The patient was a 69-year-old woman who sustained injury in a traffic accident, when the car she was driving collided with a telephone pole, and she was transferred to our hospital with precordial pain and abdominal pain. Abdominal CT showed injury of the medial segment of the liver, with active extravasation. While she was on the CT table, her blood pressure dropped and transcatheter arterial embolization was performed to stabilize the vital signs. A CT performed 14 days after the injury showed portal vein thrombosis, and another performed 21 days after the injury showed expansion of the thrombus. Therefore, oral administration of edoxaban was initiated. A CT on the 10th day after the initiation of oral edoxaban administration showed reduction in the size of the thrombus, and on the 56th day, complete disappearance of the thrombus was confirmed, and oral edoxaban was discontinued. No recurrence of the portal vein thrombosis has been observed during follow-up. There are few reports of portal vein thrombosis after liver injury, and there is no established standard therapy for portal vein thrombosis. In recent years, the efficacy of direct-acting oral anticoagulants for portal vein thrombosis has been reported, and in our case reported here, oral administration of edoxaban completely eliminated the thrombus.

In recent years, the laparoscopic transabdominal preperitoneal（TAPP）approach has been widely adopted for the repair of inguinal hernia, because of its minimal invasiveness and diagnostic advantage. However, as compared to conventional anterior hernia repair, TAPP may be associated with laparoscopic-specific postoperative complications. An 82-year-old man underwent TAPP for right inguinal hernia（Japanese Hernia Society classification Ⅱ-1）. Two days after the TAPP operation, abdominal computed tomography（CT）showed intestinal herniation into the Retzius cavity, and emergency laparoscopic operation was performed. Laparoscopic intraoperative observation revealed incarceration of the small intestine through a peritoneal defect formed in line with the suture made during the TAPP surgery. We cut the peritoneal suture to reduce the herniated small intestine, resected the damaged portion of the small intestine, followed by reconstruction, and performed careful re-closure of the peritoneum. The postoperative course was uneventful, and the patient was discharged 10 days after the re-operation. In view of the risk of herniation and incarceration of the bowel through a defect potentially forming in line with the peritoneal suture after a TAPP operation, it is important to close the peritoneum firmly, with utmost care, during a TAPP surgery.

Parastomal hernia is a common complication after stoma construction. However, incarceration of a parastomal hernia is rare, because of the wide hernia orifice. We encountered two cases of incarcerated parastomal hernia, which were repaired with stoma relocation. Case 1: An 80-year-old man was diagnosed as having an incarcerated parastomal hernia 8 years after he had undergone abdominoperineal resection for rectal cancer. The incarcerated small bowel was resected, the stoma was closed, and the colostomy was reconstructed in the left upper abdomen. No recurrence of the parastomal hernia has been observed until now, 4 years after the surgery. Case 2: An 82-year-old woman developed an incarcerated parastomal hernia 8 months after undergoing Hartmann’s operation. The incarcerated small bowel was resected, the stoma was closed, and the colostomy was reconstructed in the left upper abdomen. No recurrence of the parastomal hernia was noted until 10 months after the surgery, when the patient died of another unrelated cause. Incarcerated parastomal hernias often require enterectomy. Mesh repair is not recommended for such cases. Stoma relocation is a rational and feasible treatment option for incarcerated parastomal hernia.

A 91-year-old woman was referred to our hospital with acute upper abdominal pain and a painful mass in the abdomen. Abdominal computed tomography revealed gallbladder swelling, and narrowing from the neck to the duct, with inward deviation. A provisional diagnosis of gallbladder torsion was made, and laparoscopic cholecystectomy was performed. Intraoperative findings revealed incomplete gallbladder torsion, and examination of the resected specimen revealed an elevated lesion at the fundus of the gallbladder. Histopathologically, the gallbladder showed infarct changes, and the neoplastic lesion at the fundus was diagnosed as an adenosquamous carcinoma. It is very rare for the diagnosis of gallbladder adenosquamous carcinoma to be made accidentally, after surgery, in a patient presenting with gallbladder torsion. Therefore, we report this case herein.

An 81-year-old woman who had undergone perineal stapled prolapse resection（PSPR）for rectal prolapse two years earlier developed recurrent rectal prolapse within a few months. However, she did not visit our hospital then, and instead, she presented to us now and was admitted with evisceration of a 100-cm segment of the small bowel through the anus after sneezing. Abdominal CT revealed perforation of the rectum near the staple line of the PSPR, with evisceration of the small bowel through this perforation. Recurrent rectal prolapse was thought to be the cause of the rectal perforation. An emergency operation was performed. Intraoperative exploration revealed a perforation measuring about 3 cm in diameter in the anterior wall of the rectum, with evisceration of the small bowel through this perforation. We reduced the small bowel and performed simple transanal closure of the perforated rectal wall. The rectum was transected orad to the perforation, and a sigmoid colostomy was created. To reinforce the perforated wall, the anterior rectal wall was sutured and fixed to the uterine body. The patient discharged on the 20th postoperative day with no complications.

