Background: Although intraoperative bile culture is frequently performed during emergency laparoscopic cholecystectomy (LC) for acute cholecystitis, its clinical significance remains unclear; this study was aimed at evaluating its clinical relevance and limitations. Methods: We retrospectively analyzed the data of 136 patients who had undergone emergency LC for acute cholecystitis between January 2014 and December 2023. We compared the clinical and perioperative factors in relation to the results of bile culture. Results: The bile cultures were positive in 49.3％ of the cases. Bile culture positivity was associated with older age, higher ASA physical status grade, and elevated postoperative serum CRP levels. It was also associated with prolonged antibiotic treatment and extended postoperative hospital stays. However, no significant association was found between bile culture positivity and cholecystitis-specific factors, such as the severity of cholecystitis or time from symptom onset. Importantly, the culture results did not lead to any changes in the antibiotic regimens used. Conclusions: Bile culture positivity was associated with delayed postoperative healing and with older age and higher ASA-PS grade. However, due to the time required to obtain the results of culture, its utility in immediate clinical decision-making is limited. Further evaluation is needed to determine its role in perioperative management.

In this study, we investigated the efficacy of restrictive fluid therapy as a fluid management strategy during open abdomen management (OAM) for lower gastrointestinal diseases. We retrospectively analyzed the data of 53 patients who underwent OAM during their initial surgery for sepsis associated with lower gastrointestinal diseases over the previous six-year period. Patients were divided into two groups: the goal-directed hemodynamic therapy (GDHT) group, in which fluid management was guided by pulse pressure variations, stroke volume variations, stroke volume index, and urine output; and the restrictive normovolemic therapy (RNT) group, in which fluid management was guided by the mean arterial pressure and lactate levels. The 28-day mortality rate (33.3％ vs. 28.1％) did not differ significantly between the two groups. However, the cumulative fluid balance was significantly lower in the RNT group. Furthermore, the duration of OAM, the period of mechanical ventilation, and the tracheostomy rate were all also significantly lower in the RNT group. Restrictive fluid therapy for lower gastrointestinal diseases requiring OAM might not significantly improve the survival, but it could contribute to shortening of the treatment duration without increasing complications.

A 56-year-old man with a history of liver cirrhosis presented with acute chest and back pain. Abdominal contrast-enhanced computed tomography revealed a large volume of hemorrhagic ascites in Morison’s pouch, an impacted gallstone in the gallbladder neck, and hyperdense content within the gallbladder. Based on the findings, we considered the diagnosis of hemorrhagic cholecystitis with intraperitoneal bleeding. Emergency laparotomy confirmed gallbladder perforation with ongoing hemorrhage. Following cholecystectomy, because of the ongoing bleeding from the gallbladder bed and abdominal wall, we undertook damage control surgery with gauze packing to stabilize the patient and manage the hemorrhage. A second-look surgery confirmed complete hemostasis, and the patient was successfully discharged on postoperative day 21 without complications. Hemorrhagic cholecystitis is rare. Early surgical intervention in combination with damage control surgery may be crucial for achieving a life-saving outcome.

A 72-year-old man with a history of alcoholic hepatic cirrhosis (10C), and umbilical hernia diagnosed a year previously and severe alcoholic hepatic cirrhosis was under observation. He visited our hospital with a 3-day history of nausea, abdominal distention and somnolence. Physical examination revealed a fist-sized erythematous swelling that was warm to the touch in the umbilical region and signs of peritoneal irritation. Blood examination revealed abnormally elevated serum C-reactive protein level (24 mg/dL). Contrast-enhanced abdominal CT revealed a large amount of ascites and an incarcerated umbilical hernia. The hernia sac contained herniated small intestine without perforation. Based on the findings, we made the diagnosis of small bowel necrosis and acute generalized peritonitis associated with acute umbilical herniation. Emergency partial resection of the small intestine and umbilical hernia repair were performed on the same day. After wound closure, negative pressure wound therapy (NPWT) of the median incision was used to prevent delayed postoperative wound healing. The patient was discharged on postoperative day 13 without complications such as postoperative wound infection. We consider this case as a rare and valuable example of a patient with severe liver cirrhosis who underwent NPWT of an umbilical hernia without postoperative complications.

