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We report a surgical case of bronchial artery aneurysm (BAA) that directly connected to a pulmonary artery and a pulmonary vein through an abnormal vessel. It was complicated by racemose hemangioma. This is a rare vascular malformation. An 82-year-old female had a large BAA that was found incidentally. First, we consider treating the BAA with embolization by interventional radiology (IVR). However, because of strong meandering of the bronchial artery, we could not advance a microcatheter into the BAA. Therefore, a surgical operation was performed through a standard posterior lateral thoracotomy. The BAA was located between the upper and lower lobes and directly connected to the pulmonary artery. Some bronchial artery branches that provided inflow to the aneurysm were ligated, and the abnormal vessel that connected the BAA to the upper pulmonary vein was ligated easily. A fistula between the BAA and pulmonary artery was sutured by the cardiovascular surgeon using an artificial cardiopulmonary device, with permissive stenosis of A2b (ascending A2).

Background The incidence of acute empyema has increased in various countries; some elderly patients with acute empyema have contraindications for surgery under general anesthesia. Therefore, suitable management based on a patient’s clinical condition is required. Methods We evaluated the different surgical and nonsurgical therapeutic approaches available for patients with acute empyema. This was a retrospective study of 57 patients with acute empyema who received treatment in our department between May 2015 and February 2019. For patients who did not initially improve with drainage or drainage combined with fibrinolytic therapy, surgery, or additional percutaneous drainage was performed based on their general condition. We compared several clinical factors pertaining to the patients who underwent surgical versus nonsurgical treatment. Results Our study showed that the patients with a performance status of 0–2 and an American Society of Anesthesiologists physical status classification of class II or lower underwent surgery safely without major operative complications. The combination of repeated drainage of the pleural cavity and fibrinolytic therapy appeared to be a reasonable nonsurgical management option for patients in poor overall condition. Conclusion For an aging population, we think that the combination of repeated pleural cavity drainage procedures and fibrinolytic therapy is a reasonable nonsurgical strategy for the management of patients with acute empyema.

Background: On May 18, 2020, Kanagawa Prefecture in Japan set up a 180–bed temporary prefabricated field hospital to provide care to coronavirus disease 2019 (COVID–19) patients. The field hospital was designated as a COVID–19 specific medical institution exclusively for moderately ill patients, with mainly elderly patients aged over 65 years, patients with underlying diseases at a high risk of severe COVID–19, and patients with oxygen demands not requiring mechanical ventilation. The purpose of this report is to describe the details of the field hospital and the epidemiological characteristics of the patients. Methods: COVID–19 patients admitted between May 18 and October 23, 2020 were retrospectively analyzed. Results: During the study period, 399 patients were hospitalized. Of the 388 new cases, oxygen was administered to 57 patients (14.7%) at the time of admission and 103 patients (26.5%) during hospitalization. Of the 103 patients, 90 (87.3%) received steroid treatment. Thirty–seven patients (9.5%) had a high oxygen demand of 6L/min or more; of these, 12 (3.1%) were transferred to intensive care facilities, and 15 (3.9%) died. Conclusion: The temporary COVID–19 field hospital dedicated to moderate illness possibly contributed to preventing progression to critical COVID–19.

Endoscopic resection, particularly endoscopic submucosal dissection (ESD), for colorectal cancers enables a precise pathological diagnosis and safe R0 resection. The recurrence rate after ESD is generally extremely low, with annual surveillance colonoscopy recommended. However, surveillance may not be considered for super-elderly patients owing to their condition. This is a case report of an 85-year-old man in whom curative resection was achieved for an intramucosal adenocarcinoma with ESD. The patient presented with a hypoechoic mass located in his lower right abdomen, diagnosed via surveillance abdominal ultrasound. He had undergone curative ESD for intramucosal cecal cancer 2 years prior. Colonoscopy revealed a type 2 epithelial tumor at the proximal aspect of the ESD scar. Ileocolic resection with lymph node dissection was performed. An epithelial tumor and well-differentiated adenocarcinoma but not a submucosal tumor was detected in the mucosal layer. The lesion was diagnosed not as a local recurrence after ESD but as a newly emerged original advanced cancer. After ESD for colorectal cancer, a newly developed advanced cancer may occur at the site of the ESD scar in a shorter term than usual. Surveillance colonoscopy after ESD is necessary even for super-elderly patients.

