We conducted a retrospective review of the data of 149 patients who underwent surgery for colorectal perforation at our facility from January 2008 to December 2017, to explore the preoperative and intraoperative prognostic factors. Twelve patients died during hospitalization, and the mortality rate was 8.1％. We excluded 2 cases of death, as these patients died due to terminal cancer, and investigated the relevant clinical variables in the non-survivor group（n＝10）and survivor group（n＝137）. According to the univariate analysis, there were significant differences between the two groups in terms of the age, percentage of patients with shock, contaminated area during laparotomy, preoperative SOFA score, and preoperative POSSUM score. Multivariate analysis identified presence/absence of shock, preoperative SOFA score, and preoperative POSSUM score as independent prognostic factors. Our findings suggest that the preoperative SOFA score and preoperative POSSUM score could serve as prognostic factors in patients with colorectal perforation.

【Introduction】Intussusception in adults accounts for 1-5% of all cases of intussusception, and colorectal cancer is found in approximately 60% of cases of adult intussusception. We investigated the characteristics and clinical courses of adult intussusception caused by colorectal cancer.【Methods】A total of 10 patients with adult intussusception caused by pathologically proven colorectal adenocarcinoma were included in this study. Their characteristics and clinical courses were retrospectively analyzed.【Results】Of the 10 patients with a median age of 75.5 years, three were male and seven were female. The cancer was located in the cecum in two cases, in the ascending colon in five cases, in the transverse colon in two cases, and in the sigmoid colon in one case. Nine patients underwent elective surgery. Eight patients underwent laparoscopic surgery, of which two needed conversion to laparotomy. The overall survival was 385（63-673）days and the disease-free survival duration was 366（63-673）days. Local recurrence occurred in one patient within 1 year after surgery.【Conclusion】Adult intussusception caused by colorectal cancer is not necessarily an emergency condition, and elective surgery via a laparoscopic approach may be a suitable strategy. Further studies with large sample sizes are needed for more precise evaluation of the long-term outcomes.

We present a case of laparoscopic appendectomy performed for acute appendicitis in a patient with a ventriculoperitoneal shunt（VPS）and lumboperitoneal shunt（LPS）. An 84-year-old man was admitted to our hospital with abdominal pain of sudden onset and was diagnosed as having gangrenous appendicitis. He had previously undergone VPS and LPS placement for hydrocephalus. The VPS tip was located near the appendix. We performed emergency single-incision laparoscopic appendectomy after consulting with a neurosurgeon. Both shunts were ligated near the tip, to prevent retrograde infection. After resecting the appendix, 8 cm of the shunt was excised, including the ligature. The patient was treated postoperatively with antibiotics until he recovered completely and there was no evidence of shunt infection or hydrocephalus. However, in surgeries involving infections, such as appendicitis, in patients with VPS or LPS, it is imperative to devise an appropriate treatment plan considering the urgency and degree of infection in the abdominal cavity, to prevent retrograde infection.

【Case1】A 51-year-old woman was admitted to our hospital complaining of epigastric pain. She was diagnosed as having strangulated ileus by contrast-enhanced abdominal CT and emergent operation was performed. Intraoperative exploration revealed an internal hernia through a defect of the broad ligament of the uterus, and we reduced the hernia and sutured the defect. Postoperatively, we recognized deviation of the ovarian vein by the expanded small intestine on preoperative CT.【Case2】A 58-year-old woman was admitted to our hospital complaining of abdominal pain and nausea. On the third day of hospitalization, she was diagnosed as having strangulated ileus by contrast-enhanced abdominal CT and referred to our department. We diagnosed internal hernia through a defect of the broad ligament of the uterus and performed emergent laparoscopic surgery, because the CT showed the same findings as in Case 1. We confirmed the diagnosis by laparoscopy and converted the surgery to laparotomy for resection of the necrotic ileum and suturing of the hernia defect.

