The general condition of patients with left colonic perforation often deteriorates even after successful surgical drainage; therefore, initial treatment by anesthesiologists, especially circulatory support with catecholamines, is of great importance to prevent septic shock. This retrospective study was aimed at identifying preoperative predictors of intraoperative catecholamine requirement in patients during emergent Hartmann’s procedure for left colonic perforation. The catecholamine use group consisted of 15 patients who received continuous catecholamine infusion intraoperatively, while the non-catecholamine use group comprised 17 patients in whom the blood pressure was maintained only by infusions and transfusions, without intraoperative catecholamine administration. There were significant differences in the ASA physical status, preoperative white blood cell count, and serum lactate levels immediately after anesthesia induction between the two groups and these three factors were entered as covariates into a logistic regression analysis model. Only serum lactate was identified as an independent predictor of intraoperative catecholamine support, and we obtained the cutoff value for serum lactate using receiver operating characteristic curve analysis (sensitivity 0.824, specificity 0.867, cutoff value 1.3 mmol/L). The cutoff value of 1.3 mmol/L appears to be a suitable marker for anesthesiologists to start preemptive circulatory management to prevent septic shock.

The Department of Medical Oncology at Kyorin University Hospital provides cancer chemotherapy to approximately 500 patients annually, mainly patients with gastrointestinal cancers. During the 10-year period from January 2011 to September 2021, a total of 3,238 patients received chemotherapy for cancer, and about a half of these (1,527) patients were hospitalized in an emergency while receiving the treatment. Patients with gastrointestinal problems accounted for 1,294 (85％) of these patients, including 968 patients with disease exacerbations, and 326 patients with treatment-related problems. Patients without non-gastrointestinal problems accounted for 233 (15％) patients, and management of these patients required the cooperation of 22 departments of our hospital. Patients admitted for treatment-related emergencies were 3 years younger than those admitted for disease exacerbations. Although the number of patients receiving cancer chemotherapy has been increasing over the past 10 years, the proportion of emergency admissions among patients receiving cancer chemotherapy has, in fact, been gradually decreasing (e.g., from 80％ in 2011 to 20％ in 2021). Both appropriate usage of cancer chemotherapy and improved collaborations between hospitals and medical establishments outside the hospital could be presumed to have contributed to the gradual decrease of emergency admissions over the years among patients receiving chemotherapy for cancer.

Gastrointestinal adverse events are relatively frequently encountered during cancer chemotherapy. It is particularly important to distinguish them from cancer-associated symptoms in patients with gastrointestinal cancers. In this report, we discuss our treatment approach in 10 patients who presented to our hospital with gastrointestinal adverse events that developed while they were receiving chemotherapy, and required urgent or semi-urgent treatments, including surgery; all of these patients presented after the onset of the COVID-19 pandemic and we analyzed the impact of the pandemic on the management of these patients in our practice. The adverse events were bowel obstruction in three patients, colitis/diarrhea in four patients, infection in two patients, and bleeding in one patient. Chemotherapy-related adverse events could not be ruled out in five cases, and chemotherapy could be resumed after recovery in all the patients. The adverse events were diagnosed as being cancer-related in the remaining five patients, and surgery was performed in two patients. Screening for COVID-19 infection prior to emergency examination and treatment for the underlying disease is essential to prevent the spread of COVID-19, so that more effort and time are required in the outpatient service than prior to the pandemic. Therefore, modified methods for outpatient care need to be devised for early initiation of treatment for serious adverse events.

INTRODUCTION: Gastrointestinal perforation caused by angiogenesis inhibitors administered as chemotherapy for metastatic colorectal cancer (mCRC) is a potentially fatal adverse event. OBJECTIVE: To determine the frequency of and most appropriate treatment for gastrointestinal perforation developing during chemotherapy for mCRC. METHODS: We retrospectively investigated the incidence of gastrointestinal perforation (CTCAE v3.0 Grade 3 or higher) developing in patients who received chemotherapy for mCRC at our center between January 2020 and February 2022. RESULTS: A total of 55 patients were included in the study. The median age was 63.5 (36-89) years, and the male/female ratio was 31/24; the PS at the start of chemotherapy was 0/1/2 in 44/9/2 cases. There were 2 (3.6％) cases of Grade 3 or higher gastrointestinal perforation. One of the patients was managed conservatively with antimicrobial agents, while the other was treated by surgery with omental plugging and drainage. Both patients had received treatment with angiogenesis inhibitors. There were no cases of treatment-related death. CONCLUSION: We report two cases of chemotherapy-induced gastrointestinal perforation: one of the patients was successfully managed conservatively, while the other required surgery.