Background Upper gastrointestinal (GI) bleeding is the most important presentation of an aorto-duodenal fistula (ADF). Early diagnosis is difficult, and the disease is associated with high mortality. The present study aimed to examine the clinical and the endoscopic characteristics of ADF in eight patients who presented to our hospital. We also sought to clarify the diagnostic approach towards the disease. Methods The present study examined the clinical and the endoscopic/computed tomography (CT) characteristics of ADF in eight patients who were definitively diagnosed with this condition in a 12-year period at our hospital. Results The patients comprised of five men and three women, with a mean age of 69.8 years. Upper gastrointestinal bleeding was the chief complaint for all the patients. Out of these, two patients presented with shock. The patients’ mean haemoglobin at presentation was 7.09 g/dL, and the mean number of blood transfusions was 7.5. All patients had undergone intervention to manage an aortic pathology in the past. As the first investigation, an upper GI endoscopy in 5 and a CT scan in 3 patients were performed. In cases where CT scan was performed first, no definitive diagnosis was obtained, and the diagnosis was confirmed by performing an upper GI endoscopy. In cases where endoscopy was performed first, definitive diagnosis was made in only one case, and the other cases were confirmed by the CT scan. In some cases, tip attachments, converting to long endoscopes, and marking clips were found useful. Conclusions In patients who have undergone intervention to manage an aortic pathology and have episodes of upper gastrointestinal bleeding, ADF cannot be definitively diagnosed with only one investigation. In addition, when performing upper GI endoscopy in cases where an ADF is suspected, tip attachment, converting to a long endoscope, and using marking clips can be helpful.

Background Pre-operative kidney function is known to be associated with surgical outcomes. However, in emergency surgery, the pre-operative kidney function may reflect chronic kidney disease (CKD) or acute kidney injury (AKI). We examined the association of pre-operative CKD and/or AKI with in-hospital outcomes of emergency colorectal surgery. Methods We conducted a retrospective cohort study including adult patients undergoing emergency colorectal surgery in 38 Japanese hospitals between 2010 and 2017. We classified patients into five groups according to the pre-operative status of CKD (defined as baseline estimated glomerular filtration rate < 60 mL/min/1.73 m2 or recorded diagnosis of CKD), AKI (defined as admission serum creatinine value/baseline serum creatinine value ≥ 1.5), and end-stage renal disease (ESRD): (i) CKD(-)AKI(-), (ii) CKD(-)AKI(+), (iii) CKD(+)AKI(-), (iv) CKD(+)AKI(+), and (v) ESRD groups. The primary outcome was in-hospital mortality, while secondary outcomes included use of vasoactive drugs, mechanical ventilation, blood transfusion, post-operative renal replacement therapy, and length of hospital stay. We compared these outcomes among the five groups, followed by a multivariable logistic regression analysis for in-hospital mortality. Results We identified 3002 patients with emergency colorectal surgery (mean age 70.3 ± 15.4 years, male 54.5%). The in-hospital mortality was 8.6% (169/1963), 23.8% (129/541), 15.3% (52/340), 28.8% (17/59), and 32.3% (32/99) for CKD(-)AKI(-), CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD, respectively. Other outcomes such as blood transfusion and post-operative renal replacement therapy showed similar trends. Compared to the CKD(-)AKI(-) group, the adjusted odds ratio (95% confidence interval) for in-hospital mortality was 2.54 (1.90–3.40), 1.29 (0.90–1.85), 2.86 (1.54–5.32), and 2.76 (1.55–4.93) for CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD groups, respectively. Stratified by baseline eGFR (> 90, 60–89, 30–59, and < 30 mL/min/1.73 m2) and AKI status, the crude in-hospital mortality and adjusted odds ratio increased in patients with baseline eGFR < 30 mL/min/1.73 m2 among patients without AKI, while these were constantly high regardless of baseline eGFR among patients with AKI. Additional analysis restricting to 2162 patients receiving the surgery on the day of hospital admission showed similar results. Conclusions The differentiation of pre-operative CKD and AKI, especially the identification of AKI, is useful for risk stratification in patients undergoing emergency colorectal surgery.

