Postpancreatectomy hemorrhage (PPH) is a serious complication after pancreaticoduodenectomy (PD). We investigated the risk factors for PPH after PD. In 205 consecutive patients who underwent PD between 2013 and 2022, 138 patients with intermediate risk or higher for pancreatic fistula (PF) formation were enrolled in our study. Of these 138 patients, 10 (7.2％) developed PPH. Multivariate analysis identified age, intraoperative bleeding, and International Study Group of Pancreatic Fistula (ISGPF) as being significant risk factors for PPH. The cutoff value for intraoperative bleeding was 689 mL. When PD is performed in patients at a high risk of PE formation, intensive care and survey for PPH would be required, especially in cases with significant intraoperative bleeding.

The patient was a 51-year-old man with cerebral palsy who visited a neighborhood physician with a history of recurrent episodes of vomiting. A plain X-ray of the abdomen revealed coffee bean-like dilatation of the colon. He was referred to our hospital with suspected volvulus of the sigmoid colon. Abdominal CT revealed a closedloop of the colon, and the cecum and sigmoid colon were confirmed in the lower abdomen. We diagnosed him as having transverse colon volvulus, and performed emergency surgery. Intraoperatively, the transverse colon was found to be twisted 540° counterclockwise around the mesentery of the colon. The necrotic intestinal tract was resected and reconstructed after the volvulus was released. To prevent internal herniation into the transverse mesocolon space, we closed the space with the omentum. After the operation, the patient developed paralytic ileus of the small intestine and aspiration pneumonia, but his condition improved with conservative management, including antibiotic treatment. He was discharged from the hospital 14 days after the operation. We report a case of transverse colon volvulus with some review of previously published literature.

A 71-year-old man visited our hospital with a history of fever and epigastric pain. Abdominal contrast-enhanced computed tomography (CT) revealed a low-density hepatic tumor (50 mm in diameter) in the left lateral segment, with perihepatic fluid collection. The patient was diagnosed as having a ruptured hepatocellular carcinoma and treated by left lateral segmentectomy. The tumor protruded outside the liver, and a part of the tumor had collapsed. However, the tumor was covered with omentum, and no intra-abdominal hemorrhage was observed. Histopathological evaluation of the resected specimen showed coagulative necrotic tissue occupying most of the tumor, with moderately-to-poorly differentiated hepatocellular carcinoma at the tumor margin, and a thick fibrous peritumoral capsule. Parts of the tumor capsule and liver capsule were disrupted, and we identified a hematoma outside the liver. Therefore, we made the final diagnosis in the patient of extensive spontaneous necrosis and rupture of hepatocellular carcinoma. We speculated that the reduced blood flow and necrotic changes in the tumor might have prevented massive bleeding despite rupture of the tumor. We report a case of extensive spontaneous necrosis and rupture of hepatocellular carcinoma.

A 77-year-old man with a 10-days’ history of abdominal pain and distension was referred to our hospital. Abdominal contrast-enhanced CT revealed massive intestinal emphysema and intraabdominal free air. The patient gave a 6-month history of receiving α-glucosidase inhibitor (α-GI) treatment and of suffering from constipation and abdominal distension during this period. Laparoscopic exploration revealed pneumatosis cystoides intestinalis (PCI), but no evidence of intestinal perforation. We reviewed the data of 32 cases reported in Japan and found that such cases probably require no surgery, including laparoscopic exploration, that a good prognosis can be achieved with conservative treatment, and that there have been no fatalities associated with this condition. Therefore, the possibility should be borne in mind of the development of PCI during α-GI treatment and drugs of this class should be administered with caution.

The patient was a 39-year-old woman who had undergone ventriculo-peritoneal shunt implantation following surgery for multiple myeloma. She was brought to our hospital with a history of fever and impaired consciousness. Computed tomography (CT) of the head showed ventricular dilatation on the left side, and abdominal CT showed accidental migration of the ventriculo-peritoneal (VP) catheter into the small intestine. We performed ventricular drainage and examination of cerebrospinal fluid revealed signs of bacterial meningitis. We considered that the fever was due to meningitis caused by retrograde infection via the VP shunt. We treated the patient by removing the VP shunt tube on the ventricular side, fixing the VP shunt tube on the abdominal side to the abdominal wall, and creating a fistula. Two weeks later, after confirming that only the fistula was visible, the tube was removed. Perforation of the VP shunt tube through the gastrointestinal tract is a rare complication. In our case, exosomy was considered to be an effective treatment to avoid surgery under general anesthesia.

