Clinical outcomes after surgical decompression of median arcuate ligament syndrome-An observational study.

BACKGROUND AND OBJECTIVES: Median arcuate ligament syndrome is caused by compression and stenosis of the celiac artery. Incision of the median arcuate ligament improves persistent abdominal symptoms. The study aimed at evaluating the outcomes in patients who underwent median arcuate ligament syndrome decompression using a self-report questionnaire. METHODS: This single-center retrospective study included patients with median arcuate ligament syndrome who underwent decompression surgery between April 2021 and February 2023. The medical records were retrospectively reviewed. RESULTS: Ten patients were included in the study. Laparotomy and laparoscopic surgeries were performed in seven and three patients, respectively. The median operation time was 147 minutes. The median hospitalization period after the operation was seven days. The degrees of celiac artery stenosis before and after surgery were compared and the per cent diameter stenosis did not significantly improve; five of 10 patients (50%) had > 50% stenosis in the celiac artery after the operation. Compared to the baseline, the scores of upper gastrointestinal symptoms significantly improved during the six months' period (p < 0.001). Additionally, we evaluated the influence of post-operative per cent diameter stenosis and divided the patients into two groups (≥ 50% vs, < 50%). The scores of upper gastrointestinal (GI) symptoms in both groups improved significantly from baseline. However, the symptomatic improvement at six months in the post-operative per cent diameter stenosis < 50% group was significantly greater than that in the ≥ 50% group (p = 0.016). The scores of lower gastrointestinal symptoms did not change significantly during the six-month period. CONCLUSION: Decompression surgery for median arcuate ligament syndrome could improve upper gastrointestinal symptoms regardless of the post-operative per cent diameter stenosis.

[BRCA2 Mutation Profile in a Proband with Hereditary Breast and Ovarian Cancer-Two Germline Pathogenic Variants Aligned in the Cis Position].

We report the first Japanese case of hereditary breast and ovarian cancer(HBOC)carrying 2 germline pathogenic variants (GPVs)in the BRCA2 gene. Genetic testing of the BRCA1 and BRCA2 genes was performed in a young woman with HBOC and 2 GPVs were identified in the BRCA2 gene. Since simultaneous GPVs in both parental alleles(ie, trans)in the BRCA2 gene is diagnostic of Fanconi anemia, which is characterized by bone marrow dysfunction and susceptibility to malignancy, we genetically tested her relatives. The same variants were revealed, and both variants were located in the cis position. For patients with multiple GPVs in the BRCA2 gene, we should consider genetic testing of the relatives to confirm whether the variants are located in the cis or trans position under appropriate genetic counseling.

The Sasaki-W anastomosis for recurrent Crohn's disease stenosis after the Kono-S anastomosis.

BACKGROUND: Postoperative recurrence is frequently encountered in the management of patients with Crohn's disease and is most often found at the anastomotic site. A novel technique, the Sasaki-W anastomosis, is an antimesenteric cutback end-to-end isoperistaltic anastomosis. We report a patient with Crohn's disease who underwent partial intestinal resection for postoperative anastomotic stenosis, reconstructed with the Sasaki-W anastomosis, after initial intestinal resection reconstructed with a Kono-S anastomosis. CASE PRESENTATION: A 30-year-old male was diagnosed with Crohn's disease and treated with mesalamine and adalimumab, and he underwent ileocecal resection using the Kono-S anastomosis at the time of diagnosis. He was treated with infliximab without any symptoms or recurrence for 7 years. He was admitted presenting with upper abdominal pain. Physical examination showed mild tenderness and distension in the upper abdomen. Laboratory data showed no remarkable findings. Computed tomography scan showed wall thickening in the ileum with proximal dilation and fluid retention. Non-operative management with antibiotics and fasting did not improve the symptoms within 7 days. Ten days after admission, ileocecal resection reconstructed with the Sasaki-W anastomosis was performed. At operation, there was a 15-cm intestinal stenosis at the site of the previous Kono-S anastomosis. The transverse colon and ileum were reconstructed with the Sasaki-W anastomosis. The postoperative course was uneventful, and the patient was discharged 17 days postoperatively. The patient had no obstructive symptoms and no findings consistent with bowel obstruction were observed on computed tomography scan one year postoperatively. CONCLUSIONS: The Sasaki-W anastomosis is a viable option for intestinal reconstruction in patients with postoperative recurrence after a Kono-S anastomosis.

