The usefulness of single-port laparoscopic omental patch closure for perforated gastroduodenal ulcers was examined by comparing this procedure with conventional 4-port surgery. The subjects were 77 patients who underwent laparoscopic surgery for perforated gastroduodenal ulcers, excluding those with anastomotic ulcer perforation. The data of patients who underwent 4-port surgery in or before 2011（multiport group, n＝64）were compared with those who received single-port surgery in or after 2012（single port group, n＝13）. The operation time in the single port group was significantly shorter than that in the multiport group（97 vs. 113 min）. The median time to removal of all drains was 7 days postoperatively in the multiport group. The postoperative hospitalization period was significantly shorter in the single port group as compared to the multiport group（17 vs. 21 days）, and the incidence of postoperative Clavien-Dindo Class Ⅲ or higher complications was lower in the single port group（0％ vs. 10.9％）. Single-port surgery appeared to be as useful as equivalent in efficacy to multiport surgery, especially when certain techniques were adopted, and could shorten the operation time and improve esthetic outcomes.

A man in his 70s was transferred to our hospital with the complaint of low back pain. Abdominal CT showed a large pancreatic pseudocyst in the dorsal aspect of the stomach, with poor contrast effect. Since the lactic acid level was not elevated, we decided to carefully follow-up the patient. However, as we observed an increase of the serum lactate level and decrease of the blood pressure after 16 hours, and a repeat CT failed to provide a better view of the ischemic changes in the upper gastrointestinal tract, we performed emergency surgery; intraoperative exploration revealed acute gastric necrosis of the upper part of the stomach and septic shock associated with pancreatic pseudocyst infection. Therefore, the stomach and esophagus were transected, and proximal gastrectomy and cystogastrostomy were performed. Gastrointestinal reconstruction was not performed due to concerns about anastomotic leakage, and the initial surgery was completed. Five months after the initial operation, once the patient’s general condition and nutritional status improved, we performed double tract reconstruction using the elevated jejunum.

A 73-year-old man was found lying unconscious in front of the entrance to his home in winter. He was in cardiopulmonary arrest when the ambulance crew arrived. He was resuscitated after he was transported to our hospital. On arrival, the bladder temperature was 32.0℃, and the Hb concentration was 2.3g/dL; thus, the patient had moderate hypothermia and anemia. Abdominal CT showed a poor contrast area of the small intestine, and necrosis of the small intestine was suspected. Laparoscopic-assisted resection of the small intestine was performed, and a 60-cm section of the small intestine was found to be necrotic, which was resected. The day after the surgery, he developed gastrointestinal bleeding from a duodenal ulcer that required endoscopic hemostasis. The patient had a good neurological outcome and on day 40 after admission to our hospital, he was transferred to a rehabilitation hospital. Our definitive diagnosis was NOMI, which was consistent with the pathological findings. We have reported a rare case of a patient with NOMI who was transported to our hospital with hypothermia and cardiopulmonary arrest caused by hemorrhagic shock, and was successfully treated.

A man in his 20s visited the emergency department with a sore throat following suicidal ingestion of low-concentration hydrogen peroxide. Abdominal CT showed gas accumulation in the greater curvature of the stomach and intrahepatic portal veins. Upper gastrointestinal endoscopy revealed mucosal abrasions in the lower part of the esophagus and also gastric mucosal erosions. As arterial blood gas analysis revealed metabolic acidosis, abdominal contrast-enhanced CT was performed to exclude intestinal ischemia. However, no evidence of intestinal ischemia was detected, and we treated the patient conservatively with a proton-pump inhibitor and sodium alginate. Twenty-two hours later, a repeat CT no longer revealed evidence of hepatic portal venous gas. A repeat endoscopy performed two days later revealed no changes. The patient was discharged after five days of hospitalization. In general, hepatic portal venous gas is fatal. However, there are several reports of elimination of hepatic portal gas associated with hydrogen peroxide ingestion by conservative therapy.

