Purpose: To evaluate the outcomes of colonic diverticular bleeding and clarify the indications for surgery. Materials and Methods: This retrospective study involved the data of 286 patients with colonic diverticular bleeding who were treated at our institution. Among the 110 patients in whom the source of bleeding was identifiable, the bleeding resolved without surgery in 74 patients and the remaining 36 patients required surgery for the control of bleeding. The clinical characteristics and outcomes were compared, and the surgical outcomes were evaluated. Results: There were no significant differences in the proportions of patients receiving treatment with antithrombotic drugs and NSAIDs between the groups that required and did not require surgery. In the surgery group, a larger number of patients had cerebral infarction at the same time as the colonic bleeding and received transfusion therapy. The indications for surgery were failure of endoscopic hemostasis, repeated bleeding, and severe bleeding. The median operation time was 103.5 minutes, the median blood loss was 30 mL, and complications（C-D, grade＞2）were observed in 10 cases（28％）. There was no mortality. The re-bleeding rate was 3％ in the surgery group. Conclusions: At present, the indications for surgery remain failure of endoscopic hemostasis, recurrent bleeding, and severe bleeding. We propose to consider the criteria of surgical indication.

NOMI is associated with multifocal and segmental intestinal ischemia, caused by vasoconstriction, and it is often difficult to precisely determine the area of bowel resection. In this study, we enrolled 51 patients who had undergone emergency surgery for NOMI between May 2012 and November 2020 at our institution. We performed intraoperative evaluation of bowel circulation using Indocyanine Green（ICG）fluorescence in 27 of the 51 patients. In order to study the usefulness of the ICG fluorescence method, we investigated the clinical variables in the survivor and non-survivor groups, and in the ICG fluorescence imaging and non-ICG fluorescence imaging groups. In addition, the findings of ICG fluorescence imaging and intraoperative findings were compared with the postoperative pathological findings. The data analysis revealed that postoperative onset of NOMI, preoperative serum lactate, and the SOFA score were significantly higher in the non-survivor group. Use of ICG fluorescence imaging allowed significantly shorter bowel resection, but had no influence on the prognosis. ICG fluorescence allowed identification of necrotic lesions that could not be identified by macroscopic examination in 7.4％ of cases. Necrosis and ischemia in the signal-deficient region on ICG fluorescence imaging were confirmed by the histopathological findings in all cases. ICG fluorescence imaging is a useful tool to determine the extent of intestinal resection in cases of NOMI.

We evaluated the therapeutic results of transcatheter arterial embolization（TAE）for postoperative pseudoaneurysm rupture, and clarified the technical problems associated with each bleeding site. Between 2001 and 2019, 24 patients experienced hemorrhage after surgery due to the development of pseudoaneurysms. The primary diseases were gastric cancer in 6 patients, bile duct cancer in 6 patients, ampullary cancer in 3 patients, pancreatic cancer in 2 patients, gallbladder cancer in 1 patient, colon cancer in 1 patient, and benign disease in 5 patients. The operative procedure was pancreatectomy in 15 cases（including pancreaticoduodenectomy in 11 cases）. Embolization with pushable microcoils was performed for a total of 23 events of hemorrhage, and was successful in all cases, except one with celiac trunk aneurysm, because of coil migration, in whom the treatment was combined with insertion of detachable balloon. TAE was performed once in 16 cases, twice in 6 cases, and thrice in 2 cases. The most frequent site of bleeding was the gastroduodenal artery stump（11 cases）. The complications of TAE were hepatic infarction in 3 cases（one requiring plasma exchange）and duodenal perforation in 1 case. Of the 24 patients who underwent TAE, hemostasis was achieved and the patients were discharged alive in 22 cases（91.7％）. The case in which hemostasis was difficult to establish by TAE had celiac trunk bleeding. The two cases in which bleeding could not be stopped had peripheral hemorrhage from the SMA with an intractable pancreatic fistula.

