Postesophagectomy hiatal hernia (PDH) is infrequent, but one of the potentially fatal complications after esophagectomy. We encountered a case of symptomatic PDH that was triggered by endoscopic submucosal dissection (ESD). An 81-year-old female patient with a history of having undergone esophagectomy with gastric tube reconstruction via the posterior mediastinal route was treated by ESD for cervical esophageal cancer. A day after the surgery, the patient developed severe epigastric pain, nausea and vomiting. Thoracoabdominal CT showed herniation of the small bowel through the esophageal hiatus into the mediastinum. We diagnosed the patient as having incarcerated hiatal hernia, and performed emergency surgery. Intraoperative exploration revealed the small bowel prolapsing into the left mediastinum through the esophageal hiatus, which had become widened after the previous surgery. We pulled the herniated bowel into the abdominal cavity and resected a 90-cm necrotic segment of the small bowel. The widened esophageal hiatus was covered with a patch from the greater omentum to prevent recurrence. At one and a half year after the surgery, the patient remains healthy without recurrence. Symptomatic PDH can be triggered by the elevated intraabdominal pressure during ESD. For patients with symptomatic PDH, covering the esophageal hiatus with the greater omentum is useful when it is difficult to perform suture cruroplasty.

A 38-year-old woman with a history of dysmenorrhea visited our emergency room with intermittent abdominal pain in the right lower abdomen. She was diagnosed as having intussusception of the ileum by simple contrast-enhanced CT of the abdomen. Although endoscopic repair was attempted, it proved to be inadequate, and a semi-urgent laparotomy was performed for the intussusception. Intraoperatively, while the intussusception had been reduced, the normal appendix could not be identified, and a mass was found in the cecum. Since multiple enlarged lymph nodes were found along the ileocolic artery, we performed an ileocecal resection (D3 dissection) considering the possibility of malignancy. Postoperative histopathological examination revealed appendiceal endometriosis. An inflammatory mass formed by the appendiceal endometriosis was at the advancing end of the intussusception. Intussusception caused by appendiceal endometriosis is extremely rare, and is difficult to diagnose either preoperatively or intraoperatively. Although endometriosis is a benign disease, lymph node dissection should be performed if the possibility of cancer cannot be ruled out.

The patient was an 85-year-old woman in whom a plain abdominal X-ray revealed a linear foreign body in the pelvis, and CT showed a high-absorptive foreign body measuring 6 cm in length stuck within a diverticulum of the sigmoid colon. The patient was referred to our internal medicine department because it was determined that removal of the hairpin by colonoscopy was necessary due to the risk of intestinal perforation due to the foreign body being stuck in the gastrointestinal tract for a long time. Colonoscopy revealed a hairpin with both ends stuck within the wall of a diverticulum of the sigmoid colon, making it poorly mobile. As the risk of intestinal perforation during removal was high and endoscopic removal was deemed difficult, we performed laparoscopic and endoscopic cooperative surgery. The hairpin was safely removed by the colonoscopy without damage to the bowel. We report this case, as so far, there have been no case reports of a hairpin becoming stuck in a diverticulum of the sigmoid colon; the hairpin in our case could be safely removed by laparoscopic and endoscopic cooperative surgery adding a literature consideration.

A 57-year-old woman was admitted to our hospital complaining of pain around the navel and anorexia. She gave a history of liquid discharge from the umbilicus for over a decade. Physical examination showed peri-umbilical erosion and discharge of fecal matter through the umbilicus. Urinalysis showed feces in the cloudy urine. Abdominal CT showed low-density lesions extending from the umbilicus to the transverse colon and dome of the bladder. Fistulography via the umbilicus showed inflow of the contrast medium into the transverse colon and urinary bladder. Based on the findings, we made the clinical diagnosis of urachal infection with transverse-colon fistula. Ileostomy and open abdominal drainage were performed, which led to improvement of the umbilical condition. Three years later, however, the patient presented with recurrence of the liquid discharge from the umbilicus. Abdominal CT and fistulography via the umbilicus showed recurrence of the colo-umbilical fistula. Right hemicolectomy and fistula resection were performed. Finally, stoma closure was performed. At 3 years after the stoma closure, the patient was doing well without recurrence of the symptoms.

