Serum procalcitonin (PCT) is a commonly used biomarker for the diagnosis of bacterial infections. We performed a single–center retrospective analysis of 122 patients diagnosed as having with acute cholangitis at our hospital to evaluate the usefulness of serum PCT for early diagnosis of acute severe cholangitis. The results of our statistical analyses revealed that the serum PCT level increased significantly as the severity grade of the cholangitis increased. The area under the curve (AUC) of the serum PCT was significantly greater than that of the white blood cell count or the serum C–reactive protein level. The serum PCT level was significantly higher in the case with bacteremia than in the cases without bacteremia. The ROC–AUC of the serum PCT level for discriminating between cases with and without bacteremia was 0.65 (P＜0.05), and the optimal cutoff value for the diagnosis of cases with bacteremia was 1.3 ng/mL. The blood platelet counts of the patients with serum PCT levels of over 1.3 ng/mL were significantly lower those of patients with serum PCT levels of under 1.3 ng/mL. A negative correlation was observed between the serum PCT level and the platelet count in both cases with mild and moderate cholangitis. Furthermore, our analyses also suggested that the optimal cutoff value of the serum PCT for predicting the need for emergency biliary drainage was 1.3 ng/mL. In conclusion, these findings suggest that the serum PCT could be a useful biomarker for early diagnosis of severe acute cholangitis.

Reduced–port cholecystectomy is now widely performed in patients with cholecystitis. Our study was aimed at assessing the safety of reduced–port surgery (RPS) for cholecystitis based on the TOKYO Guidelines 2018. 【Method】From January 2016 and April 2019, we performed laparoscopic cholecystectomy in 174 patients with cholecystitis. Conventional surgery was performed in 104 patients and RPS in 70 patients. We compared the short–term surgical outcomes between the two groups, especially in patients with mild cholecystitis. 【Results】In regard to the intraoperative outcomes, the estimated blood loss was lower in the RPS group. On the other hand, similar short–term postoperative outcomes were noted between the RPS group and conventional surgery group. 【Conclusion】RPS for mild acute cholecystitis can be safely performed, with superior short–term outcomes, such as reduced intraoperative blood loss as compared to the conventional surgery group.

An 82–year–old woman presented to our hospital with the chief complaint of vomiting. Abdominal CT showed a right obturator hernia with incarcerated small intestine. Since no apparent bowel ischemia was suspected, we performed manual reduction under ultrasound guidance. Elective laparoscopic surgery was performed eight days after the reduction. Laparoscopy revealed a right obturator hernia and a right femoral hernia. We conducted transabdominal preperitoneal repair of both hernias using a reversed 3D MAX^TM Light Mesh (3D mesh). It was possible to ensure an anatomically correct fit and minimized wrinkling, because of the three–dimensional curved shape and shape retaining sealed edge of the reversed mesh.

We report a rare case of peritonitis caused by perforation of an ileal diverticulum. A 56–year–old male patient was admitted to our hospital with fever of sudden onset and abdominal pain. Localized tenderness in the lower right abdomen prompted an abdominal computed tomography, which revealed an increase in the concentration of fatty tissue around the ileocecal region and a diverticulum each in the ascending colon and terminal ileum. We diagnosed localized peritonitis caused by perforation of the ileal diverticulum or ascending colon diverticulum. Conservative treatment was initiated. On day 6, as the patient’s condition deteriorated, surgery was performed. Abscess formation with localized inflammation was observed in the ileocecal region. An ileocecal resection was performed. Histopathological examination of the resected specimen revealed perforation of the diverticulum near the terminal ileum. The postoperative course was uneventful, and the patient was discharged on day 10 after the operation.

The patient was a 63–year–old man who developed abdominal pain of sudden onset and was transported to the emergency department of our hospital. Contrast–enhanced abdominal computed tomography revealed an extravasation of superior mesenteric artery (SMA). He was diagnosed as having hemorrhagic shock, and hemostasis, transverse colectomy and ileostomy were performed on the same day. The hemorrhagic shock recurred two days after the operation, and contrast–enhanced abdominal computed tomography revealed SMA occlusion and poor contrast enhancement over the intestine. Resection of most of the small intestine and right hemicolectomy and a re–ileostomy were performed. The histopathological diagnosis of the resected specimen after the first operation was segmental arterial mediolysis (SAM), and that after the second operation was intestinal obstruction caused by a fresh thrombus and intestinal necrosis. We encountered a very rare case of a patient with thrombosis of the SMA occurring after operation for intraperitoneal bleeding from the SAM who we were able to rescue. We report this case to underscore the necessity to bear in mind the risk of obstruction of blood flow by thrombosis after hemostasis.