An 82-year-old man presented to our hospital with severe epigastric pain. He was a patient of chronic kidney disease and had been on maintenance hemodialysis for four years. In addition, he had hypertension, chronic obstructive pulmonary disease, and dementia. On admission, his abdomen was distended, with rebound tenderness. Abdominal computed tomography revealed pneumoperitoneum around the lesser curvature of the stomach and ascites. Gastroscopy revealed extensive mucosal necrosis of the stomach fundus. Emergency laparotomy was performed because of suspected spontaneous necrosis of the stomach（fundus and corpus）following perforation, which was confirmed intraoperatively. Abdominal lavage and construction of a jejunostomy for enteral nutrition were undertaken due to the poor general condition of the patient. The patient developed melena on postoperative day 9. Colonoscopy revealed necrosis of the ascending colon with active ulcers and exposed blood vessels. The patient developed metabolic acidosis, his physical status worsened, and he died on postoperative day 34 due to sepsis. Spontaneous necrosis of the stomach is very extremely rare and carries a very poor prognosis. To the best of our knowledge, this is the first published case report of spontaneous necrosis of the stomach and ascending colon.

A man in his early 50s was found lying at the railway station alongside the tracks and was transferred to our hospital. He was hemodynamically unstable and had abdominal tenderness, and focused assessment by sonography for trauma（FAST）was positive. Following fluid resuscitation, computed tomography（CT）was performed, which revealed grade Ⅲb liver injury, according to the classification of the Japanese Association for the Surgery of Trauma. Because the patient again developed hemodynamic instability after the CT examination, we performed emergency operation with direct liver suturing, perihepatic packing, and drainage tube placement. Control of the arterial bleeding that could not be managed by surgery was achieved by subsequent transcatheter arterial embolization（TAE）. Repeat abdominal CT on day 7 after admission revealed major hepatic necrosis（MHN）in the right lobe and a pseudoaneurysm in hepatic segment 8, which was managed by coil embolization. Considering the risk of intraoperative massive hemorrhage due to tight adhesions, surgery was avoided and conservative therapy, including percutaneous debridement and irrigation through the drainage tube, was continued. The patient was discharged on day 44. The irrigation treatment was continued at the ambulatory department and the drainage tube was removed approximately five months after the initial surgery. Percutaneous irrigative debridement of MHN is minimally invasive and may represent a useful therapeutic option.

A 60-year-old man presenting with acute myocardial infarction was treated by emergency percutaneous coronary intervention（PCI）and initiation of dual antiplatelet therapy（DAPT）with prasugrel and aspirin. On the sixth hospital day, a rapid decrease of the blood hemoglobin level and black stools were detected. Upper and lower gastrointestinal endoscopies neither revealed the source of bleeding nor any clear causative disease. As the anemia continued to worsen, contrast-enhanced abdominal computed tomography was performed, which revealed a hypervascular mass in the jejunum measuring 3 cm in size. As the patient had just undergone PCI, it was essential to continue the antiplatelet therapy, while emergency surgery was needed to achieve control of the bleeding. Partial resection of the small intestine was performed with single-hole laparoscopic assistance using the umbilical approach. The patient was discharged eight days after the surgery without any notable cardiovascular events or perioperative complications. Massive gastrointestinal bleeding associated with the use of antiplatelet drugs is a challenging abdominal emergency, and it is necessary to balance management of the primary disease with the surgical invasiveness. Early surgical intervention may be effective for achieving both control of the gastrointestinal bleeding and avoiding stent restenosis, and minimally invasive surgery with single-hole laparoscopic assistance may be acceptable.

