Purpose: To describe and investigate risk factors associated with surgical site infection (SSI) in digestive surgery for suppression, we clarified risk factors of SSI development in SSI surveillance. Subjects and Method: SSI surveillance was begun in our institution in 2005. This was a retrospective study of 1,560 patients who underwent digestive surgeries during the period between 2009 and 2013 under the standardized protection. We analyzed risk factors of SSI development and investigated the incidence of SSI for each surgical approach according to surgical technique. The incidence and factors associated with SSI following digestive surgery were investigated by the type of surgical procedures. Results: Univariate analysis revealed that the following factors were associated with a significantly high incidence of SSI: age, diabetes mellitus, malignant disorder, SSI Risk Index Score, wound classification, American Society of Anesthesiologists score (ASA score), construction of stoma, emergency operation, combined resection/surgery, surgical approach (laparotomy/laparoscopic surgery), and operative time. No increase in the incidence of SSI was recognized for the factors of sex, obesity, and smoking. Multivariate analysis revealed that the factors judged to be significant by univariate analysis revealed ASA scores of ≥3 points, malignant disorder, laparotomy, combined resection/surgery, construction of stoma, diabetes mellitus, and age ≥80 were independent risk factors for the incidence of SSI, in descending order of odds ratio. Furthermore, in hepatobiliary and pancreatic surgery and colon surgery, the incidence of SSI decreased significantly when laparoscopic surgery was performed. Conclusion: This study based on the SSI surveillance suggests that the surgical approach is important to suppress the incidence of SSI in patients with a risk of SSI.

A 52-year-old man was admitted to our hospital due to dysphagia. Upper and lower endoscopy showed type 3 tumor and type 1 tumor in the gastric cardia and antrum, respectively, with multiple various-sized polyps in the corpus of the stomach, but absence of polyps in the duodenum and colon. The patient did not have typical mucocutaneous pigmentation or family history that suggested Peutz-Jeghers (PJ) syndrome. Laparoscopic total gastrectomy with D2 lymphoadenectomy was performed and microscopic examination of the specimen revealed adenocarcinomas arising in the hamartomatous polyps with lymph node metastasis. He was given a diagnosis of gastric cancer and incomplete PJ syndrome. Gastric PJ type polyps are very rare, and to the best of our knowledge only 4 cases of gastric cancer arising in PJ type polyps without familial polyposis coli nor mucocutaneous pigmentation have been reported. It has been argued whether PJ type polyps of incomplete PJ syndrome has malignant potential similar to that of PJ syndrome. Further investigation is needed to establish appropriate management for incomplete PJ syndrome patients.

A 13-year-old boy was admitted to our hospital because of acute onset epigastric abdominal pain and vomiting. Similar symptoms had started 4 years prior, and he had been managed conservatively with the diagnosis of chronic pancreatitis. A CT scan at this admission revealed a duodenal intussusception including the head of the pancreas. We attempted to release the intussusception by using upper gastrointestinal (GI) endoscopy and a long tube. The intussusception was successfully released by pulling out the long tube inserted into the jejunum. An upper GI contrast study and endoscopy were performed again after the improvement of his general condition and the pancreatitis. A duodenal web was revealed in these studies, and the web was thought to cause the intussusception and the pancreatitis. At laparotomy, a windsock web was confirmed in the second portion of the duodenum. The web was excised and the duodenotomy closed transversely. Here we report a rare case presenting duodenal intussusception and pancreatitis secondary to a duodenal web.