Parasitic leiomyoma（PL）is a rare disease in which an isolated uterine leiomyoma grows ectopically via nutrient vessels from other organs. In this study, we report a case of PL in the abdominal wall associated with strangulated bowel obstruction. The patient was a 46-year-old woman who had never given birth and had no previous history of abdominal surgery. She presented to the emergency room with a history of fever and repeated vomiting. Abdominal CT showed strangulated bowel obstruction and a mass lesion with calcification. Release of bowel obstruction by laparoscopic surgery was performed as the initial operation, and laparoscopic resection of the tumor was performed as a reoperation. Tumor penetration into the abdominal wall and its adhesion to the small intestine were observed. Since a small intestinal tumor could not be ruled out, combined resection of the small intestine was performed, and histopathological examination confirmed the diagnosis of PL. In adult women, especially those with a history of uterine fibroids, PL should be considered in the differential diagnosis of bowel obstruction associated with intra-abdominal masses.

Calcium polystyrene sulfonate（CPS）is a cation exchange resin that is used for treating hyperkalemia in patients with renal failure. This drug causes hard stools and constipation. As a serious side effect, intestinal tract perforation has also been reported. We report two cases of patients with chronic kidney disease（CKD）under maintenance hemodialysis who developed CPS-induced sigmoid colon perforation. Case 1 was an 88-year-old woman, and Case 2 was a 76-year-old man; both had CKD and were undergoing maintenance hemodialysis. In both cases, surgical exploration revealed sigmoid colon perforation near the mesenteric side. Histopathological examination of the resected specimen revealed accumulation of CPS crystals in the intestinal wall around the perforation site in both cases. In CKD patients, as the intestinal wall is already vulnerable due to chronic blood flow disturbance caused by uremia and arterial sclerosis, the risk of intestinal perforation associated with increase of the intestinal pressure is high in these patients. Therefore, appropriate measures for defecation control is important in patients with CKD started on treatment with CPS.

A 58-year-old man was admitted to our hospital for right upper quadrant pain. He had undergone distal gastrectomy and Roux-en-Y reconstruction and cholecystectomy two years earlier. Findings of abdominal computed tomography（CT）were suggestive of duodenal diverticulitis with an enterolith. Endoscopy revealed a diverticulum with an impacted enterolith. Following removal of the enterolith using a gripping forceps, wall thinning and partial necrosis of the diverticulum were observed, and we performed a laparotomy. Because the diverticulum on the outside of the descending duodenum was fragile and easily torn, excision of the diverticulum was difficult; therefore, the mucosa at the base of the diverticulum was closed by sutures and wrapped around the diverticular wall. A 12 Fr gastric tube was inserted from the duodenal stump and a T-tube was placed in the common bile duct for decompression. Although he developed wound infection and liver dysfunction, he was treated conservatively and was discharged on the 35th postoperative day. We report the case of a patient with duodenal diverticulitis with an enterolith that developed after gastrectomy and Roux-en-Y reconstruction, who showed a good course after sewing and decompression.

Aortic graft infection is a serious complication and is associated with high mortality and morbidity rates. We report a successfully treated case of rectal perforation with abdominal aortic graft infection that developed in a patient who had undergone graft replacement for an abdominal aortic aneurysm. A 68-year-old man visited a physician with a history of generalized malaise and was diagnosed as having rectal perforation with aortic graft infection. He failed to improve with antibiotic therapy and was referred to our hospital for surgery. Abdominal computed tomography revealed a perigraft abscess in the aortic graft and rectal perforation. We performed emergency surgery with the cooperation of cardiovascular surgeons. A perforation was detected in the rectosigmoid area in the vicinity of the Y-graft. We made the diagnosis of rectal perforation-induced aortic graft infection and performed an extra-anatomical bypass, graft body removal, and Hartmann’s operation. The patient’s postoperative course was uneventful, and he was discharged on the 25th postoperative day. It is necessary to perform surgical debridement and extra-anatomical bypass for cases of abdominal aortic graft infection associated with rectal perforation.