An 88-year-old woman with senile dementia who was totally dependent on assistance for eating was brought to our hospital with a history of vomiting. Abdominal CT revealed findings suggestive of small bowel obstruction caused by a bezoar, which was 35 mm in size. She was in a good general condition, and we adopted conservative therapy with insertion of an ileus tube to avoid the risk of surgery. Gastrografin flowed to the ascending colon on the next day and the bezoar was found in the transverse colon on hospital day 4. The patient passed the bezoar via the anus during an enema on hospital day 7. She was discharged from the hospital on day 14. A bezoar commonly causes bowel obstruction or perforation, and consequently, surgery should be considered. Invasive treatments such as endoscopic lithotripsy are also frequently required. Conservative therapy with insertion of an ileus tube is a therapeutic option for those in whom surgery needs to be avoided. However, patients for conservative therapy should be properly selected and carefully followed up over time to judge whether conservative therapy can be continued or not.

An 80-year-old man with a 2-day history of dyspnea and palpitation was transferred to our hospital with difficulty in moving. At the first examination performed by the emergency service staff, the patient’s consciousness level was I-3（JCS）, body temperature was 37.9℃, pulse was 117 bpm, and respiratory rate was 24/min. The blood pressure, which was initially 90/60 mm Hg, increased to 151/70 mm Hg after the start of fluid infusion. The scrotum was swollen and black in color, and emitted a bad odor. On digital examination of the rectum, a tumor was seen exposed from the anal canal, with bloody stool. Abdominal CT revealed subcutaneous emphysema from the scrotum to the pelvis. The patient was diagnosed as having Fournier’s Gangrene, and debridement and colostomy were carried out immediately. Infusion of the broad-spectrum antibiotics meropenem and clindamycin was started. The histopathological diagnosis was anal canal cancer. Fournier’s Gangrene is rarely caused by rectal or anal canal cancer. This disease is associated with a poor prognosis, with a mortality rate of 20％-50％; therefore, early diagnosis and surgery are indispensable.

There are some reports of cases of aneurysm associated with median arcuate ligament syndrome（MALS）, however, cases of hemorrhagic duodenal ulcer in such cases are rare. A 58-year-old man visited a neighborhood clinic with a history of hematemesis. Upper gastrointestinal endoscopy revealed intractable bleeding from a duodenal ulcer and emergency laparotomy with omental plombage was performed. However, the hemorrhage recurred and the patient was transferred to our hospital. Abdominal CT revealed a gastroduodenal artery aneurysm near the ulcer, which was thought to be the actual source of the bleeding. Therefore, coil embolization was performed as an emergency interventional radiologic（IVR）procedure and was successful. The patient was diagnosed as having MALS by the detection of stenosis at the origin of the celiac artery. Therefore, median arcuate ligament release was performed 3 months later, and the bleeding has not recurred since. Based on this experience, we wish to emphasize that it is important to be alert to the possibility of MALS in patients presenting with an intractable hemorrhagic duodenal ulcer and IVR should be performed immediately when MALS is detected.

A 37-year-old man was admitted to our hospital with a day’s history of abdominal pain. A plain X-ray of the abdomen showed fluid levels and bowel obstruction was suspected. Abdominal CT showed distended and poorly enhancing loops of small bowel and a band, associated with caliber change of the small bowel at the site. We suspected strangulated bowel obstruction due to internal herniation and performed an emergency operation. At laparotomy, Meckel’s diverticulum was identified, located in the ileum 40 cm proximal to the end of the ileocecal valve, and a band was seen, originating from the top of Meckel’s diverticulum and adhering to the mesentery of the terminal ileum, forming a potential hernial orifice. Since the ischemic changes of the incarcerated ileum recovered after the band was released, only diverticulectomy was performed. The histopathological diagnosis of the resected cord, containing vessel components, was mesodiverticular vascular band（MVB）. Intestinal obstruction caused by a MVB is rare, but this possibility should be considered in the differential diagnosis of intestinal obstruction, especially in patients without a previous history of laparotomy.