Several large-scale studies have assessed the endovascular and surgical treatments for nonocclusive mesenteric ischemia (NOMI); nonetheless, the prognostic factors for NOMI remain unclear.In this single-center study, we retrospectively reviewed the electronic medical records of 197, 149 patients were retrieved from the inpatient database of our hospital from January 2011 to January 2020; 79 patients with NOMI were observed. A total of 44 patients who underwent laparotomy were statistically analyzed and divided into the survivor and non-survivor groups. Prognostic factors were compared between the 2 groups. Exploratory laparotomy based on a second-look surgery was the first treatment choice.The overall mortality rate was 61.3%, with a male-to-female ratio of 1.6:1. The median Sequential Organ Failure Assessment (SOFA) score was 11.06 [5.75-17.25]. The median SOFA score was 5 [interquartile range: 3-8] in the survivor group and 14.8 [interquartile range: 10.5-19] in the non-survivor group. The log-rank test showed a significant difference in the presence of diabetes mellitus (P = .025), hypoglycemia (P = .001), SOFA score ≥10 (P .001), hemoglobin levels ≥11 g/dL (P = .003), platelet count ≥12.9 × 104/μL (P = .01), lactate levels ≥2.6 mmol/L (P = .005), and base excess-3.0 (P.023). Multivariate analysis using the factors with significant differences revealed that SOFA score ≥10 (hazard ratio for death, 1.199; 95% confidence interval, 1.101-1.305; P .001) was an independent prognostic factor.The SOFA score can be used to assess disease severity. A SOFA score of ≥10 may be associated with increased mortality.

Introduction and importance Blunt abdominal aortic injury (BAAI) resulting from blunt abdominal trauma is rare; therefore, there are no standard guidelines for its treatment. Herein, we report the successful treatment of BAAI via endovascular aortic repair (EVAR) performed immediately after emergency laparotomy to repair a bowel injury. Case presentation A 78-year-old man was injured after being caught between a shovel car and the bumper of his own car for approximately 15 s. Upon arrival at the hospital, the patient was conscious and had stable vital signs, abdominal and low back pain, and numbness in the right lower limb. Computed tomography revealed contrast medium leakage into the mesentery, as well as aortic dissection and rupture. Hemostasis and intestinal resection were completed, and EVAR was performed immediately after abdominal closure. The patient was discharged from the hospital at 35 days after surgery. Clinical discussion In this case, there existed a risk of artificial blood vessel infection if reconstruction was simultaneously performed with intestinal resection. Symptoms of lower limb ischemia that were observed prior to surgery resolved. After open surgery, bleeding was controlled, and the patient's vital signs were stable. EVAR was performed as treatment for aortic injury, thereby reducing the risk of direct implant infection and enabling minimally invasive treatment. Conclusion EVAR may be useful for the treatment of BAAI in the presence of intestinal injuries, reduce the risk of implant infection, and allow for a one-time, minimally invasive treatment., Highlights • Blunt abdominal aortic injury (BAAI) resulting from blunt abdominal trauma is rare. • Endovascular aortic repair may be useful in the treatment of BAAI. • EVAR reduces the risk of implant infection.

Background: An aorto-duodenal fistula presents with upper gastrointestinal bleeding and hematemesis. Early diagnosis is difficult, and the disease is associated with high mortality. Sometimes, a small amount of bleeding, known as herald bleed, occurs repeatedly and may be judged as upper gastrointestinal bleeding, prompting emergency upper endoscopy. Diagnostic methods and surgical treatment during herald bleeding are important for saving lives. However, most fistulas form in the horizontal duodenum, and active bleeding is rarely found in patients with herald bleeding. Moreover, an aorto-duodenal fistula is rarely diagnosed based on upper endoscopy alone. Methods: The present study examined the clinical and endoscopic characteristics of aorto-duodenal fistula in eight patients who underwent upper endoscopy before diagnosis at our hospital. It also sought to clarify how aorto-duodenal fistula can be appropriately diagnosed. Results: All patients had a history of aortic treatment, and many could not be diagnosed by computed tomography scan or upper endoscopy alone. Regarding the endoscopic findings, patients were seen to have stent/vascular prosthesis exposure, which is diagnostic of aorto-duodenal fistula as well as pulsatile lesions and massive fresh bleeding of obscure origin in the duodenum. Conclusions: If the diagnosis is unclear, clinicians may need to observe the horizontal duodenum using a fitted tip attachment or long scope. Since vital signs may fluctuate during endoscopy, a series of tests should be performed immediately. Proactive placement of marking clips in likely areas of the fistula may facilitate diagnosis via computed tomography. The present results demonstrate that proper diagnosis and prompt surgical treatment save lives in patients with aorto-duodenal fistula.