We report the case of a patient with isolated polycystic liver disease who presented to us with dyspnea and orthopnea. A 76-year-old woman presented to us with a history of dyspnea and orthopnea. Abdominal CT showed multiple liver cysts, including a hepatic cyst measuring 13cm in maximum diameter in the right lobe of the liver, compressing the heart, diaphragm, inferior vena cava and upper gastrointestinal tract. With percutaneous transhepatic drainage, both the dyspnea and orthopnea promptly improved. A streptococcal strain was isolated from the drainage fluid, indicative of infection of the cyst. After drainage of the cyst, the patient’s general condition improved. As a curative procedure, monoethanolamine oleate was injected into the cyst on day 15 of admission, and the patient showed a satisfactory course. The dyspnea and orthopnea were thought to be caused not by impaired myocardial contractility, but by diastolic dysfunction of heart. Diaphragmatic elevation could also have contributed to the symptoms. However, further analysis and accumulation of data on symptomatic isolated polycystic liver disease is required for cases with symptoms of dyspnea and orthopnea.

A 9-year-old boy was brought to our hospital with a day’s history of abdominal pain. Contrast-enhanced computed tomography revealed strangulated small bowel obstruction with poor contrast enhancement of a segment of the intestine, as well as of a blind-end structure that was suspected as the Meckel’s diverticulum; a mesodiverticular band was found attached to the diverticulum. Intraoperatively, the strangulated small bowel segment was found to be adjacent to the mesodiverticular band and the Meckel’s diverticulum was included in the strangulating band, with torsion. Since the ischemia did not improve even after release of the torsion and strangulation, we performed partial resection of an approximately 5-cm segment of the small bowel. The postoperative course was good and the patient was discharged on postoperative day 7. Simultaneous occurrence of torsion of the diverticulum and strangulation of the small bowel by a mesodiverticular band is rare. Meckel’s diverticulum may be dependent on the MB for its blood flow. Therefore, partial small bowel resection rather than a wedge resection in the case of Meckel’s diverticulum with mesodiverticular band may help improve the prognosis.

Small bowel mesenteric lymphangioma is a relatively rare disease, and preoperative diagnosis is often difficult. A 10-year-old child was brought to our hospital with progressively worsening right lower abdominal pain. Physical examination revealed tenderness and rebound tenderness in the right lower abdomen. Laboratory examination showed an elevated inflammatory responses（WBC count 12,000/μL and serum CRP 0.04mg/dL）. Contrast-enhanced abdominal CT revealed a mildly enlarged appendix, a positive whirl sign at the end of the superior mesenteric artery, and a mass in the pelvis showing poor contrast enhancement. An emergency operation was performed for acute abdomen on the same day. Laparoscopic examination revealed a multifocal cystic lesion bordering the small intestine, about 70 cm from the ligament of Treitz, with minimal inflammation of the appendix. We performed laparoscopic resection of the appendix and partial resection of the ileum. Histopathological examination revealed minimal inflammation of the appendix, and the cystic lesion was diagnosed as a mesenteric lymphangioma. The patient was discharged from the hospital without any complications on the 6th postoperative day, and no recurrence has been observed since. Preoperative diagnosis of small bowel mesenteric lymphangioma is sometimes difficult, and laparoscopic surgery may be useful, including for diagnostic purposes, in cases of small bowel mesenteric lymphangioma presenting with an acute abdomen.

Intestinal endometriosis is found in more than 10％ of women with endometriosis. Intestinal endometriosis involving the ileum, while rare, is sometimes known to cause bowel obstruction. The patient was a 35-year-old woman with no prior history of surgery. She gave a history of having been hospitalized twice earlier for bowel obstruction and further examinations were scheduled for the outpatient department, but since the patient developed abdominal pain, she was admitted to our department. A diagnosis of intestinal endometriosis was made on the basis of the findings of MRI. Laparoscopic surgery was performed. Endometriosis of the right ovary and hemorrhagic ascites associated with menstruation were confirmed. A similar lesion was identified 10 cm distal to the terminal ileum, and partial resection of the small intestine was performed. Histopathological examination of the resected specimen showed the presence of endometrial tissue within the subserosal and muscular layers, with fibrosis and bleeding. Intestinal endometriosis must be borne in mind as a possible cause in women of reproductive age presenting with small bowel obstruction. MRI is useful for diagnosing intestinal endometriosis and extensive observation was possible by laparoscopic surgery in our case.

