Background: There is a lack of evidence to support the adoption of interval appendectomy（IA）for complicated appendicitis, defined as appendiceal abscess, in the elderly. We evaluated the safety and efficacy of IA in elderly patients with appendiceal abscess. Methods: We retrospectively analyzed the data of 36 patients aged ≧65 years with appendiceal abscess who underwent surgery at Southern Tohoku General Hospital between April 2011 and August 2021; we evaluated the patient characteristics, IA implementation rate, IA success rate, total length of hospital stay, and total medical costs in the study population. We compared the type of surgical procedure and incidence of complications between patients who underwent emergency operation（EO）and those who underwent successful IA（IA-S）. Results: Of the 36 patients, 23 patients（64％）were classified into the EO group, and 13（36％）were classified into the IA group. IA was successful in 10 of the 13 patients. There were no significant differences in the patient characteristics between the EO group and the IA group. Our analysis revealed the following findings（EO : IA-S）: postoperative complications, 9 : 1; surgery, 17 : 1; ileocecal resection, 16 : 2; and total length of hospital stay, 13 : 17.5 days. The total cost of hospitalization was not significantly different between the two groups. Conclusion: IA for appendiceal abscess may be safe and effective in the elderly.

In Japan, ingested fish bone is the most common cause of perforation of the gastrointestinal tract, and the most common sites of perforation are the transverse colon, sigmoid colon, small intestine, and esophagus, in that order. Cases of stomach perforation are rare. Complicating intra-abdominal and perianal abscesses are common, but liver abscess is rare. We report a case of gastrointestinal fishbone perforation with a liver abscess, which was diagnosed early by CT and promptly treated by laparoscopic surgery.

We present a rare case of a patient with dedifferentiated retroperitoneal liposarcoma（DDLPS）who presented with intra-tumoral hemorrhage. The patient, a 75-year-old woman, was diagnosed as having a retroperitoneal tumor located above the left kidney. While waiting for surgery, she presented with symptomatic anemia（hemoglobin 7.6 g/dL）. A plain CT of the abdomen showed a high-density area in the tumor, and we made the diagnosis of intra-tumoral hemorrhage within the retroperitoneal tumor. As the patient was hemodynamically stable, we opted for elective surgery after blood transfusion. At laparotomy, there was no bloody ascites. The tumor was resected with the mesocolon, left adrenal grand, Gerota’s fascia, and suprarenal capsule. Macroscopic examination of the resected specimen showed a white yellowish and solid mass with a subcapsular hematoma. On histological examination, the tumor was composed of proliferating spindle-shaped cells with prominent small vessels. The findings were similar to those of a solitary fibrous tumor, however, immunohistochemical staining showed positive staining of the tumor cells for MDM2, CDK4 and CD34. On the basis of the above findings, the tumor was diagnosed as a DDLPS. The patient died of local recurrence and lung metastases 23 months after the surgery. Intra-tumoral hemorrhage within a DDLPS is rather rare. Although preoperative diagnosis is difficult, curative resection must be attempted considering the possibility of DDLPS.

A 74-year-old man with sigmoid colon cancer was referred to us for surgical treatment. We performed laparoscopic sigmoid colectomy without intraoperative complications, and the patient resumed oral intake on the third postoperative day. However, he developed vomiting on the fifth postoperative day. Abdominal contrast-enhanced computed tomography revealed upper bowel obstruction due to internal herniation of the intestine via a large mesenteric defect measuring about 12 cm in diameter. Exploratory laparoscopy and repositioning was performed. Laparoscopic observation showed herniation of a 50-cm segment of the small intestine near Treitz’s ligament through the mesenteric defect into the left side of the abdomen. We repositioned the small intestine, with suturing at two points（left upper part of the descending colon and left lower part of the mesentery）. The abdominal symptoms improved after surgery and the patient was discharged from the hospital on the seventh day after the second surgery.

A 72-year-old man with hematemesis visited a neighborhood hospital, where endoscopy revealed bleeding from an ulcer on the lesser curvature of the upper body of the stomach. The patient was referred to our hospital for endoscopic hemostasis; however, endoscopy performed at our hospital suggested possible perforation at the site of the bleeding lesion. Computed tomography revealed herniation of the stomach into the mediastinum with an upside-down stomach, as well as free air and a fluid collection within the hernia sac, and free mediastinal air. We diagnosed gastric perforation within the esophageal hiatus hernia sac and performed emergency laparoscopic surgery. The perforation was closed with sutures using the lesser omentum for coverage, and the stomach and abdominal walls were sutured to prevent reherniation of the stomach. The patient’s postoperative course was uneventful, and he was discharged 19 days after the surgery. Gastrointestinal perforation within an esophageal hiatus hernia sac could become fatal in patients who develop severe mediastinal or intrathoracic infection. However, laparoscopic surgery is a useful therapeutic option for patients in a good general condition without thoracic cavity or mediastinal penetration.

