Bailout surgery (BOS) has been recommended for difficult cases to ensure safe cholecystectomy. However, the usefulness of BOS for intraoperative hemorrhage and bile duct injury (BDI) in patients with acute cholecystitis (AC) is unknown. The purpose of this study was to evaluate the efficacy of BOS in patients with AC and the usefulness of Lap-BOS as compared with open conversion. Of 256 patients, 237 who underwent early surgery for AC (as defined by the Tokyo Guideline 2018) between April 2015 and March 2023 followed by laparoscopic surgery were divided into two groups: the laparoscopic total cholecystectomy group (Lap-C group) and the BOS group, and the background characteristics and perioperative variables between the two groups were compared: severe inflammatory findings, including predominantly inflammatory around the gallbladder, were more common in the BOS group, with longer operation time and greater blood loss also observed in this group; however, there was no significant difference in the incidence of BDI or postoperative bile leakage between the two groups. Next, comparison of the laparoscopic BOS group (Lap-BOS) with the open conversion group revealed a shorter operative time, lower blood loss and shorter postoperative hospital stay in the Lap-BOS group as compared with the open group. BOS is useful in difficult cases of AC to avoid BDI, and even the Lap-BOS group showed acceptable postoperative results.

Introduction: Early cholecystectomy is recommended for acute cholecystitis, but standby cholecystectomy is often required. In this study, we investigated the influence of and appropriate preoperative treatment for laparoscopic cholecystectomy (LC). Methods: We retrospectively evaluated the data of 76 patients who underwent standby LC for acute cholecystitis between June 2014 and June 2023 at our hospital. Patients were classified by preoperative treatment into antimicrobial, antimicrobial ＋ percutaneous transhepatic gallbladder drainage (PTGBD), and antimicrobial ＋ percutaneous transhepatic gallbladder aspiration (PTGBA) groups, and the preoperative outcomes, surgical difficulty, and surgical outcomes were compared among the three groups. We also compared the period from treatment to normalization of the leukocyte count and serum CRP levels among patients with mild and moderate/severe disease. Results: In patients with mild disease, the period duration to normalization of the leukocyte count/serum CRP was 3/7 days in the antimicrobial group, 4.5/10.5 days in the PTGBD group, and 3.5/8.5 days in the PTGBA group, with no significant differences among the groups. However, in patients with moderate/severe disease, the period to normalization of the leukocyte count/serum CRP was significantly longer in the antimicrobial group: 8/16 days in the PTGBD group, 4/11 days in the PTGBD group, and 4.5/11 days in the PTGBA group. Conclusion: When preoperative treatment for acute cholecystitis is undertaken assuming standby LC, early biliary drainage should be considered in patients with moderate/severe disease.

Purpose: We investigated the treatment outcomes in patients with obstructive colorectal cancer. Methods: We identified 462 patients with colorectal cancer pStage Ⅱ/Ⅲ at our hospital between January 2007 and December 2018; the patients were divided into two groups; the obstructive colorectal cancer (OCC) group (n＝91) and the non-obstructive colorectal cancer (NOCC) group (n＝371). The background characteristics and treatment outcomes of the two groups were compared retrospectively, and the prognostic factors in patients with OCC were explored. Results: The body mass index and serum albumin level were significantly lower, and the serum CEA level was significantly higher in the OCC group. The OCC group also showed significantly higher frequencies of pT4 and pN2/3 disease. There was no significant difference in the pStage Ⅱ/Ⅲ classification rate between the two groups. There were also no significant differences in the operation frequency of postoperative complications between the two groups. The 5-year relapse-free survival rate and overall survival rate were significantly lower in the OCC group. A multivariate analysis identified Alb ＜4.0 g/dL as an independent poor prognostic factor in patients with OCC. Conclusions: The OCC group had a poorer prognosis than the NOCC group. Hypoalbuminemia was an independent poor prognostic factor in patients with OCC.