Localization of the small bowel bleeding site with intraoperative angiography and indocyanine green injection., Aim Bleeding in the small bowel rarely occurs, and its treatment is challenging. Surgery is sometimes required in unstable patients; however, intraoperative identification of the bleeding site is extremely difficult. Many methods have been reported, but no standard strategy has been established yet. Here, we aimed to assess the safety and feasibility of intraoperative angiography with indocyanine green staining to accurately identify small bowel bleeding sites. Methods This retrospective study analyzed contrast‐enhanced computed tomography images of patients (n = 8) with small bowel extravasation who underwent surgery. If extravasation or other vessel abnormalities that were potential bleeding sites were detected on intraoperative angiography, a microcatheter was placed as close as possible to the extravasation site. Laparotomy was carried out, and 3–5 mL indocyanine green was injected through the microcatheter. The green‐stained segment of the small bowel was resected. Results Seven of the eight patients had positive angiographic findings and underwent bowel resection. The eighth patient had no abnormalities and hence did not undergo laparotomy. The rate of hemostatic success among the resected cases was 85.7% (six of seven cases). The resected specimens showed pathologic features in six of the seven patients (85.7%), all of whom achieved hemostasis. One patient had pneumonia and congestive heart failure that required longer hospital stay, but no mortality occurred. Conclusions Intraoperative angiography with indocyanine green injection, followed by resection for massive small bowel bleeding is effective. This can be a therapeutic option for hemodynamically unstable patients.

Summary: Background/objective: Patients with left-sided malignant colorectal obstruction require emergency treatment. Emergency stoma surgery has traditionally been recommended, however many stomas became permanent, decreasing patient quality of life. Recently, self-expandable metallic stents (SEMS) and transanal decompression tubes (TDT) have become widely used decompression methods to avoid stoma surgery. In this study, we evaluated: 1) the efficacy of SEMS compared with TDT and emergency surgery (ES) to avoid permanent stomas; and 2) the safety and success rate of each treatment. Methods: We retrospectively reviewed data from 56 patients who underwent SEMS, TDT, or emergency surgery for malignant left-sided colon obstruction. We compared the permanent stoma rate of each group, and assessed whether or not each treatment was an independent risk factor for permanent stomas. We compared morbidity and mortality for each treatment group (SEMS, TDT, ES), and the success rate of the decompression procedures (SEMS and TDT). Results: The permanent stoma rates in the SEMS, TDT, and ES groups were 5.3%, 50.0%, and 56.0%, respectively. Emergency surgery (vs. SEMS) and TDT (vs. SEMS) were independent risk factors for permanent stomas, as was age ≥ 75 years. Operative morbidity, mortality, and hospital stay were not different between groups. The success rate of SEMS was significantly higher than TDT; however, two deaths, including one perforation, occurred in the former group. Conclusion: SEMS seems to be effective in avoiding permanent stomas, but caution should be taken to avoid complications. Keywords: Emergency stoma surgery, Left-sided malignant colon obstruction, Self-expandable metallic stents, Transanal decompression tubes

