In this retrospective study, we attempted to investigate the usefulness of single percutaneous drainage, including PTGBD(Percutaneous Transhepatic Gallbladder Drainage) and PTGBA (Percutaneous Transhepatic Gallbladder Aspiration), in elderly patients (75 years old or older) with acute cholecystitis, as compared to that in younger patients (under 75 years old). We used a clinical database of a cohort of 62 patients with acute cholecystitis at a single center between January 2016 and December 2017. Percutaneous drainage using an 18G needle was performed in 32 patients who were 75 years old or older (elderly group) and 30 patients who were under 75 years old (non–elderly group). PTGBA was selected for 14 patients and PTGBD for 18 patients of the elderly group, as compared to 6 and 24 patients, respectively, of the non–elderly group. One patient from the elderly group, who had undergone PTGBA, developed recurrence after drainage. One patient of the non–elderly group who had undergone PTGBD developed the complication of bleeding necessitating blood transfusion. Even though the proportion of patients with moderate–to–severe disease was statistically significantly higher in the elderly group, there was no significant difference in the rate of hospitalization or the outcome of percutaneous drainage between the two groups. Our findings suggest that PTGBA or PTGBD, as the first medical therapy, is a useful treatment, with few complications.

A 38–year–old man with no history of surgery was admitted to hospital because of acute abdominal pain. An enhanced abdominal CT scan showed a mass with a diameter of 4 cm in the left transverse colon. A colonoscopy revealed a longitudinal ulcer, and he was treated conservatively with observation in the outpatient clinic. Seven months thereafter, he was admitted to hospital once again because of acute epigastric abdominal pain, and an enhanced abdominal CT scan showed a larger mass with a diameter of 5 cm in the same area and free air around this mass. He was diagnosed as having colon perforation, and emergency surgery was performed. An extramural tumor was found in the left colic flexure, and abscess formation was seen at the omental bursa. We resected the tumor together with the transverse colon. Histological examination revealed a desmoid tumor comprised of spindle cells with collagen fibers. We report a case of sporadic abdominal desmoid tumor with no history of abdominal surgery that might have caused diverticulitis, which might have been related to colon perforation.

A 58–year–old woman who had been diagnosed as having multiple liver, lung and bone metastases and parasternal lymph node metastases after surgery for right breast cancer presented with abdominal pain, dizziness and general fatigue. An intraperitoneal hemorrhage caused by the spontaneous rupture of a metastasic liver tumor in the anterior segment was suspected according to the enhanced CT findings. Transcatheter arterial embolization (TAE) to the anterior branch of the right hepatic artery was performed using a gelatin sponge. Her symptoms immediately improved; however, she died of her disease 15 days after the TAE. TAE can be a promising treatment option and can improve quality of life under these difficult disease conditions. We herein report this case with a review of the relevant literature.

A 72–year–old man was admitted with a prior diagnosis of advanced rectal cancer with invasion of the bladder and small bowel. Clinical examination revealed a strangulated small bowel obstruction. Emergency surgery showed that the rectal cancer had also invaded the appendix and confirmed the presence of small–bowel strangulation. An appendectomy, small bowel resection, and colostomy were performed. Strangulated small–bowel obstruction caused by rectal cancer invasion of the appendix is rare, which is why this case warrants reporting. When addressing patients with a malignant pelvic tumor, surgeons must consider the possibility of a strangulated bowel obstruction arising from an appendix harboring an invasive malignant tumor.

The patient was a woman in her 60s who was admitted to our hospital because of a bulging in her right inguinal area. Computed tomography showed a tumor–like mass extending from the abdominal cavity to the right femoral area, and we diagnosed her as having an incarcerated femoral hernia on the righthand side. She underwent elective surgery because she was not exhibiting any symptoms of pain or bowel obstruction. Laparoscopic observation revealed that the appendix had fallen into the righthand femoral ring, which was diagnosed as a de Garengeot hernia. Since the incarcerated appendix had strongly adhered to the hernia sac and was not released by traction and transcutaneous compression, we relieved the hernia orifice by additionally performing an inguinal incision, which succeeded in releasing the hernia sac. We then performed a laparoscopic appendectomy, after which we applied a transabdominal preperitoneal approach. The patient’s postoperative course was good, and she was discharged on the third postoperative day. A laparoscopic approach for femoral hernias is considered to be useful for treatment and diagnosis.