A 62-year-old woman was admitted to our hospital complaining of abdominal pain of sudden onset, and enhanced abdominal computed tomography（CT）showed an 8.5-cm-sized tumor on the posterior surface of the left lobe of the liver, without unequivocal extravasation. Three days later, emergency surgery was performed because of progression of anemia and growth of the tumor. Intraoperatively, a mass was observed under the lesser omentum, which was resected to the extent possible. The histopathological findings were consistent with a pheochromocytoma. The patient showed no typical symptoms such as high fever, hypertension, or hyperhidrosis, either prior to or during the surgery, making the diagnosis difficult. The postoperative course of the patient was satisfactory and the tumor showed no apparent recurrence. Ectopic occurrence of pheochromocytoma accounts for about 10％ of all cases, and is common around the abdominal aorta. The diagnosis of giant and ectopic pheochromocytomas is often difficult because of the lack of typical symptoms. In this article, we report a case of ectopic giant pheochromocytoma that was difficult to diagnose preoperatively.

Pneumatosis intestinalis（PI）is defined as gas in the bowel wall, and is a condition that can range from benign to fatal. It is sometimes associated with acute mesenteric ischemia, which would necessitate urgent surgical intervention. The pathogenesis of PI is thought to be multifactorial, and the causes include mechanical, bacterial and biochemical factors. Several reports have been published of PI caused by molecular-targeted therapy, including treatment with epidermal growth factor receptor（EGFR）inhibitors, such as panitumumab and cetuximab. Herein, we report a case of PI that developed during treatment with panitumumab in a patient with recurrent transverse colon cancer. We did not undertake surgical exploration, as bowel necrosis and bowel obstruction seemed unlikely. The patient gradually stopped complaining of symptoms, and the PI was no longer detected on CT on the 8th hospital day. PI can be resolved by discontinuation of the culprit drugs, which could help avoid emergency surgery.

Herein, we report two cases of food-induced small bowel obstruction caused by mushrooms. Case 1: A 56-year-old woman with cerebral palsy and no previous history of abdominal surgery was admitted to our hospital complaining of abdominal pain and vomiting. Abdominal computed tomography revealed small bowel dilatation and a mass with air density inside. Because the patient was unable to communicate, and considering the possibility of intestinal necrosis, we performed emergency surgery. A movable mass was observed in the ileum. The ileum was incised, and a shiitake mushroom was removed. Case 2: A 39-year-old woman without a previous history of abdominal surgery was admitted to our hospital complaining of abdominal pain and vomiting. Abdominal computed tomography revealed small bowel dilatation and a mass with air density inside. As she gave a history of having eaten sukiyaki containing mushrooms the day before, we considered the possibility of food-induced small bowel obstruction and performed emergency surgery. A soft lump was observed in the ileum. The ileum was incised, and enoki mushrooms were removed. In cases of ileus without a previous history of abdominal surgery, food-induced small bowel obstruction should be considered in the differential diagnosis.

A 78-year-old woman complaining of dyspnea and epigastric pain was brought to our hospital. Her vital signs were unstable, and she showed central cyanosis and evidence of severe acidosis. Contrast-enhanced computed tomography（CT）revealed an obscure contrast enhancement of the superior mesenteric artery, which made it difficult to identify the roots of the celiac and superior mesenteric arteries. Due to the wide ischemic region and poor general condition of the patient, we considered that surgery would be highly challenging. However, the following morning, the general condition of the patient was markedly improved. A repeat CT revealed improved intestinal blood flow and slightly better contrast of the root of the superior mesenteric artery. An angiography performed subsequently demonstrated collateral blood flow from the inferior mesenteric artery to the celiac and superior mesenteric arteries, which was considered to have maintained the intestinal blood flow in the superior mesenteric artery. After three months, the patient was discharged from the hospital. Acute mesenteric artery ischemia often requires urgent and invasive treatment, and only a few cases of non-invasive treatment for this disease have been reported in the literature. Herein, we report this rare case of non-invasive treatment, along with a brief review of the literature.