Highlights • Hepatic gas gangrene is with a high progression and mortality rate. • Hepatic gas gangrene due to clostridial infection has a very low prognosis. • Malignancies and Diabetes Mellitus seem to increase the risk of developing hepatic gas gangrene. • Laparotomy is the procedure of choice to prevent lethal outcomes from hepatic gas gangrene., Introduction Liver gas gangrene is rare and has a low prognosis. This case, reports a successful treatment of hepatic gas gangrene using an open drainage technique, followed by antibiotics and hyperbaric oxygen therapy (HBO). Presentation of the case An 82-year-old male with a history of left hepatectomy and bile duct resection for hilar cholangiocarcinoma presented with chilling, lethargy and dyspnea. He had a history of diabetes mellitus, hypertension, atrial fibrillation, and angina pectoris. Physical examination revealed scleric icterus, right hypochondrium tenderness and percussion tenderness of the liver, with warm extremities. Laboratory findings revealed leukocytosis and increased levels of hepatobiliary enzymes. A computed tomography (CT) scan showed gas accumulation in an S8 lesion with portal vein gas. Percutaneous drainage was performed immediately, and broad-spectrum antibiotics were started, but the drainage was insufficient. Consequently, laparotomy drainage was carried out, followed by HBO. No abscess was detected at one-year of follow-up. Discussion Hepatic gas gangrene progresses rapidly and has a high mortality rate. Malignant disease and diabetes mellitus may be predisposing factors. While half of non-clostridial cases survive, most cases of hepatic gas gangrene are associated with clostridial infection and have a fatal outcome. Conclusion All survival cases of hepatic gas gangrene were treated by laparotomy drainage, thus immediate laparotomy seems essential to prevent a fatal outcome.

Highlights • Small intestinal metastasis from oesophageal carcinoma is extremely rare. • Most cases of it involve male patients with squamous cell carcinoma. • Most cases are associated with ileus or perforation with fatal outcome. • The combination of resection and chemo-radio-therapy seems to be essential., Introduction Small intestinal metastasis from oesophageal carcinoma is rare. We report a case of small intestinal metastases from oesophageal carcinoma presenting as a perforation and discuss the aetiology with other cases of small intestinal metastasis from oesophageal carcinoma reported in previous literature. Presentation An 86-year-old man presented with fever and coughing. He had choked while eating and had history of weight loss. He was diagnosed with aspiration pneumonia. Two days after the admission, he complained of abdominal pain. Physical examination revealed guarding and rebound tenderness in the upper abdomen. A contrast computed tomography of the abdomen showed ascites, free air, and irregular thickness of the small intestinal walls. Small intestinal perforation was noted, and surgical resection of the small intestine was performed. The pathological findings of the resected small intestine revealed ulcers with squamous cell carcinoma, and upper gastrointestinal endoscopy demonstrated oesophageal tumour, whose biopsy revealed squamous cell carcinoma. A diagnosis of small intestinal metastases from oesophageal carcinoma was made, but the patient died one month after the diagnosis. Discussion Most cases found in the literature of oesophageal tumour involve squamous cell carcinoma with male patients, and specific symptoms are divided into obstruction and perforation. All patients with small intestinal metastasis from oesophageal carcinoma who survived were treated by a combination of resection and radiation and/or chemotherapy; thus, immediate treatments seem essential to improve the prognosis. Conclusion Physicians should keep in mind the possibility of small intestinal metastasis when patients with a history of oesophageal cancer have abdominal symptoms.

Background: In Japan, laparoscopic distal gastrectomy (LDG) is common for early gastric cancer. Formerly, we used to verify the location of the marking clip to decide the proximal incisional line with our hand, through a small epigastric incision. In 2015, we introduced intracorporeal reconstruction and started to decide the incisional line using intraoperative fluoroscopy. Herein, we aimed to evaluate the efficacy and safety of intraoperative fluoroscopy in LDG. Patients and Methods: A total of 19 patients were included in this retrospective observational study. On the day before operation, we endoscopically clipped several points located 2 cm proximal to the tumour edge to cover about half of the tumour. After lymph node dissection, we incised the stomach with an endoscopic linear stapling device, including the previously placed clips, guided by intraoperative fluoroscopy. Reconstruction was performed in all patients who underwent Billroth I and Roux-en-Y procedures. Results: No complications were observed during pre-operative endoscopic clipping or intraoperatively. On pathological examination, all resected specimens had negative margins, and the mean distance from the tumour edge was 28.5 ± 16.5 (13–60) mm. Conclusion: Stomach resection with intraoperative fluoroscopic guidance was safe and effective.