The incidence of primary gastrointestinal lymphoma is high, and the most common histological type is diffuse large B-cell lymphoma (DLBCL). This disease progresses rapidly, and serious gastrointestinal complications, such as perforation and/or bleeding can develop at disease onset or during chemotherapy in patients with gastrointestinal involvement. Herein, focusing on cases of primary gastrointestinal DLBCL, we reviewed the data of patients at our hospital, along with a review of the relevant literature. Our findings revealed that among patients with DLBCL, the outcomes of patients with primary gastrointestinal DLBCL were relatively good. As compared with cases of primary gastric lesions, those with primary lesions in the intestine, especially the small intestine, are at a higher risk for perforation. Even though resection is not recommended for primary gastric tumors, resection should be considered in cases with primary intestinal lesions for the purposes of definitive diagnosis and reducing the risk of perforation. We believe that the intensity of the initial chemotherapy should be carefully considered for each individual patient depending on the site and depth of invasion of the lymphoma.

Introduction: Bevacizumab (BV) is known to be associated with specific adverse effects, such as gastrointestinal perforation. The postoperative complication rate in these patients treated by surgery was high. Material and Methods: Between April 2009 and December 2022, we encountered 23 patients who developed acute abdomen during BV administration. The clinical characteristics and outcomes of surgical/conservative treatment are presented. Results: The most common cause of acute abdomen in the patients was gastrointestinal perforation (n＝13, 57％). Emergency surgery was performed in 12 patients (52％). All patients with gastrointestinal perforation underwent drainage only or colostomy. Postoperative complications (Clavien-Dindo classification ≥ grade Ⅱ) were observed in 7 patients (54％). Three of the 4 patients with gastrointestinal perforation who were treated conservatively died within 50 days of the onset, while all the 9 patients who were treated by surgery were discharged from the hospital, with a median survival duration of 202 days (70-2,353 days). Conclusion: Acute abdomen during BV administration is frequently caused by gastrointestinal perforation, and postoperative complications were observed in a high percentage of patients who underwent surgery for treatment. In cases of gastrointestinal perforation, the condition may be expected to improve with surgery in patients who can tolerate surgery.

The patient was a 77-year-old woman who was diagnosed as having a laterally spreading tumor in the sigmoid colon, and treated by endoscopic submucosal dissection (ESD). Two days after the ESD, the patient developed abdominal pain, and as a contrast-enhanced CT revealed ascites, she was referred to our department. We made the diagnosis of perforation of the sigmoid colon and acute diffuse peritonitis, and performed emergency surgery. We performed laparoscopic Hartmann’s procedure, because the patient also had severe coronary artery disease. She was discharged with ADL at the preoperative level, without complications.

The patient was a man in his 30s who visited a neighborhood hospital complaining of epigastralgia and was referred to our department. Abdominal ultrasonography (US) revealed an enlarged gallbladder (GB). Computed tomography (CT)/magnetic resonance cholangiopancreatography (MRCP) revealed that the fundus of the GB was located in the left hepatic lobe, and that the fatty tissue density around the GB was increased. The right portal vein branches diverged from the umbilical portion, and we made the diagnosis of acute cholecystitis with the right umbilical portion. Laparoscopic cholecystectomy (LC) was successfully performed by inserting the epigastric port into the left side of the round ligament and performing fundic dissection of the GB. Even in a case of acute cholecystitis with the right umbilical portion, it is important to determine the location of the biliary tree and biliary tract on preoperative imaging, although it may prove difficult in cases with severe inflammation, and a bailout surgery policy should be kept in mind.

Perforated Meckel’s diverticulum accompanied by a true enterolith is extremely rare. Few studies have reported its preoperative diagnosis and laparoscopic treatment. Herein, we report the case of a male patient in his 30s who was diagnosed as having a perforated Meckel’s diverticulum, with a brief review of the literature. The patient presented with a history of fever and lower abdominal pain. Seven years prior, he had been examined for gastrointestinal bleeding, but the cause could not be determined. Blood test results indicated increased levels of inflammatory response markers. Abdominal computed tomography revealed ileal edema and a small intestinal blind-ended luminal structure. A highly absorptive area in the lumen that appeared to be an enterolith was also observed. The patient was diagnosed as having perforated Meckel’s diverticulum and underwent laparoscopic-assisted small bowel resection. Intraoperative findings showed the Meckel’s diverticulum, with edematous ileal loops in the pelvis. The diverticulum was perforated, and the enterolith had slipped out; subsequently, extracorporeal resection of the ileum was performed. Histopathological examination revealed ectopic gastric mucosa in the diverticulum, and biochemical analysis of the enterolith revealed a bile acid stone. The patient’s postoperative course was uneventful. This case highlights that surgery should be considered in the presence of an enterolith in a Meckel’s diverticulum, even if the patient is asymptomatic.