An 88-year-old man was admitted to a nearby hospital with abdominal pain. Blood examination revealed anemia and contrast-enhanced abdominal CT revealed extravasation of the contrast medium in the upper left abdomen; therefore, bleeding from the spleen was suspected, and the patient was referred to our hospital for treatment. Based on review of the CT findings at our hospital, we diagnosed gastric volvulus and intraabdominal hemorrhage from the spleen. We performed emergent laparotomy, and the intraoperative findings revealed that the greater curvature of the stomach had moved towards the left diaphragm and the pylorus had also moved towards the ventral aspect of the cardia. Splenectomy was performed because of persistent hemorrhage. The spleen was apparently injured by the strong traction force caused by the gastric volvulus. After we restored the stomach to the normal position, the patient has not presented with any recurrent symptoms of gastric volvulus, and we did not perform gastropexy. The patient’s postoperative course was uneventful, and he was discharged on the 9th postoperative day. Based on this experience, we wish to underscore the importance of being aware of the characteristic CT findings of gastric volvulus. Although intraabdominal hemorrhage due to splenic injury caused by gastric volvulus has rarely been reported, such a possibility must be borne in mind when treating a patient with gastric volvulus.

A 21-year-old woman visited our hospital complaining of acute abdominal pain. Physical examination revealed marked distension of the abdomen, with mild tenderness. Contrast-enhanced abnormal CT revealed an enlarged wandering spleen containing a splenic cyst（measuring 14 cm in diameter）. The right side of the spleen was ischemic. We diagnosed torsion of the wandering spleen with a splenic cyst and performed hand-assisted laparoscopic splenectomy. The spleen was rotated 180 degrees clockwise and derotated gently manually, followed by stapling of the entire splenic hilum. Histopathological examination showed a pseudocyst of the spleen with marked congestion. Wandering spleen is a major cause of splenic torsion and a splenic cyst could be a risk factor for torsion in patients with a wandering spleen.

A 75-year-old man was admitted to the hospital with intestinal obstruction following manual reduction of an incarcerated right inguinal hernia. As the intestinal obstruction persisted despite insertion of a long intestinal tube, the patient was transported to our hospital 5 days after the reduction, for an operation. Abdominal CT showed the properitoneal hernial sac sign without poor contrast of the intestinal wall. We diagnosed the condition as reduction en masse of the inguinal hernia and performed an emergency operation. At laparotomy, we observed that the incarcerated small bowel had been reduced together with the entire hernial sac into the preperitoneal space. We reduced the small intestine without enterectomy and performed mesh repair of the inguinal hernia via an anterior approach. The hernia was diagnosed as type M1, according to the Japanese Hernia Society classification. Reduction en masse of inguinal hernia is simple to diagnose by visualization of the properitoneal hernial sac sign on CT images. Therefore, CT examination should be performed in patients presenting with persistent intestinal obstruction after hernia reduction. Although rare, early operation is crucial to release the bowel from incarceration.

A 53-year-old woman visited our hospital with the complaint of a left inguinal bulge and an uncomfortable sensation in the abdomen. The bulge was as large as a ping pong ball in size, with tension, but no redness, of the overlying skin. Based on the findings, she was diagnosed as having an incarcerated inguinal hernia. During abdominal ultrasonography, the hernia could be reduced by compression with the ultrasound transducer. Abdominal CT showed some fat tissue and ascites in the left inguinal area. Emergency laparoscopic surgery was performed. The intraoperative diagnosis was supravesical hernia, because laparoscopically, the hernia orifice was found to be located just medial to the medial umbilical ligament. The herniated, incarcerated segment of the intestine was reddish in color; however, as there was no evidence of necrosis, laparoscopic repair was performed via the transabdominal approach（TAPP）. We report a case of incarcerated external supravesical hernia that was successfully treated by laparoscopic surgery.