A 65-year-old woman was diagnosed as having initially unresectable locally advanced gallbladder cancer (LAGBC) with direct invasion to the liver, the extra hepatic bile duct, the common hepatic artery, and the head of the pancreas. She received chemotherapy with gemcitabine and S-1. After 8 courses of chemotherapy, the size of the main lesion decreased and the invasion to the adjacent organs disappeared. We performed extended right hepatectomy and extrahepatic bile duct resection with combined resection of the common hepatic artery. Pathological investigation confirmed moderately differentiated tubular adenocarcinoma of the gallbladder, pT3N1M0, Stage IIIB, and R0 resection margins. The patient received adjuvant chemotherapy with S-1. Eight months after the surgery, she was alive with no signs of recurrence. The efficacy of conversion surgery for unresectable LAGBC has not been determined. Further studies are required to establish treatment strategy for unresectable LAGBC. However, it is important to pursue the feasibility of conversion surgery for patients with unresectable LAGBC.

A 40-year-old man was admitted to a previous hospital because of acute pancreatitis. Next day, CT showed hypo-enhanced area in the body and tail of pancreas. He was referred to our hospital on the diagnosis of severe acute pancreatitis. CT showed progressive retroperitoneal necrosis during hospitalization. Two months later, we performed video-assisted retroperitoneal debridement (VARD) through a 6 cm diameter incision in the left flank after underwent ultrasound-guided percutaneous drainage. He was discharged on postoperative day 32, without any additional treatment. This procedure is one of effective minimally invasive treatments for infected pancreatic necrosis.

A 68-year-old man was admitted to our hospital with right back pain. CT showed a 60-mm tumor in the head of the pancreas. Gastrointestinal endoscopy showed a submucosal tumor at the same location. Under a diagnosis of gastrointestinal stromal tumor (GIST) from fine needle aspiration, pancreatoduodenectomy (PD) was performed. Intraoperative findings showed a drainage vein of the pancreas head passing under the superior mesenteric artery (SMA). Because there was a risk of deep bleeding by a SMA, we avoided an artery first approach. We considered that a drainage vein that passes under the SMA, as in our case, might represent one form of anatomical variation at the pancreas head. When we perform an artery first approach that become widespread, attention should be paid to aberrant drainage veins, as well as arteries.

We report a case of wandering spleen with peculiar collateral circulation resected by laparoscopic surgery. A 33-year-old woman underwent diagnosis with wandering spleen 10 years previously, but had only been under follow-up thereafter as the abdominal pain was not severe. She had severe recurring pain in the left side abdomen on exertion, a few days prior to visiting our hospital. Since contrast enhanced CT scan revealed poorly enhanced region of the wandering spleen accompanied by coiling vessel bundles suggesting splenic torsion, we performed a laparoscopic surgery. The spleen was not fixed to the retroperitoneum, but bound at 2 points by coiling vessel bundles with severe torsion; one bundle was to the splenic hilus and the other peculiar bundle was attached to the opposite side of the splenic hilus. The bundle at the splenic hilus (splenic artery and vein) had already been obstructed with fibrosis. The peculiar bundle attached to the opposite side of the splenic hilus was found to be derived from gastroepiploic vessels and formed collateral circulation of the spleen.

A 91-year-old woman suffered from repeated intestinal obstructions with short intervals after percutaneous transluminal coronary angioplasty for myocardial infarction. We conducted an operation for intestinal obstruction, and she was given a diagnosis of intestinal perforation and stenosis caused by cholesterol crystal embolization (CCE). We report this case with reference to the literature reported in Japan. We classified 20 cases of CCE into three groups by its clinical findings (perforation, necrosis, stenosis), and analyzed their clinical features. Skin lesion or renal dysfunction, which is a common complication of CCE, was not seen in cases of the necrosis or stenosis group. Patients in this group were successfully treated by short partial resections of the intestine, and none of them died. On the other hand, in the perforation group, skin lesion and severe renal dysfunction were seen in almost all cases. The sites of perforation were multiple, therefore a wide resection was needed. Moreover, the rate of postoperative re-perforation or leakage was high; 12 of 13 patients of the perforation group died. CCE rarely causes intestinal perforation or stenosis, but is thought to increase accordingly as the number of elderly people increase. Therefore, understanding CCE is essential.