Optimal tentative abdominal closure for open abdomen: a multicenter retrospective observational study (OPTITAC study).

BACKGROUND: Primary fascia closure is often difficult following an open abdomen (OA). While negative-pressure wound therapy (NPWT) is recommended to enhance successful primary fascia closure, the optimal methods and degree of negative pressure remain unclear. This study aimed to elucidate optimal methods of NPWT as a tentative abdominal closure for OA to achieve primary abdominal fascia closure. MATERIALS AND METHODS: A multicenter, retrospective, cohort study of adults who survived OA greater than 48 h was conducted in 12 institutions between 2010 and 2022. The achievement of primary fascia closure and incidence of enteroatmospheric fistula were examined based on methods (homemade, superficial NPWT kit, or open-abdomen kit) or degrees of negative pressure (<50, 50-100, or >100 mmHg). A generalized estimating equation was used to adjust for age, BMI, comorbidities, etiology for laparotomy requiring OA, vital signs, transfusion, severity of critical illness, and institutional characteristics. RESULTS: Of the 279 included patients, 252 achieved primary fascia closure. A higher degree of negative pressure (>100 mmHg) was associated with fewer primary fascia closures than less than 50 mmHg [OR, 0.18 (95% CI: 0.50-0.69), P =0.012] and with more frequent enteroatmospheric fistula [OR, 13.83 (95% CI: 2.30-82.93)]. The methods of NPWT were not associated with successful primary fascia closure. However, the use of the open-abdomen kit was related to a lower incidence of enteroatmospheric fistula [OR, 0.02 (95% CI: 0.00-0.50)]. CONCLUSION: High negative pressure (>100 mmHg) should be avoided in NPWT during tentative abdominal closure for OA.

Laparoscopic Heller myotomy and Dor fundoplication following an unsuccessful peroral endoscopic myotomy.

BACKGROUND: Achalasia is an esophageal motility disorder that presents as dysphagia and severely affects quality of life. An esophageal myotomy has been the golden standard for treatment. Peroral endoscopic myotomy (POEM) as a first-line therapy has an acceptable outcome. However, after the clinical failure of POEM, appropriate second-line therapy is rather controversial. Here, we present the first published case in English of a patient who was successfully treated using laparoscopic Heller myotomy (LHM) with Dor fundoplication following an unsuccessful POEM. CASE PRESENTATION: A 64-year-old man with type 1 achalasia who had been previously treated with POEM visited our hospital for further treatment. After undergoing LHM with Dor fundoplication, his Eckardt score improved from 3 to 0 points. On a timed barium esophagogram (TBE), the barium height improved from 119 mm/119 mm (1 min/5 min) to 50 mm/45 mm. No significant complications have occurred postoperatively for 1 year. CONCLUSION: Treating refractory achalasia is challenging, and treatment options are controversial. LHM with Dor fundoplication after POEM could be a safe and efficient option for the treatment of refractory achalasia.

Transrenal Ureter Embolization for Refractory Urine Leaks from Iatrogenic Ureteric Injury Following Colorectal Surgery.

We present the cases of two patients who underwent ureteral occlusion using coils and/or Amplatzer Vascular Plug with N-butyl cyanoacrylate glue after extensive advanced rectal surgery. Both patients had complex urine leaks unresponsive to urinary diversion. In view of the progress of the disease and the history of polysurgery, reconstructive surgery or anterograde ureteral stent insertion was not chosen. All patients had immediate resolution of urinary leakage after ureteral embolization, resulting in symptom relief throughout the follow-up period. There were no procedure-related complications or side effects.

Normalization of Flow in the Common Hepatic Artery after Decompression of Median Arcuate Ligament Syndrome with Diminution of a Pancreatoduodenal Arcade Aneurysm.

