We report a case of small-intestinal duplication with primary bowel obstruction. A 27-year-old man presented to our hospital with a history of abdominal pain and vomiting. Abdominal computed tomography revealed dilatation of the small intestine with pronounced caliber change in the ileum. We initially made the diagnosis of intestinal obstruction secondary to Meckel’s diverticulum. The patient’s symptoms improved with insertion of a long tube into the intestine; however, the symptoms recurred after the patient took some food, and we performed laparoscopic-assisted surgery. A T-shaped segment of the small intestine measuring 60 cm from the terminal ileum was successfully resected with the mesentery. Histopathological examination showed a muscular layer in the resected ileum, which led us to make the diagnosis of ileus duplication. Although intestinal duplications are rare, they should be considered in patients presenting with acute abdominal pain. Partial bowel resection is often the treatment of choice for intestinal duplications. However, laparoscopic-assisted surgery, with wedge resection, may also be a useful option.

A 21-year-old woman with a history of autism and mental retardation developed vomiting while she was hospitalized for medical care and protection in the psychiatric department. Abdominal computed tomography revealed that the stomach was filled with a highly diffuse foreign body. The vomiting was determined as being caused by the foreign body in the stomach and endoscopic removal was attempted. However, the foreign body became stuck in the cervical esophagus during the procedure, and emergency surgery was performed. The foreign body was found to be a pair of vinyl gloves. There are numerous reports of vinyl glove pica in patients with mental retardation and dementia. Ingested vinyl gloves are difficult to diagnose because of the absence of any characteristic findings on computed tomography. They are also known to easily harden, so that their immediate removal without waiting for natural extrusion is necessary in long-term indwelling cases. We report a case of vinyl gloves incarcerated in the cervical esophagus during endoscopic foreign body removal, which necessitated surgical removal, with a review of the relevant literature.

The subject was a 55-year-old woman, who had undergone laparoscopic cecopexy after endoscopic reduction 11 years previously for cecal volvulus associated with a mobile cecum. She visited us with the chief complaint of hypogastric pain, which was determined upon further examination as being caused by a recurrent cecal volvulus. Due to difficulty in endoscopic reduction, an emergency operation was carried out. Intraabdominal exploration via a laparotomy revealed that the fixation to the retroperitoneum had been released, with a 720-degrees clockwise rotation with respect to the cecum at the center. Because the significant dilatation of the bowel segment from the cecum to the ascending colon would have made detection of a rupture in the serous membrane rather difficult, we performed ileocecal resection. Following an uneventful postoperative course, the patient was discharged on the 11th day after the surgery.

The patient was a 6-year-old boy, who presented to our hospital with a history of abdominal pain and frequent vomiting. At the first medical examination, abdominal computed tomography (CT) revealed hernia through the foramen of Winslow (HFW) with incarceration of the herniated segment of ileum. Because his abdominal findings were mild and CT revealed no evidence of intestinal ischemia, we initially expected improvement by decompression using a nasogastric tube. However, the following day, his abdominal signs worsened, and we performed emergency surgery. At first, we performed laparoscopic surgery, which later needed conversion to open laparotomy because of the poor visualizability caused by the dilated intestinal segment. We did not detect necrosis of the incarcerated ileum, and enterectomy was not necessary. We did not treat the foramen of Winslow, such as by suture, because the foramen was not found to have expanded. The patient was discharged 7 days after the surgery and showed no evidence of recurrence at one year after the surgery. We report this case herein, as there are very few reported cases of HFW in children.

Spontaneous esophageal rupture is caused by a rapid increase in the esophageal pressure. Although it is rare, it is associated with a high risk of mortality. The most common site of rupture is the left wall of the lower thoracic esophagus, and a left thoracotomy approach is often selected to treat it. We report four cases of spontaneous esophageal rupture in which transesophageal suture closure was performed via a laparotomy. The patients ranged in age from 48 to 74 years, and the rupture occurred after violent vomiting in all the cases. The perforation site was the lower thoracic esophagus in all the cases. After the diagnosis was made by computed tomography, surgery was performed with an epigastric midline incision. The postoperative hospital stay ranged from 35 to 45 days. Comparison of these four cases with the three cases operated via a left thoracotomy approach revealed that the operation time was shorter in the laparotomy group than in the thoracotomy group. Laparotomy affords a relatively poor visual field, making surgical manipulation on the oral side of the midthoracic esophagus more difficult; however, when using a laparotomy approach, one-lung ventilation is unnecessary, and patients can undergo enterostomy, perforation coverage, and bilateral thoracic lavage in the same surgical field, while being maintained in the supine position. Laparotomy is a useful technique for spontaneous esophageal rupture in terms of both anesthesia management and surgical manipulation.

