Objective: Pulmonary thromboembolism (PTE) developing after abdominal surgery is a life-threatening complication. The aim of this study was to elucidate the disease-specific frequency of development and prognosis of PTE in patients undergoing abdominal surgery.

Methods: We conducted a retrospective analysis of the records acquired from 11 hospitals, of patients who had undergone abdominal surgery and were diagnosed as having PTE between January 2002 and December 2011. To calculate the annual postsurgical incidence of PTE, we combined the cases of abdominal surgery and cases of postsurgical occurrence of PTE, and analyzed the variables associated with the onset, treatment, and prognosis of PTE.

Results: The incidence of PTE in the patients who had undergone surgery was 0.033％ (17/51,787 patients). The risk factors were age ≥65 years, underlying cancer, especially pancreatic or colorectal cancer and other colorectal diseases, history of cardiovascular disease, and operation time > 2 h. Four patients (23.5％) died shortly after the onset of PTE. The 30-days survival rate after the development of PTE was 76.5％. The poor prognostic factors in the cases of PTE were comorbid blood coagulation disorder(s), preoperative history of anticoagulant therapy, and operation time > 2 h.

Conclusions: Older patients undergoing pancreatic or colorectal cancer surgery appear to be at a higher risk of development of PTE. Presence of congenital or acquired blood coagulation disorder(s) had an adverse influence on the prognosis of patients with PTE.

Objective： We assessed whether the addition of aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy to Ligation and Excision (LE) might reduce the incidence of of postoperative hemorrhage (PH) after hemorrhoidectomy.

Methods： We enrolled a total of 1,056 patients with internal hemorrhoids who had undergone hemorrhoidectomy at our hospital between 2007 and 2017. We evaluated the patient characteristics, incidence of PH and predictors of PH after hemorrhoidectomy from the patient data.

Results： The patients were divided into two groups, the LE group (n=575) and the EA group (n=481). Of all the patients included in this study, 40 (3.7％) had developed PH. The incidence of PH was significantly lower in the EA group as compared to the LE group (p=0.022). The length of postoperative hospitalization was also significantly shorter in the EA group than that in the LE group (p<0.001). However, the postoperative recurrence rate of hemorrhoids was not significantly different between the two groups. A multivariate analysis identified the number of excised piles and the operative procedure used as independent predictors of PH after hemorrhoidectomy.

Conclusion： The present results suggest that use of EA therapy might contribute to reducing the incidence of PH, and could become the standard treatment.

Introduction: Many previous RCTs comparing single-incision laparoscopic colectomy (SILC) with multiport laparoscopic colectomy (MPLC) have reported that there are no significant differences in the short-term results between the two types of procedures. However, there are many procedures whose safety and reliability in SILC remain uncertain.

Patients and methods: Introduction of our surgical techniques and identification and evaluation of our experience. Retrospective review of the surgical procedures and outcomes of 376 cases of SILC conducted between September 2009 and September 2020.

Results: There were at total of 194 men and 182 women, and the median age was 74.0 years. Of the total, 65 patients underwent ileocecal resection, 65 patients underwent right hemicolectomy, 36 patients underwent transverse colectomy, 29 patients underwent left hemicolectomy, 52 patients underwent sigmoidectomy, 99 patients underwent high anterior resection, 29 patients underwent low anterior resection, and 1 patient underwent abdominoperineal resection. The mean operative time was 227.5 min, and the mean operative blood loss was 5 ml. Clavien-Dindo classification Grade 3 postoperative complications were detected in 14 (3.7％) cases.

Discussion: SILC is feasible in patients with colorectal cancer. In terms of the short-term outcomes, SILC is similar to MPLC. Our procedures can be performed with no particular difficulty by those who have the skills to perform conventional MPLC.

Diaphragmatic rupture is caused by trauma in most cases, and spontaneous diaphragmatic rupture is extremely rare. We describe the case of a patient with spontaneous diaphragmatic rupture and ileal strangulation, who was managed by emergency surgery.

An 82-year-old man with acute abdominal pain who had been diagnosed as being in a shock state was transferred to the emergency department of our hospital approximately 12 hours after the onset of abdominal pain. The patient had received an enema that had been prescribed for abdominal pain thought to be caused by constipation. Abdominal computed tomography (CT) revealed herniation of the small intestine into the left thoracic cavity, and emergency surgery was performed. Laparotomic exploration revealed herniation of the small intestine into the left thoracic cavity through a defect in the left hemidiaphragm. After reduction of the herniated small intestine into the abdominal cavity, the defect was repaired primarily by a continuous suture. The herniated small intestinal segment was found to be necrotic and was resected. The patient recovered without complications.

Spontaneous diaphragmatic rupture and gastrointestinal herniation can be complicated by respiratory failure or small bowel strangulation and can be fatal. Therefore, rapid diagnosis and treatment are necessary for gastrointestinal herniation into the thoracic cavity.

