woman who underwent laparoscopic sigmoidectomy for colonic cancer. Case 3: A 49-yr old man who underwent open ileocecal resection for an appendiceal tumor. Colonic anastomosis was performed by functional end-to-end anastomosis in all patients. Anastomotic hemorrhage occurred on postoperative day 1 (POD1), POD2, and POD3, respectively, in the patients. In all patients, emergency endoscopy was performed, which revealed massive bleeding on the suture line, and we performed endoscopic clipping to achieve hemostasis. The postoperative courses in all three patients were uneventful, with none of the cases showing either re-bleeding or anastomotic leakage. In conclusion, endoscopic treatment for anastomotic hemorrhage is safe and effective, even in patients presenting with hemorrhage immediately after surgery.

A 91-year-old woman with dementia was transported by ambulance with a history of vomiting and abdominal pain. Her vital signs were stable. Abdominal examination and blood tests showed few findings suggestive of severe intraperitoneal infection. Abdominal CT showed pronounced gas shadows in the portal vein and foamy intramural emphysema in the stomach, descending duodenum and proximal jejunum. Although the CT images showed findings characteristic of emphysematous gastritis, we suspected gastric emphysema based on the patient’s clinical presentation, including excessive vomiting. CT performed on the following day revealed remarkable improvement of the vascular gas shadows and intramural emphysema, and showed wall thickening of the same portion of the gastrointestinal tract. Culture of bloody gastric juice specimens obtained at the time of admission was positive for three kinds of gas-producing bacteria. Based on information from the family of the patient, our isolation of gas-producing bacteria and the findings of upper gastrointestinal endoscopy performed on day 7 of hospitalization, we concluded that our patient had emphysematous gastritis caused by her poor personal hygiene due to dementia. Her condition resolved successfully with conservative management.

A 71-year-old man was referred to our hospital with a history of right lower abdominal pain and melena. Laboratory findings revealed evidence of inflammatory reaction. Abdominal contrast-enhanced CT showed a 13-cm cystic lesion with an air- fluid level in the ileocecal region, and enhancement of the cyst wall. Based on the findings, the patient was diagnosed as having an abdominal abscess, of tumor or infectious origin. Treatment by drainage was not effective. Colonoscopy and irrigoscopy revealed fistula formation between the tumor abscess and the sigmoid colon. Subsequently, the patient’s condition became worse and he developed peritonitis, necessitating emergency operation. Intraoperative exploration revealed a huge tumor originating from the ileal mesentery directly invading the small intestine and sigmoid colon with hemorrhagic ascites and scattering of the cellular debris from the ruptured tumor. We performed wide resection of the small intestine, sigmoid colectomy, colostomy and abdominal irrigation. Immunohistochemical examination revealed positive staining of the tumor cells for c-kit and CD34. Based on the findings, the patient was diagnosed as having a gastrointestinal stromal tumor arising from the mesenterium of the small intestine forming a fistula with the sigmoid colon. Gastrointestinal stromal tumor with intratumor abscess forming a fistula with the colon is very rare. Herein, we report this rare case with a review of the literature.

【Background】 Inflammation of the epiploic appendage is a disease that can be cured by conservative treatment, and carries a favorable prognosis. We report seven cases of epiploic appendagitis. 【Patients and method】 Herein, we present the clinical findings and imaging features of seven patients with epiploic appendagitis in whom the condition was diagnosed by abdominal CT at our hospital. 【Results】 The patients were one man and six women, with a median age of 36 years (22-83 years). All the patients presented with abdominal pain, and both the white blood cell counts/serum CRP levels were normal or slightly elevated. The sites of occurrence included the descending colon (n=4), ascending colon (n=2), and sigmoid colon (n=1), and the left side of the colon was the predominantly affected site. The condition was primary in 6 patients, and secondary in one patient. In the patient with secondary epiploic appendagitis, the inflammatory markers in the blood were elevated to a higher degree as compared to those in the patients with primary epiploic appendagitis. In regard to treatment, six patients received conservative treatment, whereas one patient was preoperatively diagnosed as also having appendicitis and underwent surgery. 【Conclusion】 In cases of epiploic appendagitis, discriminating the site of occurrence and the cause （in cases of secondary epiploic appendagitis） is imperative for appropriate selection of the treatment.