The patient was a 74-year-old man who had undergone total gastrectomy for early gastric cancer with retrocolic Roux-en-Y reconstruction 9 years ago. He presented to our hospital complaining of upper abdominal pain, abdominal fullness, and fever. We made a diagnosis of acute afferent loop obstruction and performed emergency open surgery. Intraoperatively, the jejunum was found to be strangulated through the mesenteric defect of the Roux-en-Y anastomosis, and we released the ileus and closed the hernia orifice. On the sixth postoperative day, the patient developed abdominal pain and fullness, and high fever (39℃). Abdominal CT revealed a retroperitoneal abscess, and we performed emergency surgery again under the diagnosis of peritonitis. Intraoperative exploration revealed a late-onset perforation of the third portion of duodenum with intestinal necrosis involving a 4-cm segment, and we performed debridement of the necrotic area and external drainage using a T-tube because of external fistula formation. The postoperative course was satisfactory, and the patient was discharged on the 38th postoperative day. We report this case with a review of the literature, as it was a case of delayed duodenal perforation due to a rare afferent loop obstruction that was difficult to treat.

Inflammatory myofibroblastic tumor is an intermediate-grade malignancy characterized by myofibroblast proliferation and inflammatory cell infiltration, and it occasionally originates in the liver. In this case, a man in his 80s presented with fever and liver dysfunction. Abdominal CT revealed an intrahepatic mass, and liver biopsy revealed an inflammatory myofibroblastoma. The patient was transferred to another hospital for rehabilitation before surgery was scheduled. After 43 days, the patient developed jaundice, and imaging revealed enlargement of the tumor. Despite being treated in the intensive care unit for systemic inflammatory response syndrome, the patient died of acute liver failure and respiratory failure. We report an extremely rare case of a rapidly exacerbating inflammatory myofibroblastic tumor of the liver.

The patient was a woman in her 50s who was transported to our hospital because of a sliding tube having slipped into her rectum during endoscopy. Abdominal computed tomographic examination revealed the sliding tube in the sigmoid colon and extensive air densities in the retroperitoneal space. We diagnosed the patient as having developed a rectal retroperitoneal penetration caused by the sliding tube slipping into the sigmoid colon and performed emergency surgery. A balloon catheter usually used for colonic dilatation was inserted endoscopically into the sliding tube, the balloon was inflated to fix the catheter to the sliding tube, and then the tube was removed transanally along with the catheter. Thereafter, colonoscopy showed a deep injury in the upper rectum, probably caused by the retroperitoneal penetration. The injury was closed using a clip under colonoscopic guidance. We demonstrated that the sliding tube could be safely removed using a combination of endoscopy and laparoscopy.

A 53-year-old Japanese man presented to our hospital with severe left lower abdominal pain a day after barium gastrography. Abdominal computed tomography showed extraintestinal gas around the sigmoid colon and stagnated barium in the rectum. We made the diagnosis of sigmoid colon perforation and performed emergency operation. Laparotomy revealed perforation of the sigmoid colon with local peritonitis. In addition, an extremely hard, oval foreign object was palpable in the rectum. This was identified as a barium fecal stone, which caused the sigmoid colon perforation mechanically. Partial sigmoidectomy including the perforation site, extraction of the rectal fecal stone, and covering ileostomy were performed. The postoperative course was good and the patient was discharged 3 weeks after the surgery. Stoma closure was performed 2 months after the initial surgery. In Japan, colonic perforation related to barium gastrography is extremely rare, but should be borne in mind, as it is a severe complication resulting from a medical diagnostic procedure. We report the clinical course and operative findings of this case for safety management.

Case 1 was a 45-year-old woman who was transferred to the emergency room with abdominal pain and vomiting. Abdominal computed tomography (CT) revealed intestinal obstruction due to an internal hernia. Emergency laparoscopy was performed, which revealed a transomental hernia. The hernia orifice was opened laparoscopically without intestinal resection. Case 2 was a 41-year-old woman who was transferred to the emergency room with abdominal pain and diarrhea. We initially diagnosed the patient as having enteritis, but an abdominal CT on the following day revealed an internal hernia. Emergency laparotomy was performed and the transomental hernia was released without intestinal resection. Transomental hernias can cause intestinal necrosis and intestinal resection is often required if surgery is not performed early. The presence or absence of intestinal necrosis is related to the number of days after the disease onset and length of the obstructed intestinal tract. If there is no intestinal necrosis and intestinal dilatation is mild, surgery can be performed laparoscopically and early postoperative recovery can be expected. Preoperative diagnosis of transomental hernia is often difficult; therefore, if an internal hernia or strangulated ileus is diagnosed, emergency surgery, including a review laparoscopic surgery, should be considered.