A 52-year-old woman underwent a laparoscopic appendectomy for acute appendicitis after failed conservative treatment. During the surgery, a 12-mm port was inserted at the umbilicus and left lower abdomen, and a 5-mm port on the pubic bone. She began to vomit on postoperative day 2, and a skin bulge was observed below the 12-mm port wound in the left lower abdomen, followed by the patient complaining of left lower abdominal pain. Abdominal CT performed on the same day revealed an incarcerated portion of the small intestine in the 12-mm port wound. The diagnosis of strangulated intestinal obstruction due to a port-site hernia was made, and emergency surgery was performed. The port wound was found on the external edge of the abdominal rectus muscle, which is the Spigelian aponeurosis. When the incarcerated intestine was removed from the wound of the 12-mm port in left lower abdomen, necrosis was suspected, and partial resection of the small intestine was performed. The Spigelian aponeurosis lacks a posterior capsule in the rectus abdominis muscle, making it anatomically fragile and a risk factor for the development of port-site hernia. Herein, we report our case with some discussion of the relevant literature.

We report a case of symptomatic extrahepatic portal venous thrombotic aneurysm which shrunk with conservative therapy. A 53-year-old female patient who had been diagnosed as having portal venous aneurysm measuring approximately 40mm in diameter at the junction of splenic vein and superior mesenteric vein and been followed for 1 year at our hospital presented with the complaint of upper abdominal pain. Enhanced abdominal CT showed a distended portal venous aneurysm measuring approximately 50mm in length containing a thrombus. Intrahepatic portal flow was maintained and there was no evidence of liver damage. She was admitted to our hospital and started on anticoagulant therapy with heparin along with therapy for deep vein thrombosis. The patient was subsequently switched from heparin treatment to oral apixaban, and discharged after confirmation of regression of the thrombus and symptomatic improvement. Enhanced CT at 3 months after the discharge showed shrinking aneurysm measuring approximately 40mm in diameter, containing a thrombus. We have followed her up without recurrence of the symptoms for 6 months. Although this length of follow-up is limited, we report our case of extrahepatic portal venous aneurysm with thrombus, which is often treated surgically, that improved with conservative therapy.

A 40-year-old man with no previous history of abdominal surgery, who visited his local clinic complaining of upper abdominal pain, was referred to our hospital with the diagnosis of bowel obstruction. Abdominal CT revealed dilated loops of the small intestine behind the stomach on the side of the lesser curvature, and we suspected internal hernia. Because the patient’s pain worsened progressively after hospitalization, surgery was performed on the day after admission. The small intestine was found to have herniated through a defect in the greater omentum behind the stomach, and also through another defect in the lesser omentum into the abdominal cavity. The bowel segment that had herniated through the defect in the lesser omentum was found to be strangulated and necrotic. The necrotic segment of the small intestine was resected, with closure of the defects in the greater and lesser omentum were performed. A greater and lesser transomental hernia is extremely rare, and we report our case, along with a review of the literature.

We report a case of appendiceal adenocarcinoma with neuroendocrine differentiation that was diagnosed post-appendectomy. A 34-year-old woman with right lower abdominal pain and nausea was referred to our hospital. Abdominal CT revealed a swollen appendix, with the dirty fat sign around the appendix. A diagnosis of appendicitis was made, and laparoscopic appendectomy was performed. Although macroscopic examination of the resected specimen revealed no tumors, histopathology revealed appendiceal adenocarcinoma with neuroendocrine differentiation showing invasion of the muscularis propria at the appendiceal apex. Therefore, the patient underwent further laparoscopic cecum resection with lymph node dissection. No evidence of recurrence has been detected until date, one year since the surgery. Careful examination, for any tumors, of the resected appendiceal specimens after appendectomy is important, even for young patients.

The patient was an 81-year-old man who visited a neighborhood doctor with the chief complaint of left lower abdominal pain, and was started on oral antibiotic treatment. However, as there was little symptomatic improvement, the patient was referred to our hospital on day 12 after the onset. Abdominopelvic CT revealed sigmoid colon penetration caused by a foreign body, and the patient was admitted to the hospital. The foreign body was suspected as being a fish bone based on its shape and the clinical history. The fish bone was removed by lower gastrointestinal endoscopy, and the patient improved with conservative treatment. He was discharged from the hospital 5 days after the endoscopic removal of the fish bone. The treatment method in such cases should be selected keeping in mind that even in cases of lower gastrointestinal perforation and penetration, conservative treatment, without surgery, may be effective.