Median arcuate ligament syndrome (MALS) is caused by constriction of the celiac artery (CA) by the median arcuate ligament of the diaphragm. Ligament release improves perfusion of the CA, resulting in resolution of abdominal symptoms. A 51-year-old female had postprandial abdominal pain for 10 years and underwent computed tomography (CT) scan showing severe stenosis of the CA with pancreatoduodenal arcade aneurysm formation. MALS was diagnosed, and open median arcuate ligament incision was performed to decompress the CA. Intraoperative ultrasonography showed bidirectional turbulent flow in the common hepatic artery (CHA). The median arcuate ligament was uneventfully incised, and compression of the CA released. The perfusion in the CHA was changed to an antegrade direction, and the flow increased. Seven days after the laparotomy, the patient was discharged uneventfully. Follow-up CT scan 20 days after operation showed a diminished pancreatoduodenal arcade aneurysm and inferior pancreatoduodenal artery. Epigastric pain and postprandial distress symptoms were improved. In conclusion, perfusion of the CHA became normalized after median arcuate ligament release. Surgical intervention for MALS not only improved blood flow in the tributaries but also diminished the pancreatoduodenal arcade aneurysm.

Important risk factors for gallstones after laparoscopic gastrectomy: a retrospective study.

BACKGROUND: The frequency of gallstones is higher in patients who have undergone gastrectomy than in the general population. While there have been some studies of gallstone formation after open gastrectomy, there are few reports of gallstones after laparoscopic gastrectomy (LG). Therefore, this study aimed to evaluate the incidence of gallstones after LG. METHODS: We retrospectively reviewed the records of 184 patients who underwent LG between January 2011 and May 2016 at Saiseikai Utsunomiya Hospital. After gastrectomy, abdominal ultrasonography was generally performed every 6 months for 5 years. Patients who underwent cholecystectomy before LG, underwent simultaneous cholecystectomy, and did not undergo abdominal ultrasonography, with an observation period of < 24 months, were excluded from the study. Finally, 90 patients were analyzed. Laparoscopic cholecystectomy was performed whenever biliary complications occurred. Patient characteristics were compared using the two-tailed Fisher's exact test or Chi-square test. In addition, the risk factors for postoperative gallstones were analyzed using logistic regression analysis. RESULTS: Among the 90 patients included in this study, 60 were men (78%), and the mean age was 65.5 years. Laparoscopic total gastrectomy was performed for 15 patients and laparoscopic distal gastrectomy for 75 patients. D2 lymph node dissection was performed for 8 patients (9%), whereas 68 patients underwent LG with Roux-en-Y reconstruction (76%). Gallstones were detected after LG in 27 of the 90 (30%) patients. Multivariate analysis identified Roux-en-Y reconstruction and male sex as significant risk factors of gallstones after gastrectomy. The incidence of gallstones was significantly higher (53%) in male patients who underwent Roux-en-Y reconstruction. Symptomatic gallstones after laparoscopic cholecystectomy were found in 6 cases (6/27, 22%), and all patients underwent laparoscopic cholecystectomy. CONCLUSION: Roux-en-Y reconstruction and male sex were identified as significant risk factors for gallstones after LG.

Perioperative clinical parameters associated with short-term mortality after colorectal perforation.

PURPOSE: Although early prediction of mortality is useful for the management of patients with colorectal perforations, no significant perioperative predictive factors have been identified. The purpose of this study was to identify useful prognostic factors for patients with colorectal perforation. METHODS: This single-center retrospective study included consecutive patients undergoing emergency surgery for colorectal perforation from January 2012 to December 2019. The primary outcome was combined 30 day and in-hospital mortality. Patient- and disease-related factors obtained perioperatively were evaluated for mortality prediction. A scoring system was developed to enhance clinical utility. RESULTS: Overall, 146 patients were included and 20 (14%) died after surgery. Multivariate logistic regression identified five predictive factors: age, hemodialysis, uncommon perforation etiology, plasma albumin level, and decreased platelet count. The area under the receiver operating curve for the scoring system using these parameters was 0.894 (95% CI 0.835-0.952). Patients at high-risk of mortality were classified by the proposed score with a sensitivity of 90.0% and negative predictive value of 98.0%. CONCLUSION: This study identified five perioperative factors significantly associated with mortality of patients with colorectal perforation. Although these parameters predict mortality of patients with colorectal perforation using a score with high discrimination, further study is required to confirm these findings.

Delayed mesh infection after inguinal hernia repair: a case report.