A 69-year-old woman was transferred to our hospital with abdominal pain. Abdominal computed tomography (CT) revealed ascites and free air in the lower abdomen. We suspected gastrointestinal perforation and performed emergency laparotomy. The perforation was not found in the intestine, but in the fundus of the uterus. Based on the diagnosis of panperitonitis caused by perforation of a pyometra, we performed supra-vaginal hysterectomy. After discharge, the patient complained of abnormal vaginal bleeding and closer examination led to the diagnosis of cervical cancer. Perforation of a pyometra, which can be associated with gynecological malignancy, is a rare cause of acute panperitonitis. Patients diagnosed as having pyometra should be worked up to exclude the presence of gynecological malignancy.

We report an adult patient with lymphangioma of the greater omentum who was treated by laparoscopic surgery. A 23-year-old woman presented to us with a history of abdominal pain. Abdominal CT showed a polycystic lesion in the pelvis measuring 10 cm in diameter. The tumor was supplied by the left gastroepiploic artery, which led us to make the diagnosis of tumor of the greater omentum. The abdominal pain was thought to be caused by torsion of the tumor, but as strangulation and necrosis were ruled out, a laparoscopic resection was performed. The surgery was performed via three ports: one at the umbilicus and two on the right side of the abdomen. The tumor was located in the greater omentum, and the feeding vessels were rotated in multiple layers. The tumor was excised and collected in a plastic bag for specimen collection through a transverse incision in the lower abdomen. The histopathological diagnosis was lymphangioma of the greater omentum. The patient was discharged 5 days after the surgery. As of 3 years and 6 months postoperatively, there was no recurrence.

A 76-year-old man was brought to the emergency room with the chief complaints of black vomit and pericardial discomfort. Abdominal contrast-enhanced computed tomography (CT) revealed an abscess around the duodenal papillary region extending into the retroperitoneal space. An emergency upper gastrointestinal endoscopy showed a periampullary diverticulum, but no active bleeding or any clear perforation site was identified during the procedure. Since the patient’s general condition was stable, he was started on conservative treatment in the intensive care unit. Three days after admission, he developed fever and abdominal pain associated with deteriorating inflammatory response marker levels, and we discontinued conservative treatment and scheduled surgical intervention. We selected pancreatoduodenectomy as a radical treatment. Although the patient developed a pancreatic fistula postoperatively (biochemical leakage), it resolved with conservative treatment, and the patient was discharged on postoperative day 15. Spontaneous perforation of a paraduodenal diverticulum is rare, and we present a case that was successfully managed by pancreatoduodenectomy.

A 79-year-old man was transported to our hospital with severe injuries sustained in a traffic accident while riding his bicycle. Examination revealed bilateral multiple rib fractures, bilateral hemopneumothorax, bilateral lung injury, subarachnoid hemorrhage, liver injury, right kidney injury, and multiple thoracolumbar fractures, all of which improved with conservative treatment. Computed tomography revealed the incidental finding of left-sided Bochdalek hernia. It was difficult to determine whether the hernia was congenital or caused by the traumatic injuries sustained in the accident. As the hernia contained only retroperitoneal fat, we treated the patient conservatively with careful follow-up. One year later, there were no symptoms suggestive of strangulation of the hernia. Although Bochdalek hernia is observed predominantly in neonates, cases of adult onset have also been reported. Most of the reported cases in adults have been treated surgically, with very few managed conservatively over an extended period of time. Conservative management was deemed a viable option in the present patient, considering the mechanism of trauma, symptoms, and hernia contents.