The patient was an 88-year-old woman who presented with fever, vomiting and abdominal pain. Whole-body CT revealed bilateral pneumonia and small bowel dilatation, but no findings suggestive of neoplastic lesions. We started the patient on antibiotic therapy for treating the pneumonia and inserted an ileus tube for relief of the intestinal obstruction. While the pneumonia responded well to the treatment with antibiotics, the intestinal obstruction failed to be relieved by the conservative treatment, and surgery was needed. Exploratory laparotomy revealed small bowel dilatation, evidence of ischemia of the ileum due to strangulation by a band between the appendix and the retroperitoneum, and a cystic lesion of the appendix. Repositioning, appendectomy, and partial ileostomy were performed. The appendiceal cyst was 1.8 cm in diameter and the histopathological diagnosis was low-grade appendiceal mucinous neoplasm. We report this case, as there are only few case reports of small bowel obstruction caused by an appendiceal neoplasm.

Case 1: Woman in her 40s. She was admitted our hospital with the chief complaints of left lower quadrant pain and vomiting. She had no previous history of abdominal surgery. Contrast-enhanced abdominal CT showed small bowel dilatation and formation of a closed loop in the pelvis. We made the diagnosis of strangulated small bowel obstruction and performed emergency laparoscopic surgery. At surgery, the small intestine was found to have herniated through a defect in the sigmoid mesentery. Case 2: Man in his 50s. He was admitted our hospital with the chief complaint of abdominal pain. Contrast-enhanced abdominal CT showed small bowel dilatation and formation of a closed loop near the sigmoid colon. The patient had no previous history of abdominal surgery. Laparoscopic surgery was performed on the seventh day of admission. Intraoperatively, a pocket was found to have formed in the sigmoid colon mesentery, and a segment of the ileum was found to be entrapped in it. Intersigmoid hernia is an internal hernia, and preoperative diagnosis is difficult. In our cases, contrast-enhanced CT showed a short closed loop on the left side of the pelvis, which could be preoperatively diagnosed as an intersigmoid hernia.

A 71-year-old male patient was admitted to our hospital with a history of abdominal pain of sudden onset. CT revealed obstruction of the superior mesenteric vein by a thrombus and necrosis of the small intestine. We performed emergency surgery, resected a 100-cm necrotic segment of the small intestine, and performed end-to-end anastomosis. We started the patient on intravenous heparin a day after the surgery. On postoperative day 6, the heparin was replaced by oral edoxaban, and on postoperative day 11, the patient was discharged. Because the patient had no identifiable cause of secondary superior mesenteric vein thrombosis, we made the diagnosis of primary superior mesenteric thrombosis. CT performed six months postoperatively revealed complete resolution of the superior mesenteric vein thrombosis. Two years postoperatively, the patient continues to take edoxaban and has had no recurrence of the superior mesenteric vein thrombosis.

The patient was a woman in her 20s who was undergoing treatment for schizophrenia and had a history of repeated self-harm during the treatment. She was admitted to our hospital with the chief complaint of persistent upper abdominal pain. A plain abdominal X-ray revealed the presence of 10 wire-like foreign bodies that appeared to be needles. Abdominal computed tomography further suggested that some of these needles may have punctured the liver and colon. We performed emergency laparoscopic surgery and identified 7 needles that were covered by the omentum in the peritoneal cavity. While some of the needles had either punctured the liver or were in contact with the colon, we determined that there was no need for hemostasis or repair of the colon. The needles found in the peritoneal cavity were carefully removed laparoscopically under X-ray fluoroscopic guidance. The extracted needles included 3 straightened-out paper clips and 7 sewing needles. We demonstrated that combined use of laparoscopy and X-ray fluoroscopy was effective in removing a relatively large number of foreign bodies (10 needles) in a safe and minimally invasive manner. Our findings also suggest that elective surgery may be considered if the needles were self-embedded through the skin, since the risk of organ damage in such cases is minimal.

A 58-year-old man visited our hospital because of abdominal pain. Abdominal computed tomography showed an approximately 5-cm tumor near the ileocecal region with intestinal obstruction. Therefore, ileocecal resection was performed. Gross examination of the surgical specimen revealed no evidence of a mucosal tumor; however, microscopic examination revealed a moderately differentiated adenocarcinoma in the colonic wall, involving a diverticulum, which was considered as the site of origin of the cancer. The patient died 1 year later of liver and lung metastases. Colorectal cancer arising in a diverticulum is rare. Our review of 32 reported cases of such cancers revealed that they are rarely diagnosed preoperatively. Over half of these patients present with acute abdominal symptoms, such as abdominal pain and melena, and almost all are treated surgically. Many of the tumors are single, located in the left colon, originate from pseudodiverticula, and are surrounded by an inflammatory reaction. Despite frequently being small at presentation, the tumors are characteristically advanced by the time of diagnosis.