In adults with acutely irreducible groin hernias, use of a mesh for hernia repair remains debatable in cases with an increased risk of infection. At our hospital, for such cases, we use 2-stage laparoscopic surgery. We present a case series of 7 patients who underwent this procedure. All the patients were women, with a mean age of 82 years. According to the new Japanese Hernia Society classification, the hernias were of the L type in 2 cases, of the M type in 1 case, and of the F type in 4 cases. The reasons for selecting 2-stage surgery were the presence of contaminated ascites in 3 cases, and need for concurrent intestinal resection in 4 cases. Hernia sac inversion and ligation were the procedures of first choice for preventing recurrence during the waiting period. Among the 7 cases, the 2-stage surgery could be performed electively without complications in 5 cases. The remaining 2 developed recurrent incarceration or abscess formation during the waiting period, likely attributable to peritoneal disruption at the initial surgery, and required additional treatment. Although appropriate case selection and surgical attention are needed at the initial operation, 2-stage laparoscopic hernia repair combined with hernia sac inversion and ligation is a rational treatment strategy for acutely irreducible groin hernias.

Cytomegalovirus (CMV) typically infects individuals in early childhood, with 60％-80％ of adults harboring antibodies. While most infections remain asymptomatic, CMV reactivation can occur in immunosuppressed individuals. CMV enteritis can affect the entire gastrointestinal tract; however, small intestinal perforation due to CMV enteritis is rare. We report such a case. A 56-year-old man with a history of schizophrenia and bronchial asthma had been receiving prednisolone for four years. In October 23, he was admitted to our emergency department with paraplegia and abdominal pain. We suspected eosinophilic granulomatosis with polyangiitis based on the patient’s symptoms and laboratory findings and initiated the patient on steroid pulse therapy with methylprednisolone (1 g/day) on November 6. On November 10, the abdominal pain recurred, and abdominal radiography and computed tomography revealed small intestinal perforation, necessitating partial bowel resection. Postoperative histopathology confirmed CMV enteritis as the cause of the perforation. Ganciclovir therapy was initiated, and serology for CMV antigen became negative by day 14. This case highlights the importance of considering CMV infection in the differential diagnosis of acute abdominal conditions in immunosuppressed patients.

A 68-year-old woman presented with a two-week history of colicky left lower quadrant abdominal pain. She gave a history of suffering from constipation and taking laxatives, but had no previous surgical history. Abdominal computed tomography showed distention of the transverse colon and the whirl sign in the left upper quadrant. Based on the findings, we made the diagnosis of transverse colon volvulus at the splenic flexure, and performed emergency laparoscopic surgery. Intraoperatively, the splenic flexure was found to be rotated 270°clockwise, with no signs of intestinal necrosis. We incised the adhesion that served as the shaft of the volvulus and repositioned the colon. The postoperative course was uneventful. Transverse colon volvulus is uncommon and splenic flexure volvulus has almost never been reported. Considering the operating field, laparoscopic surgery would be useful for splenic flexure volvulus.

Breast cancer rarely metastasizes to the small bowel, but metastases can occasionally lead to bowel obstruction or gastrointestinal perforation. We report a case of small bowel obstruction caused by multiple metastatic lesions in a patient with invasive lobular carcinoma of the breast. The patient was an 85-year-old woman with right breast cancer and multiple bone metastases who had been receiving chemotherapy and been subsequently transitioned to palliative care. She presented with persistent abdominal pain, and contrast-enhanced abdominal CT suggested strangulated small bowel obstruction, prompting emergency surgery. A neoplastic lesion serving as the point of obstruction was found in the terminal ileum, approximately 50 cm proximal to the ileocecal junction, and another lesion was identified more proximally. We performed partial resection of the small bowel, including both lesions. The findings of histopathological examination of the resected specimen, including the negative staining of the tumors for E-cadherin, confirmed the diagnosis of small bowel metastasis from invasive lobular carcinoma. Even in patients with end-stage breast cancer, persistent abdominal pain should raise the suspicion of gastrointestinal metastases, including those to the small bowel. Furthermore, when encountering obstruction caused by a metastatic small bowel tumor, the possibility of multiple lesions must be borne in mind.