A 69-year-old man who had undergone distal gastrectomy for duodenal ulcer 40 years ago presented to the hospital with the chief complaints of sudden epigastric pain and frequent vomiting. Abdominal and pelvic contrast-enhanced computed tomography revealed invagination of the small intestine into the gastric remnant near the gastric remnant–jejunal anastomosis site, with a typical target sign. The patient was diagnosed as having intussusception of the small intestine into the gastric remnant near the anastomosis site. Emergency surgery was performed. The Billroth Ⅱ method was used for post-gastrectomy reconstruction, and the efferent loop showed retrograde invagination into the gastric remnant. As no intestinal necrosis was observed, only manual reduction was performed. Four months later, the patient returned to the hospital with a recurrence of the symptoms, and abdominal CT revealed recurrence of the intussusception. The anastomosis was separated again via open surgery, and a different procedure, the Roux-en-Y method, was used for the reconstruction. No recurrence was observed 3 years postoperatively. Cases of intussusception at the anastomosis site after gastrectomy are rare. We report a case in which a change in the reconstruction procedure was needed because of the recurrence of intussusception soon after open reduction.

Parastomal hernia (PH) is a known complication after radical cystectomy and urinary diversion with an ileal conduit (IC). However, IC rupture due to PH incarceration has never previously been reported. Herein, we report surgical correction of a PH with simultaneous successful conservative management of a concealed IC perforation. A 56-year-old man presented with the chief complaint of overt hematuria and generalized abdominal pain. Emergent surgery was performed based on the diagnosis of an incarcerated PH. While the incarcerated intestine was viable, indigo carmine dye was detected in the abdominal cavity after instillation via a Foley catheter placed in the IC. The operation had to be completed with primary repair and drainage tube (DT) placement to avoid further damage. Decreased urine output and increased discharge from the DT were observed postoperatively. Computed tomography revealed contrast leakage, indicative of an IC perforation. Thus, a Nelaton catheter was placed in the IC for decompression. Consequently, the urine output returned to normal, and the discharge from the DT immediately decreased. On the 7th postoperative day, the DT was removed, and the patient was discharged.

A 59-year-old male patient was admitted to the emergency room with the chief complaint of left hypochondriac pain. Abdominal CT revealed an irregular mass in the spleen and fluid accumulation around the mass, on the hepatic surface, and in the pelvis, which was thought to be blood. Based on these findings, we made the diagnosis of intra-abdominal hemorrhage due to a ruptured splenic mass. A primary splenic lymphoma was suspected based on the elevated soluble IL-2 receptor level in the serum. A splenectomy was performed for diagnostic and therapeutic purposes. Intraoperative exploration revealed a tear in the splenic membrane, consistent with the diagnosis of a splenic mass, the presumptive cause of the hemorrhage. A pancreatic fistula observed postoperatively improved with conservative treatment. The patient was discharged on postoperative day 21. Histopathological examination of the resected specimen led to the diagnosis of diffuse large B-cell lymphoma (DLBCL) of splenic origin. Currently, 16 months after the operation, CMR (complete metabolic response) is maintained. Splenogenic malignant lymphoma presenting with non-traumatic splenic rupture is very rare. When a splenic tumor is recognized as the cause of non-traumatic splenic rupture, diagnostic splenectomy should be aggressively considered in anticipation of postoperative chemotherapy.

The origin of hepatic encephalopathy with disturbed consciousness includes portosystemic shunts other than metabolic disorders such as Wilson disease, urea cycle enzyme deficiency, amino acid metabolism abnormalities, and disordered liver parenchymal function. We found favorable outcomes of balloon-occluded retrograde transvenous obliteration (B-RTO) to treat a superior mesenteric vein-left renal vein shunt resulting from repeated episodes of hyperammonemia. A 68-year-old man was admitted to hospital three times with disturbed consciousness of unknown origin. Hyperammonemia and a superior mesenteric vein-renal vein shunt were finally identified, and B-RTO was performed, which resulted in decreased ammonia levels and improved consciousness. The patient has since remained free of recurrence. We consider that B-RTO is effective for treating non-cirrhotic hepatic encephalopathy associated with a portosystemic shunt.

We report the case of a patient in whom a penetrating ileal diverticulum was diagnosed preoperatively. A 77-year-old man was admitted to our hospital with a week’s history of fever, vomiting, and abdominal pain. He had right lower abdominal pain but there were no signs of peritoneal irritation. Multiplanar reconstruction (MPR) of plain CT images revealed a diverticulum in the terminal ileum, increased density of the surrounding fatty tissue, and air. Based on these findings, we made the diagnosis of penetrating ileal diverticulum into the mesentery. Although conservative treatment was selected, the abdominal pain and blood test abnormalities worsened on the third day of hospitalization, and laparoscopic ileocecal resection was performed. The resected specimen showed penetration of the diverticulum into the mesentery at 4 cm from the ileocecal valve. Since a penetrating ileal diverticulum often does not respond to conservative treatment, it is necessary to differentiate it from appendicitis or ascending colon diverticulitis. For diagnosis, MPR of CT images are very useful, as they were in our case, and surgical treatment should be aggressively considered as soon as possible after the diagnosis.