An 88-year-old woman with a history of cholelithiasis was referred to our hospital with a history of abdominal pain and vomiting. Computed tomography (CT) revealed a 3.5-cm stone in the small intestine and a dilated intestinal segment on the oral side of the stone, but no stones in the gallbladder. Based on the findings, we made the diagnosis of gallstone ileus. An abdominal CT performed in the patient 3 years earlier had also revealed a stone in the small intestine, however, because of her advanced age and absence of symptoms, she had been followed up without treatment. Because spontaneous passage of the stone was considered unlikely, we performed emergency surgery. Intraoperatively, a 5-cm mass was found at a site approximately 50 cm from Bauhin’s valve, and partial small intestinal resection was performed. The resected small intestinal specimen was incised, and the impacted gallstone was removed. Following this, a depressed lesion was found on the small intestinal wall. Histopathological examination revealed primary small intestinal cancer with lymph node metastasis. Gallstone ileus complicated by small intestinal cancer is extremely rare. In such a case, it is assumed that stimulation by the prolonged presence of gallstones in the small intestine promotes carcinogenesis, followed by tumor growth. Thus, unless intestinal stones show spontaneous evacuation, they should be aggressively treated even in the absence of symptoms.

A 63-year-old man who had undergone surgery with colostomy for volvulus of the sigmoid colon was referred to our hospital complaining of acute abdominal pain. At presentation, visual inspection revealed ischemic change of the mucosal layer of the artificial anus and abdominal computed tomography showed abnormally dilated intestinal loops, and ascites. Emergency surgery was performed under the diagnosis of strangulation ileus associated with the artificial anus. Laparotomy revealed a gap between the elevated large bowel of the artificial anus and the abdominal wall. An adjacent loop of the small intestine was incarcerated through the gap. The incarcerated portion of the intestine exhibited ischemic change, and we resected the ischemic intestinal segment. The small intestine became strangulated when it got wound on to the elevated intestinal tract through the large gap between the elevated large bowel and the abdominal wall. When an intraperitoneal course is chosen for colon construction with an artificial anus, care should be taken to avoid leaving a gap, in consideration of the possibility of occurrence of this rare type of strangulation ileus.

The patient was a 71-year-old woman who visited our hospital complaining of abdominal pain. She had undergone right colectomy, and physical examination revealed a surgical scar measuring 150 mm in length on the right side of the abdomen. Abdominal CT showed edema-like change of the gallbladder, bile duct dilation, and a high-density lesion on the papilla of Vater. Therefore, additional MRCP and ENBD angiographic imaging were performed. MRCP showed no common bile duct stone or tumor, while cholangiography during ENBD angiography showed discontinuity of the cystic duct. Based on these findings, the patient was diagnosed as having gallbladder torsion, and emergency surgery was performed. Because the presence of severe adhesions on the right side of the abdomen was confirmed, the ports for laparoscopic surgery were positioned at the umbilicus, epigastrium, and left abdomen. The gall bladder was congested and twisted 180 degrees counterclockwise (Gross type Ⅱ gallbladder torsion）. The operation time was 92 minutes, the bleeding volume was small, and the postoperative course was good. The patient was discharged on day 6 after the onset of symptoms. In the present case, we found severe adhesions; however, laparoscopic cholecystectomy was made possible by appropriate positioning of the ports according to the location of the adhesions. This case is reported herein, with a consideration of the pertinent literature.

