Diverticular perforation of the small intestine, while relatively rare, can be life-threatening and should be kept in mind in the differential diagnosis of acute abdomen. We have encountered seven cases of perforated small intestinal diverticulum at our hospital until date, and reviewed their clinicopathological characteristics. The patients included 3 men and 4 women, with an average age of 73.7 years. All the patients presented with the complaint of abdominal pain, but the pain tended to be milder in patients who visited the hospital more than a week after the symptom onset. There were no cases with shock vitals before surgery. The diagnosis of perforation of the small intestine was made preoperatively in 4 cases, even though the exact site of perforation could not be identified on the images. Intraoperatively, 5 patients had perforation of a jejunal diverticulum, located in each case within 110 cm of the Treitz ligament, and 2 patients had diverticular perforation in the terminal ileum. All patients underwent partial resection of the perforated intestinal segment, and none showed any perioperative complications. From our experience, perforated small intestinal diverticula appear to be less deadly than they used to be, presumably because of recent improvements in diagnostic imaging techniques and in perioperative systemic management.

A 63-year-old female patient with cancer of the sigmoid colon was referred to our department for surgery. The cancer had invaded the bladder and the left ovary, but there was no distant metastasis. Therefore, we performed resection of the sigmoid colon, a part of the bladder, and the left ovary. Postoperative histopathological examination revealed poorly differentiated and moderately differentiated tubular adenocarcinoma invading the bladder and left ovary, but the surgical margins were negative. Lymph node metastasis was observed, so that we classified the cancer as Stage IIIc and started the patient on adjuvant chemotherapy with CAPOX. Follow-up CT after completion of 8 courses of chemotherapy revealed no evidence of recurrence, although PET-CT showed extensive uptake in the spine and iliac bones. Blood tests revealed Disseminated Intravascular Coagulation Syndrome (DIC), based on which we diagnosed the patient as having disseminated bone marrow carcinomatosis and hospitalized the patient. The DIC progressed rapidly, resulting in subarachnoid hemorrhage and subdural hematoma, making further chemotherapy unfeasible. Thereafter, the condition progressed to brain herniation and the patient died. Reports have shown that prompt initiation of chemotherapy can lead to rapid resolution of DIC and extend patient survival. Therefore, in patients with suspected disseminated bone marrow carcinomatosis, early introduction of chemotherapy as an oncologic emergency is necessary.

A 53-year-old woman presented to us with a history of palpitations and exertional dyspnea. A clinical workup revealed severe anemia (Hb 5.2 g/dL) and a small-intestinal tumor with ulceration measuring 6 cm in diameter on contrast-enhanced CT. Although no active bleeding was observed, the anemia was thought to be caused by bleeding, with the tumor considered as the likely source of bleeding. We performed partial resection of the small intestine after transfusion of 4 units of packed red cells. The resected specimen showed an ulcer on the surface of the intestinal tumor, which was considered as the source of bleeding. Histopathological examination confirmed the tumor as a desmoid tumor. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 7. She showed no recurrence of the anemia or desmoid tumor until follow-up at the end of one year. While desmoid tumors are often associated with abdominal bloating or pain, cases of severe anemia caused by tumor bleeding are rare. Despite the fibrous nature of desmoid tumors, surgery was warranted in this case because of gastrointestinal bleeding.

The patient was a 60-year-old woman who visited her local doctor with the complaints of diarrhea and vomiting, and was referred to our department with suspected rhabdomyolysis and multiple organ dysfunction. We diagnosed her as having septic shock, multiple organ dysfunction, and disseminated intravascular coagulation (DIC) due to acute cholecystitis and performed percutaneous transhepatic gallbladder drainage (PTGBD). Bile culture showed growth of Edwardsiella tarda and Klebsiella pneumoniae. Blood purification therapy (continuous hemodiafiltration and endotoxin adsorption) was performed, during which the patient was diagnosed as having bleeding from the sigmoid colon and deep venous thrombosis, which necessitated the Hartmann’s procedure and initiation of anticoagulant therapy with direct oral anticoagulants (DOACs). After laparoscopic cholecystectomy and colostomy closure on day 59 of hospitalization, the patient made good progress and was discharged ambulatory on day 84 of hospitalization. Both of the causative organisms in this case are known to be associated with a high fatality rate due to complications such as multiple organ dysfunction, DIC, and venous embolism secondary to intra-abdominal infection and sepsis. The pathology of this case, which involved sigmoid colon bleeding and massive deep venous thrombosis, and the therapeutic strategy adopted to enable complete social reintegration of the patient are reported, together with a discussion of the literature.