A 65-year-old man was diagnosed with acute appendicitis and treated conservatively with antibiotics by a local physician. Temporary improvement was achieved, but he was evaluated at our hospital because of recurrence. Abdominal examination revealed a palpable, hard, elastic mass the size of a hen’s egg in the right lower quadrant. The patient reported back discomfort when raising the right leg. CT revealed a mass with non-uniform contrast enhancement in the right lower quadrant and a 3×4-cm low-density area dorsally in the iliopsoas muscle. Abdominal US showed a patchy non-uniform area in the iliopsoas muscle. Acute appendicitis with abscess perforation into the iliopsoas muscle was diagnosed, and surgery was performed. As expected preoperatively, the tip of the appendix had perforated into the iliopsoas muscle, but no pus was present inside. Instead, a discharge of 2- to 3-mm pearl-like globules was seen. The appendix was resected, the globules were removed, and the inside of the iliopsoas muscle was rinsed. A drain was then placed and surgery was completed. Histopathology showed moderate atypia, but no evidence of malignancy. The diagnosis was mucinous cystadenoma of the appendix with myxoglobulosis. As of about 5 years after surgery, no recurrence has been identified.

The patient was a 55-year-old man who was brought to the hospital as an emergency with a chief complaint of abdominal pain. The patient had a past history of atrial fibrillation. Abdominal contrast CT revealed occlusion of the ileocolic artery and both reduced blood flow and edematous changes in the ileum, and a diagnosis of superior mesenteric artery (SMA) occlusion was made. Intestinal necrosis was suspected based on the physical and diagnostic imaging findings, and urgent diagnostic laparoscopy was performed. Examination of the abdominal cavity revealed a slightly discolored segment of intestine extending for approximately 1 meter from the end of the ileum, but because there was good peristalsis, progression to necrosis was ruled out. We then performed intraoperative endovascular treatment and observed the improvement in blood flow. Repeat laparoscopy confirmed the absence of intestinal discoloration, and we concluded the operation. The postoperative course was favorable, and the patient was discharged on postoperative day 14. Cases of SMA occlusion in which it has been possible to avoid open surgery by performing diagnostic laparoscopy and intraoperative endovascular treatment are rare. Performing diagnostic laparoscopy in an operating room where endovascular treatment can be performed in SMA occlusion cases in which the viability of the intestine is unknown makes it possible to immediately choose the method of treatment and perform it, and if no intestinal necrosis is observed, open surgery can be avoided.

The case subject was a 68-year-old man who while being treated as an outpatient for systemic lupus erythematosus and vasculitis presented at the emergency care centre of our hospital with a chief complaint of abdominal pain. Because plain abdominal X-ray revealed a small volume of bowel gas, contrast-enhanced CT of the abdomen was performed. Findings led to a diagnosis of incarcerated right femoral hernia. Following manual reduction, the subject was hospitalized for follow-up observation. Contrast-enhanced CT of the abdomen was performed because of the reoccurrence of abdominal pain. Findings revealed the formation of a pseudoaneurysm in the mesenteric artery of the small intestine and the presence of ascetic fluid with high absorbency in the pelvic cavity. These findings were indicative of intra-abdominal bleeding. The patient’s haemoglobin count had decreased to 7.9 g/dl, and his anaemia progressed despite the administration of 2 units of packed red blood cells. Therefore, contrast-enhanced abdominal angiography was performed. Contrast enhancement of the superior mesenteric artery revealed bleeding from a pseudoaneurysm in the proximity of the ileocecum. Therefore, coil embolization was performed. Following surgery, because there was no recurrence of gastrointestinal symptoms, the patient was allowed to ingest meals. The femoral hernia was subsequently repaired using laparoscopy once the patient’s general condition had stabilized. Here we report a relatively rare case in which the manual reduction of incarcerated femoral hernia led to the formation of a mesenteric pseudoaneurysm that was later treated by hernia repair using laparoscopy.