An 82-year-old woman presented with suspected intraperitoneal bleeding in the upper abdomen following a traffic accident. Coil embolization was performed to stop the bleeding from the pancreatic head arcade. During exploratory laparotomy, pancreatic hook bruising was found, but no gastrointestinal injury was identified. However, urgent surgery on postoperative day 1 due to difficulty in maintaining the blood pressure. Pulsatile bleeding from the pancreatic contusion and discoloration of the duodenum were observed, which led to the decision to perform a pancreaticoduodenectomy. To shorten the operation time, we performed only pancreatico-jejunoanastomosis and choledocho-jejunoanastomosis, and implemented open abdominal management. On postoperative day 3, we performed gastro-jejunal anastomosis and jejunoenterostomy. We discharged the patient on the 42nd day after surgery, despite postoperative pancreatic fistula formation, categorized as ISGPF Grade B. This case serves to highlight our successful use of the damage control strategy and two-stage pancreaticoduodenectomy in treating traumatic pancreatic injury.

An 85-year-old Japanese woman presented to our hospital with a history of severe upper abdominal pain and nausea. Abdominal CT showed slight ascending colon wall thickening, slight dilatation of the transverse colon, and moderate ascites in the right colic gutter. She was diagnosed as having ischemic colitis and was carefully monitored without invasive surgical treatment. Although the abdominal pain was stable, marked increase of the serum CRP level was noted on the second day. On the fourth day, we opted to operate on the patient as she had also become tachycardic. Laparotomy was performed, and intraoperative exploration revealed irreversible ischemic changes on the left side of the transverse colon. A left hemicolectomy and transverse colostomy were performed. Although the patient required treatment for repeated urinary tract infections, her postoperative course was fair. She was discharged from the hospital six months after the surgery. Determining the surgical indication in cases of ischemic colitis is sometimes challenging because no proven diagnostic criteria or specific laboratory test findings have been established yet. We report the preoperative course and operative findings for effective management of this disease in the future.

We report three patients who developed pseudoaneurysm following self-expandable metallic stent (SEMS) placement for malignant biliary stenosis and were treated by transcatheter arterial embolization (TAE). [Case 1] A 61-year-old woman developed cholangitis following gastric cancer surgery due to a recurrent lesion invading the right and left bile ducts and SEMS placement. The right hepatic artery was successfully embolized for a pseudoaneurysm that developed within the SEMS on day 45 after the stent placement, and the bleeding did not recur. [Case 2] An 82-year-old man underwent SEMS placement for stenosis of the bile duct anastomosis after gallbladder cancer surgery. The right hepatic artery was embolized for a pseudoaneurysm that developed outside the SEMS on day 78 after the stent placement, but the patient developed multiple organ failure and died on day 34 of hospitalization. [Case 3] A 78-year-old woman underwent chemotherapy after SEMS placement for bile duct cancer. The right hepatic artery was embolized for a pseudoaneurysm that developed in the SEMS on day 42 after the stent placement, and the bleeding did not recur. [Conclusion] TAE was effective for avoiding fatal bleeding from hepatic pseudoaneurysms even in terminally ill patients.

The patient was a 69-year-old woman who had been diagnosed as having mixed connective tissue disease (MCTD) 6 years prior to the surgery. A chest X-ray performed for suspected heart failure in the patient revealed free air in the abdomen and the patient was referred for surgery to our department. Even though there was no obvious evidence of inflammation, with a WBC count of 2,700/μL and serum CRP of 0.04mg/dL, and physical examination revealed only abdominal fullness and mild tenderness, we considered that surgery was indicated as the patient was on immunosuppressant treatment and had marked free air in the abdomen and ascites. Laparotomy was performed, and intraoperative exploration revealed only a moderate amount of serous ascites and no obvious perforation. Postoperatively, the patient had some alternating diarrhea and constipation which was difficult to control. She was discharged from the hospital on the 21st postoperative day without other problems. In this report, we describe a case of emergency laparotomy performed on a woman with MCTD who presented with significant abdominal distention, free air in the abdomen, and ascites, without any perforation of the gastrointestinal tract.

A 55-year-old woman visited her previous doctor with the chief complaint of abdominal pain and was treated conservatively for perforated sigmoid colon diverticulitis. Five months later, she developed fever and abdominal pain again and was referred to our department after an abdominal contrast-enhanced CT revealed an enlarged left ovary. We diagnosed the patient as having a recurrent ovarian abscess and we performed laparoscopic Hartmann’s operation and left adnexal resection. The ovary was found to be adherent to the sigmoid colon and abdominal wall due to chronic inflammation. Diverticulitis of the sigmoid colon with penetration into the uterine adnexa is a rare condition, and only one case of laparoscopic resection has been reported previously. In our own case, adhesion and sclerosis due to chronic inflammation were observed, however, the operation could be performed laparoscopically.