An 87-year-old female patient with a day’s history of vomiting and watery diarrhea was referred to our hospital. Abdominal CT showed extensive dilatation of the small intestine, and the target sign in the pelvic floor. The patient was diagnosed as having intussusception, and emergency laparotomy was performed. Intraoperative exploration revealed, ileoileal intussusception, which was repositioned by the Hutchinson’s procedure. A tumor, which was presumably the cause of the intussusception, was palpable in the ileum, 50 cm orad to the Bauhin valve. Therefore, partial resection of the intestinal segment including the tumor was performed. Histopathological examination of the resected specimen revealed the diagnosis of cystic lymphangioma. Lymphangioma of the small intestine is rare, and cystic lymphangioma is particularly rare. However, the possibility needs to be borne in mind in adult cases of ileoileal intussusception.

A 70-year-old man who had been receiving treatment for over 10 years for alcoholic liver cirrhosis, presented to our emergency department with sudden onset of leakage of ascites and abdominal tissue prolapse from the umbilical region. He was diagnosed as having a ruptured umbilical hernia with prolapse of the omentum, and prepared for emergency surgery. However, chest CT revealed severe pneumonia, which was considered as a contraindication for general anesthesia; therefore, we performed the hernia repair under local anesthesia. At surgery, the prolapsed omentum was protectively reduced into the abdominal cavity, and the hernial orifice was closed by simple suture. After the surgery, ascitic fluid leakage through the drain placed under the skin continued at the rate of ≥ 1,000 mL/day. Therefore, cell-free and concentrated ascites reinfusion therapy was initiated, following which the drainage volume gradually reduced, the drain was removed on postoperative day 8, and the patient was discharged. Umbilical hernia rupture is rare, with only a few reported cases. We report a case of umbilical hernia rupture that was repaired under local anesthesia.

An 87-year-old female patient visited our emergency department with a history of lower abdominal pain. Abdominal computed tomography（CT）showed a mass containing calcification inside a dilated segment of the small intestine. We made the diagnosis of small bowel obstruction and performed emergency surgery. The surgery was started using the laparoscopic approach, but conversion to open surgery became necessary. The dilated intestine was actually Meckel’s diverticulum with an enterolith. We performed small bowel resection. Histopathology showed pancreatic mucosal tissue in the diverticular mucosa, with mucosal necrosis, bleeding, and abscess formation. Analysis of the stone revealed bile acids. Based on the findings, we made the final diagnosis of Meckel’s diverticulitis with a true enterolith. Herein, we present a rare case of Meckel’s diverticulitis with a true enterolith, along with a discussion of the relevant literature.

Hyperammonemia is known to be a rare adverse effect of 5-Fluorouracil（5-FU）. We report a case of hyperammonemia developing in an esophageal cancer patient during neoadjuvant chemotherapy with 5-FU and cisplatin（FP）. The patient was a 66-year-old man with clinical Stage Ⅲ（T3N1M0）esophageal cancer who had been initiated on FP therapy. On treatment day 3, he complained of anorexia. On day 5, he became disoriented with elevation of the plasma ammonia level and laboratory evidence of progressive renal dysfunction, and was diagnosed as having hyperammonemia induced by 5-FU. We immediately stopped the 5-FU infusion and began infusion of branched-chain amino acids solutions. The patient became fully conscious, with the serum ammonia level returning to normal range by the following day. Subsequently, esophagectomy was performed, and the patient is being followed up without any chemotherapy. At present, 54 months after the surgery, the patient is doing well, with no evidence of recurrence. We speculate that dehydration, renal dysfunction, and a low skeletal muscle mass possibly contributed to the development of hyperammonemia during FP therapy. It is important for clinicians to be aware that hyperammonemia as an adverse effect of FP-based chemotherapy.

An 81-year-old male patient was referred to our hospital with abdominal pain and vomiting. Physical examination of the abdomen revealed both tenderness and rebound tenderness over the entire abdomen. Enhanced abdominal CT demonstrated free air in the upper abdomen and bladder wall emphysema in the pelvis. The findings led to the suspicion of upper gastrointestinal perforation, and emergency surgery was performed on the same day. While laparoscopic intraperitoneal exploration revealed no upper gastrointestinal perforation, a perforation was confirmed in the wall of the bladder on the right side. The bladder wall was sutured laparoscopically, and the abdominal cavity was irrigated with 3,000 mL of normal saline. No complications were observed after the operation, although the patient was in the hospital for 35 days after the surgery for rehabilitation. This case underscores the need to bear in mind the possibility of bladder rupture in the differential diagnosis of patients presenting with acute abdomen with free air in the abdomen. Herein, we report a case of bladder rupture associated with emphysematous cystitis who underwent emergency surgery under the diagnosis of gastrointestinal perforation.