Enterovesical fistula is a known complication of Crohn’s disease involving the urinary tract, although there are still very few reports of enterourachal fistula. Herein, we report the case of a 26-year-old man who presented with a few years’ history of intermittent fever, lower abdominal pain, and fecaluria observed occasionally. He was detected as having a urachal remnant and examination of the digestive tract revealed the diagnosis of Crohn’s disease. An enterourachal fistula was suspected and he was referred to our hospital for surgical treatment. Elective surgery was performed after 3 weeks of medical treatments. En bloc resection of the ileum, urachus, and partial bladder wall was performed. The resected specimen revealed the presence of an ileo-ileal fistula and ileo-urachal fistula. In this case, there were no symptoms of urachal remnant until the patient reached adulthood, and it is considered that the symptoms became apparent with the formation of a fistula after the onset of Crohn’s disease. The enterourachal fistula was diagnosed preoperatively and the surgery was safely performed after preoperative medical treatment of inflammation.

An 86-year-old woman was transferred to our emergency room due to frequent vomiting. CT demonstrated herniation of the gastric antrum into the lower mediastinum through the esophageal hiatus, and we made the diagnosis of esophageal hiatal hernia with an upside-down stomach. We performed laparoscopic surgery and dissected the adhesions between the gastric serosa and hernia sac, and repositioned the stomach. The hiatal hernia defect was repaired by mesh placement after the primary crural closure. Fundoplication was then performed by the Nissen method. The postoperative course was uneventful. The patient was discharged 11 days after surgery and has since remained free of symptoms.

We managed two cases of intestinal obstruction caused by small intestinal incarceration into the preperitoneal space from the peritoneal closure gap after transabdominal preperitoneal repair (TAPP). The patients were an 86-year-old man and a 79-year-old man. Emergency surgery was performed on the 18th and 2nd postoperative day, respectively, after the diagnosis of intestinal obstruction. Both patients presented with intestinal obstruction due to small intestinal herniation into the preperitoneal space through a gap in the peritoneal closure. In the former case, the small intestine was found to be strongly adherent to the abdominal wall and mesh in the preperitoneal space, and the patient required small bowel resection. In the latter case, only re-suturing of the peritoneal space was required. A tight peritoneal closure in TAPP is critical to prevent bowel incarceration into the peritoneal defect formed in line with the first suture after the operation. Furthermore, in a suspected case of bowel obstruction after TAPP, immediate diagnosis and treatment are essential.

A 70-year-old female patient who underwent subtotal stomach-preserving pancreaticoduodenectomy after neoadjuvant chemotherapy. A few days after the surgery, she showed evidence of delayed gastric emptying, and was started on enteral nutrition. She developed high fever on postoperative day 20, and went into shock the following day. She was transferred to the intensive care unit, but developed cardiac arrest. After she was resuscitated, examinations revealed a low ejection fraction, hypoxia, and low blood pressure. Therefore, we decided to start her on extracorporeal membrane oxygenation (ECMO). Her cardiac function gradually improved, her general condition became stable on day 12 after initiation of ECMO, and she was weaned from the ECMO. We suspected that she had developed sepsis-induced cardiomyopathy (SICM) due to infection by Serratia marcescens transmitted through enteral nutrition. While the usefulness of ECMO in sepsis patients remains controversial, some reports have suggested that it is possibly effective in patients with SICM. We suggest use of ECMO for these patients while attention is paid to treatment of the causative infection.

The patient was a 68-year-old male. In April 20XX, he inserted a vibrator through the anus for masturbation, but could not remove it, and visited our department. Computed tomography (CT) revealed a vibrator measuring 4 × 18 cm in diameter and height, respectively. In the emergency outpatient unit, manual removal was attempted, but failed. Although various types of forceps were tried, grasping of the object proved difficult. As the general condition of the patient was stable, emergency removal in the lithotomy position under general anesthesia was attempted the following day. In the operating room, manual removal was attempted by elevating the lower limbs into a high lithotomy position, flexing the hip, and compressing the abdomen in preparation for endoscopy and intraoperative fluoroscopy, but again failed. In addition, grasping with forceps was attempted under endoscopic guidance, but the cylindrical shape of the object still made grasping difficult, and removal was impossible. Finally, a doctor from another department with a small hand was requested to perform manual removal under fluoroscopic guidance and a surgeon’s instructions, which proved successful. There were no complications after the surgery, and the patient was discharged on the 3rd postoperative day. As rectal foreign bodies are sometimes difficult to remove based on our experience, we report this patient, with a review of the literature.

A 72-year-old woman presented to us with the chief complaints of sudden right hypochondrial pain and breathlessness. Abdominal computed tomography revealed herniation of the transverse colon, small intestine and greater omentum into the right thoracic cavity, and we diagnosed the patient as having hernia of Morgagni based on the position of the hernial orifice. We elected to perform laparoscopic surgical repair, and during the laparoscopic surgery, the hernial orifice was found on the right side and behind the sternum, confirming our preoperative finding. Even though all of the transverse colon, small intestine and greater omentum had invaginated into the hernial orifice, which was 7×5 cm in diameter, we were able to easily reduce them into the abdominal cavity. We sutured the hernial orifice and covered it with Symbotex^TM Composite Mesh. The patient was discharged seven days after the surgery, and has had no relapse until now, 2 years since the operation. Hernia of Morgagni is relatively rare, and no standard surgical treatment method has been established. Laparoscopic surgical repair using a mesh may be an easy and minimally invasive treatment method for hernia of Morgagni.