Purpose: No standardized management of patients receiving antithrombotic drugs, and undergoing gastro­enterological surgery, has been established. We investigated whether antithrombotic drugs usage could be a risk factor for postoperative complications after emergency abdominal surgery. Materials and Methods: A total of 454 patients who underwent abdominal emergency surgeries between Jan 2012 and Sep 2017, were retrospectively identified and included in this study. Patients were divided according to whether they had antithrombotic drugs treatment (n=58; Group A), or not (n=396; Group B). Background and perioperative variables were investigated. Result: Patients receiving antithrombotics have increased with time. Postoperative complications (Clavien-Dindo Classification ≥III), bleeding complications, and mortality rates were 24.2%, 2.0%, and 3.3%, respectively. Patients in Group A were older, with more comorbidity and higher transfusion rates than those in Group B. Postoperative complication and mortality rates in Group A were significantly higher than those in Group B (41.4% vs 21.7%; P<0.01, 8.62% vs 2.52%; P=0.031, respectively), but no statistical difference was observed in bleeding complication rates. Multivariate analysis identified variables of ASA ≥3, open surgery, and transfusion, but not antithrombotic drug usage as independent predictive factors for postoperative complications. Conclusion: Antithrombotic drug usage was not identified as an independent risk factor for postoperative complications. Complication factors, including comorbidity and surgical stress, may contribute to the occurrence.

A 74-year-old man lost consciousness and arrived at our hospital by ambulance. He had experienced chest tightness and appetite loss for two weeks after falling and bruising the lower jaw. A chest X-ray and CT images revealed a denture with clasps in the lower thoracic esophagus. Endoscopic removal was difficult because the denture did not move. For this reason, a surgical approach was selected. The patient was placed in the prone position with left-lung ventilation. The esophagus was dissected and the upper thoracic region was then transected via a thoracoscopic approach. An abscess had formed around the damaged lower esophagus and the clasps of the denture protruded outside the esophageal wall. The denture was removed from the esophagus and immediately placed in a plastic bag to avoid contamination and injury. With the patient in the dorsal position, we performed laparoscopic dissection of the esophageal hiatus from the abdominal cavity, then the thoracic esophagus and the denture in the bag were pulled into the abdominal cavity. A perforated duodenal ulcer was diagnosed intraoperatively and omental repair was also performed. The abdominal esophagus was transected and specimens were removed via the umbilical wound. A cervical esophagostomy, gastrostomy, and jejunostomy were created. The surgical duration was 322 minutes and blood loss was 170 ml. No major postoperative complications arose and the patient was transferred to an affiliated hospital on postoperative day 21.

A 71-year-old man without a history of hepatitis virus infection underwent intensive examination for cough. Contrast enhanced CT showed a 42 mm ring-enhanced low density area and a 35 mm low density area, which was enhanced homogenously in the early vascular phase and washed out in the late vascular phase, in liver segment VIII. Serum testing indicated PIVKA-II of 253 mAU/ml and CEA of 6.3 ng/ml. A segment VIII hepatectomy was performed. Macroscopically, there were two yellowish-white solid tumors. Histopathological examination revealed that the 42 mm tumor was combined hepatocellular and cholangiocarcinoma, which consisted of CK7/CK20 positive adenocarcinoma and arginase I positive hepatocellular carcinoma components. The 35 mm tumor was hepatocellular carcinoma. Therefore, double cancer of combined hepatocellular and cholangiocarcinoma and hepatocellular carcinoma was diagnosed. The non-cancerous liver tissue was alcoholic hepatitis. Postoperative lymph node recurrence occurred 4 months after surgery and partial response was obtained by chemotherapy with S-1. The patient died 11 months after surgery due to disease progression. To the best of our knowledge, there have been no reported cases of double cancer of combined hepatocellular and cholangiocarcinoma and hepatocellular carcinoma coexisting in chronic non-viral hepatitis. Here, we present our experience with a review of the literature.

A 78-year-old man was referred to our hospital in 2017 for a curative operation for gastric cancer after treatment of endoscopic submucosal dissection. We performed proximal gastrectomy and recognized tumors (5–20 mm in size) at the greater omentum. We resected the tumors with the greater omentum. The tumors were pathologically diagnosed as epithelioid hemangioendothelioma. Because he had previously undergone a resection of an abdominal tumor in our hospital in 2013, we retrospectively reviewed the series of imaging and the surgical and pathological findings of this tumor to evaluate the relation to the tumors resected in 2017. According to the operation records and the imaging in 2013, this tumor was about 10 cm in diameter, and located solitarily near the middle of the major curvature of the stomach, but there was no direct communications with the left lobe of liver, the stomach, or the transverse colon. We suspected that this tumor in 2013 was derived from the greater omentum, too. We examined the immuno­histochemical staining of this tumor, and finally diagnosed it as pseudomyogenic hemangioendothelioma, which was different from the tumors resected in 2017. It is extremely rare that the different types of hemangioendothelioma (pseudomyogenic hemangioendothelioma and epithelioid hemangioendothelioma) occurred at the greater omentum metachronously.

A 75-year-old afebrile man complaining of fatigue was admitted to our hospital, and physical findings showed slight tenderness on the right flank. In addition to increased inflammation on blood testing, contrast CT showed an enlarged appendix measuring 10 mm, right hydronephrosis, and surrounding panniculitis that resulted in the diagnosis of acute appendicitis and right pyelonephritis. He underwent emergency laparoscopic appendectomy. Histopathologic findings of the resected specimens revealed coexisting low-grade appendiceal mucinous neoplasm (LAMN) and appendiceal goblet cell carcinoid (GCC). He was discharged 12 days postoperatively. Repeat laparotomy and rapid pathological examination 46 days after the initial surgery demonstrated peritoneal dissemination of GCC. Curative surgery was considered impossible. He underwent FOLFOX+bevacizumab chemotherapy, but died of GCC 223 days after the initial operation. LAMN as well as GCC are relatively newly proposed diseases with no clear and effective treatment guidelines. We report a very rare case of coexistent GCC and LAMN, which has never been reported in Japan to our knowledge.

An 85-year-old woman was admitted to our hospital because of a bulge and pain in the right inguinal region. A ping-pong ball-sized mass accompanied by redness and pain under pressure were observed at the caudal site of the right inguinal ligament. A CT image showed a swollen appendix in the right femoral hernia sac with an increase in fat content around the hernia sac. She was given a diagnosis of De Garengeot hernia complicated by appendicitis. No increase in body temperature or inflammatory reaction were observed and a defined incarcerated wall of the appendix was detected by CT. Therefore, conservative treatment was chosen rather than emergency surgery. Subsequently, inflammation of the appendix disappeared and simultaneous laparoscopic repositioning of the incarcerated appendix, resection of the appendix, and femoral hernia repair were performed electively. Complications such as infection at the incision site and the inserted mesh, did not occur. It is critical to perform emergency surgery for a De Garengeot hernia accompanied by acute appendicitis. However, it is possible to simultaneously perform a laparoscopic appendectomy and femoral hernia repair electively in cases where no necrosis of the appendix is found.