A 64-year-old man was urgently transferred to a previous hospital with hematemesis and dyspnoea in March 2022. CT examination showed a left pneumothorax and mediastinal emphysema, suggesting oesophageal perforation. After the patient was transported to our hospital, we performed upper gastrointestinal endoscopy, which showed no evidence of oesophageal perforation, but revealed a duodenal ulcer and pyloric stenosis, with difficulty in negotiating the scope beyond the obstruction. The patient was treated conservatively, but on the fourth day following admission, he developed hematemesis and hemorrhagic shock, and we performed emergency surgery for hemorrhage from the duodenal ulcer. The intraoperative findings suggested that partial resection and suture hemostasis would be difficult, so that we performed pancreaticoduodenectomy (PD). The patient was discharged on postoperative day 24. Histopathological examination of the resected specimen revealed a deep duodenal ulcer, the possible source of the hemorrhage. Gastric cancer was also found in the pyloric region, with duodenal invasion, which could also cause pyloric stenosis. Endoscopic hemostasis is the treatment of first choice for upper gastrointestinal bleeding, but in cases with scar stenosis or surrounding fibrosis due to ulceration or malignant disease, it is difficult to perform endoscopic hemostasis or limited operation, and an extended procedure, such as pancreatoduodenectomy, may be necessary.

We report a case of bleeding duodenal ulcer with a duodenal-common bile duct fistula. The patient was a 61-year-old man who was transported to our hospital because of disturbance of consciousness. We diagnosed the patient as having hemorrhagic shock due to upper gastrointestinal hemorrhage, and performed emergency endoscopy. However, due to the difficulty in endoscopic hemostasis, emergency surgery was necessitated. Intraoperatively, active bleeding from the posterior wall of the duodenal bulb and a duodenal-common bile duct fistula were observed. After direct suture hemostasis was performed, it became difficult to control bleeding in the entire surgical field, and damage control surgery was performed with gauze packing. The patient’s general condition stabilized thereafter in the ICU. We performed Dubois antroduodenectomy and inserted a T-tube into the common bile duct, and the patient’s postoperative course was good. There is no standard treatment for bleeding duodenal ulcers with duodenal-common bile duct fistulas. This two-stage surgery is minimally invasive, can avoid serious postoperative complications, and may be a rational treatment option.

An 81-year-old woman presented to a nearby hospital with a 2-week history of appetite loss. She had been taking steroid treatment for 15 years, from the age of 66 years, for organizing pneumonia. Plain abdominal X-ray suggested intra-abdominal pneumatosis, but since the abdominal findings were very unclear, the patient was kept under observation. Five days later, she visited our hospital with the same complaints, and a screening esophagogastroduodenoscopy was performed, which revealed no significant endoscopic findings. She returned to the hospital on the following day with fever. Abdominal enhanced CT revealed pneumatosis cystoides intestinalis (PCI) with extensive retroperitoneal emphysema. Physical examination revealed no signs of peritoneal irritation. The enhanced CT also showed no evidence of intestinal necrosis. We selected nonsurgical treatment with close follow-up, antibiotic treatment, and abstention from oral intake, while being prepared for emergency surgery. Sequential CT showed progressive shrinkage of the emphysema lesions, with complete disappearance of the PCI on the 20th day; the patient was discharged on the 27th day. We report a rare case of successful nonsurgical treatment of PCI with retroperitoneal emphysema that developed during steroid therapy.

An 80-year-old man who was receiving outpatient gemcitabine-cisplatin therapy for cancer recurrence following surgery for carcinoma of the intrahepatic bile duct was hospitalized for cellulitis that occurred at the site of a right tibial fracture that he had suffered from a fall at home. During hospitalization, the patient developed abdominal pain and diarrhea of sudden onset and went into a shock state; he was admitted into the intensive care unit. Abdominal computed tomography revealed marked submucosal edema from the rectum to the sigmoid colon, which led us to diagnose severe infectious enteritis. A stool smear examination subsequently revealed the diagnosis of strongyloidiasis. Klebsiella and Escherichia coli (extended spectrum beta-lactamase: ESBL) were also detected by blood culture, based on which we made the diagnosis of disseminated strongyloidiasis. Deworming was performed promptly following the diagnosis, and the patient was saved. Severe disseminated strongyloidiasis can occur in cancer patients who are immunosuppressed during chemotherapy. Therefore, screening tests for Strongyloides should be performed prior to chemotherapy to understand the infection status, and preventive therapies should also be considered. The specific CT findings in this case may be helpful for early diagnosis and are reported here.