A 48–year–old woman presented with a 2–day history of slight fever and was prescribed NSAIDs by another physician. She was transferred to our hospital and was admitted for hypoxemia and hypotension with pyuria and abdominal distention. Laboratory tests revealed elevated inflammatory markers and evidence of renal function impairment. Abdominal computed tomography showed ascites and dilated intestinal segments with thickening of the intestinal wall. There was no free air. We suspected septic shock due to peritonitis of unknown cause and performed emergency laparotomy. Intraoperatively, the bladder wall was found to be irregular and thickened, without any obvious perforation. Based mainly on these clinical findings, we made the diagnosis of bladder rupture of unknown origin with pseudo renal failure. First, the blood urea nitrogen and serum creatinine levels in the ascites fluid were much higher than the corresponding levels in the blood. Second, her renal function improved significantly on the day after the surgery. Finally, bacterial culture of both blood and ascites fluid were positive for E. coli. After treatment, the patient was discharged on day 33. Thus, in cases with suspected bladder rupture, examination of the ascites fluid may be useful.

A 75–year–old female patient with a huge black abdominal bulge and signs of shock was transported to the emergency department of our hospital. She was diagnosed as having incarcerated umbilical hernia, with necrosis of the herniated ileum. Emergency surgery with two partial ileal resections was performed. Then, we simply closed the hernia orifice, without a mesh. While it is important to perform emergency surgery as soon as possible to avoid intestinal resection in patients with incarcerated hernia, changes in the skin tone should be significantly paid attention too.

A 77–year–old female patient with a past medical history of diabetes mellitus and autoimmune hepatitis receiving treatment with prednisolone was hospitalized for subarachnoid hemorrhage, and underwent coil embolization. The patient was started on tube feeding, and 6 days later, she developed fever, vomiting and epigastric pain. Physical examination revealed intense epigastric tenderness. CT imaging showed air within the gastric wall, edematous mucosa of the pylorus, and a small amount of portal venous gas. Urgent esophagogastroduodenoscopy showed markedly inflamed and partially necrotic mucosa from the gastric body to the pylorus. Exploratory laparotomy was performed because transmural ischemia of the stomach was suspected. However, the gastric serosa was intact, and the gastrostomy tube was inserted from the anterior wall of the pylorus into the duodenum. Culture of a specimen of gastric mucosa was positive for Klebsiella pneumoniae. Antibiotic therapy was de–escalated from meropenem/vancomycin to cefotaxime. Repeat endoscopy revealed recovery of the gastric mucosa 9 days after the surgery and enteral feeding was started. The patient was discharged 3 months after the surgery. Emphysematous gastritis is a rare, but life–threatening disease, and herein, we discuss the pathophysiology and treatment of the disease.

A 75–year–old woman with aortic stenosis underwent major cardiac surgery. On day 6 after the surgery, she complained of abdominal pain and her serum lactate level increased. Abdominal CT scan revealed extensive mural pneumatosis of the small bowel and the presence of gas in the portal and superior mesenteric veins. Based on the findings, she was diagnosed as having non–occlusive mesenteric ischemia (NOMI) and emergency laparotomy was performed. Extensive ischemia was observed in a discontinuous manner in the small bowel. Two independent portions of the small bowel that were determined as being necrotic were resected, leaving 180 cm of healthy small bowel between the resected bowel, with jejunostomy on the distal stump. The proximal jejunal and distal ileal stumps were closed and the intestinal contents were drained through an ileus tube and the anus, respectively. The mucosal surface of the remaining small bowel was endoscopically observed on day 10 after the laparotomy, which revealed no further ischemic damage. After the general condition of the patient became stable, small bowel reconstruction was performed on day 21 after the 1st surgery. The postoperative course after the 2nd surgery was uneventful, and the patient was discharged from the hospital on day 49 after the 1st laparotomy. The serum albumin level returned to 3.9 g/dL of, the same level as that recorded prior to the cardiac surgery at 11 months after discharge. This case highlights the importance of preserving portions of the small bowel that do not show ischemic injury, to prevent short bowel syndrome.