Diaphragmatic hernia developing after hepatectomy is rare. A 51-year-old female patient who had undergone right hepatectomy via a thoraco-laparotomy presented 9 months later complaining of upper abdominal pain and nausea. An abdominal CT revealed a diaphragmatic hernia and bowel obstruction, and we performed laparoscopic surgery. The cause of the herniation was determined as failure of the sutures of the diaphragm. The hernia orifice was repaired with a mesh coated with an adhesion inhibitor. Thus, laparoscopic surgery is a valid treatment option for diaphragmatic hernia developing after liver resection. As incarcerated diaphragmatic hernias could prove fatal, the possibility of diaphragmatic hernias developing as a late complication after liver resection should be borne in mind.

A 76-year-old woman was admitted to Kawaguchi Municipal Medical Center complaining of lower abdominal pain. Abdominal computed tomography （CT） revealed a thick-walled cystic lesion containing fluid measuring 40 mm in diameter in the lower abdomen. Based on these findings of abdominal CT and the hematological findings, the patient was suspected as having an intra-abdominal abscess. The patient had a past history of having undergone colpoplasty using an intestinal graft. Thus, it was determined that the intra-abdominal abscess was derived from the intestinal stump of the reconstructed vagina. The patient was successfully treated with antibiotics and discharged after 11 days in hospital. The abscess resolved almost completely, with no evidence of recurrence for the subsequent 24 months of follow-up. Thus, it is important to consider the postoperative complication of abscess in patients with a history of colpoplasty using the digestive tract.

A 41-year-old man with abdominal pain was referred to our hospital and was diagnosed as having portal vein obstruction caused by extramural compression by an abdominal tumor. Despite the anticoagulant treatment that the patient was initiated on, blood tests revealed a continued fall of the hemoglobin level, and multidetector-row computed tomography (MDCT) showed an increase in the size of the abdominal tumor, a pancreaticoduodenal artery aneurysm, and celiac axis compression syndrome. Based on the findings, we diagnosed the patient as having a large hematoma and performed transcatheter arterial embolization for treating the pancreaticoduodenal artery aneurysm, and then, surgical removal of the abdominal hematoma and portal vein thrombus. The patient was discharged on day 40 after the initial surgery. Follow-up MDCT showed steady portal venous flow 2 years after the surgery. Portal vein obstruction caused by an abdominal hematoma resulting from pancreaticoduodenal artery aneurysm is extremely rare.

A 77-year-old male patient with a history of abdominal pain was transported to our emergency room in a shock state. Blood tests revealed anemia and evidence of prerenal renal failure. Abdominal CT showed bloody ascites and extravasation of contrast from the vicinity of the sigmoid colon. We made the diagnosis of intraabdominal hemorrhage from the sigmoid mesocolon, and undertook emergency surgery. At laparotomy, a large hematoma was found, and the source of the hemorrhage was the epiploic appendage of the sigmoid colon. The bleeding was controlled by ligature of the epiploic appendage, and the patient was transferred to his previous hospital on postoperative day 20. As far as we know, this is the first presented case from Japan of hemorrhage as the main manifestation of a epiploic appendage in the abdominal cavity.

The patient was a 68-year-old woman who visited our hospital with the chief complaint of persistent pain in her left abdomen. She had previously undergone incisional hernia repair. She was taking only antihypertensive medication. On physical examination, an immovable mass with tenderness could be palpated in the left abdomen. Blood examination revealed a slight increase of the serum in C-reactive protein level (0.58 mg/dL) and slight decrease of the blood hemoglobin level (11.5 g/dL), with no evidence of coagulation abnormalities. Abdominal contrast-enhanced CT revealed a hematoma in the left abdominal wall, measuring approximately 4 cm in diameter, with contrast extravasation. Based on these findings, the patient was diagnosed as having non-traumatic rectus sheath hematoma (RSH). She was admitted to our hospital for conservative therapy, because her condition was stable. Since the subjective symptoms gradually improved, she was discharged after 4 days of admission. RSH is a relatively rare condition, with a hematoma forming inside the sheath of the rectus abdominis muscle as a result of rupture of the superior or inferior epigastric arteriovenous vessels, often precipitated by violent contractions of the abdominal muscles. Herein, we have reported a case of non-traumatic RSH caused by a coughing fit, with a review of the relevant literature.