An 87-year-old woman with a history of pericholecystic abscess who was being treated conservatively with percutaneous gallbladder drainage presented to the emergency department complaining of abdominal pain. Contrast-enhanced computed tomography revealed gallstone migration into the duodenal bulb, and emergent gastrointestinal endoscopy confirmed a large gallstone occupying the duodenal bulb lumen. Endoscopic lithotripsy was performed with forceps, since the gallstone was soft. However, when the descending duodenum was examined following the lithotripsy to confirm its condition, the lumen was found to be severely stenosed; therefore, lithotripsy alone proved insufficient to allow passage of food. Surgery was considered difficult due to the poor general condition of the patient, and endoscopic balloon dilatation of the duodenum was performed. After confirming duodenal dilatation, the patient was able to resume oral intake and no recurrence of the gastrointestinal symptoms has been observed to date. This treatment strategy could be considered as being an effective option for patients with Bouveret’s syndrome who are at a high surgical risk.

An 88-year-old woman was brought to the orthopedic department of our hospital with a right femoral neck fracture. During open reduction and internal fixation, a Kirschner wire penetrated the femur and hipbone and strayed about 20 cm into the abdominal cavity. Since the vital signs of the patient were stable, a CT was carefully performed to assess any injuries to the intra-abdominal organs and great vessels. The CT findings led to the suspicion of damage to the right external iliac vein. On laparotomy, the wire was found to have penetrated the right external iliac vein and small mesentery, although there was no intra-abdominal bleeding. Blood flow of the right external iliac vein was blocked on both sides of the injured area with bulldog forceps, and the injured area was sutured. The postoperative course was uneventful, and the patient was discharged from our hospital about a month later. While in this case, there were fortunately no life-threatening complications or injuries to the intra-abdominal organs, it is necessary to take instant decisions on the appropriate treatment in such cases, depending on the patient’s condition, decide whether to administer the various treatments.

A 54-year-old man presented to our hospital after he had inserted a cylindrical container into his anus and wasn’t able to remove it. Extraction by hand was unsuccessful at the bedside. Therefore, we performed laparotomy under general anesthesia. We noted that the small intestine was incarcerated due to intussusception into the rectum through the foreign body. As the small bowel appeared viable after reduction from the rectum, we did not perform ileal resection. In addition, an incision was made in the anterior rectal wall and the foreign body was removed. The foreign body was a cylindrical plastic bottle that measured 10 centimeters in diameter, with the bottom cut off. Since the bottom of the bottle was used as the leading part and inserted into the anus, the rectal intussusception was occurred. We encountered a rare case of intussusception of the intestine through a rectal foreign body. In cases of foreign bodies within the bowel, it is important to select the treatment taking into consideration the risk of incarceration.

A 19-year-old man was referred to our hospital with a day’s history of right flank pain and vomiting. Abdominal contrast-enhanced computed tomography revealed an encapsulated omentum with localized enhancement of the adipose tissue, raising the suspicion of omental infarction. We performed laparoscopic surgery for diagnostic and therapeutic purposes. A conglomerated nodular mass was found contiguous with the greater omentum, and we performed omental resection. Histopathological examination revealed that the lesion was composed of adipose tissue showing signs of degeneration, with bleeding and partial necrotic changes, consistent with the diagnosis of omental infarction. The postoperative clinical course was favorable, and the patient was discharged from the hospital on the second postoperative day. Omental infarction is a rare condition, but it should be considered in the differential diagnosis of acute abdomen with right flank pain. Although conservative treatment may be effective in some cases, laparoscopic surgery may enable both early diagnosis and treatment.