A 68–year–old man complaining of right back pain was referred to a local doctor. Laboratory studies revealed elevation of the liver and biliary enzymes. MRCP showed a filling defect in the lower common bile duct. ERCP was subsequently performed, but the presence of stones was not confirmed. The patient recovered well and was discharged. On the day after discharge, he was discovered lying on the floor at his house and was transferred to our hospital. At arrival, he went into cardiopulmonary arrest, and was revived by cardiopulmonary resuscitation. Blood tests showed prolongation of the prothrombin time and elevation of the levels of hepatobiliary enzymes. Plain abdominal computed tomography showed biliary obstruction caused by gallbladder hemorrhage. An upper gastrointestinal series revealed duodenal stenosis. It was considered difficult to perform ERCP for adequate drainage because of duodenal stenosis. Therefore, we had no choice but to select conservative therapy. We performed resection of the gallbladder under a tentative diagnosis of gallbladder hemorrhage due to gallbladder carcinoma. The patient was discharged without postoperative complications. While biliary obstruction caused by gallbladder carcinoma via hematoma formation has been reported, there is no report of biliary obstruction leading to cardiopulmonary arrest. Herein, we report the case of a patient who was revived from cardiopulmonary arrest complicating biliary obstruction due to hematoma.

An 85–year–old man complaining of abdominal pain and melena was diagnosed as having small bowel obstruction and referred to our hospital. Abdominal computed tomography showed evidence of small bowel obstruction caused by ileocecal intussusception. Colonoscopy revealed a small bowel tumor, and an attempt at reducing the intussusception failed. We planned ileus tube drainage and elective laparoscopic surgery. On day 7, we performed laparoscopic reduction and ileocecal resection with lymph node dissection. We consider this case as worthy of reporting, because invagination caused by small bowel cancer treated by laparoscopic reduction is rare.

The patient was a 27–year–old male, who was transported to our hospital after he was involved in a traffic accident caused by altered sensorium while he was driving to the hospital for 3–day history of worsening abdominal pain. Abdominal ultrasonography showed massive intra–abdominal hemorrhage, and contrast–enhanced computed tomography revealed a hemorrhagic mass between the tail of the pancreas and the hepatic flexure of the colon. The patient was diagnosed as having either rupture of a branch of the splenic artery or hemorrhage from the tumor in the pancreatic tail, and underwent emergency laparotomy. During surgery, active bleeding was seen from the tumor measuring 4 cm in diameter in the tail of the pancreas. As the tumor was found to be tightly adherent to the splenic flexure of the colon, distal pancreatectomy and partial colectomy, including the tumor, were performed. Histopathology of the resected specimen suggested that the tumor originated in the mesentery of the colon. Histologically, the tumor was found to be composed of proliferating spindle–shaped cells, and to invade a branch of the splenic artery. Immunostaining showed negative staining of the tumor for ALK, CD34, c–kit, desmin, DOG–1, S–100, SMA, and STAT6, and positive staining for only β–catenin. Therefore, the tumor was diagnosed as a desmoid tumor. From the clinical course and intraoperative findings, it was thought that the hematoma formed as a result of invasion by the tumor of a branch of the splenic artery which then ruptured into the abdominal cavity, causing the worsening abdominal pain and altered consciousness. The patient had a favorable postoperative course and was discharged from the hospital on day 27. There have been only a few reports of desmoid tumors with hemorrhage. We report this case with some review of the literature.

The patient was an 88–year–old woman who had been admitted to the previous hospital with mucous stools and a 1–month history of diarrhea and anorexia. Although the findings of CT suggested intussusception, no clear lesion was noted in the invaginated segment of the bowel. As the intussusception could not be reduced by endoscopy, the patient was referred to our hospital. A mass was palpable around the umbilicus, with tenderness in the area of mass. An emergency laparotomy was performed, which revealed invagination of the ileocecal region up to the middle of the transverse colon. Right hemicolectomy was performed. The excised specimen was treated by injection of 80 mL of formalin fixative from the oral side. After twelve hours, a longitudinal incision was made, and a 35×25 mm 0–Ⅱa lesion was found in the invaginated segment of the bowel, and the histopathological diagnosis was Tis. In adult cases of colon intussusception, more detailed histopathological investigation of the invaginated segment seemingly without lesions, for example, by injection of formalin fixative is useful.