A 61-year-old woman with vomiting and diarrhea was transferred to our hospital with a diagnosis of diabetic ketoacidosis. At the time of transfer, the patient had bloody stools and physical examination revealed muscular guarding. Abdominal computed tomography showed full-thickness edema of the intestinal wall, pneumatosis intestinalis of the transverse colon, and portal vein gas. During laparoscopy, we observed massive cloudy yellow ascites in the abdominal cavity, and the bowel segment from the transverse colon to the descending colon was gangrenous. Therefore, we converted the surgical approach to open laparotomy. Subtotal colectomy and ileostomy were performed, because the mucosa on the entire surface of the resected intestine was necrotic. Histology showed prominent fibrous edema in the lamina propria, as well as edema and neutrophil infiltration of the submucosa. Most of the mucosal gland ducts were lost, and gram-negative rods were identified. It was presumed that the ischemic changes and the pneumatosis intestinalis were induced by bacteria and hepatic portal vein gas. The patient was discharged on postoperative day 15. This patient had the most severe type of ischemic colitis, which could have progressed to the entire colon and become fatal in the absence of immediate intervention. It may be useful in such cases to consider the extent of resection by lower gastrointestinal endoscopy.

A woman in her forties presented to us with the complaint of hematochezia. Digital rectal examination revealed bright red blood per in the rectum. Contrast-enhanced CT showed the presence of fluid from the cecum to the rectum, and we presumed colonic diverticular bleeding. Emergent colonoscopy performed on the same day after bowel preparation showed a large amount of bright red blood from the cecum to the ascending colon. On a review of the contrast-enhanced CT images during the colonoscopy, we recognized extravasation at the tip of the appendix, suggestive of appendiceal hemorrhage. Therefore, we flushed the area, and recognized active bleeding from the appendiceal orifice, and made the diagnosis of appendiceal hemorrhage. We succeeded in stopping the bleeding temporarily with hemostatic clips and performed single-incision laparoscopic appendectomy on the same day, considering the risk of rebleeding. Histopathological findings revealed granulation tissue at the distal end of the appendix, which was considered as the source of bleeding, and on the basis of this finding, we made the diagnosis of idiopathic appendiceal hemorrhage.

A 65-year-old man underwent left hepatic trisectionectomy for hilar cholangiocarcinoma and duodenal mucosal resection for early duodenal cancer on the 19th postoperative day. Peritoneal drainage was performed for 6 weeks, however, bile leakage persisted at 100-300 mL/day. Plastic stents were placed in the bile duct through the stump of the jejunal limb via an endoscopic approach, which resulted in successful control of the bile leakage. The peritoneal drainage tube was removed 9 days later. The plastic stents were endoscopically removed 4 months later via the stump-jejunostomy, which was surgically closed immediately after the procedure. The patient remains alive without recurrence at present, 2 years after the initial surgery. Endoscopic placement of stents via the jejunostomy is a reasonable option for the treatment of bile leakage after major hepatectomy with bile duct reconstruction.

Arterial-enteric fistula is a rare cause of massive gastrointestinal bleeding that can be fatal, and is considered as an abdominal emergency. While there are a few reports of aortoduodenal fistulae occurring as a complication of artificial vascular grafting, reports of arterio-enteric fistulae involving the lower gastrointestinal tract are extremely rare and carry a particularly poor prognosis, as early diagnosis is difficult. Herein, we report our experience of such a case: the patient, a 56-year-old man, had an internal iliac-rectal fistula and presented with hypovolemic shock secondary to massive gastrointestinal hemorrhage. Arterial embolization by an interventional radiology team and intestinal gauze tamponade proved life-saving. The patient had been undergoing chemotherapy after completion of a course of chemoradiotherapy for unresectable rectal cancer, and presented to the hospital with the chief complaint of dark, tarry stools. We were able to identify bleeding from a fistula between the left internal iliac artery and the rectum, and performed transcatheter arterial embolization. Because of the well-developed collateral circulation, embolization alone was insufficient to achieve complete hemostasis, and we inserted gauze into the anus and distal aspect of the loop sigmoid colostomy for tamponade. Successful control of the bleeding was achieved, and the patient’s hemodynamics stabilized. He was discharged on the 17th hospital day and survived for 22 months before dying from rectal cancer.