Background Pneumothorax is a rare complication of coronavirus disease 2019, and many of its associated factors are related to mechanical ventilation. We investigated the incidence and clinical features of patients with pneumothorax and coronavirus disease 2019 at a field hospital for patients who did not require intubation. Materials and methods An isolated field hospital for COVID-19 patients who did not require ventilation was constructed. Patients who developed pneumothorax were extracted and reviewed retrospectively. Results Between May 2020 and February 2021, 1061 patients were admitted to this field hospital. Among them, eight patients (0.75%, three men and four women) developed pneumothorax. The mean age at incidence was 79.9 (range: 20–96) years; all patients were over the age of 80 years, except one 20-year-old woman. Six of these eight patients (75%) died. Conclusion Although pneumothorax is a rare complication of coronavirus disease-2019, it is predictive of a poor prognosis in older-adult patients.

Introduction There are no reports regarding sigmoid colon strangulation caused by bilateral fallopian tubes, which is a rare type of large bowel obstruction. Herein, we report a case of successful laparoscopic treatment of sigmoid colon strangulation. Presentation of case A 54-year-old woman presented to our hospital with intermittent abdominal pain. Her medical history was significant for endometriosis; however, there was no surgical history. The physical examination revealed tenderness over the lower abdomen. CT scan shows closed loop obstruction of sigmoid colon. Exploratory laparoscopy was performed, and a sigmoid colon strangulated by bilateral fallopian tubes was detected. The adhesions consisting of bilateral fallopian tubes were dissected laparoscopically. The patient's postoperative course was uneventful, with no complications. Discussion The most common cause of large bowel obstruction (LBO) is colorectal cancer, including volvulus and diverticulitis. In this case, the adhesion of both the right and left fallopian tubes caused LBO, and it is conceivable that the etiology involved is endometriosis. Few cases have reported bowel obstruction associated with a fallopian tube, and the laparoscopic approach is very rare. In our case, we immediately performed laparoscopic exploration before colon strangulation led to necrosis or perforation. Therefore, we succeeded in releasing the strangulation laparoscopically. Conclusion We report a case of sigmoid colon strangulation that was treated laparoscopically. This approach can be the treatment of choice for sigmoid colon strangulation., Highlights • A first case of successful laparoscopic treatment of sigmoid colon strangulation by fallopian tubes • A 54-year-old woman with intermittent abdominal pain • Exploratory laparoscopy revealed sigmoid colon strangulated by fallopian tubes. • Laparoscopic exploration done before strangulation led to necrosis or perforation. • This approach can be the treatment of choice for sigmoid colon strangulation.

Highlights • CT or MRI scan is crucial in the diagnosis of adventitial cystic disease (ACD). • Surgery is the first line in the treatment of ACD at the popliteal artery. • The short saphenous vein was successfully employed in bypass graft surgery., Introduction Adventitial cystic disease is relatively rare vascular disease, frequently occurred in the popliteal artery. No definitive treatment has been established yet. Prentation of case A 53-year-old woman presenting intermittent claudication of the right leg was diagnosed as adventitial cystic disease of popliteal artery. Percutaneous balloon dilation yielded an immediate recurrence. The disease was successfully treated by bypass grafting utilizing the short saphenous vein to replace the part of the popliteal artery containing the adventitial cyst. No postoperative complication was found six months after surgery. Discussion Comparing to a great saphenous vein, a short saphenous vein as a material of bypass graft has a significant advantage, as only a single surgical field is necessary. Conclusion We propose that bypass graft surgery employing a short saphenous vein is worth considering as a treatment of adventitial cystic disease at the popliteal artery.