Non–occlusive mesenteric ischemia (NOMI) is a fatal disease that is difficult to diagnose early. We present a case of NOMI in which the color of the patient’s stoma aided early diagnosis and treatment. A man in his 60s showed the progression of acidosis and hypotension. He complained of abdominal pain one day after treatment for acute lower limb artery occlusion. Although an enhanced CT examination did not show any abnormality in the abdominal cavity, NOMI was suspected, since the patient’s colostomy showed swelling and a dark–red discoloration. The angiography revealed a narrowed superior mesenteric artery and poor enhancement of the marginal arteries. Therefore, the patient underwent continuous arterial infusion therapy using papaverine. The acidosis was normalized promptly, and the color of the stoma gradually improved. Additional surgical intervention was avoided. The early diagnosis of NOMI is often challenging, and delayed diagnosis directly results in a poor prognosis. In our case, the findings of the stoma suggested the progression of intestinal ischemia, compared with the CT findings. Arterial infusion therapy using papaverine is safe and a less invasive treatment for NOMI. Treatment should be started without hesitation in cases suspected of having NOMI.

A 74–year–old woman was referred to our hospital because of an intraabdominal retained needle that had been found incidentally. She had no abdominal symptoms, and no damage, such as perforation of the digestive tract, was present. Because the patient’s condition remained stable, we performed the preoperative examinations with strict observation and scheduled an elective operation on the third day after the first visit. The operation was performed laparoscopically, and an X–ray scope was helpful for detecting the retained needle. The needle was removed completely using a combined resection of part of the coalescent omentum tissue. The patient was discharged on the third postoperative day. Our report refers to a rare case of an intraperitoneal foreign body that had not been noticed for 5 years. In recent years, candidates for laparoscopic surgery are increasing. We report the successful application of the laparoscopic removal of a fragile retained needle without any remaining debris.

【Case】A 30s woman with a pain in her lower left abdomen consulted our emergency department. Abdominal contrast medium–enhanced computed tomography showed an enlarged appendix in the lower left abdomen, and we diagnosed her as having acute appendicitis. The operation was initiated, and the surgeon, assistant, and monitor were placed in positions opposite to the usual placement for an appendectomy. The gallbladder and ileocecal region were found on the left, and the stomach was found on the right; we diagnosed the patient as having a complete visceral inversion. We lifted the ileocecal region out of the abdominal cavity and excised the appendix. A histopathological examination revealed phlegmonous appendicitis. The postoperative course was uneventful, and the patient was discharged on the fourth day after surgery. 【Discussion】Surgery in cases of visceral inversion is sometimes difficult because of the anatomical peculiarity, but an appendectomy rarely causes vascular system–related problems. We were able to perform the single–incision laparoscopic surgery safely.

A 68–year–old man was admitted to hospital with the sudden onset of abdominal pain. A CT scan showed a giant retroperitoneal hematoma predominantly located around the pancreatic head. We performed emergency surgery because of hemorrhagic shock, and the intraoperative findings revealed a giant hematoma in the retroperitoneal cavity with active hemorrhage from multiple sites of the dilated pancreaticoduodenal artery, necessitating a pancreaticoduodenectomy. The pathological findings showed vacuolization in the vascular smooth muscle of the pancreaticoduodenal artery and arterial dissection, which provided a diagnosis of segmental arterial mediolysis. The patient was discharged on the 30th postoperative day with a good postoperative prognosis, and neither arterial dissection nor arterial aneurysm has occurred since then. This case was complicated by median arcuate ligament syndrome, and only a few similar cases have been reported to date.

The patient was a male in his mid–eighties who regularly visited our hospital for the treatment of renal dysfunction. He complained of abdominal distension continuing for one week. Abdominal computed tomography showed appendicitis with a large abscess. The completion of noninvasive medical treatment seemed difficult because of the large abscess cavity and his frail and elderly status equivalent to an American Society of Anesthesiologists–Physical Status (ASA–PS) of 3. On day 2 of his hospitalization, an emergency laparoscopic drainage operation was planned because percutaneous drainage was difficult anatomically and an antiplatelet drug that he had been taking was expected to increase the risk of hemorrhage during an appendectomy. In fact, tight adhesion and easy hemorrhage caused by the antiplatelet drug use were recognized. The patient was discharged on postoperative day 18. On postoperative day 89, a laparoscopic appendectomy was performed. Loose adhesions were detected around the appendix, and the surgery was safely performed. A two–stage laparoscopic surgery is an alternative approach for appendicitis with abscess.

An 87–year–old man who developed severe abdominal pain was diagnosed as having an intestinal perforation with an intraabdominal abscess based on CT findings. Thus, the patient underwent an emergent laparoscopic operation requiring a partial intestinal resection. However, the patient postoperatively had a relapse of the same symptoms. A second CT showed another abscess near the anastomosis. Thus, conservative management was performed. The patient was discharged, but he was later re–admitted with an abscess in another location. Moreover, another abscess required the patient to be hospitalized a third time. CT and intestinal endoscopy indicated a diagnosis of intestinal diverticulitis caused by multiple intestinal diverticula. However, the persistent symptoms required the patient to undergo laparoscopic surgery. The resected specimen revealed that a needle–like foreign body was in fact a wooden toothpick. This case serves as an important reminder to consider foreign bodies in investigations of all possible causes of intraabdominal abscess with a repeated history of abscess.

