[Objective] This study was aimed at reviewing the indications for surgery in patients with mesenteric injury (MI) caused by blunt trauma, including those with concomitant intestinal injury, at our hospital. [Methods] For this retrospective study, we reviewed the medical records of patients with blunt trauma who had been found to have intramesenteric extravasation, intraperitoneal fluid collection, or increased mesenteric density on abdominal contrast-enhanced CT, suggestive of MI, at hospital arrival during the 15-year period from 2006. [Results] A total of 45 patients were identified. The acute care surgery group comprised 24 patients, including 13 patients who underwent combined surgery for mesenteric and intestinal injuries and 11 patients who underwent surgery for MI alone. The early conservative treatment group comprised 21 patients, including four patients who developed delayed intestinal injury. The percentage of patients with ≥ 2 CT findings suggestive of MI was significantly higher in those who underwent surgery for MI alone than in those who recovered with conservative treatment (P ＜ 0.01). [Conclusion] The presence of ≥ 2 CT findings upon hospital arrival was possibly a significant factor for determining the surgical indication for MI. Concomitant intestinal injury was observed in 54.2% of patients in the acute care surgery group.

Background: Balloon enteroscopy-assisted endoscopic retrograde cholangiography (BE-ERC) is a newly developed cholangitis treatment technique for patients with surgically altered anatomy (SAA). This study was conducted to evaluate the efficacy of endoscopic treatment for acute cholangitis in patients with SAA. Methods: This single-center，retrospective study was conducted between April 2018 and April 2021. Results: The subjects of the study were 69 cases (male: 51 cases) of cholangitis. The mean age was 74.7 years. The reconstruction method was gastrectomy in 19 cases, pancreatoduodenectomy in 38 cases, hepaticojejunostomy in 10 cases, and gastrojejunal bypass in 2 cases (including Roux-en-Y reconstruction in 25 cases). The severity of cholangitis defined by Tokyo Guideline 2018 criteria was mild/moderate/severe in 32/31/6 cases. The etiology of cholangitis was bile stone/malignant stricture/stent occlusion/others in 33/20/5/13/5 cases. The procedure success rate of the first treatment, mainly BE-ERC, was 77% (53 cases). The failure cases were treated by repeat BE-ERC (n＝5) or EUS-guided biliary drainage (n＝5). Of the 69 cases, 63 (91%) were treated by endoscopic drainage; the remaining 6 cases were treated by percutaneous transhepatic biliary drainage (n＝5) or conservatively, with antibiotics (n＝1). Two patients (2.9%) died in the hospital. Two patients developed complications (perforation in 1 case and bleeding in 1 case). A review of the literature revealed success of BE-ERC in 480/585 cases (80.1%) of acute cholangitis cases with SAA and development of adverse events in 115 cases (4.2%). Conclusion: BE-ERC is useful for treating acute cholangitis in patients with SAA.

The standard treatment for patients with acute cholecystitis is cholecystectomy, as established by the 2018 Tokyo Guidelines. PTGBD (percutaneous transhepatic gallbladder drainage) and endoscopic drainage methods are recommended in patients at high risk for surgery. A retrospective review of cholecystitis treatment at our hospital revealed that ETGBD (endoscopic transpapillary gallbladder drainage) was the most commonly performed procedure. Herein, we shall discuss tips for the ETGBD procedure. An important step to complete ETGBD is to seek the cystic duct and guide the device. The following are examples of difficulties that could be encountered: 1) the cystic duct branches caudally; 2) the CBD is dilated; 3) the cystic duct does not fill with contrast; 4) the cystic duct is stenotic. The following are some ways to address the above, respectively: 1) hook and find a pigtail ENBD (endoscopic nasobiliary drainage); 2) narrow the diameter of the CBD by aspirating bile; 3) apply positional changes; and 4) form a loop at the tip of the GW.