A 72-year-old woman underwent Hartmann’s operation for rectal perforation and panperitonitis, and subsequently, stoma closure five months after the initial operation. After the patient resumed oral intake on postoperative day (POD) 3, she showed signs of sepsis on POD 4. However, neither computed tomography nor enema examination showed any anastomotic leakage or infectious focus. On POD 6 and POD 7, the patient was diagnosed as having disseminated intravascular coagulation (DIC) and septic shock, respectively. Finally, we made the diagnosis of bacterial translocation (BT), and initiated the patient on intensive treatment, including on assisted ventilation, in the intensive care unit. She was discharged from the hospital on POD 46. We speculate that the BT occurred when the digestate passed through the disused atrophic intestinal tract after stoma closure. Once BT occurs, it could lead to serious complications. Therefore, it is important to consider and take measures to prevent BT in patients scheduled for stoma closure.

We report the case of a 70-year-old female patient who developed esophageal perforation and cardiopulmonary arrest during endoscopic removal of an accidentally ingested clasp denture. She was referred to a local clinic for endoscopic removal of the foreign body. Upper gastrointestinal endoscopy revealed the clasp denture in the stomach. Using endoscopic forceps, the object was grasped with endoscopic forceps and gently extracted upwards through the esophagus, but the object became stuck to the esophageal wall during this procedure. While the attending physician attempted to dislodge the object, the patient went into sudden cardiopulmonary arrest, and resuscitation was initiated. Her heartbeat resumed after the resuscitation, and a subsequent CT revealed bilateral pneumothorax with free air around the esophagus. Esophageal perforation was suspected, and the patient was transported to our hospital for emergency surgery. The denture-clasp object was found to be protruding through the esophagus and removed. Thereafter, we performed esophagectomy and cervical esophagostomy and jejunostomy. On the 42nd postoperative day, we reconstructed the esophagus using a gastric tube via the subcutaneous route. The patient recovered well and was discharged on the 81st postoperative day.

An 89-year-old man who had been admitted to a nursing care facility was brought to our hospital with a 3-days’ history of vomiting, abdominal distention, and difficulty in defecation. Abdominal computed tomography revealed a 55-mm fecalith in the lower rectum with calcification, and the patient was admitted to our hospital with a diagnosis of sub bowel obstruction caused by a rectal fecalith. We failed in our attempt at colonoscopic removal of the fecalith. Therefore, we undertook surgery to attempt transanal extraction of the fecalith. However, crushing of the fecalith with forceps proved impossible, and extraction of the fecalith in toto was difficult even with muscle relaxation. Finally, we injected Coca Cola transanally four times at intervals of 5 minutes (a total of 1,000 mL was injected), which softened the fecalith, and the fecalith was crushed with Magir forceps and extracted. In recent years, there have been some reports of the efficacy of cola dissolution therapy not only for bezoars, but also for enteroliths and fecaliths. We report a case in which transanal surgery combined with cola dissolution therapy was useful to extract a rectal fecalith.

A 53-year-old female patient presented to our emergency department with a 1-day history of acute persistent abdominal pain. The abdomen was distended, with marked tenderness in the region of the umbilicus. The blood test findings were normal. Abdominal plain CT showed dilatation of the colon with a positive whirl sign and dirty fat sign. Based on the symptoms and CT findings, we suspected strangulated ileus. As no additional examinations could be performed in the patient due to the severe abdominal pain, we performed an emergency exploratory laparotomy. The ileocecum was rotated clockwise by 360 degrees around the ileocolic vessels and turned to the left. No obvious intestinal necrosis was observed, but we found serosal damage. We performed ileocecal resection taking into consideration the possibility of recurrence. The patient was discharged on the 14th hospital day. We reviewed the reconstructed plain CT images after the surgery, and found that preoperative diagnosis could have been made in this case. Reconstruction of plain CT images should be considered for preoperative diagnosis in a case of suspected cecal volvulus.

A 43-year-old woman presented with epigastric pain at 38 weeks three days of gestation. An emergency cesarean delivery failed to resolve the patient’s pain, and abdominal computed tomography revealed evidence of small bowel obstruction. We performed intestinal decompression by inserting a nasogastric tube, followed by insertion of long intestinal tube. A small bowel series performed with the long intestinal tube in place revealed a beak sign in the upper abdomen. Exploratory laparoscopy showed a herniated incarcerated segment of the small intestine through the lesser omentum, posterior to the stomach. We carefully pulled the incarcerated intestine back into the abdomen, and performed laparoscopic closure of the hernial orifice. Retrospective evaluation of the operative finding showed a large hernial orifice in the greater omentum, although the risk of incarceration was considerably low. We report, for the first time, a case of a lesser omental hernia in a pregnant woman who was treated successfully by laparoscopic surgery.