ICG fluorescence angiography using a near-infrared camera (ICG-FA) for intraoperative evaluation of blood flow in patients with strangulated intestinal obstruction (SIO) is drawing attention. The patient reported herein was a 42-year-old woman with neonatal hypoxic encephalopathy and its sequelae who presented to us with a 2-day history of abdominal pain and vomiting. We diagnosed her as having SIO with extensive intestinal ischemia based on the findings of abdominal contrast-enhanced computed tomography (CT) and performed emergency surgery. Intraoperatively, extensive torsion of the small intestine caused by adhesions at the jejunal origin and mesenteric root was observed. ICG-FA evaluation showed good fluorescence of the grossly dark red segment of the small intestine (White: W, 100 cm at the mouth) and also mosaic-like irregular fluorescence (Gray: G, 150 cm at the anorectal side). The mosaic-like irregular fluorescence (G, 150 cm anorectal side) was evaluated as a different type of fluorescence. The 50-cm segment of dark brown ileum on the anorectal side was rated as B, because it altogether lacked intestinal fluorescence. The 30-cm segment of G-assessed small intestine lacked sufficient blood flow from the vasa recta. We judged that the ischemic damage of the intestine in these two latter regions could not be reversed and performed partial intestinal resection of the 80-cm segment of ischemic intestine. The remnant intestine was preserved after 47 hours of two-stage surgery, and intestinal anastomosis was performed after partial resection of the G-assessed small intestine.

The patient was an 80-year-old man taking regular oral anticoagulant medication after undergoing surgery for valvular heart disease. He presented to us complaining of abdominal pain, anorexia, and nausea. CT of the abdomen demonstrated gastric volvulus with splenic hemorrhage. His vital signs were normal and the abdominal CT revealed no obvious extravascular leakage; therefore, we treated the gastric volvulus by endoscopic repositioning. The hemorrhage was controlled and the gastric volvulus did not recur after the procedure. The gastric volvulus was considered as having been caused by a cascade stomach. Treatment by endoscopic repositioning without operation for a case of gastric volvulus with splenic hemorrhage is rare. However, as endoscopic repositioning is a minimally invasive technique, it is considered as the treatment of the first choice for gastric volvulus in high-risk patients, like in this case.

A 90-year-old woman with decreased cardiac function who had undergone Miles’ operation for rectal cancer about 20 years previously presented to us with a history of recurrent vomiting and abdominal distension. Abdominal computed tomography (CT) revealed a parastomal hernia and small-bowel obstruction without any poor contrast area. Therefore, we selected conservative management and inserted a gastric tube to reduce the pressure in the gastrointestinal tract. The parastomal hernia was no longer visualized on a CT repeated the following morning and the patient started eating and drinking toward recovery. However, she vomited again on the 7th day of hospitalization and the parastomal hernia had recurred. Therefore, we performed minimally invasive surgery for the parastomal hernia in the very elderly patient with decreased cardiac function using a composite mesh. We report the case with a review of the literature.

We report a rare case of idiopathic pneumoperitoneum that required emergency decompression of the abdominal cavity due to increased intra-abdominal pressure. A 57-year-old male patient injured in a motorcycle accident was transported to our hospital. His respiratory condition was poor, with a respiratory rate of 24/min and SpO₂ of 93% (O₂ 10 L/min.); there was subcutaneous emphysema and a flail chest on the right side. Chest CT revealed multiple fractures of the right 2nd to 7th ribs and traumatic hemopneumothorax. We performed tracheal intubation and initiated the patient on positive pressure ventilation. The day after admission, we performed thoracoplasty with rib plate fixation and pulmonary suture. CT performed on the day of the surgery showed a large amount of free air in the abdominal cavity. There were no findings suggestive of gastrointestinal perforation, but as the abdomen was tense and the intravesical pressure was high (19 mmHg), we performed emergency decompression of the abdomen. The patient was extubated on the 4th postoperative day and transferred to another hospital for rehabilitation on the 31st postoperative day. While idiopathic pneumoperitoneum resulting in increased intra-abdominal pressure has not been reported in the past, early intervention may be required to avoid abdominal compartment syndrome.