Delayed deep mesh infection is a rare complication and the precise mechanism of its development is unknown. We report a case of delayed deep mesh infection after inguinal hernia repair. A 65-year-old man was admitted for treatment of colon cancer. He had a history of bilateral hernioplasty repaired with mesh-plugs 6 years previously. Fluorine-18 fluorodeoxyglucose positron emission tomographic scan showed positive findings in the right inguinal region similar to cancer. He had no complaints or findings to suspect mesh infection. Postoperative computed tomography scan over time revealed a fluid collection with inflammation. Eleven years after hernia repair, the patient presented with inflammation in the right inguinal region and emergency operation was performed. An abscess cavity was found and the mesh-plug covered with granulation tissue was removed. The patient remains free of recurrence of inguinal hernia or inflammatory changes after 3 years of follow-up.

Nonsurgical rescue after basket-stone impaction by endoscopic cutting of a metallic lithotripter and laser lithotripsy.

Video 1Endoscopic rescue strategy for basket-stone impaction.

Pharmacological treatment to reduce pulmonary morbidity after esophagectomy.

Esophagectomy for esophageal cancer is one of the most invasive procedures in gastrointestinal surgery. An invasive surgical procedure causes postoperative lung injury through the surgical procedure and one-lung ventilation during anesthesia. Lung injury developed by inflammatory response to surgical insults and oxidative stress is associated with pulmonary morbidity after esophagectomy. Postoperative pulmonary complications negatively affect the long-term outcomes; therefore, an effort to reduce lung injury improves overall survival after esophagectomy. Although significant evidence has not been established, various pharmacological treatments for reducing lung injury, such as administration of a corticosteroid, neutrophil elastase inhibitor, and vitamins are considered to have efficacy for pulmonary morbidity. In this review we survey the following topics: mediators during the perioperative periods of esophagectomy and the efficacy of pharmacological therapies for patients with esophagectomy on pulmonary complications.

The impact of blood type on the mortality of patients with severe abdominal trauma: a multicenter observational study.

Few studies have investigated the relationship between blood type and trauma outcomes according to the type of injury. We conducted a retrospective multicenter observational study in twelve emergency hospitals in Japan. Patients with isolated severe abdominal injury (abbreviated injury scale for the abdomen ≥ 3 and that for other organs < 3) that occurred between 2008 and 2018 were divided into four groups according to blood type. The association between blood type and mortality, ventilator-free days (VFD), and total transfusion volume were evaluated using univariate and multivariate regression models. A total of 920 patients were included, and were divided based on their blood type: O, 288 (31%); A, 345 (38%); B, 186 (20%); and AB, 101 (11%). Patients with type O had a higher in-hospital mortality rate than those of other blood types (22% vs. 13%, p < 0.001). This association was observed in multivariate analysis (adjusted odds ratio [95% confidence interval] = 1.48 [1.25-2.26], p = 0.012). Furthermore, type O was associated with significantly higher cause-specific mortalities, fewer VFD, and larger transfusion volumes. Blood type O was associated with significantly higher mortality and larger transfusion volumes in patients with isolated severe abdominal trauma.

Antithrombotic drugs have a minimal effect on intraoperative blood loss during emergency surgery for generalized peritonitis: a nationwide retrospective cohort study in Japan.

BACKGROUND: The effect of antithrombotic drugs on intraoperative operative blood loss volume in patients undergoing emergency surgery for generalized peritonitis is not well defined. The purpose of this study was to investigate the effect of antithrombotic drugs on intraoperative blood loss in patients with generalized peritonitis using a nationwide surgical registry in Japan. METHOD: This retrospective cohort study used a nationwide surgical registry data from 2011 to 2017 in Japan. Propensity score matching for the use of antithrombotic drugs was used for the adjustment of age, gender, comorbidities, frailty, preoperative state, types of surgery, surgical approach, laboratory data, and others. The main outcome was intraoperative blood loss: comparison of intraoperative blood loss, ratio of intraoperative blood loss after adjusted for confounding factors, and variable importance of all covariates. RESULTS: A total of 70,105 of the eligible 75,666 patients were included in this study, and 2947 patients were taking antithrombotic drugs. Propensity score matching yielded 2864 well-balanced pairs. The blood loss volume was slightly higher in the antithrombotic drug group (100 [10-349] vs 70 [10-299] ml). After adjustment for confounding factors, the use of antithrombotic drugs was related to a 1.30-fold increase in intraoperative blood loss compared to non-use of antithrombotic drugs (95% CI, 1.16-1.45). The variable importance revealed that the effect of the use of antithrombotic drugs was minimal compared with surgical approach or type of surgery. CONCLUSION: This study shows that while taking antithrombotic drugs is associated with a slight increase in intraoperative blood loss in patients undergoing emergency surgery for generalized peritonitis, the effect is likely of minimal clinical significance.