In the Clinical Practice Guidelines for the management of acute pancreatitis: JPN GL 2021, early endoscopic retrograde cholangiopancreatography (ERCP)/endoscopoic sphincterotomy (EST) is recommended for gallstone pancreatitis, but there is an ongoing debate about the validity of performing stent placement alone without EST for such cases. In this study, we compared cases that had received plastic stent placement alone and those that had received EST ＋ plastic stent placement for gallstone pancreatitis; the two groups comprised 19 cases each. We compared the time needed for the patients to resume normal oral intake, as the endpoint, between the two groups. In the group that received only plastic stent placement, the median age was 72 years, as compared with the median age of 64 years in the EST ＋ stent placement group, there was a higher proportion of patients with comorbidities, and a higher proportion of patients receiving antithrombotic therapy (10 cases vs. 1 case). In regard to the time to resumption of normal oral intake, there was no significant difference between the group that received stent placement alone and the group that received EST ＋ stent placement (4 days in the former group and 7 days in the latter). Therefore, we consider that plastic stent placement alone may be a valid treatment in situations where EST cannot be safely performed.

We conducted a retrospective analysis of 87 patients with walled-off necrosis (WON) treated using a step-up approach at ABC Hospital between 2005 and 2019. The overall clinical success rate was 86.2%. However, logistic regression analysis revealed that a high Charlson Comorbidity Index (CCI) and extension of WON into the pelvic cavity were significant independent risk factors for endoscopic treatment failure and percutaneous drainage failure. Additionally, a high CCI was identified as a significant independent risk factor for mortality. Successful step-up approach for WON requires multidisciplinary teamwork, and patients with multiple comorbidities have a high mortality risk. Therefore, support from regional partnerships to enable transfer of patients to appropriate medical facilities as necessary is crucial.

In this study, we attempted to evaluate the differences in the outcomes of management of biliary emergencies in patients with surgically altered anatomy. The subjects of the study were 55 cases of biliary emergencies managed between 2021 and 2022. The evaluated parameters included the endoscopic reach rate, bile duct cannulation rate, procedure completion rate, and complications. The median age of the patients was 74 years. The reconstruction techniques included SSPPD (30 cases), B-II (9 cases), R-Y (9 cases), and hepaticojejunostomy (9 cases). The outcomes of balloon enteroscopy-assisted ERCP (BE-ERCP) were as follows: endoscopic reach rate, 89.5%; biliary cannulation rate, 98%; and procedure completion rate, 90%. Complications included perforation (2 cases), intestinal mucosal tear (3 cases), cholecystitis (1 case), cholangitis (1 case), pancreatitis (1 case), liver abscess (1 case), and esophageal variceal rupture (1 case). Secondary treatments included repeat BE-ERCP (2 cases), interventional (IV)-EUS (3 cases), percutaneous transhepatic biliary drainage (PTBD) (4 cases), and conservative treatment (2 cases). Combining BE-ERCP, IV-EUS, and PTBD may potentially achieve a higher completion rate of conservative management.

The patient was a 70-year-old male in whom a chest x-ray and CT performed during a routine medical checkup revealed a mass in the upper lobe of the right lung. He visited our emergency department with a history of having noticed black stools five days previously and experiencing periumbilical pain from the day before. Abdominal CT revealed evidence of intestinal obstruction. The patient was hospitalized, but he failed to improve with conservative treatment. Therefore, we performed laparoscopic-assisted surgery on hospital day 13. In addition to the tumor that was believed to be the main cause of the intestinal obstruction, multiple tumors were found throughout the small intestine. One of these tumors caused invagination, and we performed partial resection of the main lesion and the tumor causing the intussusception. After surgery, the anemia caused by bleeding from the remaining intestinal tumors and newly found tumors in the duodenum progressed rapidly and the patient died on hospital day 26. The resected tumors were histopathologically diagnosed as metastatic lesions from a pulmonary pleomorphic carcinoma. Small bowel metastases from a pulmonary pleomorphic carcinoma are relatively rare and carry an extremely poor prognosis. In some cases, such as our case reported herein, the cancer progresses rapidly and we believe it is important not to miss the appropriate time for initiation of chemotherapy.