We report a case of acute abdomen caused by torsion of a giant wandering spleen. A 26-year-old woman was referred to our hospital complaining of sharp lower abdominal pain of sudden onset. Abdominal CT revealed an intraperitoneal mass with the whirl sign and ascites in the lower abdomen. We diagnosed strangulated bowel obstruction, and performed emergency laparotomy. Intraoperatively, the intestine-like mass was found to be an enlarged wandering spleen. The spleen was twisted four times around the splenic vessels, and looked pale. After the torsion was released, the color tone of the spleen improved. However, because of the enormous splenomegaly and long splenic vessels, we considered the high risk of recurrence of the torsion or internal hernia, and performed splenectomy. The postoperative course was uneventful and the patient was discharged on the 7th day after surgery.

The patient was a 67-year-old man with schizophrenia under long-term hospitalization at another hospital, who complained of abdominal discomfort. Abdominal CT revealed intra-abdominal free air, which raised the suspicion of gastrointestinal perforation, and the patient was referred to our hospital for further detailed examination and treatment. Physical examination was negative for signs of peritoneal irritation, and blood test results did not reveal an increased inflammatory response. Since difficulty in communicating with the patient hampered accurate pain assessment, an exploratory operation was performed for suspected gastrointestinal perforation. During the operation, the ascitic fluid did not appear to be contaminated, and no apparent perforation of the stomach, small intestine, or colon were identified. A drain was placed on the posterior aspect of the duodenum. The postoperative course was uneventful and the patient was discharged after 21 days. One month after being discharged, the patient vomited, was found to have intra-abdominal free air again on abdominal CT, and was referred to us. There were no abnormal findings, as was the case in the previous examination; the patient was diagnosed as having idiopathic pneumoperitoneum, which improved after conservative therapy. Our case is worth remembering as an example to demonstrate that surgery may be unnecessary in some patients who show intra-abdominal free air on CT when there are few other abnormal findings.

A 95-year-old woman who underwent the Hartmann’s procedure seven years ago was transported to the emergency room due to difficulty in moving and eating. She was urgently hospitalized with a diagnosis of electrolyte imbalance due to severe dehydration, prerenal renal failure, and impaired consciousness. During the course of this illness, she developed fever of sudden onset, and redness, swelling, tenderness, and a high inflammatory response around the stoma was observed. CT was performed and a diagnosis of perforation of the stoma limb was made. Because of the high surgical risk, we performed local incision and drainage for the purpose of infection control, and started her on treatment with antibacterial drugs. In response to the treatment, the inflammation subsided, and after confirming the external fistula of the stoma perforation, meals were resumed. Ten months have passed since the procedure, and the patient remains alive.

Foreign bodies in the intestinal tract could be introduced via trans-anal insertion for the purpose of masturbation, etc., rarely reaching the adoral rectum below the peritoneal reflection in such cases. In this study, we report a case in which an anally inserted foreign body lodged in the sigmoid rectum was extracted by hand-assisted laparoscopic surgery（HALS）. The patient was a 67-year-old man with a 2-to 3-year history of repeatedly inserting and ejecting foreign objects, such as balls, into and from his anus for the purpose of masturbation. He visited our emergency room complaining of difficulty in ejecting a foreign body that he had inserted 2 days previously and persistent abdominal pain since. Examination revealed that the foreign object was located in the sigmoid colon. We attempted to remove it by lower gastrointestinal endoscopy under general anesthesia with complete endoscopy, but it was difficult to move or grasp. Finally, the foreign object was removed successfully by colonoscopy with HALS. Based on the experience reported from Japan, we created a treatment algorithm for foreign body removal from the intestinal tract with a minimal risk of peritonitis/gastrointestinal perforation.