Single-incision laparoscopic-assisted percutaneous endoscopic gastrostomy (SILAPEG) was performed in three consecutive patients in whom conventional percutaneous endoscopic gastrostomy (PEG) could not be performed. The mean operation time was 64 min, and the mean blood loss was 2 ml. There were no perioperative complications. The mean interval to the commencement of enteral nutrition through the gastrostomy tube was 3.3 days. Recently, LAPEG has come to be recognized as a safe and useful procedure. Based on our experience, SILAPEG might be one of the safest and most useful methods for performing gastrostomy, especially in cases where conventional PEG is difficult.

The patient, an 83-year-old woman, visited another hospital with the complaint of hematemesis, and was diagnosed as having duodenal diverticular bleeding. She was transported to our hospital for further management, as the diverticulum perforated while she was undergoing endoscopic treatment. Abdominal computed tomography showed a hematoma and free gas around the perforation, which were thought to be caused by the perforated duodenal diverticulum, and emergency laparotomy was performed. Intraoperatively, hematoma, emphysema and inflammation were pronounced at the affected site. A perforated diverticulum was noted on the outside of the descending peduncle of the duodenum, which was resected at the site of the healthy intestinal wall using an automatic suture device.

At the same operation, the gallbladder was removed and a drainage tube was placed in the cystic duct. After distal gastrectomy and postcolonic Roux-Y reconstruction (duodenal diverticulum), a drainage tube was placed retrogradely in the duodenal stump. The operation time was 3 hours 11 minutes. The postoperative course of the patient was satisfactory and she was discharged 16 days after the surgery.

A 74-year-old woman was referred to our hospital with anemia and a submucosal tumor in the duodenal bulb showing intraluminal growth, with ulceration at the top. Surgery was planned, and partial resection of the duodenal bulb was performed by laparoscopy and endoscopy cooperative surgery (LECS). Submucosal layer dissection was performed to the maximum extent possible, the deepest part was perforated by endoscopy and laparoscopic full-thickness resection was performed with the least margin. The defect in the duodenal bulb was closed with Albert-Lembert sutures, using an omental patch. The tumor, which measured 5 × 3 cm in size, was successfully extracted through the 2-cm wall defect. No postoperative stenosis was observed. The histopathological diagnosis was Brunner’s gland hyperplasia. We report a case in which LECS was useful for resection of a giant duodenal Brunner’s gland hyperplasia with bleeding.

We report, herein, a case of ileocolic resection performed for small bowel obstruction caused by ileal endometriosis. A 37-year-old woman had undergone laparoscopic appendectomy for acute appendicitis caused by appendiceal endometriosis 3 years ago. After the operation, she had received progesterone therapy for two years, but this therapy was discontinued as she began to receive fertility treatment. After three weeks, she complained of abdominal pain, which was diagnosed as resulting from small bowel obstruction caused by ileal endometriosis, and ileocolic resection was performed. Intestinal endometriosis is reported in 12％ of individuals with endometriosis. The most commonly affected sites are the sigmoid colon and rectum (72％), while the small bowel (7％) and appendix (3％) are rarely affected. The patient reported herein needed surgery twice for endometriosis occurring at rare sites during fertility therapy.

A 74-year-old man underwent endoscopic mucosal resection for polyps found on colonoscopy. Histopathological analyses revealed early-stage colon cancer with a submucosal tumor invasion depth of >1,000 μm. Therefore, additional surgical resection was required.

Laparoscopic right hemicolectomy was performed via a medial-to-lateral approach. Intraoperatively, we could not confirm the presence of the Toldt fusion fascia outside the penetrated mesocolon. Change of the field of view revealed incomplete intestinal malrotation, with partial fusion of the right mesocolon with the retroperitoneum at the lateral side.

This was a rare case of incomplete intestinal malrotation. It is important to perform diagnostic imaging to detect intestinal malrotation and confirm the anatomical anomaly perioperatively.

A 50-year-old woman with hepatocellular carcinoma (HCC) in segment 6 and 3 of the liver with underlying hepatitis B underwent hepatic resection．Six months after the hepatic resection，intrahepatic recurrence was detected in segment 7, and repeat hepatic resection was performed．Six months after the second hepatic resection，multiple nodules were detected in the lungs bilaterally．The nodules were suspected to be metastases from the HCC, and the patient was initiated on systemic chemotherapy with oral Tegafur-Uracil (UFT)．A review performed 6 months after the start of chemotherapy showed that none of the lung nodules had increased in size and that no new lesions had emerged in the liver．Therefore，pulmonary resection was performed．At present, 92 months after the pulmonary resection，the patient is doing well, with no evidence of recurrence．We encountered a case of hepatocellular carcinoma that showed long-term survival after multidisciplinary treatment，including pulmonary resection，for multiple bilateral pulmonary metastasis from HCC.