A 79-year-old man visited us complaining of constipation and abdominal fullness. While physical examination revealed no abnormal findings, a plain chest X-ray showed free air in the abdomen. Laboratory examination showed slight elevations of the serum C-reactive protein level and white blood cell count. Perforation of the gastrointestinal tract was suspected, and he was referred to a nearby hospital. At the hospital, abdominal computed tomography showed free air in the abdomen and multiple colonic diverticula. However, his symptoms and laboratory data did not suggest severe peritonitis. He received non-surgical management. An upper gastrointestinal series revealed diverticula and no perforation in the jejunum. A barium enema showed multiple diverticula and no perforations in the descending or sigmoid colon. His condition improved after resumption of diet. After 6 days of hospitalization, he was discharged. Approximately two months later, he exhibited the same symptoms again with free air on a plain X-ray of the chest. He again received conservative treatment, and his condition improved. Based on the clinical course, the diagnosis of repeated idiopathic pneumoperitoneum was established.

Herein, we report the case of a 73-year-old man with hemophilia type A who presented with acute cholecystitis. Since it was considered that emergent cholecystectomy would be risky, we first performed percutaneous transhepatic gallbladder drainage after adequate supplementation of coagulation factor Ⅷ. Subsequently, open cholecystectomy was performed. The postoperative course was uneventful. The dose of coagulation factor Ⅷ was determined according to the guideline proposed by The Japanese Society on Thrombosis and Hemostasis. Thus, adequate replacement of coagulation factors enabled cholecystectomy for acute cholecystitis after PTGBD in a patient with hemophilia.

An 84-year-old man had visited his previous doctor complaining of black stools. Esophagogastroduodenoscopy revealed no significant source of bleeding, however, blood examination revealed severe anemia, and he was referred to our hospital. Total colonoscopy, contrast-enhanced computed tomography（CT）, and capsule endoscopy failed to reveal any significant lesions. The patient presented with recurrent bloody stools, and repeat CT identified an enhancing mass in the small intestine. Urgent enteroscopy failed to reveal the lesion, and emergency surgery was performed; postoperative histology revealed a pyogenic granuloma（PG）of the jejunum. PG, which is a polypoid lobular capillary hemangioma commonly involving the skin and oral cavity, rarely occurs in the gastrointestinal tract, to cause obscure gastrointestinal bleeding（OGIB）. PG could be difficult to detect, but can cause fatal anemia, so that it should be considered in the differential diagnosis in patients presenting with OGIB.

A 44-year-old woman who had undergone sigmoidectomy 42 months earlier for rectosigmoid cancer presented to our hospital with acute abdominal pain. The anal side of the tumor had been cut with an automatic suture equipment, and anastomosis had been performed by the double stapling technique. Abdominal CT showed a closed loop of small intestine and a positive whirl sign. Based on the findings, the patient was diagnosed as having strangulated small bowel obstruction and emergent open laparotomy was performed via a midline abdominal incision. We elevated the small intestine from the pelvic cavity manually, and the strangulation was released. Examination confirmed the formation of a band containing a staple on the oral side of the small intestine, with ischemic change and scar formation on the mesentery on the anal side. We suspected that the strangulation was caused by a band with the slipped-down staple. Bowel resection was not needed. The patient was discharged 6 days after the operation. We think it is important to take measures to prevent staples from an automatic suture equipment from slipping down during the operation.

A 71-year-old male patient with a history of chronic myelomonocytic leukemia was transferred to our facility from a local hospital with a diagnosis of septic shock due to suspected acute cholecystitis. The patient underwent an urgent open cholecystectomy during which mild redness on the serosal surface of the ileum was observed, with no obvious necrosis. The patient remained hypotensive after the laparotomy, but his condition worsened, necessitating continuous infusion of adrenaline. The ileal lesion, previously identified during the cholecystectomy, was suspected as the cause of the septic shock and therefore resected. After the surgery, the patient’s circulatory status improved dramatically, and the adrenaline infusion was discontinued 12 hours later. Histopathology indicated infiltration of the leukemia cells into the intestinal wall. Bacterial translocation after massive ulceration due to leukemic infiltration was considered as the cause of the sustained hemodynamic instability. This case highlights how, in unusual cases, chronic myelomonocytic leukemia can present with septic shock.