The patient was a man in his 40s who had sustained injuries in a head-on collision of his car （which he was driving, with the seat belt on）with an oncoming truck. We diagnosed the patient as having hemorrhagic shock due to an open fracture of the femur. Damage control resuscitation was started, and damage control orthopedics（external fixation）was immediately performed. We suspected small bowel perforation, and computed tomography（CT）was performed 6 h after the patient’s arrival; however, no free air was detected. Also, no signs of peritoneal irritation were apparent on physical examination. Intraabdominal free air was detected at 18 h after arrival and emergency laparotomy was performed. Small bowel perforation is not always detected on arrival. In the present case, the signs of peritoneal irritation were presumably not apparent, because of the patient had consciousness disturbance arising from the brain injury. We must monitor the CT findings in patients with suspected small bowel injury and consciousness disturbance, regardless of the abdominal findings. Furthermore, appropriate resuscitation, including to improve the coagulation ability of the patient for surgery, is important for patients with hemorrhagic shock who are considered to be potential candidates for surgery.

A 54-year-old man with a history of having undergone lower abdominal surgery in childhood was admitted with a history of vomiting. Abdominal computed tomography showed a caliber change in the ileum adjacent to the cecum. The preliminary diagnosis was adhesive small bowel obstruction or paracecal hernia. We treated the patient conservatively using an ileus tube. Although good decompression was obtained, the obstruction did not improve. Therefore, we performed laparoscopic surgery and made the diagnosis of lateral paracecal hernia based on the intraoperative findings. The hernia orifice was opened to release the incarcerated small intestine. No evidence of intestinal ischemia was observed. The patient was discharged 4 days after the surgery. Until the last follow-up at 1 year 4 months after the operation, no recurrence was observed. Laparoscopic surgery allows detailed observation of the abdominal cavity under sufficient decompression, and is particularly useful for cases such as this, where definitive differentiation between adhesive ileus and internal hernia cannot be made before surgery. We report a case of lateral paracecal hernia that could both be diagnosed and treated by laparoscopic surgery.

The patient, a 66-year-old woman, was referred to our hospital with a history of fever, abdominal pain and vomiting. Blood tests showed elevated inflammatory marker levels and abnormal liver and kidney function parameters. Abdominal CT showed a low-density area in the lateral segment of the liver, and abdominal ultrasonography showed a multifocal cyst measuring 70 mm in diameter in the same region. Based on the findings, we diagnosed the patient as having a liver abscess complicated by sepsis and DIC, and started on antimicrobial therapy; drainage of the abscess was difficult because it was multifocal and lacked liquid components. On day 5 of treatment, we noticed symptoms and signs of peritoneal irritation, and performed emergency surgery on the same day with the suspected diagnosis of peritonitis caused by rupture of the liver abscess. Intraoperatively, a large amount of bloody ascites and a hematoma on the liver surface were observed, and a fist-sized mass with a laceration of the hepatic capsule was found in liver S3. Lateral segment hepatectomy was performed. Histopathological examination of the resected specimen showed a ruptured liver abscess. Blood culture, ascitic fluid culture, as well as abscess fluid culture grew Klebsiella pneumoniae. The patient was discharged on day 18 after surgery. Liver resection could be an effective treatment for liver abscesses that are difficult to drain and refractory to conservative treatment, as in this case.

A 58-year-old man who had been diagnosed as having chronic cholecystitis with cholecystolithiasis and was scheduled for surgery visited our emergency department with a day’s history of frequent vomiting（about 10 times a day）. Abdominal CT showed a cholecystoduodenal fistula and gallstone ileus. We admitted the patient and performed enterolithotomy on the 5th hospital day; however, the cholecystoduodenal fistula was treated conservatively in the absence of cholangitis at admission. The patient was discharged on day 8 after surgery, with no evidence of cholecystitis, cholangitis, or recurrence of ileus. Contrast-enhanced radiography performed 4 months after discharge showed persistence, but at a reduced size, of the cholecystoduodenal fistula. We report a case in which we performed enterolithotomy, but treated the cholecystoduodenal fistula conservatively.

We report 4 cases of diverticulitis of the colon and portal vein thrombosis. Case 1: A 59-year-old man diagnosed as having diverticulitis of the ascending colon and superior mesenteric vein（SMV）thrombosis underwent emergency right hemicolectomy. He was administered warfarin and developed SMV narrowing and occlusion. Case 2: A 58-year-old man diagnosed as having diverticulitis of the transverse colon and portal vein and SMV thrombosis underwent emergency right hemicolectomy. He received warfarin and later developed partial portal vein occlusion and cavernous transformation. Case 3: A 56-year-old man diagnosed as having diverticulitis of the ascending colon and portal vein and SMV thrombosis received conservative treatment with edoxaban, which led to resolution of the thrombosis. Case 4: A 45-year-old man diagnosed as having diverticulitis of the ascending colon and portal vein and SMV thrombosis received conservative treatment with apixaban and showed residual SMV thrombosis.