A 52-year-old woman was admitted to our hospital because of colonic diverticulitis. Ceftriaxone (CTRX) was administered at the dose of 2 g/day for 8 days. The patient complained of right hypochondralgia 15 days after the start of CTRX administration. Abdominal computed tomography and ultrasonography revealed stones and sludge in the gallbladder and common bile duct, and thickening of the gallbladder wall. In addition, drip-infusion cholangiographic computed tomography demonstrated acute curvature of the gallbladder neck, which lay close to the bile duct. We diagnosed acute cholecystitis caused by CTRX- associated biliary pseudolithiasis. Emergency laparoscopic cholecystectomy was performed, considering the risk of bile duct injury if the inflammation worsened. Laparoscopy revealed a right-sided ligamentum teres. We started dissection from the gallbladder fundus, and resected the gallbladder without causing bile duct injury. The common bile duct stone disappeared on postoperative day 3, and the patient had a satisfactory postoperative course.

A 73-year-old man was referred to our hospital with ascites and abdominal distension. At admission, abdominal CT revealed massive ascites and irregular wall thickening of the greater curvature of the stomach. After admission, the patient complained of abdominal pain. On the 9^th hospital day, contrast-enhanced abdominal CT showed a hematoma measuring 6 cm in diameter in the omental bursa, that was distinct from the pancreas. On the 20^th hospital day, a repeat contrast-enhanced CT revealed increase in the size of the hematoma, now measuring 12 cm in diameter, and a pseudoaneurysm in the splenic artery. The patient was diagnosed as having a hemorrhagic pancreatic pseudocyst and splenic artery pseudoaneurysm, and was treated by distal pancreatectomy and splenectomy. The postoperative course was uneventful, and the patient was discharged from the hospital 14 days after the surgery. Hemorrhagic pancreatic pseudocyst is a life-threatening condition. In a patient with chronic pancreatitis, even detection of a hematoma that can be distinctly delineated from the pancreas should raise the suspicion of a hemorrhagic pancreatic pseudocyst.

A 70-year-old woman who was identified as having a cystic lesion in the tail of the pancreas was referred to our department for further investigation. Because of the liquid contents of the lesion, EUS-guided aspiration was avoided to prevent dissemination. Somatostatin receptor scintigraphy showed an abnormal accumulation in the pancreatic tail. In addition, blood examination revealed an elevated serum level of chromogranin A. Thus, the patient was treated by laparoscopic distal pancreatectomy. The histopathological findings and positive immunohistochemistry for synaptophysin and CD56 led to the diagnosis of NET-G1. This case serves as an important reminder of the importance of considering pancreatic NET in the differential diagnosis of pancreatic cystic lesions.

Generalized edema can occasionally be found in the terminal stage of cancer, but it can also result from exocrine pancreatic insufficiency in patients with pancreatic cancer. We encountered a case of generalized edema in a patient with recurrent pancreatic cancer after pancreatoduodenectomy, which improved with pancreatic enzyme replacement therapy. A 71-year-old man underwent pancreatoduodenectomy for pancreatic head cancer at a previous hospital in 2014. Two years after surgery, he was diagnosed as having recurrence by computed tomography and was initiated on chemotherapy; however, as the anemia and generalized edema worsened, the patient was referred to our hospital for palliative therapy in 2018. At the time of admission, the patient had severe generalized edema and difficulty in walking. Because the patient gave no history of receiving oral treatment with digestive enzyme preparations, we suspected that exocrine pancreatic insufficiency could be the cause of the edema. The patient was initiated on pancreatic enzyme replacement therapy, and three months later, marked resolution of the edema was observed and the patient became ambulant. Administration of digestive enzyme preparations for exocrine pancreatic insufficiency is essential after pancreatic resection. Caution is required as overlooking prompt replacement may result in chronic worsening. Even in exocrine pancreatic insufficiency associated with pancreatic cancer, the QOL rapidly improves with pancreatic enzyme replacement.

A 72-year-old woman presented to the emergency department with abdominal and left femoral pain. She had a history of multiple recurrences of the same symptoms, but they resolved spontaneously each time. Abdominal computed tomography revealed a left-sided strangulated obturator hernia without any evidence of ischemia of the herniated bowel segment, and we performed ultrasound-guided hernia reduction. Two months later, we performed elective laparoscopic transabdominal preperitoneal repair. The hernia was covered and fixed by inverting the mesh (Bard 3D Max) upside down and from left to right. Intraoperatively, we observed a right-sided obturator and femoral hernias, which were repaired in a similar manner. The patient was discharged 3 days postoperatively, with no recurrence of the hernia to date. Obturator hernias are usually bilateral and may be complicated by other hernias; elective laparoscopic surgery performed after manual reduction is useful for patients without intestinal ischemia.