An accessory spleen is found in 10％-30％ of the population and in most cases, it is asymptomatic. We report a rare case of infarction of an accessory spleen, which was diagnosed preoperatively and resected laparoscopically. A 35-year-old man was transported to our hospital by ambulance with the complaint of acute left-sided abdominal pain. A plain CT showed a spherical mass measuring 31mm in diameter, with a slight increase of the fat surrounding the spleen on the cranio-ventral side, and another spherical mass measuring 18mm in diameter at the splenic hilum. On contrast-enhanced CT, while the former mass was non-enhancing, the latter showed marked enhancement. US showed the feeding vessel to the mass on the cranio-ventral side of the spleen, but without blood flow. Therefore, the patient was diagnosed as having infarction of an accessory spleen caused by torsion, and laparoscopic resection was performed. We found a dark red accessory spleen in the greater omentum. The greater omentum was adherent to the vascular pedicle of the accessory spleen, so that we could not confirm the torsion. After resecting the vascular pedicle using a coagulation-cutting device, we removed the accessory spleen. Histopathological examination revealed splenic tissue with severe bleeding and congestion. The postoperative course was uneventful and the patient was discharged on postoperative day 4.

A 73-year-old man with thalamic pain after right thalamic hemorrhage was urgently hospitalized for massive melena. Upper gastrointestinal endoscopy and colonoscopy showed no active bleeding. Emergency double-balloon small intestine endoscopy showed multiple erosions, which were judged as representing nonsteroidal anti-inflammatory drug-induced mucosal damage, but the source of the bleeding could not be identified. No extravasation was identified on abdominal contrast-enhanced CT. The melena subsided at first, and the patient was watched closely in the intensive care unit. However, 2 hours later, the patient developed massive melena again, resulting in hemorrhagic shock, and emergency laparotomy was performed. Intraoperatively, no obvious abnormalities were found on the serosal side of the small intestine. When the endoscope was inserted from the incision site of the jejunum, which was 20 cm aborad to the ligament of Treitz, massive occult blood was observed in the bowel segment extending from 20 cm to 100 cm aborad to the ligament of Treitz. Therefore, partial resection of the jejunum was performed, following which the hemodynamic status promptly stabilized. Histopathological examination of the resected specimen revealed a ruptured dilated artery protruding from the mucosal defect, which was diagnosed as a jejunal Dieulafoy’s lesion.

A 47-year-old female patient with a history of chronic abdominal pain was admitted to our hospital. Abdominal ultrasonography and plain abdominal CT revealed an appendiceal mass. Contrast-enhanced abdominal CT showed a 2-cm enhancing nodule in the appendiceal body. Based on the findings, neuroendocrine neoplasm was suspected, and laparoscopic ileocecal resection was performed. Histopathological examination of the resected specimen revealed appendiceal endometriosis. This case serves to underscore the importance of keeping in mind the possibility of endometriosis in the differential diagnosis in premenopausal women presenting with an appendiceal mass.

We report a case of food starch-induced foreign body granuloma formation after gastric perforation. The lesions appeared as small white nodules and were indistinguishable from peritoneal dissemination. A 58-year-old woman was admitted to our hospital with a history of abdominal pain and distention. Endoscopy revealed a large ulcer in the lesser curvature of the stomach, and CT showed fluid accumulation with free air on the ventral aspect of the stomach. We diagnosed the condition as an abscess secondary to perforation of a gastric ulcer and performed laparoscopic abscess drainage, followed by closure of the perforation site. Intraoperatively, we observed small white nodules in the abdominal cavity and suspected peritoneal dissemination. However, histopathological evaluation of biopsy specimens from the peritoneal nodules showed food starch-induced formation of foreign body granulomas. Clinicians should bear in mind the possibility of food starch-induced foreign body granuloma formation in the differential diagnosis, besides peritoneal dissemination, of patients with intra-abdominal nodules and a history of gastrointestinal perforation. Histopathological confirmation of the diagnosis is essential.

An 18-year-old man was admitted to our hospital complaining of epigastric pain. He gave a history of having voluntarily swallowed a metal piece 3 months earlier. Abdominal examination revealed no rebound tenderness or guarding of the abdomen. Laboratory data showed elevated levels of inflammation markers. Abdominal computed tomography revealed the long linear metal piece penetrating through the duodenum into the right lobe of the liver and a large liver abscess measuring 65 mm in diameter. Percutaneous transhepatic abscess drainage（PTAD）was immediately performed. Subsequently, 4 days after the PTAD, surgery was performed to remove the metal piece measuring 106 mm in length from the duodenum. A long linear thin piece, similar to a fish bone and/or a toothpick, caused delayed liver abscess formation following secondary penetration of the liver from the gastrointestinal tract. This is among the first reports of formation of a liver abscess 3 months after penetration of the liver by a swallowed metal piece from the duodenum.