Background：The strategies for pseudoaneurysms after pancreatectomy are being established. However, the measures are still extremely important.Methods：A total of 268 pancreatectomies （pancreaticoduodenectomy, n＝196 and distal pancreatectomy, n＝72） performed in our department from April 2011 to March 2019 were retrospectively examined for the results of treatment for pseudoaneurysms.Results：Out of 268 cases, the pseudoaneurysms were observed in 8 cases （3.0％）. Arterial embolization was performed in 7 cases. Two cases required laparotomy for stopping bleeding, but one of them died. The pseudoaneurysms were detected by dynamic CT on day 7 after surgery （3 cases）, sentinel bleeding （3 cases）, bloody bowel discharge （1 case） and hemorrhagic shock （1 case）, and the median period to identify them was 18 （7-71, range） days. Bacteria were detected by drain culture on day 3 after surgery in 5 cases, and intraperitoneal drain was replaced in 7 cases at the time of identification of pseudoaneurysms.Conclusions：Dynamic CT on day 7 after pancreatectomy are useful for searching for the pseudoaneurysms. Patients with early infection of drain discharge have a high risk of pseudoaneurysm development after pancreatectomy.

case 1：55-year-old female with hemorrhagic shock due to ruptured inferior pancreaticoduodenal artery aneurysm underwent decompressive laparotomy for abdominal compartment syndrome （ACS） after transarterial embolization （TAE）. There was no active bleeding at initial laparotomy, but active mesenteric hemorrhage and non-occlusive mesenteric ischemia （NOMI） were identified at relaparotomy. She passed away due to NOMI on the 2nd hospital day despite complete hemostatic mesenteric suture.case 2：53-year-old male with hemorrhagic shock due to ruptured middle colic artery branch aneurysm underwent decompressive laparotomy for ACS after TAE. There was active mesenteric hemorrhage at initial laparotomy and he underwent colectomy with hemostatic mesenteric suture. The anastomosis was achieved on the following day and he was discharged on the 14th hospital day.discussion：It is evident that decompressive laparotomy for ACS is useful; however the procedure increase the risk of rebleeding of critically ill patients with ruptured visceral artery aneurysm even though the hemostasis is achieved with TAE.

We report two cases of retroperitoneal bleeding caused by median arcuate ligament syndrome in which one alive and the other dead after Interventional radiology （IVR） and laparotomy. Case 1：A 67-year-old man was performed laparotomy for intestinal necrosis after angioembolization, and he got well. Case 2：A 53-year-old woman was performed laparotomy after angioembolization, however the bleeding was continuing. Therefore, we performed second angioembolization. Three days later, she passed away of the wide duodenal necrosis. Discussion：We thought that the required time to stop bleeding and the presence of intraperitoneal bleeding are the points of life and death. Although IVR tends to the first choice for diagnosis and treatment, we should recognize the therapeutic limitations. Conclusion：We should stop bleeding as early as possible not adhering to only one procedure.

Background：Management of isolated mesenteric injury is affected by the presence of bowel injury. This study will assess the necessity of laparotomy for mesenteric injury. Methods：We examined retrospectively trauma with mesenteric injury for 11-years at a trauma center. Thirty-seven patients diagnosed as isolated mesenteric injury at the time of admission without intraluminal air on CT were examined retrospectively. Result：Blunt trauma was 37 cases. Laparotomy was performed in 32 cases, and bowel injury was complicated in 17 cases （45.9%）. Comparison between isolated mesenteric injury cases and complicated bowel injury cases, there were no significant difference. In laparotomy case, 7 cases （46.6%） needed bowel resection due to ischemia. Eight cases were changed laparotomy after initial non-operative management, and 5 cases had bowel injury. Conclusion：Although CT scan is useful for diagnosing mesenteric injury, it is difficult to rule out bowel injury. The rate of surgical repair for mesenteric injury is high, laparotomy should be performed.

Background：The standard management of isolated mesenteric injury without intestinal injury is laparotomy. Some reports represent the usefulness of non-operative management （NOM） including interventional radiology （IVR） as the alternative therapy, but the indication was unclear. The objective of this study is to compare the contrast-enhanced CT （CECT） to operative findings, and investigate the optimal management for isolated mesenteric injury. Method：We experienced 25 mesenteric injuries required intervention from February 1, 2015 to January 31, 2020. Of them, 16 isolated injury cases were retrospectively analyzed. Results：Twelve cases （75%） had contrast blush on CECT, 9 cases （56.3%） were hemodynamically unstable. Interventions included 8 open repairs, 7 laparoscopic repairs （including 3 open conversion cases）, and one IVR. We can represent that preoperative CECT hardly reveal ①pattern of hemorrhage, ②complicated ischemic intestine, and ③range and degree, of injured mesentery. Isolated mesenteric injury often has the discrepancy between preoperative CECT and operative findings. Conclusion：The gold standard management of isolated mesenteric injury is laparotomy. The indication of laparoscopic repair or NOM including IVR should be carefully considered.