We describe the case of a 62-year-old woman who presented with a history of multiple episodes of bloody stools over the previous 5 years. Upper and lower gastrointestinal endoscopy had failed to identify the bleeding source. She was admitted to a local hospital after abdominal computed tomography showed a small intestinal tumor as the possible source of bleeding. On the night of admission, as her hemodynamic status deteriorated, she was transferred to our hospital for further management. Emergency laparotomy revealed a 7-cm mass on the contralateral aspect of the mesentery of the jejunum, and we performed partial resection of the small intestine. Postoperative histopathological examination revealed the diagnosis of gastrointestinal stromal tumor (GIST). In this case, although the source of bleeding was a small-sized intestinal tumor, the patient developed hemorrhagic shock while waiting for surgery. Prompt resection is the most appropriate treatment when a small intestinal tumor (GIST in this case) is identified as the source of intestinal bleeding.

A 47-year-old woman was referred to us for evaluation of abdominal pain. Physical examination showed a palpable non-tender right lower abdominal mass (approximately 3 cm in diameter), accompanied by localized tenderness in the right pelvic cavity. Abdominal computed tomography (CT) revealed a Riedel’s lobe extending to the right lower abdomen and an edematous appendix anterior to the right pelvic cavity. We diagnosed the patient as having acute appendicitis and performed laparoscopic appendectomy, paying close attention to avoiding injury to the Riedel’s lobe. Following an uneventful procedure, the patient was discharged on the fifth postoperative day without complications. Riedel’s lobe, a congenital hepatic anomaly, refers to a tongue-like projection extending from the right lobe of the liver to below the umbilicus. It may be palpable as a right lower abdominal mass, potentially interfering with the diagnostic process during medical examination. Extreme caution is warranted during surgical procedures in the presence of anatomical variations, owing to the risk of inadvertent organ injury. Based on CT-documented data at our hospital, Riedel’s lobe was identified in 40/410 patients (9.8%), which highlights the relatively frequent occurrence of this abnormality. Clinicians should be mindful of this anomaly in patients presenting with right lower abdominal conditions, including appendicitis.

An 87-year-old man was brought to our hospital by ambulance after sustaining injury in a motorcycle accident. There were no significant physical findings other than a laceration in the right forearm, which was sutured before the subject was sent home. After returning to his home, the man developed abdominal pain and vomiting, and was brought back to our hospital 8 hours after the injury. Abdominal CT revealed free air in the abdomen and we decided to do an emergency operation. We performed open surgery and found a 1-cm perforation in the cecum. As the inflammation around the perforation was mild, we performed a simple suture closure of the perforation. The patient was discharged home on postoperative day 15 and continues to recover without complications. In regard to colorectal injury, the transverse colon and sigmoid colon are considered to be the most common sites of injury, and only a few cases of cecal injury have been reported. Although cecal perforation caused by blunt trauma is rare, we believe that trauma physicians should bear the possibility of such injuries in mind.

We report a case of intragastric emphysema caused by placement of a nasogastric tube that developed into portal venous gas. A 72-year-old man was transferred for rehabilitation following treatment for a left cerebral infarction. The patient was being fed through a nasogastric tube. On the 6th day after transfer, he developed hematochezia and hypotension. Abdominal CT revealed gastric wall emphysema and extensive portal venous gas. Since there were no signs of intestinal perforation, necrosis, or ischemia, we diagnosed the patient as having intragastric emphysema and treated the patient conservatively. After six days, a repeat CT showed resolution of both the intragastric emphysema and portal venous gas. Gastrointestinal endoscopy revealed no active ulcers or mucosal defects. Gastric intramural emphysema can be caused by a variety of factors, including placement of nasogastric tubes, prolonged bed rest, and tracheal intubation, and its symptoms are diverse, including abdominal pain, vomiting, and hematochezia. While intragastric emphysema can be relieved with conservative treatment, surgery may be required for emphysematous gastritis, and careful follow-up and preparation for surgery are important.