The patient was a 75-year-old woman who had undergone endoscopic choledocholithotomy followed by laparoscopic cholecystectomy for cholecystitis and choledocholithiasis. During the laparoscopic cholecystectomy, the gallbladder was perforated and gallstones spilled into the peritoneal cavity. The patient was discharged with a good postoperative prognosis, but was readmitted to the hospital about 2 months after the surgery with inflammatory symptoms such as high fever. Abdominal CT revealed hepatic abscesses, presumably caused by the spilled gallstones into the peritoneal cavity during the surgery. She was treated by percutaneous abscess drainage as well as intravenous and oral antibiotics. Over 2 years have passed since the treatment, and neither the hepatic nor the intraperitoneal abscesses have recurred. Unretrieved gallstones from the peritoneal cavity sometimes cause peritoneal abscesses, but hepatic abscesses are rarely reported. Herein, we report a rare case of hepatic abscesses caused by unretrieved gallstones with a review of similar cases reported in the literature.

A 46-year-old man was admitted to our hospital complaining of left lower abdominal pain. Findings of abdominal plain CT suggested ischemic colitis and the patient was hospitalized. On the 4th hospital day, the left abdominal pain worsened in severity, an abscess and free air were confirmed on abdominal plain CT, and emergency surgery was performed, consisting of sigmoidectomy and colostomy. Histopathology revealed a partial defect of the proper muscle layer in both the lesion part and the normal part of the bowel, and the patient was diagnosed as having segmental absence of the intestinal musculature. Until date, 2 years since the surgery, he has had no recurrence.

We report our experience of two patients with ascending colon cancer who presented with obstructive ileus and were successfully treated by laparoscopic tumor resection after decompression with cecostomy. Patient 1 was a female in her 80s who presented with upper abdominal bloating and frequent vomiting. Comprehensive examinations led to the diagnosis of obstructive ileus caused by ascending colon cancer. Frequent vomiting caused electrolyte abnormalities, and decompression using a transnasal ileus tube was considered difficult; thus, an emergency cecostomy was performed. Then, laparoscopic right hemicolectomy was performed after the decompression. Patient 2 was a female in her 70s who regularly visited our outpatient department because she had dementia and was diagnosed, after a thorough examination for appetite loss, as having obstructive ileus caused by ascending colon cancer. Although decompression was attempted with a transnasal ileus tube, cecostomy was performed because of frequent self-extubation by the patient. Laparoscopic right hemicolectomy was subsequently performed. Cecostomy was again recognized as an effective procedure for decompression, when it is selected on the basis of the patient background characteristics.

A 68-year-old woman was admitted to another hospital for implantation of a drug-eluting stent（DES）after she was diagnosed as having coronary arterial stenosis, and was started on prasugrel hydrochloride and apixaban as antiplatelet therapy. She was discharged on POD 7. On the same day, she was admitted to our hospital with abdominal pain of acute onset and shock. Contrast-enhanced computed tomography showed rupture of a left gastric artery aneurysm and massive ascites. Emergency surgery was carried out. Arterial bleeding occurred during the laparotomy, and aneurysm resection was performed. Histopathological findings revealed a ruptured left gastric artery aneurysm due to segmental arterial mediolysis（SAM）. After the surgery, the patient resumed taking the oral prasugrel hydrochloride on POD 2, and apixaban on POD 6. The postoperative course was uneventful, and neither rebleeding nor stent thrombosis was observed. Even if emergency operation is required early after DES implantation, it is essential for the patient to be restarted on antiplatelet therapy as soon as possible.