A 30–year–old male patient was admitted to the emergency room of our hospital complaining of persistent abdominal pain of acute onset and weakness. Focused assessment with sonography for trauma (FAST) revealed ascites in the pericystic region and on the surface of the liver. Abdominal CT revealed massive intraabdominal hemorrhage with extravasation of contrast medium near the rectum, thinning of the anterior rectal wall, and parenteral gas in the perirectal region. An additional medical interview to determine a history of trauma revealed that the patient had inserted a plastic bottle into his anus six hours prior to the onset of the symptoms. He was diagnosed as having rectal arterial bleeding caused by transanal insertion of a rectal foreign body, and angiography was performed. Inferior mesenteric artery arteriography indicated extravasation of contrast medium from a branch of the superior rectal artery. Therefore, we performed selective transcatheter arterial embolization (TAE) of the vasa recta of the superior rectal artery, and succeeded in achieving hemostasis. The patient was able to eat on postoperative day 2 and was discharged, after an uneventful postoperative course, on postoperative day 8. Colonoscopy performed on postoperative day 7 showed a rectal ulcer that was thought to be due to ischemia. We report a rare case of intraabdominal hemorrhage caused by transanal insertion of a rectal foreign body, in which hemostasis was successfully achieved by selective TAE.

The patient was a 65–year–old woman with an abdominal tumor who was diagnosed as having metastatic cancer of the cecum with multiple metastases in the liver and lung. She was started on mFOLFOX6＋bevacizumab chemotherapy. Eight months later, abdominal computed tomography (CT) revealed progressive disease and the treatment was switched to FOLFIRI＋bevacizumab. Ten days after the treatment switch, the patient developed right lower abdominal pain. Abdominal CT revealed marked enlargement of the appendix, and emergent surgery was performed under the diagnosis of obstructive appendicitis caused by obstruction of the appendiceal orifice by cecal cancer. Ileocecal resection was performed via a laparoscopic approach and a hand–sutured anastomosis was performed for reconstruction. No postoperative complications were noted. The patient was discharged on postoperative day (POD) 10 and the chemotherapy was resumed on POD 32. Gastrointestinal perforation is a serious complication of bevacizumab therapy, and surgical site infection and dehiscence can cause delayed healing. However, these risks may be decreased by adopting a laparoscopic approach for surgery and a modified method for anastomosis.

An 84–year–old Japanese man with a history of cervical spine injury, diabetes mellitus, and coronary artery bypass surgery presented to us with vomiting and abdominal pain. Abdominal computed tomography (CT) showed calcification in the duodenum and adhesions on the gallbladder and duodenum. We made the diagnosis of gallstone ileus with a cholecystoduodenal fistula. Initial conservative therapy by insertion of a gastric tube did not elicit satisfactory response, therefore, surgery was performed. Enterolithotomy was successfully performed by single–incision laparoscopic surgery. No additional surgery, such as cholecystectomy or resection of the cholecystoduodenal fistula, was performed. The fistula had closed spontaneously, with no complications, by 2 months postoperatively.

Acute hemorrhagic rectal ulcer (AHRU) is characterized by sudden onset of painless and massive bleeding, and most commonly occurs in elderly bedridden patients with severe underlying disorders. A 73–year–old Japanese woman was diagnosed as having subarachnoid hemorrhage (SAH) and hospitalized for operation. At 38 days after the operation, she developed massive rectal bleeding and went into hypovolemic shock, and was diagnosed as having an AHRU. Although we performed endoscopic hemostasis (coagulation, clipping and hypertonic saline–epinephrine instillation) 10 times over a period of two weeks from the start of bleeding, the bleeding persisted and the ulcer enlarged in size. Then, we applied a polyglycolic acid sheet (PGA sheet) and fibrin glue on the rectal ulcer via an endoscope. Seven days after the treatment, we confirmed complete hemostasis by colonoscopy, and the patient was discharged on the 80th day after the operation for SAH. Endoscopic ulcer sealing of an AHRU with a PGA sheet and fibrin glue is considered as a safe and effective treatment alternative for refractory AHRU.

A 19–year–old man presented to our hospital with a chief complaint of right lower abdominal pain. Contrast–enhanced computed tomography revealed telescoping of the cecum into the ascending colon. The patient was diagnosed as having ileocecal intussusception. Colonoscopy was performed, which revealed a submucosal tumor–like mass in the cecum that showed no characteristics of a malignant tumor. The symptoms of the patient improved immediately after the endoscopic reduction. However, the ileocecal intussusception recurred and emergency surgery was performed. Laparoscopic observation revealed highly loose attachment of the cecum to the retroperitoneum and ileocecal intussusception. As the cecum was firmly adherent to the ascending colon, laparoscopic reduction could not be performed and laparoscopy–assisted ileocecal resection was necessitated. Histopathological examination did not reveal any organic lesions. The patient was diagnosed as having had idiopathic intussusception associated with mobile cecum syndrome. His postoperative course was favorable and he was discharged on postoperative day 9. He has shown no evidence of recurrence until now, 20 months after the operation.