Highlights • Liver gas gangrene is a rare condition with a highly mortality rate. • Development of liver gas gangrene is associated with host conditions such as malignancy and immunosuppression. • We report a case of liver gas gangrene after biliary surgery which is one of the risks of the liver parenchymal infection., Introduction Liver gas gangrene is a rare condition with a highly mortality rate. It is mostly associated with host factors, such as malignancy and immunosuppression. Presentation of case A 57-year-old female was admitted to our hospital with abnormalities of her serum hepato-biliary enzymes. She had a history of hypertension, diabetes mellitus, cerebral infarction, and chronic renal failure. She was diagnosed with bile duct cancer of the liver hilum and a left hepatectomy was carried out, with extrahepatic bile duct resection. Initially her post-operative state was uneventful. However, she suddenly developed melena with anemia on post-operative day (POD) 18. A Computed tomography (CT) examination on POD 19 revealed a massive build up of gas and portal gas formation in the anterior segment of the liver. Although we immediately provided the drainage and a probe laparotomy, she died on POD 20 due to shock with disseminated intravascular coagulation. Discussion Liver gas gangrene is rare and has a high mortality rate. This case seems to have arisen from an immunosuppressive state after major surgery with biliary reconstruction for bile duct cancer and subsequent gastrointestinal bleeding, leading to gas gangrene of the liver.

Highlights • A kidney transplant recipient presented with abdominal pain and vomiting. • Computed tomography confirmed a diagnosis of renal paratransplant hernia. • Incarcerated small bowel was seen in the retroperitoneum via a peritoneal defect. • Immunosuppressed patients can benefit from the laparoscopic treatment of RPH., Introduction There are limited reports regarding renal paratransplant hernia (RPH), which is a rare type of internal hernia. Herein, we report a case of successful laparoscopic treatment of RPH. Presentation of case A kidney transplant recipient presented to our emergency department with a 6-h history of abdominal pain and vomiting. The patient had received a living-related donor kidney transplantation and native nephrectomy in our hospital last year. Computed tomography (CT) confirmed a diagnosis of RPH. We performed laparoscopic exploration, and the findings showed an incarcerated small bowel in the retroperitoneal space through a peritoneal defect. Short laparotomy was performed to resect the non-viable bowel. The peritoneal defect was opened adequately. The patient’s postoperative course was uneventful, with no complications. Discussion RPH is an uncommon variant of internal hernia, which is a rare surgical complication after kidney transplantation. Early diagnosis and treatment are important once RPH develops. Due to immunosuppression in kidney transplant recipients, typical signs of peritonitis were not observed. This event can be critical to the patient. Laparoscopic surgery has recently become a treatment option for small bowel obstructions. We believe that this surgical procedure is useful for patients with RPH. Conclusion We report a case of RPH treated laparoscopically. This approach can be a treatment of choice for RPH.

Background. Thoracic endovascular aortic repair of an aortoesophageal fistula is an effective emergency treatment for patients with T4-esophageal cancer, as it prevents sudden death, and is a bridge to surgery. However, the course of unresectable malignant aortoesophageal fistula treated with thoracic endovascular aortic repair alone is not well-known. Case Presentation. We report a 67-year-old Japanese man with T4-esophageal cancer who experienced a chemoradiation-induced aortoesophageal fistula and was rescued with thoracic endovascular aortic repair. He recovered after the procedure and survived for 4 additional months with management of a mycotic aneurysm and secondary aortoesophageal fistula with the exposure of the stent graft into the esophagus. Thoracic endovascular aortic repair of aortoesophageal fistula with T4-esophageal cancer extended life for nearly an average of 4 months in the reported cases. As a postoperative complication, the exposure of the stent graft into the esophagus is rare but life-threatening; the esophageal stent insertion was effective. Conclusions. With postoperative management advances, thoracic endovascular aortic repair can improve survival and increase the quality of life of patients with T4-esophageal cancer.

Background: To investigate the efficacy of electrical diaphragm pacing (DP) for sleep condition in patients with amyotrophic lateral sclerosis (ALS). Method: We investigated 5 Japanese ALS patients without positive-pressure mechanical ventilation (3 men and 2 women, aged 59.6 ± 9.6 years). All of them were implanted NeuRx RA/4 Diaphragm Pacing System R (NeuRx) in the diaphragm laparoscopically. We assessed physical status and polysomnographic recordings before implantation and after 6 months of conditioning with DP turned on. Results: 4 patients completed the evaluation. Sleep condition showed the tendency to improve far from getting worse despite of deterioration of physical status and respiratory function. Conclusion: DP with NeuRx might assist the sleep condition in ALS patients at least in 6 months of follow up.