A 71-year-old man underwent transabdominal preperitoneal repair (TAPP) for right inguinal hernia. On postoperative day 1, he vomited after a meal. Abdominal CT showed paralytic ileus without obvious obstruction. Conservative treatment with an ileus tube failed to afford relief, and on postoperative day 14, an ileus tube-assisted small bowel series showed small bowel obstruction and caliber change near the site of the peritoneal closure in the right inguinal region. Therefore, we performed emergency laparoscopic surgery for suspected small bowel obstruction. The small intestine was found to have herniated through the peritoneal defect and was partially adherent to the mesh. We repositioned the small intestine and resutured the peritoneal defect. We did not think the mesh needed to be removed, because there were no ischemic changes in the incarcerated intestine. Intestinal obstruction related to the peritoneal defect in the suture line is a rare complication after TAPP. Precise peritoneal closure at surgery is necessary, and if the intestinal obstruction occurs in the early operative period after TAPP, early diagnosis and surgical intervention are important.

A 77-year-old woman visited the emergency room with the complaints of fever and white vaginal discharge. Computed tomographic examination revealed uterine pyometra, and we treated her by uterine drainage and administration of antimicrobial agents. Two months later, she visited the emergency room again with a history of generalized malaise and fever. Abdominal CT showed a liver abscess and a sigmoid-uterine fistula. We considered that the uterine pyometra and liver abscess were caused by the sigmoid-uterine fistula. After drainage of the liver abscess, we performed a laparoscopic colostomy to control the local inflammation. After three months, we performed a radical operation. As the sigmoid colon was found to be adherent to the uterus, we performed sigmoid colon resection, total hysterectomy, and bilateral adnexectomy. Histopathological examination revealed that the fistula was caused by penetration of a sigmoid colon diverticulum. We report this case of a sigmoid-uterine fistula, with a review of the literature.

Internal hernia of the broad uterine ligament is a relatively rare disease, in which the intestinal tract herniates through a defect in the broad ligament of the uterus. We encountered such a case and performed laparoscopic surgery. The patient was a 41-year-old woman who was transported to our hospital with severe lower abdominal pain and vomiting. Abdominal computed tomography showed dilated segments of the intestine to the left side of the uterus, suggesting that it was not closed bowel obstruction. As the patient complained of persistent, though mild, abdominal pain, we performed laparoscopy, which revealed a defect on the left side of the broad uterine ligament and partially inflamed intestinal loops (reducible hernia). The transiently incarcerated intestine appeared viable, so that we only reduced the hernia and sutured the hernial orifice. Thus, although we made the diagnosis intraoperatively, detection of the characteristic uterine shift due to the entrapped intestine could lead to a preoperative diagnosis and would be helpful for successful management by laparoscopic surgery.

A 77-year-old man presented to our emergency department with persistent abdominal pain after having being accidentally struck in the abdomen (was kneed by his 5-year-old granddaughter) while sitting on a sofa at home. Initial contrast-enhanced CT imaging showed no evident free intraperitoneal gas, but a small amount of ascites in the pelvic, and the patient was admitted for observation. A follow-up CT scan the following morning demonstrated the presence of free intraperitoneal gas and an increase in the ascites, and we performed emergency surgery. Intraoperative exploration through a laparotomy revealed a 5-mm perforation in the small intestine, approximately 150 cm from the ligament of Treitz, which we closed by suturing. Additionally, a left inguinal hernia (classified as type M2 by the Japanese Hernia Society) was also identified. A review of the initial CT images revealed a small amount of free gas within the hernia sac. Bowel perforation within a hernia sac due to a sudden increase of the intra-abdominal pressure is a rare occurrence. A possible association with a pre-existing left inguinal hernia was suggested in this case. We report this case, along with a literature review on traumatic bowel perforation associated with inguinal hernias.

The patient, a 79-year-old woman, presented to our hospital with a two-week history of persistent abdominal pain. An abdominal CT scan revealed a linear hyperabsorptive zone in the small intestine in the right lower abdomen and free gas in the abdominal cavity. We diagnosed the patient as having gastrointestinal perforation caused by a fishbone, and prepared for emergency surgery. Intraoperative exploration revealed strong adhesions between segments of the intestine due to peritoneal dialysis, making it difficult to identify the foreign body and perforation site. Therefore, we utilized intraoperative ultrasonography to confirm the presence of the foreign body in the intestinal tract. The adhesions of the intestinal tract where the foreign body was present were carefully dissected. The foreign body was then extracted by perforating the intestinal tract in a manner that allowed the foreign body to be pushed out of the lumen. The perforation was closed with an absorbable suture and the operation was completed. The patient had a satisfactory postoperative course and was discharged from the hospital on the 15th postoperative day. Intraoperative ultrasonography holds promise for actively identifying foreign bodies in the gastrointestinal tract while reducing the operating time and improving surgical outcomes.