Background：Mesenteric injury with intestinal injury is relatively easy to diagnose and treat. However, the treatment policy（including surgery and interventional radiology）for single traumatic mesenteric injury（STMI）is controversial. Materials and methods：The medical records of 66 patients with mesenteric injury who were admitted to our hospital between January 2008 and December 2019 were retrospectively reviewed. A total of 31 cases were examined, patients with other intraperitoneal organ complications, including intestinal tract complications, were excluded. Results：In patients with STMI, ascites on computed tomography（CT）and positive peritoneal irritation sign were not related to laparotomy. The positive of shock vital, extravasation, and focused assessment with sonography for trauma were relevant to laparotomy. Laparotomy was performed on all patients with mesenteric injury of traumatic classification（according to the Japanese Association for the Surgery of Trauma Organ Injury Classification 2008（JAST-OIC 2008））Ⅱb and two patients with mesenteric injury of JAST-OIC 2008Ⅱa on preoperative contrast-enhanced CT findings. Conclusion：For STMI, all patients with preoperative diagnosis of mesenteric injury of JAST-OIC 2008Ⅰa could undergo NOM, while all patients with preoperative diagnosis of mesenteric injury of JAST-OIC 2008Ⅱb underwent laparotomy. Some patients with preoperative diagnosis of mesenteric injury of JAST-OIC 2008Ⅱa required laparotomy, so surgery should be considered, or the patient should be observed in an environment where emergency surgery can be performed.

Purpose：Examination of the relationship between prognosis of abdominal emergency general surgery （AEGS） and flail. Method：We defined frailty as one or more items applied following; Hypertension, ischemic heart disease, cancer bearing condition, Serum Alb value＜3.0g/dL, Elderly Daily Living Independence≧A1, Dementia Elderly Daily Living Independence Judgment≧IIa. We examined the comparative prognosis of the Frailty group （F group） and the NonFrailty group （NF group）, and the number of Frailty hits and the prognosis, for AEGS aged 65 years or older in our hospital between January 2015 and December 2017. 151 cases （84.8％） in the F group and 27 cases （15.2％） in the NF group. Postoperative complications were 59.6％ in the F group, 29.6％ in the NF group （p＜0.01）. The one-year survival rate （1yOS） was 70％ in the F group and 100％ in the NF group （p＜0.01）. When the number of applicable Frailty items was 3 or more, the prognosis was significantly worse （p＜0.01） compared with the case of 0-2 items （1yOS: 60.8％VS 84.2％）. Conclusion：The significance of the AEGS Frailty evaluation was suggested.

Purpose：Spontaneous hemopneumothorax （SHP） is a rare, but troublesome condition as it may cause an abrupt hemorrhagic shock. We clarify the clinical feathers of SHP. Methods：Here we report 9 cases of SHP from 2014 to 2018. Results：8 cases underwent chest tube drainage. Of these, 3 cases experienced hemorrhagic shock. Two of these 3 cases required urgent surgery. Of 6 cases without shock, 3 cases subsequently required surgery due to air leakage or increased blood loss. Eventually, 5 cases required surgery and 6 cases required blood transfusion. Video-assisted thoracoscopic surgery（V ATS） was performed in all cases and hemostasis was successfully achieved without any complications by cauterizing the abnormal vessels arose from the chest wall. Mean operative time was 83 minutes. The median hospitalization in surgery group was 7 days （4-11） compared to 9.5 days （6-11） in conservative therapy group. Discussion：VATS should be considered when the patient is diagnosed as SHP in order to prevent hemorrhagic shock requiring blood transfusion. Conclusion：Caution should be exercised even in patients with conservative therapy regardless of whether the chest tube was inserted or not.

Non-operative management （NOM） with stable hemodynamics is a standard, and highly successful treatment for abdominal trauma. However, there is no standard protocol for NOM. Our hospital created a NOM protocol in April 2011, and has implemented it ever since. We scrutinized the advantages and disadvantages of this protocol. We examined 126 cases of abdominal trauma treated with the NOM protocol from January 2013 to March 2018. Bed rest was recommended for 3 days （2-4 days） and strict nil per os for 3 days （3-4 days）. The NOM completion rate was 96％. We observed pseudoaneurysms in 13.5％ of the cases, and 11.1％ of the cases required an additional endovascular treatment. The complications included deep vein thrombosis （3.2％） and pneumonia （7.9％）. After discharge, no patients experienced delayed bleeding and there were no deaths. The protocol compliance rate was 19.8%. We modified the standard image evaluation and revised the protocol. The NOM protocol is effective and improves the quality of medical care.

Encapsulating peritoneal sclerosis （EPS） is the syndrome that causes intestinal adhesion and inflammatory capsules due to multiple surgical history or peritoneal dialysis, etc. and results in recurrent small bowel obstruction. In our experience, three of 22 cases undergone the small bowel anastomosis for two years were complicated by the postoperative leakage. All of them were EPS patients. One case was caused by anastomotic disruption, another was caused by intestinal injury during adhesiolysis, and the other was caused by the both of them. All leakages were treated with conservative therapy with drainage. In EPS patients, it is reported that they have high risk of anastomotic disruption and intestinal injury after small bowel anastomosis. Therefore, it is important to minimize adhesiolysis and intestinal resection. When the leakage occur, the drainage is effective for the treatment. In EPS patients surgeons should place some drainage tubes after small bowel anastomosis considering about the leakage.