Lemmel’s syndrome, characterized by obstructive jaundice caused by a periampullary duodenal diverticulum in the absence of choledolithiasis or neoplasia, is an uncommon condition. A 73-year-old man with a history of relapsing cholangitis was admitted for intensive care after being diagnosed as having acute pancreatitis and acute cholangitis. We performed a gastrointestinal endoscopic examination after the pancreatitis and cholangitis improved, which revealed a parapapillary diverticulum; endoscopic retrograde cholangiopancreatography (ERCP) did not reveal any common bile duct stone. Assuming that both the relapsing cholangitis and acute pancreatitis were secondary to the parapapillary diverticula, we diagnosed the patient as a case of Lemmel’s syndrome. We performed endoscopic sphincterotomy (EST) to prevent biliopancreatic complications, including cholangitis and acute pancreatitis. Outpatient follow-ups in the three years following his discharge from the hospital revealed no evidence of recurrence of either condition. Thus, it appears that EST is effective for preventing Lemmel’s syndrome.

A 68-year-old man was urgently transported to our hospital with the chief complaints of epigastric pain and bloody diarrhea. Abdominal computed tomography showed obstruction from the superior mesenteric vein to the portal vein and necrosis of the small intestine, and we performed emergency open surgery. After resection of the necrotic small intestine, functional end-to-end anastomosis (FEEA) was performed. The patient was started on a continuous intravenous heparin infusion on postoperative day 1, which was switched to direct oral anticoagulant therapy on postoperative day 2. The patient was discharged on postoperative day 12. Computed tomography 6 months postoperatively showed complete disappearance of the thrombus. The patient remains on treatment with direct oral anticoagulants and has shown no evidence of recurrence of the thrombosis since.

This patient was a man in his 70s who had undergone Roux-en-Y reconstruction after total gastrectomy for gastric cancer. He was admitted to our hospital complaining of persistent epigastric pain for 5 hours. Abdominal CT revealed an occluded superior mesenteric artery (SMA) and an ischemic small intestine, and the patient was diagnosed as having acute SMA occlusion. The patient received hybrid therapy, including interventional radiology (IVR) and surgery. IVR was performed 8.5 hours after the onset of pain, which resulted in recanalization of the right colic artery. Surgery was started 10 hours after the onset of pain and a long 320-cm segment of the small intestine was resected, followed by establishment of a jejunostomy and ileal mucous fistula. Eight months after this intervention, as the patient presented with the symptoms of a short bowel syndrome, we anastomosed the jejunum and the cecum, so that oral nutrition could be maintained. At present, 15 months after completion of the first surgery, the patient remains alive and well. We report this case because SMA occlusion after gastrectomy is rare, and in the patient reported herein, hybrid treatment proved successful.

The patient was a 78-year-old man diagnosed a while ago as having a right inguinal hernia, with persistent prolapse of his intestine into the hernia sac, but he had no pain and did not seek any treatment. During a softball game, he was hit by a ball in the right inguinal area, and was admitted to a neighborhood hospital for observation. Three hours after admission, his abdominal pain worsened, and CT revealed free air in the abdomen. The patient was referred to our hospital with a suspected diagnosis of perforation of the gastrointestinal tract, and we performed emergency surgery on the same day. Intrabdominal exploration revealed that the patient had peritonitis associated with perforation of the small intestine. We sutured and closed the perforated site with laparoscopic assistance, and cleaned the abdominal cavity before completing the operation. The patient developed paralytic ileus postoperatively, but was discharged from the hospital 19 days after the surgery. Herein, we report a rare case of small intestinal perforation caused by blunt trauma to an inguinal hernia sac.

A 55-year-old woman with a history of having undergone a caesarean section visited us complaining of abdominal pain. Contrast-enhanced computed tomography showed a single loop of dilated small bowel in the pelvic cavity compressing the uterus and rectum. We diagnosed the patient as having simple intestinal obstruction and undertook conservative treatment. The abdominal pain improved transiently, but recurred immediately after the patient resumed eating. Contrast-enhanced computed tomography showed a closed loop of small intestine in the pelvic cavity compressing the uterus and rectum, and a converging image of congested mesentery in the vicinity. We made the diagnosis of incarcerated hiatal hernia and performed emergency laparoscopic surgery. Intra-abdominal examination revealed a slightly reddened small intestine incarcerated through the hiatus of the left broad ligament. The incarceration was released, and the hiatus in the broad ligament was sutured closed. No resection of the incarcerated small intestine was necessary. The patient had an uneventful postoperative course and was discharged home on postoperative day 6. Intestinal hernia through a hiatus in the uterine broad ligament should be included in the differential diagnosis in women who have been pregnant or have had a caesarean section, in whom computed tomography shows evidence of small bowel obstruction in the pelvis, with the obstructed segment compressing the uterus or rectum.