Adult umbilical hernia is relatively rare, and only a few cases of incarcerated umbilical hernia have been reported in patients undergoing peritoneal dialysis. Case 1 reported here was a 24-year-old man, who was admitted to our hospital with the chief complaint of abdominal pain. Contrast-enhanced computed tomography revealed an incarcerated umbilical hernia, and emergency surgery was performed. We found a necrotic segment of the intestinal tract incarcerated in the hernial sac, and therefore, performed partial excision of the small intestine, and the hernia defect was closed with simple sutures. Case 2 was a 60-year-old woman. An emergency operation was performed because a part of the small intestine had herniated from the umbilicus and the wall of the small intestine showed decreased contrast effect. When the hernial sac was opened and examined, the intestinal tract was found to be congested at first, but a gradual improvement of the tone with time was noted. Therefore, intestinal resection was not performed, and we completed the surgery with a simple suture of the hernia defect. In both cases, hemodialysis was initiated postoperatively, and peritoneal dialysis was resumed on postoperative day 14. Both patients were discharged from the hospital without complications. In umbilical hernias, the hernial opening is narrow, increasing the risk of incarceration of the hernial contents. Furthermore, patients undergoing peritoneal dialysis are prone to serious consequences if complications occur. To avoid postoperative complications, we consider that prompt diagnosis and treatment, with surgery performed at the first signs of incarceration, are important.

From January 2009 to December 2019, we performed elective surgery for 14 cases of sigmoid volvulus. We introduce laparoscopic adhesiotomy and present the findings of long-term follow-up of 2 cases. We assumed that a firm adhesion between the sigmoid colon and retroperitoneum caused the sigmoid volvulus, and performed not sigmoid colectomy, but adhesiotomy in these cases. This procedure seems to be useful for elderly and high-risk patients, because there appears to be little risk of postoperative complications, such as anastomotic leakage.

A 67-year-old man was referred to our department with the chief complaint of respiratory distress. Eight years ago, he had undergone right hepatectomy combined with resection of the diaphragm for hepatocellular carcinoma, and 3 years after the surgery, he had been diagnosed as having a right diaphragmatic hernia. Chest X-ray and computed tomography revealed herniation of the small intestine and right-sided colon into the right thoracic cavity through the diaphragmatic defect, with collapse of the right lung. Because the vital signs were stable and there was no evidence of intestinal ischemia, the patient was managed conservatively. However, emergency surgery was finally performed because of exacerbation of the symptoms. At surgery, after the hernia contents were returned back into the abdominal cavity, ischemia of the cecum was found, presumably because of incarceration in the hernia sac, and ileocecal resection was performed. The defect of the diaphragm was repaired using a hernia patch. The patient was discharged on postoperative day 22 without complications. We report this case as there is no report of incarcerated hernia developing 8 years after surgery; in addition, the hernia patch was useful for repairing the extensive diaphragmatic defect.

A 7-year-old Filipino girl presented to our hospital with abdominal pain. Physical examination revealed localized periumbilical tenderness. Contrast-enhanced computed tomography revealed extensive dilatation of the small intestine, with poor enhancement, a positive whirl sign, a closed loop, and massive ascites. We suspected strangulated intestinal obstruction and performed an emergency abdominal operation. Intraoperatively, two ileal loops were observed to be knotted together, and both loops were necrotic. We separated the anal side of the intestine, unknotted the ileal knot, and resected a long necrotic ileal segment（130cm）. The patient showed an uneventful postoperative clinical course, and was discharged on the 12th postoperative day. We report a rare pediatric case of an ileo-ileal knot.

A 58-year-old man, who visited our hospital for hematochezia and abdominal distension was found unresponsive in the restroom. He was transferred to the emergency room and diagnosed as being in cardiopulmonary arrest. The initial cardiac rhythm was asystole; however, return of spontaneous circulation was achieved with cardiopulmonary resuscitation and advanced cardiovascular life support. Laboratory results revealed elevated levels of inflammatory markers, coagulopathy, acute kidney injury, hypoxia, and mixed acidosis, and computed tomography showed a rectal tumor measuring 6 cm in diameter. We diagnosed the patient as being in septic shock caused by obstructive colitis associated with advanced rectal cancer. He was initiated on intensive care, including mechanical ventilation, fluid resuscitation, catecholamine support, and antibiotic treatment. Subsequently, insertion of a transanal ileus tube was attempted under colonoscopic guidance for bowel irrigation and decompression, and a large amount of muddy feces was drained. However, despite these treatments, the patient remained in a state of shock and developed acute respiratory distress syndrome and disseminated intravascular coagulation; he died of multiple organ failure 10 hours after admission. Later, Klebsiella oxytoca was cultured from the blood sample, and histopathological examination of a rectal mucosal biopsy specimen revealed well-differentiated tubular adenocarcinoma.