A 67-year-old man with the chief complaint of right-sided abdominal pain was diagnosed as having duodenal perforation and treated by emergency surgery; the semicircular perforation detected in the duodenal bulb was repaired by simple closure. On postoperative day 4, intestinal fluid drainage was observed via the drain and the patient was diagnosed as having panperitonitis, necessitating another emergency surgery. Intraoperative examination at the reoperation revealed complete failure of the suture closure. Because of the severe contamination around the perforated area, we considered that re-suturing would be dangerous, and created a duodenal diverticulum. Superior pancreaticoduodenal artery hemorrhage occurred on post-reoperation day 6, which was controlled by an emergency interventional radiologic procedure. Drain management took time, and the patient was discharged on postoperative day 78. With the widespread use of proton pump inhibitors, gastroduodenal ulcer perforations are currently treated by suture closure of the perforation and coverage by the omentum; however, this technique alone may not always yield a good prognosis. In this patient, reoperation to create a duodenal diverticulum was effective for suture failure after repair of duodenal ulcer perforation.

【Case 1】 A 54-year-old male was transported to our hospital by ambulance because of hepatic rupture. Two transcatheter arterial embolizations were performed to treat the hepatic rupture of unknown cause. Twelve days after the admission, a careful review of the history revealed that the patient had sustained blunt abdominal trauma 66 days prior to admission; consequently, the patient was diagnosed as a case of grade Ib hepatic injury. 【Case 2】 A 59-year-old female who had undergone subtotal stomach-preserving pancreaticoduodenectomy for pancreatic cancer met with a traffic accident 6 months after the surgery, and was diagnosed as having bilateral rib injuries. She then developed dyspnea and was admitted to our hospital 29 days after the accident. Abdominal computed tomography revealed grade Ib hepatic injury, and the patient underwent non-operative management. Both cases were asymptomatic in the early phase of the injury, but suffered from delayed hepatic rupture. Thus, in cases of hepatic rupture of unknown origin, a careful review of the history for any instance of blunt trauma is important.

A 10-year-old boy was taken to a neighborhood hospital with acute abdominal pain and vomiting, and was diagnosed as having hemorrhagic shock. Abdominal CT revealed rupture of a liver tumor, and the child was transferred to our hospital. We decided to perform an interventional radiologic procedure (IVR) prior to surgery, to stabilize the hemodynamic status of the patient, and performed embolization of the tumor feeding arteries. Thereafter, hepatic resection was performed on day 7 after admission. The postoperative clinical course was favorable. The histopathological diagnosis of the tumor was mixed hepatocellular carcinoma with hepatoblastoma, and the patient was initiated on postoperative chemotherapy. This case underscores the importance of selecting the appropriate treatment, including surgical procedure or IVR, for pediatric cases of liver tumor with intraperitoneal hemorrhage presenting as an oncologic emergency.

An 18-year-old woman sustained a three-point seat belt injury in a vehicle accident and was admitted to our hospital complaining of abdominal pain. On examination at admission, the seatbelt sign was positive and there was tenderness in the right middle abdomen. Contrast-enhanced CT showed a defect in the wall of the descending part of the duodenum and free air outside the duodenum, and we diagnosed duodenal perforation. Diagnostic imaging also revealed liver injury and lung contusion, rib fractures, left tibial shaft fracture. An emergency laparotomy was performed. Intraoperative exploration revealed the perforation in the descending part of the duodenum, and we performed end-to-side duodenojejunostomy and cholecystectomy. A C-tube was placed for decompression. At the same time, we performed operation for reducing the tibial fracture. The patient was discharged after an uneventful clinical course on postoperative day 21. Traumatic duodenal injury caused by a three-point seatbelt is relatively rare, and we report a case herein, with a review of the literature.