Cystic Pancreatic Neuroendocrine Tumor in a Patient with Neurofibromatosis Type 1.

Neurofibromatosis type 1 (NF-1) is strongly associated with neurofibromas and malignancies. Solid pancreatic neuroendocrine tumors (PanNETs) have been recently reported in patients with NF-1. PanNETs are always solid and rarely present with a cystic appearance due to central necrosis and hemorrhage caused by rapid growth. A 33-year-old female diagnosed with NF-1 at age 16 was referred for evaluation of a pelvic mass found on abdominal ultrasound. Magnetic resonance imaging showed a 6 cm solid pelvic mass adjacent to the left external iliac artery, and contrast-enhanced computed tomography scan showed a 3-cm solid para-aortic mass and a 3-cm cystic mass in the pancreatic tail. Endoscopic ultrasonography showed a cystic tumor with necrotic tissue and septa. Preoperative diagnosis was pancreatic cystic malignancy with para-aortic lymph node metastasis accompanied with a pelvic neurofibroma. These lesions were resected simultaneously. The specimen resected from the pancreas showed a necrotizing cystic tumor invading abutting lymph nodes. Immunohistochemical analysis showed positive chromogranin A and synaptophysin. The Ki-67 index was <1%, and the mitotic count was 1/10 in high power field. Therefore, a non-functional PanNET (grade G1) was diagnosed. The pelvic and para-aortic tumors were both neurofibromas. A cystic appearance is atypical for PanNET and makes preoperative diagnosis difficult. To the best of our knowledge, this is the first report of a cystic PanNET in a patient with NF-1.

Cholangiocarcinoma Presenting after Eight Years of Treatment of IgG4-Related Autoimmune Pancreatitis with Steroids.

Autoimmune pancreatitis (AIP) is characterized by pancreatic manifestations of IgG4-related disease. Malignancies in patients with AIP have been reported, but carcinoma of the bile duct is extremely rare. We report a patient with IgG4-related AIP who developed cholangiocarcinoma after 8 years of steroid treatment. A 76-year-old male presented with fever (37.8°C) due to biliary obstruction and cholangitis. He had been treated with steroids for 8 years to control inflammation due to IgG4-related AIP. During 8 years of treatment, hepatobiliary enzyme levels were well controlled within their normal range, but serum IgG4 levels remained elevated. A computed tomography scan showed intrahepatic bile duct dilatation. Magnetic resonance cholangiopancreatography showed obstructive changes at the junction of the cystic and common ducts. To relieve biliary obstruction, endoscopic bile duct drainage using a nasobiliary tube was performed, and cytology was Class IV. Aorto-caval lymph node enlargement was found at laparotomy, intraoperatively diagnosed as adenocarcinoma, and resection was abandoned. He died 4 months postoperatively. We report a patient with IgG4-related AIP complicated by cholangiocarcinoma which developed after 8 years of steroid treatment. Even if hepatobiliary markers are well controlled, periodic follow-up with imaging studies may facilitate detection of an early cholangiocarcinoma.

Mesenteric ischemia with pneumatosis intestinalis and portal vein gas associated with enteral nutrition: a series of three patients.

Enteral nutrition is usually associated with a low risk of intestinal complications. We report three non-critically ill patients who received enteral nutrition and developed mesenteric ischemia with pneumatosis intestinalis and hepatic portal vein gas. These findings are often considered to be indications for emergency surgery. In these three patients, prompt cessation of enteral nutrition avoided progression to intestinal necrosis obviating the need for intestinal resection, although one patient underwent surgical exploration. Follow-up computed tomography scan showed resolution of the radiologic findings, and all patients started enteral nutrition again without complications. All patients had comorbidities associated with atherosclerosis, which may have led to a mismatch between oxygen delivery and demand in the bowel, resulting in ischemia. To the best of our knowledge, this is the first report of successful management of mesenteric ischemia related to enteral nutrition in non-critically ill patients without resection. If the cause of mesenteric ischemia such as enteral nutrition, can be eliminated quickly, non-resectional and possibly nonoperative management can be a reasonable management option, with close follow-up and readiness for resection.