Although patients with von Recklinghausen disease (VRD) are known to develop aneurysms as complications because of the vulnerability of their vessel walls, few reports have described splenic artery aneurysms as possible complications. A 46–year–old male with VRD was diagnosed as having a splenic artery aneurysm next to the hilus of the spleen using abdominal CT. As the aneurysm was located beside the hilus of the spleen and was a broad–based aneurysm type and because the patient was allergic to contrast agents, we chose laparoscopic surgery. As 80％ of the spleen became ischemic after the ligation of the splenic artery trunk, we performed a laparoscopic splenectomy along with the removal of the aneurysm. Histopathological findings showed the thickening of the intima, the thinning of the tunica media, and a ruptured internal elastic plate of the aneurysm. He was uneventfully discharged on the eleventh day after surgery. No apparent relapses have been observed for 14 months since the surgery. As patients with VRD complicated by aneurysms have a relatively high risk of rupture, careful follow–up and early treatment are recommended.

Incarcerated femoral hernia frequently causes intestinal necrosis. We performed an emergency surgery in 3 cases using a femoral approach without incising the hernia sac to observe the hernia contents and by continuously evaluating the incarcerated intestine during laparoscopy. The patients were relatively elderly, ranging in age from 73 to 82 years. The performance status score of case 1 was 2. All the cases were women, the hernias were all on the right side, and the hernia contents all consisted of the small intestine. The total surgical time ranged from 35 to 121 min, and one patient with severe intestinal ischemia received an intestinal resection. The postoperative courses of all the cases were uneventful. This method, with a preceding femoral approach and evaluation of the intestinal ischemia using laparoscopy, promises the possibility of a safe and minimally invasive surgical procedure.

A 58–year–old man visited another hospital complaining of right hypochondralgia and vomiting. An abdominal enhanced computed tomography (CT) examination showed a retroperitoneal hematoma behind the pancreas head associated with a ruptured aneurysm in the posterior inferior pancreaticoduodenal artery (PIPDA). He was urgently transferred to our hospital, and transcatheter arterial embolization (TAE) for the PIPDA aneurysm was performed. On day 14 after admission, a second CT examination revealed new aneurysms in the anterior inferior pancreaticoduodenal artery (AIPDA), and the aneurysms were also treated with TAE. On day 16, the patient developed vomiting. An upper gastrointestinal endoscopy revealed an edematous stenosis at the inferior duodenal angle, and a nasogastric drainage tube was inserted. On day 21, percutaneous transhepatic gall bladder drainage was performed because of jaundice, elevated serum biliary enzyme and amylase levels, and cholecystic enlargement on CT. After symptom improvement, a transnasal feeding tube was inserted into the jejunum and enteral nutritional treatment was continued. The duodenal narrowing was gradually improved, and oral intake could be restarted. He was discharged on day 48. He is currently in good condition with no signs of aneurysm recurrence for 2 years since the treatment.

An 86–year–old woman who had a history of appendectomy during childhood was admitted to the hospital because of the sudden onset of a right lower abdominal pain after dinner. Abdominal contrast–enhanced computed tomography (CT) showed a dilated small intestine with a closed–loop situated posterolateral to the cecum and a dilated oral intestinal tract. She was diagnosed as having strangulation of the ileum because of the incarceration of a paracecal hernia, and emergency laparoscopic surgery was performed approximately 5 hours after onset. Upon exploration of the abdominal cavity, a loop of ileum was found incarcerated in a 2cm orifice located on the lateral side of the cecum. After reducing the incarceration, the incarcerated ileum was approximately 10 cm in length and the tissue remained viable. The hernia orifice was incised and widened to prevent re–incarceration. The patient’s postoperative course was uneventful, and she was discharged on the 12th hospital day without any complications. Although paracecal hernia is a relatively rare entity, preoperative diagnosis is not difficult because of characteristic CT findings. Laparoscopic surgery may be useful for the diagnosis and treatment of paracecal hernia.

A 59–year–old man arrived at the hospital by ambulance complaining of abdominal pain. A contrast CT scan revealed celiac artery stenosis, a retroperitoneal hematoma around the duodenal second portion and the pancreatic head, and the dilation of the inferior pancreatic duodenal artery. The superior mesenteric artery was imaged and the inferior pancreatic duodenal artery was dilated, but no aneurysm was noted. In addition, the common hepatic artery contained contrast medium. Thus, the rupture of the pancreatic duodenal artery arcade was thought to have been caused by median arcuate ligament syndrome (MALS), and a balloon–expandable stent of 6 × 18 mm was placed at the origin of the celiac artery. In the final imaging study, the common hepatic artery was imaged with antegrade. The postoperative course was good, and a contrast CT examination performed 6 months later showed the patency of the stent and the shrinkage of the retroperitoneal hematoma. We report a case of successful stent placement for celiac artery stenosis caused by MALS and resulting in retroperitoneal hemorrhage.