A 29-year-old man visited our hospital complaining of epigastric pain. Abdominal computed tomography（CT）demonstrated intestinal intussusception caused by a cystic gastrointestinal tumor, and emergency surgery was performed. At laparotomy, an elastic-soft tumor measuring approximately 5 cm in diameter was palpable in the small bowel, about 180 cm from the Treitz ligament. Small bowel distention and edema were also observed 60 cm distal to the tumor site. The intestinal intussusception was resolved. We assumed that the tumor was at the lead point causing the intestinal intussusception. Therefore, partial resection of the small bowel segment including the tumor was performed. The resected specimen showed a 5.0×3.0×2.5 cm cystic tumor containing clear serous fluid. The pathological findings suggested that the lesion was heterotopic pancreas tissue（Heinrich type Ⅲ）. The postoperative course was uneventful, and the patient was discharged 10 days after surgery.

A 67-year-old man presented to our hospital with the complaints of abdominal pain and melena. He was diagnosed as having gastrointestinal perforation and emergency surgery was performed. A perforating tumor was found in the jejunum; therefore, resection of the affected segment of the small intestine was performed. Histopathological examination of the resected tumor revealed undifferentiated cancer. Postoperative computed tomography revealed a 40-mm tumor in the upper lobe of the left lung. Moreover, histopathological examination of a biopsy specimen revealed that it was an undifferentiated cancer with identical characteristics to those of the small intestinal tumor. The patient was diagnosed as having primary lung cancer and intestinal metastasis. Furthermore, metastases were also found in the right supraclavicular lymph nodes, duodenum, and right adrenal gland; thus, the patient was diagnosed as having lung cancer, cT2aN3M1c, Stage Ⅳ. The postoperative course of the patient was uneventful and he was discharged on postoperative day 28. The patient responded well to pembrolizumab therapy and has done well until now, 2 years and 8 months since the surgery. Perforation associated with a small intestinal metastasis from lung cancer would be expected to carry a poor prognosis. However, early drug therapy may lead to a good long-term outcome, especially in previously untreated cases of lung cancer, depending on the clinical course and histopathological findings.

A 54-year-old woman presented to the emergency department with a 3-day history of abdominal pain and fever. Contrast-enhanced CT of the abdomen revealed closed-loop obstruction of a hypo-enhancing small bowel, suggestive of strangulated bowel obstruction. We performed emergent laparoscopic surgery. An approximately 20-cm segment of the small bowel had herniated through a band formed by the appendix, the distal end of which was inflamed and adherent to the retroperitoneum. The herniated bowel segment was not gangrenous and did not require resection. Therefore, we performed appendectomy alone. Her postoperative course was uneventful, and the patient was discharged 7 days after surgery. We present a case of strangulated bowel obstruction caused by an adherent appendix.

A 64-year-old man suffered from heatstroke in a sauna. At the time of admission, he was unconscious, hyperthermic and had an unstable hemodynamics status. We diagnosed the patient as having hypovolemic shock due to heatstroke and treated him with intravenous cold normal saline infusion and cooling blankets. On day 2, laboratory tests revealed liver failure and rhabdomyolysis. On day 3, his condition deteriorated further. Abnormal ultrasonography showed evidence of fluid collection, while abdominal computed tomography showed ascites in the pelvic cavity, with scattered thickening of the walls of the small and large intestine, which appeared more pronounced than on the day of admission. On day 4, he had bloody diarrhea and worsening lactic acidosis. We suspected intestinal necrosis, and performed immediate exploratory laparotomy. There was no obvious intestinal necrosis. We drained the contaminated ascites, and the patient gradually stabilized and recovered from the heatstroke after surgery. Bacterial cultures of both blood and ascitic fluid specimens grew Escherichia coli, and based on the clinical course of the patient, we considered that the heatstroke had caused spontaneous bacterial peritonitis. The patient was discharged on day 31. It appears that peritonitis can develop as a complication of heatstroke.