We report a case of laparoscopic cholecystectomy for cholelithiasis with a low junction between the cystic duct and common bile duct in the pancreas. A 75-year-old woman presented to our hospital with a history of epigastric pain. She was diagnosed as having cholecystitis and cholangitis, and a bile duct stent was placed. After the stent placement, the patient was referred to our department. A series of examinations revealed that the cystic duct merged with the common bile duct in the pancreas and there were stones in the cystic duct. We used intraoperative cholangiography to prevent biliary injury, and performed laparoscopic cholecystectomy without complications. The stones in the cystic duct were extracted endoscopically, and then the bile duct stent was removed. There have been many reports of this syndrome, and it is important to prevent biliary injury during the operation. In this case, we performed operation successfully using intraoperative cholangiography to determine the needed extent of resection of the cystic duct.

A woman in her 40s who had been receiving chemotherapy for cervical cancer underwent potentially curative surgery. However, a bicornuate aperture stoma was constructed because of a rapid increase in the size of the tumor. The patient developed mucosal edema of the stoma with venous return disorder 2 days later, and we enlarged the fascial hole and reconstructed a stoma at the same site. The patient’s intestinal edema improved and she was initiated on chemoradiotherapy; however, progressively worsening mucosal edema developed on day 25 after artificial anal re-construction. Manual reduction was difficult due to the pain, and palliative care was initiated for pain relief. In joint consultation with the Department of Surgery, we planned to improve the patient’s mucosal edema by reducing the osmotic pressure, together with analgesia and muscle relaxation. We administered epidural analgesia with 5 mL of 2％ lidocaine injected via a peridural catheter, and sprayed 10 g of glucose on the edematous intestinal mucosa. With this treatment, the intestinal edema improved and the anal protuberance could be reduced manually.

A 48-year-old man who had been diagnosed as having intestinal obstruction caused by a cholecystoduodenal fistula and common bile duct stone was referred to our hospital. We performed laparotomy with subtotal cholecystectomy and distal gastrectomy. On the 3rd postoperative day, the patient developed vomiting, and an abdominal CT showed significant dilatation of the duodenum and common bile duct. Ascites was also observed. We performed emergent surgery for bile leakage. Intraoperatively, the gastrojejunal anastomosis and the Braun anastomosis were found to be twisted by approximately 90 degrees. The Braun anastomosis was resected, and Roux-en-Y reconstruction was performed. Transient bowel paralysis was observed postoperatively, but the postoperative course was otherwise satisfactory. We believe that the patient developed the rare sequela of biliary leakage from the gallbladder stump. It is possible that the bile leakage was caused by bile duct reflux due to endoscopic sphincterotomy (EST) and intestinal obstruction.

We report a rare case of hemorrhagic shock with intraperitoneal hemorrhage due to a ruptured superficial blood vessel on the surface of a uterine leiomyoma. A 40-year-old female patient was transported to our hospital complaining of lower abdominal pain, which worsened on the day after menstruation. Her vital signs were unstable, with a blood pressure of 75/50 mm Hg and heart rate of 110 bpm. After her hemodynamic status improved with rapid fluid infusion, we performed computed tomographic (CT) examination. Abdominal contrast-enhanced CT showed intra-abdominal bleeding and a large tumor in the uterus. Laparotomy was performed since the patient was diagnosed as being in hemorrhagic shock at the time of transportation. Intraoperative findings revealed bloody ascites and bleeding from a blood vessel on the surface of the uterine leiomyoma. Uterine myomectomy was performed, and the postoperative course was good. The patient was discharged on the 8th postoperative day. While intraperitoneal bleeding due to uterine leiomyoma is rare, it can have serious consequences, and the condition should be considered in the differential diagnosis of disease for intra-abdominal bleeding in woman.

A man in his 90s with neck pain and difficulty in moving was transported to the hospital by ambulance, and was diagnosed as having crowned dens syndrome. Although abdominal CT revealed intra-abdominal free air, in the absence of signs of peritonitis, he was diagnosed as having spontaneous pneumoperitoneum and treated conservatively. Upper gastrointestinal endoscopy on day 7 revealed no visible cause, and colonoscopy was not performed as consent could not be obtained. Seven months after discharge, the patient was transported to the hospital with abdominal pain. Abdominal CT revealed an enlarged sigmoid colon, pneumatosis, free air, and ascites. Although imaging suggested sigmoid volvulus, surgery was performed because colonic perforation or necrosis could not be ruled out. Surgery revealed no colonic perforation or necrosis, sigmoid volvulus was repositioned, and the sigmoid colon was removed to prevent recurrence. To diagnose spontaneous pneumoperitoneum without sufficient search for a cause of intra-abdominal free air may lead to the need for emergency treatment in the future.