We present the case of 61-year-old woman in whom intestinal obstruction had a sigmoid colon loop colostomy due to rectal cancer 4 years earlier. We administered chemotherapy, and performed abdominal perineal rectal resection with combined uterine-vaginal resection. The loop colostomy was left without being rebuilt into a colostomy. The patient was transported to our hospital because of abdominal pain, and was diagnosed as having acute generalized peritonitis due to gastrointestinal perforation in a parastomal hernia sac. Intraoperative findings revealed that the anal side of the sigmoid loop colostomy was perforated in the parastomal hernia sac, with retention of feces and purulent ascites. We resected the perforated intestinal segment and reconstructed a colostomy in the upper left abdomen. It was considered that the anal stump had become adherent to the abdominal wall in the hernia sac, and was compressed and pulled by the twisting of the small intestine and colon that had herniated into the sac, resulting in perforation. This report is significant because ours was a case of intestinal perforation in a parastomal hernia, which is rare.

A 52-year-old man who presented with abdominal pain of sudden onset was diagnosed as having strangulated obstruction and referred to our department. He had no previous history of abdominal surgery or trauma. We diagnosed the patient as having strangulated obstruction caused by internal herniation, and performed emergency laparotomy. At laparotomy, a strangulated ischemic segment of the small intestine measuring about 90 cm in length was found to have herniated through a hiatus in the great omentum. As the color tone of the intestinal wall improved when the hiatus was opened, small bowel resection was not performed. The patient was discharged on the 15th postoperative day.

Gallbladder perforation after blunt abdominal trauma is rather rare. We encountered two cases of gallbladder perforation caused by a blow to the right flank. The first patient was a 77-year-old man with a history of blunt right flank trauma sustained 10 days earlier after a drinking bout. The second patient was an 86-year-old woman with a history of blunt flank trauma sustained during a fall several days before admission. The trauma in neither case was severe enough to allow immediate diagnosis of the gallbladder perforation. The two patients were operated 10 and 15 days after the injury, respectively, after a certain period of administration of antibiotics. Patients presenting with persistent pain and inflammatory findings after even mild blunt trauma to the right flank should be investigated by intraabdominal imaging to rule out perforation of the gallbladder.

A 24-year-old male patient visited his neighborhood hospital with a history of dysuria and right lower abdominal pain. He received treatment with oral antibiotics for one month, but the symptoms failed to resolve. He was referred to our hospital and diagnostic imaging conducted at our hospital showed a swollen appendix surrounded by inflamed ileocecal visceral fat and right hydronephrosis. The diagnosis of appendicitis was made and emergent appendectomy was performed. The postoperative course seemed uneventful and the patient was discharged from the hospital on the fifth day after surgery. Histopathological examination of the resected specimen after the patient was discharged revealed the diagnosis of actinomycosis. Three days after discharge, the patient presented to the emergency room with fever and abdominal pain. He was diagnosed as having a residual abscess and treated with intravenous penicillin for two weeks, followed by oral minomycin for four weeks. Abdominal actinomycosis presenting with urinary symptoms is relatively rare. It would be useful to consider this diagnosis in patients with atypical presentations of appendicitis, to avoid readmission or inadequate antibiotic therapy.

A 44-year-old man was diagnosed as having non-occlusive mesenteric ischemia the day after he underwent endovascular stent-graft repair for acute Stanford B-type aortic dissection. He was transferred to our department on the same day, and we performed a total of four surgeries, including resection of most of the jejunum, ileum, ascending colon, half of the proximal transverse colon, and jejuno-colonic anastomosis. After central venous port placement, he has discharged on home total parenteral nutrition on day 166. After discharge, he developed repeated catheter-related bloodstream infections, but ethanol lock therapy and a disinfecting cap prevented further catheter-related bloodstream infections, and the same catheter could be used for a long time. We report a case of recurrent catheter-related bloodstream infections associated with short bowel syndrome developing after extensive surgery for non-occlusive mesenteric ischemia, in whom the recurrent catheter-related blood stream infections were successfully prevented and treated by ethanol lock therapy and a disinfecting cap.