Acute appendicitis is the most common cause of acute abdomen in pregnant women. When treating pregnant women presenting with acute appendicitis, careful judgment of the indication for surgery is especially important, because of concerns about preterm delivery and fetal death. Although laparoscopic appendectomy is commonly used, the number of reports remains small. Herein, we report four pregnant women with acute appendicitis who were treated by laparoscopic appendectomy between March 2017 and February 2021, with a review of the literature. The average age was 29.8（18-39）years, and the presenting complaint in all four women was lower abdominal pain. The average weeks of gestation at presentation was 16.8（12-21）weeks. For definitive diagnosis, ultrasonography was used in 1 case, magnetic resonance imaging in 1 case, and computed tomography in 2 cases. In collaboration with anesthesiologists and obstetricians, we performed single-incision laparoscopic appendectomy with port placement according to the number of weeks of pregnancy. The average operation time was 64（50-83）minutes. Three patients stayed in hospital for 3-5 days after the surgery, while 1 patient stayed for 59 days after the surgery due to imminent preterm delivery. All the women had term delivery. Laparoscopic appendectomy is a useful treatment option for acute appendicitis in pregnant women.

The patient was a 37-year-old man who was diagnosed as having decompensated alcoholic liver cirrhosis in 201X −1 and had been visiting our department ever since. In 201X, he visited us with a several-days’ history of black stools. Examination revealed that he was in shock, and we suspected hemorrhagic shock due to bleeding from a ruptured gastrointestinal varix. High-dose fluid and vasopressor infusions were initiated, and emergency esophagogastroduodenoscopy （EGD）was performed. EGD confirmed a ruptured duodenal varix, and urgent endoscopic injection sclerotherapy（EIS）was performed using N-butyl-2-cyanoacrylate（NBCA）. The patient’s condition improved with the treatment, and he was discharged on day 10 of the illness. Emergency hemostasis by EIS may be useful in patients with Child-Pugh class C and low liver reserve, as in this case.

The patient was a 63-year-old woman, in whom we had performed laparoscopic hepatic cyst deroofing 6 months earlier for a 18-cm hepatic cyst in the lateral segment of the liver; after fenestration and suction of fluid, we had resected the cyst wall which was adherent to the left diaphragm. She presented to us 6 months after the surgery, complaining of diarrhea and fever. We made the diagnosis of pseudomembranous enteritis and admitted her to the gastrointestinal surgery department of our hospital, but she began to complain of nausea and vomiting. On the 4th day of hospitalization, CT showed rupture of the left diaphragm, with most of the stomach lying in the left thoracic cavity, and we diagnosed diaphragmatic hernia. On the same day, we performed emergent laparotomy and repaired the diaphragmatic hernia. The hernia orifice measured 3 cm in diameter. We pulled the stomach back into the abdominal cavity, and closed the hernia defect in the diaphragm by direct closure. Although delayed diaphragmatic hernia after laparoscopic hepatic cyst deroofing for a liver cyst is rare, careful observation bearing the possibility of delayed occurrence of diaphragmatic hernia in mind is necessary.

The patient was a man in his 70s who had undergone total cystectomy with ileal conduit construction for bladder cancer at another hospital approximately 2 years prior. He visited his previous physician complaining of abdominal pain, and the findings on computed tomographic（CT）imaging suggested gastrointestinal perforation. The patient was referred to our hospital and we performed emergency laparotomy; intraoperative exploration revealed a jejunal perforation, and partial resection of the small intestine was performed. Although the patient’s general condition improved rapidly postoperatively, on postoperative day 4, the urine output decreased and the serum creatinine level increased. The peritoneal cavity drain output also increased rapidly to over 2,300 mL/day, and the ascites creatinine level was as high as 36.1 mg/dL. CT urography and ileal conduit imaging confirmed leakage of contrast from the ileal conduit, and conduit injury was diagnosed. A balloon catheter was placed for conservative management, after which urine output and serum creatinine improved and drainage from the Douglas fossa drain decreased. The condition in which urinary creatinine leaking into the abdominal cavity is re-absorbed through the peritoneum to cause elevation of the serum creatinine level is called pseudo-renal failure. Often confused with acute renal failure, it should be identified early and treated.