Diverticula may be found in the jejunum, but bleeding from jejunal diverticula is rare. We encountered a case of jejunal diverticular bleeding in which balloon endoscopy was performed for diagnosis and treatment. A 75–year–old woman with cardiogenic embolism was admitted to the department of neurosurgery of our hospital. After thrombolytic therapy, she was initiated on oral rivaroxaban treatment. On hospital day 12, a blood test revealed anemia, with a hemoglobin level of 6.9g/dL, but esophagogastroduodenoscopy did not reveal any obvious source of bleeding. Contrast–enhanced abdominal computed tomography revealed leakage of contrast medium from a jejunal diverticulum. After confirmation of the bleeding point, hemostasis was accomplished by balloon–assisted enteroscopy (BAE). No worsening of the anemia was observed after the procedure. Hemostasis for jejunal bleeding has become possible with the advent of BAE. In case of suspected diverticular bleeding, BAE should be considered for both diagnosis and treatment.

A 73–year–old woman was transported to our hospital due to consciousness disorder. Her consciousness disorder was judged to have been caused by anemia associated with rectal cancer and severe aortic stenosis. Surgery for rectal cancer was planned prior to aortic valve replacement (AVR). On the day before the operation, she took magnesium citrate as instructed, as part of Mechanical Bowel Preparation (MBP). On the operation day, she vomited, became unconscious and exhibited signs of acute respiratory failure, which necessitated endotracheal intubation. Abdominal CT showed bowel dilatation, and laboratory examination revealed elevation of the serum magnesium concentration (21.2 mg/dL). We considered this as having been caused by the MBP having led to excessive absorption of magnesium through the gastrointestinal mucosa, resulting in hypermagnesemia. Hartmann’s surgery was performed and the patient was admitted to the ICU. She was extubated on the fourth day after the operation, and resumed oral intake on the 13th day. The postoperative course was satisfactory, and AVR was performed. In Japan, magnesium citrate is often used as part of MBP prior to colorectal cancer surgery, but the attending doctors should be aware of the possibility that MBP can cause severe hypermagnesemia, even in patients without a previous history of renal dysfunction.

An 83–year–old woman was referred to our hospital for abdominal pain and vomiting. Abdominal CT revealed a right incarcerated obturator hernia and emergency operation was performed via a transabdominal laparoscopic approach. After repositioning the incarcerated small bowel by the water pressure method, we inverted the hernia sac and exposed the preperitoneal space by incising and stripping the peritoneum over the obturator foramen. A prosthetic mesh was placed over the hernia defect extraperitoneally, and the peritoneum was closed over the mesh with running sutures. The postoperative course was uneventful, with no recurrence. Although the main therapeutic modality for obturator hernia is surgery, no standard surgical method has been established yet. While some authors have recently reported total repair of the myopectineal orifice for incarcerated obturator hernia, the validity of this method has not yet been investigated in detail. We report a case of laparoscopic obturator hernia repair limited to the hernia orifice. This simple and safe procedure could be a very useful treatment option for elderly patients needing emergency surgery.

A 17–year–old female patient presented with acute abdomen and ileus, and based on the findings of abdominal CT, she was diagnosed as having a left paraduodenal hernia with jejunal clustering beneath the inferior mesenteric vein. She gave a previous history of two episodes of intestinal obstruction of unknown cause, with the condition improving spontaneously with just observation on both occasions. For the present condition, she underwent successful elective laparoscopic release of the jejunal invagination and direct closure of the hernia orifice. However, on POD7, she developed signs of bowel obstruction with vomiting and abdominal pain, and CT and a gastrointestinal series revealed limited jejunal stenosis with inflammatory edema. We diagnosed the patient as having postoperative bowel stenosis with inflammatory edema caused by the surgery. Therefore, in accordance with the treatment for panniculitis, we carefully elected to treat the patient with a steroid administered by intravenous injection, which resulted in prompt and dramatic recovery of the jejunal obstruction and the patient recovered and was discharged. Laparoscopic repair is a simple and useful procedure for left paraduodenal hernia, and we showed the usefulness of steroid therapy for postoperative inflammatory jejunal stenosis.