Respiratory insufficiency is a critical problem in amyotrophic lateral sclerosis (ALS) patients. We herein present the case of an autopsied patient with sporadic ALS who underwent diaphragm pacing (DP). The pathology showed several localized adhesions with a markedly atrophied diaphragm. A marked loss of motor neurons with Bunina bodies and phosphorylated TDP-43 positive inclusions was found in the spinal cord and primary motor cortex. Mild hyalinization and a few multinucleated giant cells were present around the electrode tracks in the diaphragm. However, no infiltration of inflammatory cells was detected. Our findings suggest that full-time DP might not cause severe damage to adjacent diaphragm tissue.

Background Lumbar arterial bleeding is a severe condition. Surgical exploration is not indicated because of its rich collateral flow. Transarterial embolization (TAE) is reportedly effective, but there have been cases of failure. It may be a time-consuming procedure for patients with multiple bleeding sources or those with poor vital signs. In this case series, we used endovascular aneurysm repair (EVAR) instead of TAE. Method In this case series, we described 4 male patients (2 with traumatic injury, 1 with iatrogenic injury, and 1 with drug-induced hypocoagulability) with lumbar arterial bleeding. The reasons we chose EVAR are because 2 patients had poor vital signs, one patient was a technically difficult case for selective cannulation, and one patient had accompanying aortic dissection. Result In all patients, EVAR was performed successfully, and hemostasis was obtained although one patient died of pneumonia on postoperative day 23. Conclusions EVAR is an effective alternative for lumbar arterial bleeding although TAE is a first choice of treatment.

Highlights • Fenestration is the definitive treatment for symptomatic/complicated liver cysts. • NOTES, which has been reported recently, enables surgery without scars. • Multiple clinical and technological barriers impede further progress with NOTES. • Our safe and unique method enables minimally invasive surgery with small incisions. • This “scarless surgery” is expected to yield some clinical benefits., Introduction Symptomatic or complicated liver cysts sometimes require surgical intervention and laparoscopic fenestration is the definitive treatment for these cysts. We performed minimally invasive surgery, hybrid natural orifice transluminal endoscopic surgery (NOTES) without scarring, for a huge liver cyst. Presentation of case An 82-year-old female presented with a month-long history of right upper abdominal pain. We diagnosed her condition as a huge liver cyst by morphological studies. She denied any history of abdominal trauma. Her serum CEA and CA19-9 were normal and a serum echinococcus serologic test was negative. Laparoscopic fenestration, using a hybrid NOTES procedure via a transvaginal approach, was performed for a huge liver cyst because we anticipated difficulty with an umbilical approach, such as single incision laparoscopic surgery (SILS). Her post-operative course was uneventful and she was discharged from our hospital three days after surgery. Pain killers were not required during and after hospitalization. No recurrence of the liver cyst or bulging was detected by clinical examination two years later. Discussion A recent trend of laparoscopic procedure has been towards minimizing the number of incisions to achieve less invasiveness. This hybrid NOTES, with a small incision for abdominal access, along with vaginal access, enabled painless operation for a huge liver cyst. Conclusion We report a huge liver cyst treated by hybrid NOTES. This approach is safe, less invasive, and may be the first choice for a huge liver cyst.

症例は69歳，女性．頭痛，発熱を主訴に当院受診．項部硬直を認める以外異常な神経所見はなかったが，髄液検査にて高度の細胞数上昇を認め，髄膜炎の診断にて内科に入院し，抗菌薬治療を行った．入院時の髄液培養は陰性だったが，血液培養にてStreptococcus bovisが検出されたため，軽快退院後，消化管腫瘍精査を行ったところ，S状結腸に2型の癌を認めたため外科へ再入院し，S状結腸切除術，D3郭清を施行．病理結果は中分化腺癌，ss，ly1，v1，n1，Stage IIIaであった．本邦では，Streptococcus bovisと大腸癌との関連性の認識がまだまだ低いと考えられるため，文献的知見を加えて報告する．