A prospective feasibility study of one-year administration of adjuvant S-1 therapy for resected biliary tract cancer in a multi-institutional trial (Tokyo Study Group for Biliary Cancer: TOSBIC01).

BACKGROUND: Although surgery is the definitive curative treatment for biliary tract cancer (BTC), outcomes after surgery alone have not been satisfactory. Adjuvant therapy with S-1 may improve survival in patients with BTC. This study examined the safety and efficacy of 1 year adjuvant S-1 therapy for BTC in a multi-institutional trial. METHODS: The inclusion criteria were as follows: histologically proven BTC, Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1, R0 or R1 surgery performed, cancer classified as Stage IB to III. Within 10 weeks post-surgery, a 42-day cycle of treatment with S-1 (80 mg/m2/day orally twice daily on days 1-28 of each cycle) was initiated and continued up to 1 year post surgery. The primary endpoint was adjuvant therapy completion rate. The secondary endpoints were toxicities, disease-free survival (DFS), and overall survival (OS). RESULTS: Forty-six patients met the inclusion criteria of whom 19 had extrahepatic cholangiocarcinoma, 10 had gallbladder carcinoma, 9 had ampullary carcinoma, and 8 had intrahepatic cholangiocarcinoma. Overall, 25 patients completed adjuvant chemotherapy, with a 54.3% completion rate while the completion rate without recurrence during the 1 year administration was 62.5%. Seven patients (15%) experienced adverse events (grade 3/4). The median number of courses administered was 7.5. Thirteen patients needed dose reduction or temporary therapy withdrawal. OS and DFS rates at 1/2 years were 91.2/80.0% and 84.3/77.2%, respectively. Among patients who were administered more than 3 courses of S-1, only one patient discontinued because of adverse events. CONCLUSIONS: One-year administration of adjuvant S-1 therapy for resected BTC was feasible and may be a promising treatment for those with resected BTC. Now, a randomized trial to determine the optimal duration of S-1 is ongoing. TRIAL REGISTRATION: UMIN-CTR, UMIN000009029. Registered 5 October 2012-Retrospectively registered, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000009347.

Administration of Corticosteroids, Ascorbic Acid, and Thiamine Improves Oxygenation after Thoracoscopic Esophagectomy.

PURPOSE: The activity of corticosteroids, ascorbic acid, and thiamine against oxidative and inflammatory responses was evaluated in patients undergoing esophagectomy. This study was undertaken to investigate the effect of this combined therapy on lung dysfunction following esophagectomy. METHODS: In this retrospective before-after study, we compared the clinical course of consecutive patients undergoing thoracoscopic esophagectomy treated with the combination of corticosteroids, ascorbic acid, and thiamine between June and December 2018 with a control group treated with corticosteroids alone between January 2016 and May 2018. Outcomes included oxygenation (arterial partial pressure of oxygen (PaO2)/fractional concentration of inspired oxygen (FiO2) ratios), duration of mechanical ventilation and intensive care unit (ICU) length of stay. RESULTS: In all, 17 patients were included in this study (6 in the combination therapy group and 11 patients in the control group). Mean PaO2/FiO2 ratios in the combined therapy group were significantly higher than in the control group at all points during the observation period (p <0.001). In the combined therapy group, the duration of mechanical ventilation and ICU stay were significantly shorter (p <0.001, p = 0.009). CONCLUSIONS: This study suggests that combined therapy including corticosteroids, ascorbic acid, and thiamine may be effective in improving oxygenation after esophagectomy. Additional studies are required to confirm these preliminary findings.

[A Case of Duodenal Perforation during Bevacizumab Combination Chemotherapy in a Patient with Multiple Lung Metastasis after a Sigmoidectomy].

A 73-year-old man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. Two years after the operation, multiple lung metastasis was diagnosed and chemotherapy with bevacizumab, irinotecan, and TS-1®was started in the patient. However, epigastric pain developed 73 days after the initial course of chemotherapy. Abdominal CT revealed duodenal perforation and generalized peritonitis. Emergency operation with omental patch closure was immediately performed. The patient was discharged 15 days after the emergency operation without any complication. This is an extremely rare case of bevacizu- mab-related duodenal perforation.