A 62–year–old woman diagnosed as having colonic intussusception was admitted to hospital. She had a right lateral abdominal pain, but no mass was evident. An enhanced CT examination indicated that the end of the small intestine had invaginated into the ascending colon, and its edge was partially calcified. We diagnosed the patient as having an appendiceal mucinous tumor. Ileocecal resection with lymph node dissection was performed because of a strong possibility of mucinous cystadenocarcinoma. The final pathological diagnosis indicated a LAMN. Recent research has found that LAMN is potentially malignant, but a standard surgical treatment strategy has not been systematically established. Therefore, we report this case, with a review of the relevant literature.

A 54–year–old man who was diagnosed as having advanced squamous cell carcinoma of the esophagus in June 2017 received treatment at our institution. While he showed complete response after chemotherapy and chemoradiotherapy, he developed recurrence of the primary lesion and pulmonary metastasis after about 6 months. We planned chemotherapy after performing gastrostomy for providing nutritional support . On the 5th day after the start of chemotherapy, the patient complained of breathlessness; chest computed tomography (CT) revealed mediastinal emphysema and fluid collection in the mediastinum. Based on these findings, we diagnosed the patient as having idiopathic esophageal perforation localized to the mediastinum, and opted for conservative treatment. The following day, the patient’s respiratory condition worsened, and a repeat CT was performed which revealed findings suggestive of perforation of the esophagus into the left thoracic cavity. Emergency surgery was performed. He was discharged from the hospital on the 78th day. Idiopathic esophageal perforation is a relatively rare benign disease that causes damage to all layers of the esophageal wall due to a sudden increase of the esophageal pressure. In this case, the perforation was considered as having been caused by the increased esophageal pressure due to nausea and vomiting, with the deteriorated nutritional status of the patient due to obstruction of the upper esophagus and long–term cancer treatment serving as contributory factors.

An 87–year–old man presented with several days’ history of feeling feeble and abdominal distension. Blood biochemistry tests showed evidence of an inflammatory response. Abdominal CT revealed intestinal dilatation and intra–abdominal free air. With a suspected diagnosis of acute panperitonitis caused by gastrointestinal perforation, an emergency Hartmann’s operation was performed. During the surgery, a funicular hard foreign body was observed penetrating the ventral wall of the rectosigmoid. It appeared to be a fragment of a cushion–type denture adhesive. The postoperative course of the patient was satisfactory, and he was discharged 21 days after the operation. Although many cases of gastrointestinal perforation caused by dentures or dental prostheses have been reported, cases of perforation caused by a denture adhesive are very rare. Since patients are often unaware of accidental ingestion, denture adhesives should be borne in mind as being a possible cause of gastrointestinal perforation.

We report a case of tuberculous abdominal wall abscess forming a large cyst in the abdominal cavity. An 85–year–old male patient with a history of pulmonary tuberculosis presented to us complaining of a continuous discharge from the abdominal wall. He had been diagnosed as having peritoneal cancer 8 months before, and a peritoneal infusion port had been implanted. However, tubercle bacilli were identified in the ascitic fluid, and the patient was diagnosed as having tuberculous peritonitis and started on antituberculous therapy. Four months after implantation of the port, the port was removed due to infection. Mycobacterium tuberculosis complex was detected in the purulent discharge and the antituberculous therapy was continued. However, the purulent discharge from the abdomen persisted, and the patient was referred to our hospital. Abdominal CT revealed an area of fluid accumulation bounded by a capsule just beneath the abdominal wall. Daily percutaneous drainage irrigation was performed to treat the abscess. Bacterial testing of the abscess fluid revealed a positive result of the Polymerase Chain Reaction assay for tubercle bacilli and also a positive result for methicillin–sensitive Staphylococcus aureus, therefore, bacterial co–infection of the tuberculous abdominal wall abscess was considered. Antibacterial therapy was added, while the antituberculous therapy was continued. In response to the treatment, the purulent discharge decreased and the abscess diminished in size.

A 33–year–old female patient presented to the emergency department complaining of abdominal pain. Abdominal CT revealed a mildly enlarged appendix with an appendicolith, around which fluid retention was observed. The patient was diagnosed as a case of complicated appendicitis. We administered initial antibiotic therapy, followed by interval appendectomy. Laparoscopic observation revealed an appendiceal mucocele that was adherent to the terminal ileum. We performed appendectomy and partial resection of the ileum by reduced–port surgery. Histopathology of the resected specimen confirmed the diagnosis of mucocele of the appendix. The patient remains alive one year after the surgery. We report a rare case of mucocele of the appendix developing after appendicitis associated with an appendicolith.