The patient was a 77-year-old man who presented with the chief complaint of swelling of the left inguinal region. There was no pain, and the bulge/swelling disappeared when the patient lay in the supine position. Abdominal CT showed inguinal herniation of the greater omentum and we made the diagnosis of left internal inguinal hernia. The patient was treated by TAPP. On postoperative day 2, he developed abdominal distension and nausea, and was diagnosed as having bowel obstruction. There was little improvement with the placement of an ileus tube, and although CT revealed no evidence of blood flow obstruction, we suspected bowel incarceration. On postoperative day 7, the patient underwent bowel obstruction release surgery. The cause of the bowel obstruction was found to be prolapse of the small bowel into the anterior bladder cavity from the peritoneal closure of the TAPP surgery. There was no evidence of blood flow obstruction to the intestine, and we judged that there was no need for intestinal resection, and closed the peritoneum after reduction of the prolapse. After reoperation, the patient had a good course and was discharged on the 15th postoperative day. The number of TAPP surgeries has been increasing in recent years, and there have been reports of complications that have not been reported with conventional methods. We encountered a case of intestinal obstruction occurring early after TAPP surgery, and report it with some discussion of the literature.

A 75-year-old male patient arrived at our hospital complaining of abdominal pain of sudden onset. He had undergone transurethral resection of a bladder cancer 6 months earlier and received intravesical BCG therapy to prevent recurrence 5 days before the onset of the symptom. Abdominal contrast-enhanced computed tomography revealed intraperitoneal free air, and we performed emergency surgery under the suspicion of gastrointestinal perforation. Laparoscopic exploration of the abdominal cavity revealed no obvious site of gastrointestinal perforation. However, at laparotomy, a reddish perforated site measuring approximately 20 mm in size was found in the urinary bladder. We diagnosed the patient as having bladder rupture and treated him by lavage drainage and repair of the perforation by simple suture closure of the perforation. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. We encountered a case of bladder rupture with intra-abdominal free gas following intravesical BCG therapy, and describe the case herein, with a review of the literature.

We report a case of fistula-associated mucinous adenocarcinoma in a patient who presented with a perianal abscess and bowel obstruction, which was treated by curative resection after neoadjuvant chemoradiotherapy (NACRT). The patient was a 61-year-old male with paraplegia and defecation disorder that had developed as a result of a spinal cord injury sustained in a car accident 36 years earlier. He developed cerebral infarction 2 years ago, at which time he was also diagnosed as having an anal fistula. One month prior to his current admission, he was rushed to his previous doctor with a history of vomiting and diarrhea. Abdominal CT showed an abscess involving the perianal region and rectum, as well as bowel obstruction due to inflammation. Examination of a specimen obtained from the abscess wall revealed evidence of mucinous adenocarcinoma, and we made the diagnosis of fistula-associated adenocarcinoma. We elected to administer NACRT, as curative resection was found to be not feasible at the time of diagnosis. After 10 weeks of NACRT, total pelvic exenteration was performed. Histopathology of the resected specimen showed tumor invasion of the cauda equina, but the resection margins were negative. NACRT was considered effective for curative resection of the fistula-associated anal adenocarcinoma with perianal abscess, through causing tumor volume reduction and reducing the inflammation.

A 66-year-old man visited our Emergency Room with complaints of swelling and pain in his right inguinal region. He was diagnosed as having an incarcerated right inguinal hernia, which could not be reduced by manual maneuvers. Abdominal computed tomography revealed the contents of the incarcerated as including an enlarged inflamed appendix. Since no evidence of necrosis or perforation of the appendix was observed, the patient was hospitalized and administered antibiotic therapy, with a plan for elective laparoscopic appendectomy and two-stage hernia repair. Because the incarcerated appendix could not be reduced even after subsidence of the inflammation, we performed surgery on the 3rd hospital day. Intra-abdominal observation revealed a recurrent right inguinal hernia. Because appendiceal herniation could not be reduced, we performed appendectomy by dissecting the inguinal region and opening the hernia sac, followed by one-stage Bassini repair. Inguinal hernia associated with incarceration of the appendix is called Amyand’s hernia. Laparoscopic two-stage surgery consisting of appendectomy followed by hernia repair using the mesh technique would be the ideal treatment strategy from the viewpoints of infection control and preventing recurrence of hernia. However, when laparoscopic repositioning of the appendix proves impossible, one-stage appendectomy and open hernia repair should be chosen. Surgeons should be prepared to select the most suitable from among several procedures to treat Amyand’s hernia.