The patient was a man in his 40s who visited our hospital complaining of abdominal pain after a left flank injury. Abdominal contrast CT revealed second-degree splenic injury and bloody ascites, and we diagnosed the patient as having traumatic splenic injury. The patient was hemodynamically stable and we admitted him for conservative treatment. However, the day after admission, the anemia progressed and bloody ascites increased, and we performed transcatheter arterial embolization (TAE) of the splenic artery. Six days after the TAE, the patient developed abdominal pain and increased inflammatory response marker levels. Abdominal contrast-enhanced CT revealed a splenic abscess, and we performed percutaneous drainage using a 12Fr aspiration kit. The condition improved thereafter, the catheter was removed after 8 days, and the patient was discharged. However, the splenic abscess recurred, and he was readmitted to the hospital. We performed drainage again, but as there was little improvement, we performed a splenectomy. The condition improved and he was discharged on the 12th postoperative day. After splenic artery embolization, it is important to keep in mind the possibility of development of a splenic abscess and to consider surgical treatment without delay if conservative treatment does not result in significant improvement.

A 75-year-old man presented to us with the chief complaint of back pain while receiving multidisciplinary treatment (including pulmonary resection, cancer immunotherapy, and chemotherapy) for postoperative pulmonary metastases and lymph node recurrence that developed following esophagectomy with gastric tube reconstruction via the posterior mediastinal route performed 4 years ago for thoracic esophageal cancer. CT examination showed thickening of the ascending aortic wall. He was admitted to the hospital with suspected ascending aortitis and initiated on antibiotic treatment. However, there was no improvement, and a repeat CT revealed the presence of free gas within the pericardium, which led to the suspicion of a fistula between the gastric tube and the pericardium. We performed emergency surgery for the gastric tube ulcer penetrating the pericardium, with ligament teres hepatis and omental patch closure undertaken via an abdominal-transhiatal approach, followed by pericardial drainage via a median sternotomy. The patient died on postoperative day 48 due to liver failure. However, despite the severity of his condition, he was able to resume oral intake by postoperative day 21. Surgical pericardial drainage is critical in such cases, and a direct approach to the perforation site should be adopted to enable suture closure and filling whenever feasible.

The patient was a 68-year-old woman who was undergoing chemotherapy for ovarian cancer following tumor debulking surgery, including from the bilateral diaphragmatic regions. She presented to our emergency department complaining of abdominal pain, chest pain, and breathlessness. CT examination confirmed gastric perforation and acute pleuroperitonitis due to left diaphragmatic hernia incarceration, and we undertook emergency surgical intervention. A 2-cm perforation was identified in the anterior wall of the upper gastric body, along with a 4-cm hernial defect in the left diaphragm. We performed local gastric resection, abdominal and pleural lavage and drainage, and diaphragmatic hernia repair. The patient was immunocompromised and had DIC with septic shock, but recovered well, was extubated on postoperative day 6, and was discharged home on postoperative day 24. We hypothesized that the diaphragmatic hernia in this case was because of the use of absorbable sutures for the primary repair or thermal injury of the diaphragm. The possibility of diaphragmatic hernia should be kept in mind during surgery involving the diaphragm and its surrounding area. If chemotherapy for malignant disease is planned for such patients, in view of the elevated risk of severe diaphragmatic hernia, repair or reinforcement with non-absorbable sutures should be undertaken during the surgery.

A 19-year-old man was transferred to our hospital complaining of abdominal pain after he fell from motorcycle he was riding and hit a guardrail. Physical examination revealed rebound tenderness in the lower abdomen, but abdominal computed tomography failed to reveal any intraperitoneal free air. We performed surgery under the diagnosis of traumatic injury of abdominal organ. Laparoscopic exploration revealed a perforation in the jejunum and injury to the serosa of the cecum. We repaired the perforation of the small intestine and serosa of the cecum under laparoscopic guidance. The patient recovered satisfactorily and was discharged 16 days after the operation.

A 79-year-old woman was admitted to our hospital after having accidentally swallowed a hooked denture. She had a history of Alzheimer’s disease and Parkinson’s disease. She was referred to our hospital as an attempt at endoscopic removal of the denture at another hospital had proved difficult and the denture had become lodged in the middle thoracic esophagus. X-rays taken at the referring hospital showed that the foreign bodies were in the stomach and duodenum, but CT performed at our hospital confirmed two foreign bodies in the middle thoracic esophagus and small intestine. In addition, mediastinal emphysema was observed, so that esophageal perforation was suspected. We diagnosed the patient as having esophageal perforation and small intestinal foreign body (swallowed denture). Thoraco-laparotomy was performed for removal of the foreign bodies. Lavage and drainage were also performed. The patient developed anastomotic leakage and aspiration pneumonia after surgery, but eventually recovered before being transferred to another hospital for rehabilitation on the 55th postoperative day. Endoscopic treatment is often the treatment strategy of first choice for esophageal foreign bodies. However, due to its shape, a hooked denture may prove difficult to remove endoscopically and may cause esophageal perforation. We report a case of esophageal perforation caused by endoscopic manipulation of a swallowed denture, with a review of the literature.