Appendices epiploicae are lobulated fatty appendages protruding from the colon and represent a rare cause of intestinal obstruction. We report a case of bowel obstruction caused by a loop formed by adhesions of the epiploic appendages of the sigmoid colon, which was treated laparoscopically. An 86-year-old woman presented to the emergency department with epigastric pain and was diagnosed as having strangulated small bowel obstruction. As the patient had active delirium, we performed laparoscopic surgery following a period of conservative management. Intraoperatively, a segment of small bowel was found to be incarcerated within a loop formed by adhesion between the tips of the appendices epiploicae of the sigmoid colon. We resected the involved appendices epiploicae and released the constricting loop. Including the present case, 12 cases of intestinal obstruction caused by loop-forming appendices epiploicae have been reported in Japan. Adhesions of appendices epiploicae of the sigmoid colon were the most common, and in 75％ of cases, there was no prior history of laparotomy. Preoperative diagnosis remains challenging, as CT findings are often non-specific. Therefore, this rare condition should be considered in patients with strangulated bowel obstruction of unknown cause and no prior history of abdominal surgery. Laparoscopic surgery proved to be an effective diagnostic and therapeutic procedure in this case.

The patient was a woman in her 50s who presented to us with a 6-month history of left lower back pain. The symptom had gradually worsened over time, with the patient additionally developing a high fever and pain and swelling of the left thigh, eventually becoming unable to stand. Blood tests revealed elevated inflammatory markers (WBC 18,770/μL, CRP 21.7mg/dL). Contrast-enhanced abdominal CT revealed an abscess extending from the left lower back to the thigh. On the same day, we performed an emergency laparoscopic colostomy (transverse colon) and incision-drainage of the left thigh abscess as we suspected perforation of the sigmoid colon. A subsequent lower gastrointestinal endoscopy confirmed sigmoid colon diverticulum perforation. The patient was discharged on postoperative day 48. Six months after the initial surgery, we performed sigmoid colon resection, colostomy closure, and ileostomy (covering stoma). A further six months later, ileostomy closure was carried out. The patient was discharged on postoperative day 10 without complications. Since the abdominal symptoms were initially mild, further delay in the diagnosis could have led to a fatal outcome. Prompt colostomy and abscess drainage are essential for treatment.

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an autoimmune disorder that is known to predominantly affect young women. Approximately half of the patients present with ovarian teratomas, and prompt oophorectomy leads to a good prognosis. We report two cases in which early suspicion of the disease and prompt surgery led to favorable recoveries. Case 1; the patient was initially admitted to the Psychiatry department for acute psychiatric symptoms followed by the development of fever and seizures. On day 19, the patient was transferred to our hospital, where computed tomography (CT) scan revealed minor calcification in the ovary suggestive of an ovarian teratoma; oophorectomy was performed. Case 2; the patient presented with fever and altered consciousness and was urgently admitted. The patient’s typical clinical course and CT-identified ovarian tumor were strongly suggestive of anti-NMDA receptor encephalitis. Prompt oophorectomy led to a good prognosis. In both patients, the diagnosis of ovarian teratoma was confirmed by histopathology, and both patients exhibited rapid postoperative improvement and full recovery without sequelae. Anti-NMDA receptor encephalitis is often misdiagnosed as a psychiatric illness. In young women presenting with acute neuropsychiatric symptoms, clinicians should consider the possible diagnosis of anti-NMDA receptor encephalitis early in the disease course, proactively investigate for ovarian teratoma, and perform timely resection where indicated.

A 57-year-old woman who presented with sudden-onset abdominal pain was transferred to our hospital. Contrast-enhanced abdominal CT revealed a 30-mm aneurysm in the left hepatic artery, along with a suspected hematoma within the hepatoduodenal ligament. The left portal vein branch was compressed by the aneurysm, although contrast enhancement of the left hepatic lobe was preserved. We initially planned endovascular intervention, based on a diagnosis of ruptured left hepatic artery aneurysm. However, portal venography showed significantly reduced flow in the left portal venous branch, raising concern about possible development of hepatic infarction if embolization was performed; therefore, we selected surgical intervention instead. Intraoperative exploration revealed the hepatic artery aneurysm localized around the umbilical portion of the portal vein and hemorrhagic ascites beneath the liver. Intraoperative ultrasound confirmed reduced portal blood flow due to compression by the aneurysm. We resected the hepatic aneurysm and confirmed restoration of the portal flow. Although endovascular intervention is generally regarded as the gold standard for hepatic artery aneurysms, surgical resection could be a promising option in cases found to show reduced portal venous flow, to prevent hepatic ischemia.