Although sepsis occasionally develops as a complication of perforating appendicitis, it is rare in cases of non-perforating appendicitis. In this report, we detail our experience in managing a case of septic shock complicating non-perforating acute appendicitis. The patient was a 51-year-old male who presented to our hospital with abdominal pain and was diagnosed as having phlegmonous appendicitis based on the findings of abdominal CT. We performed laparoscopic appendectomy on the same day. The appendix was dark brown in color and enlarged, but there was no perforation. After emerging from anesthesia, the patient developed shock and findings suggestive of disseminated intravascular coagulation. He was diagnosed as having septic shock caused by the appendicitis, and placed under intensive care. He improved steadily and was discharged on postoperative day 9. A blood culture later grew Enterobacter aerogenes. Postoperative histopathology confirmed the diagnosis of phlegmonous appendicitis. It is important to note that sepsis can occasionally occur even in patients with non-perforating appendicitis without necrosis.

A 66-year-old Japanese woman presented to our hospital complaining of abdominal pain and nausea. Abdominal computed tomography revealed bowel obstruction due to jejunal intussusception. Presence of an irregular tumor was suspected at the leading end of the intussusception. Due to the diagnosis of left renal cancer made 7 years previously, jejunal metastasis from renal cancer was suspected, and partial jejunal resection was performed as palliative treatment. The postoperative course was uneventful, and the patient was discharged 16 days postoperatively; however, as she refused chemotherapy, she died 1 year postoperatively. Small-intestinal metastasis from renal cancer is rare, but important in the field of emergency abdominal care, as it may cause melena and bowel obstruction. Herein, we report the patient’s clinical course and preoperative imaging findings.

An 80-year-old female patient was admitted to our hospital with abdominal pain. Conservative treatment with ileus tube placement for adhesive intestinal obstruction following appendectomy for appendicitis was unsuccessful. We then performed laparoscopic surgery. Intraoperatively, an abnormal defect was found in the broad ligament of the uterus, causing incarceration and partial perforation of the small intestine, and we made the diagnosis of an internal hernia through a defect in the broad ligament of the uterus. We closed the defect in the broad ligament and resected the affected segment of the small intestine. Several cases of internal hernia through a defect in the broad ligament, a rare form of internal hernia, have been reported recently and laparoscopic surgery on these cases has been performed increasingly. Due to its rarity, it is often difficult to precisely diagnose the cause of intestinal obstruction in these cases, which often results in a delay in surgical intervention and consequently, a higher rate of resection of intestine. Some specific CT findings of this disease are useful to guide preoperative diagnosis. We have reported a case of successful laparoscopic surgery for internal hernia through a defect in the broad ligament, with a review of the literature.

A man in his 60s who underwent laparoscopic total gastrectomy and Roux-en-Y reconstruction for gastric cancer six years previously visited our hospital with the complaints of left lower quadrant pain and vomiting. The target sign was identified in the lower left abdomen on abdominal ultrasonography and CT. We diagnosed intussusception at the Y-leg anastomosis and performed emergency surgery. The jejunum, extending from the ligament of Treitz to the Y limb, exhibited a reddish-brown color and dilatation. The blind end of the Y limb was adherent to the elevated jejunum, forming the advancing segment, causing obstruction. We reduced the intussusception using the Hutchinson technique. We assumed that the extended blind end of the Y limb was the cause of the obstruction, and excised the blind end and buried the stump. The patient complained of vomiting after meals; an oral small bowel contrast study conducted to identify the cause revealed no recurrence of the intestinal obstruction or passage impairment. The patient was discharged on the 21st postoperative day. We deemed it desirable not to elongate the blind end during the Roux-en-Y reconstruction and opted to bury the stump.

A 55-year-old man presented to our hospital with abdominal pain. He was diagnosed as being in shock upon arrival at the hospital. Abdominal CT and angiography revealed a mesenteric hematoma formed from the ruptured middle colic artery aneurysm. We performed IVR as the patient was in hemorrhagic shock. However, during the IVR, his blood pressure decreased at an alarming rate. Consequently, as we decided to perform direct surgical ligation of the ruptured aneurysm, we performed REBOA (resuscitative endovascular balloon occlusion of the aorta) and clumped the ascending aorta partially before the surgery. This enabled us to control the bleeding before and during surgery. REBOA has been used as a hemostatic device for traumatic hemorrhage in emergency situations, but is also a useful tool for non-traumatic hemorrhage. In this report, we present a case of intraperitoneal bleeding in which we successfully used REBOA to control the bleeding before and during surgery, along with a review of the relevant literature.