Although phlegmonous gastritis usually deteriorates rapidly and is fatal disease, the diagnosis is very difficult and it is usually based on physical findings, radiological findings, and endoscopic findings for quick intervention. In our study, we investigated 6 phlegmonous gastritis cases, which were admitted to our hospital, for therapeutic strategy and operative method. All cases were diagnosed as phlegmonous gastritis without pathological findings to intervened as quick as possible, and we focused on the patientʼs vital sign and the localization of lesions for decision of treatment plan. Our study showed that we chose surgical therapy in the fatal cases, whereas we chose antimicrobial therapy in cases which were stable and the lesion was localized. Furthermore, the study also showed that it is useful to consider the vital sign and the localization of lesions for choosing the operative method.

A 62-year-old woman with a history of a pubic fracture due to a traffic accident 8 years ago was admitted to previous hospital because of left chest discomfort and nausea. CT revealed incarceration of a stomach into the left thoracic cavity. The patient was transferred to our hospital for the treatment. The next day laparoscopic surgery was performed. The stomach and the lateral segment of the liver were invaginated into the hernia orifice in the left diaphragm. The hernial components were successfully drawn back into the abdominal cavity. The hernia orifice was closed with nonabsorbable suture and reinforced with a mesh. The final diagnosis was incarcerated traumatic left diaphragmatic hernia with delayed onset. The postoperative course was uneventful, and the patient was discharged 12 days after the surgery. Laparoscopic surgery was considered one of effective method for relatively easy reduction and accurate evaluation of incarcerated organs.

An 84-year-old man was admitted to our hospital with a complaint of intermittent left-sided abdominal pain and anorexia. A week before his visit, he fell and bruised the same area. A contrast-enhanced CT scan revealed intercostal hernia complicated by incarceration. We performed laparoscopic surgery and the jejunum was incarcerated between the 10th-11th intercostal space. During an attempt to repair incarceration, contamination by the intestinal injury was found, so we sutured the damaged area extracorporeally and repaired with omentum. There are few reported cases of laparoscopic surgery for traumatic intercostal hernia and mesh repair is preferred. However, mesh repair is unlikely to be used in the cases in which infection is a concern by intestinal fluid. Laparoscopic repair using omentum was successful and maybe a useful option when the mesh repair was limited. This case is the first report of this procedure for traumatic intercostal hernia complicated by incarceration.

A 99-year-old man visited his doctor for abdominal pain and vomiting. He was diagnosed with an intestinal obstruction and referred to our hospital. A CT scan revealed a whirl sign located on right side of the stomach and an extended intestine on the left side of the stomach. It was difficult to identify the twisted portion. He was diagnosed with strangulation ileus, which required emergency surgery. It was revealed that the strangulated portion of the intestine was the terminal ileum to the ascending colon which was poorly fixed to the retroperitoneum. He underwent a right hemicolectomy. He was discharged 19 days post-operation. Ascending colon volvulus is rare and difficult to diagnose. However, a quick decision is required, because it can cause intestinal necrosis and perforation.

79-year-old man with diabetes mellitus presented to our hospital after suffering from a fever and abdominal pain. Abdominal computed tomography with contrast medium enhancement revealed a multilocular mass at the lateral segment of the liver. The patient’s pre-surgery diagnosis was a perforated liver abscess with panperitonitis. An emergency laparoscopic lavage and drainage were performed. Following treatment with antibiotics, a percutaneous transhepatic puncture, and drainage of the remaining liver abscess were performed. Post-operative progress was favorable, and the patient was discharged without complications. Liver abscess perforation has a high mortality rate and requires urgent treatment. Although laparoscopic surgery makes minimally invasive treatment possible, there have been reports that the increased abdominal pressure can cause bacteremia. For perforated liver abscess, a good outcome is obtained by laparoscopic damage control drainage, minimizing the pneumoperitoneum time in the initial surgery with minimal invasion.

A 38-year-old man was hospitalized with severe alcoholic acute pancreatitis. Despite treatment, he had persistent abdominal pain and fever. CT examination revealed gastric/duodenal/transverse colonic necrosis with fluid collection at twelve days of hospitalization. The patient was treated with percutaneous drainage to avoid surgery in the acute phase. After 47 days, CT indicated walled-off necrosis in the lower abdominal cavity. Percutaneous drainage was performed again. The patient’s condition stabilized, and minimal invasive treatment was employed to ensure adequate time for preparation for the surgery. Necrosectomy, necrotic intestinal resection, and reconstruction were performed 96 days after admission. Total pancreatectomy, total gastrectomy （Roux-en-Y anastomosis）, choledochojejunostomy, colostomy, and jejunostomy were completed. The patient was discharged 44 days after surgery without any postoperative complications.