A 36-year-old woman had undergone laparoscopic hernia repair for a broad ligament hernia at our hospital 1 year and 1 month ago. During the surgery, a defect was found in the right broad ligament of the uterus, which was closed by continuous suture with an absorbable thread. Subsequently, the patient was admitted to our hospital complaining of sudden abdominal pain, and an abdominal CT revealed a broad ligament hernia. Emergency laparoscopic repair was performed again under the diagnosis of recurrent broad ligament hernia. As at the previous surgery, a defect was found again in the right broad ligament of the uterus, and no evidence of the absorbable thread used in the previous operation could be found. The operation was completed by closure with a continuous suture using non-absorbable thread. Defects in the broad ligament causing uterine herniation are mainly closed, as in the case of other internal hernias, using absorbable sutures. However, there have been reports of recurrence following closure with an absorbable thread, as in this case, so that there is some doubt about the certainty of the technique; one possible reason is failure of adhesion of the apposed serosal surfaces of the uterine ligament even after suture using an absorbable thread. Therefore, we believe that non-absorbable thread should be used for the suture.

A 63-year-old man who had undergone gastrectomy presented with a history of abdominal pain, nausea and vomiting. Examination revealed tenderness in the right lower quadrant. Abdominal computed tomography showed evidence of obstruction of the small intestine in the lower right abdomen. We diagnosed small bowel obstruction caused by adhesions. After introduction of a transnasal ileus tube, contrast radiography of the intestines showed interruption of the contrast medium where the tip of the tube reached the site of obstruction in the right lower abdomen. On the 7th hospital day, laparoscopic surgery was performed to treat the small bowel obstruction, as the conservative treatment appeared to be inadequate to resolve the ileus. Intraoperative findings revealed a lateral type of paracecal hernia with small bowel obstruction. A review of the preoperative CT images revealed a small intestinal loops on the dorsolateral aspect of the cecum, which is considered as a characteristic finding of paracecal hernia.

A man in his 50s who had undergone laparoscopic right hemicolectomy three days ago at a previous hospital was brought to our emergency department with the complaints of abdominal pain and fullness. Contrast-enhanced CT（CECT）showed rupture of two aneurysms of the inferior pancreaticoduodenal artery associated with median arcuate ligament syndrome（MALS）. Emergent interventional radiology was performed, and the aneurysms of the anterior inferior pancreaticoduodenal artery were selectively embolized with microcoils. The patient was discharged 31 days after the procedure, despite temporary stasis of the duodenum. In this case, a review of the CECT images obtained prior to the colorectal resection showed stenosis of the celiac axis caused by MALS, with no evidence of aneurysm. Dissection of the ileocecal and the right colic artery during the right hemicolectomy procedure might have led to an increase in the blood flow to the pancreaticoduodenal artery, which may have resulted in the formation of the aneurysms and their subsequent rupture.

Reduction en masse of inguinal hernia is a rare complication of inguinal hernia, in which the hernial sac moves into the preperitoneal space along with an incarcerated bowel loop. Reduction en masse of inguinal hernia usually requires emergency surgery. Cases of intestinal necrosis and requiring resection of the intestine have also been reported. An 81-year-old man was referred to our hospital with a swelling in the right inguinal region and right lower abdominal pain. He was diagnosed as having incarcerated right inguinal hernia, and manual reduction of the hernia was attempted, with success. However, the patient then developed nausea and right lower abdominal pain. Abdominal CT showed a closed loop formation of the small intestine in the right lower abdomen. The patient was diagnosed as having strangulated bowel obstruction associated with hernia reduction. An emergency operation was performed. He was diagnosed intraoperatively as having hernia reduction en masse into the preperitoneal cavity. The incarcerated intestine could be released from the hernia sac without resection. We report a case of reduction en masse of inguinal hernia. To conclude, a surgeon should bear in mind that manual reduction of a hernia could be complicated by reduction en masse, which requires early diagnosis and operation to decrease the extent of bowel resection of intestine.