Wandering Gallbladder: A Case Report

Differences in health care use and outcomes by the timing of in-hospital worsening heart failure

Objective To analyze the data of perioperative period of patients with biliary laparoscopic surgery during the 23 years of the PLA General Hospital, and to explore the safety of laparoscopic surgery in biliary surgery. Methods We retrospectively analyzed the clinical data of 11 419 consecutive patients underwent biliary laparoscopic surgery in PLA General Hospital between Apr. 1992 and Dec. 2014 according to the inclusion criteria. The data of biliary open surgery patients in the same period were selected as the control group to compare, and the postoperative complications of the two groups were analyzed. Results (1) From Apr. 1992 to Dec. 2014, 11 419 patients underwent laparoscopic surgery in the General Hospital of PLA among 23 years, and accounted for 56.33% of patients with biliary surgery. (2) In all patients, 2 patients died in the perioperative period, the mortality rate was 0.02%, 43 cases occurred complications, and the complication rate was 0.38%. The most common complications were biliary fistula, wound infection and abdominal infection. The incidence rate were 0.18%, 0.05% and 0.05%. Among the complications, 60.42% were Grade II compications and 4.17% were Grade V. (3)The most common diseases with complication after laparoscopic surgery were gallbladder benign disease and extrahepatic bile duct stones, accounted for 58.14% and 25.58%. (4) For gallbladder benign disease patients, the intraoperative bleeding volume, operation time, hospitalization days, complication rate, mortality rate of laparoscopic surgery were superior to open surgery[(15.6±26.1)ml、(1.1±0.5)h、(2.1±1.8)d、25 patients (0.22%)、1 patient (0.01%)] vs [(136.1±168.2)ml、(1.7±0.8)h、(9.8±5.4)d、25 patients (0.22%)、80 patients (4.42%)](P<0.01). For extrahepatic bile duct stones patients, the intraoperative bleeding volume, hospitalization days and complication rate of laparoscopic surgery were superior to open surgery [(44.4±46.1)ml、(5.4±5.7)h、11 patients (3.24%)] vs [(142.5±125.0)ml、(13.0±9.1)h、(9.8±5.4)d、84 patients (13.29%)] (P<0.01). Conclusions With the development of laparoscopic technology in biliary surgery, it is the most widely used in the gallbladder benign disease and extrahepatic bile duct stones, and the perioperative effect is better than that of the open surgery. Key words: Biliary surgery; Laparoscopic surgery; Open surgery; Complication

Clinical History: A ureteroduodenal fistula (UDF) is an uncommon diagnosis associated with patient morbidity, including recurrent urinary tract infections, pneumaturia, and flank pain. Surgical management may be complex because of extensive fibrosis and scarring surrounding the UDF site secondary to chronic inflammation. Physical Examination: The patient presented with right flank pain. Diagnosis: We report the case of a 42-year-old woman with history of a right UDF secondary to iatrogenic injury causing urine extravasation during a ureteroscopy and laser lithotripsy procedure at an outside hospital 1 year prior. The patient was previously managed with chronic ureteral stent exchanges before surgery. A retrograde pyelogram was performed before definitive surgery, which demonstrated a fistula connecting the proximal right ureter to the third part of the duodenum. Intervention: We demonstrate robotic repair of a UDF in a patient with an associated ipsilateral atrophic kidney. Intraoperatively, extensive retroperitoneal fibrosis and purulent debris were evident surrounding the right renal hilum and pelvis. Intraureteral indocyanine green was observed under near infrared fluorescence to aid in dissection. A total right nephrectomy was performed, leaving a 2-cm margin of kidney parenchyma and ureter that remained connected to the duodenal fistula. The general surgery team then performed a duodenotomy and primary repair with omental patch. Follow-Up/Outcomes: Intraoperatively, estimated blood loss was 400 mL and operative time was 200 minutes. An upper gastrointestinal series was performed on postoperative day 3 that confirmed no duodenal leak. The patient was discharged on postoperative day 4 after an uncomplicated hospital course. At 16 months follow-up, there were no major (Clavien &gt;2) postoperative complications. Robotic total nephrectomy and UDF repair may be performed effectively in a patient with UDF and associated ipsilateral atrophic kidney. M.L. and J.J. have no conflicts of interest to disclose. D.E. is founder of Melzi Corp. and a consultant for Intuitive Surgical and Johnson and Johnson . Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The study was approved by the Institutional Review Board at Temple University (Protocol No. 20793). Runtime of video: 4 mins 28 secs

Mercuric oxide poisoning treated with whole-bowel irrigation and chelation therapy

First performed in 1960, hemicorporectomy, or translumbar amputation, is a rare surgery performed as a last resort for patients with life-threatening diagnoses. While rare, it is associated with significant challenging events for the anesthesiologist. Here we present a challenging hemicorporectomy case which was successfully managed using a multimodal anesthesia approach. The patient was a 40-year-old patient presenting for completion of a hemicorporectomy via a left hemipelvectomy for pelvic chondrosarcoma. The patient underwent hemicorporectomy under epidural and total intravenous anesthesia supplemented with ketamine and lidocaine infusion. The surgery lasted 17.5 h and resulted in 28 L of blood loss. The patient noted excellent pain control and was discharged on postoperative day 74 following an uncomplicated hospital course and in-house rehabilitation. Reviewing the literature, we recognized that there are no standardized anesthesia protocols published for hemicorporectomy. Based on our case report we present a novel anesthesia strategy that addresses almost all major challenges with hemicorporectomies. Our successful strategy suggests that a total intravenous anesthesia with propofol in combination with an epidural and a multimodal pain regimen with rate adjustments based on body mass reduction should be considered as a standard anesthesia protocol for hemicorporectomies. We recommend establishing a state-of-the-art anesthesia guideline for patients undergoing hemicorporectomy and encourage anesthesiologists to publish case reports describing the anesthesia approach for a hemicorporectomy.

BackgroundST-elevation myocardial infarction (STEMI) is a leading cause of morbidity and mortality, with rising incidence among younger individuals. Conventional risk factors, smoking, diabetes, dyslipidemia, and hypertension, contribute significantly to atherosclerosis, but regional data remain limited. In the UAE, STEMI often presents at a younger age than in Western populations, yet demographic, clinical, and outcome data for this group are still underreported.MethodsThis retrospective study included adults ≤45 years admitted with STEMI to major government hospitals in Dubai (2018-2023). Clinical, demographic, and angiographic data were analyzed. Patients were stratified into low-, intermediate-, and high-risk groups based on left ventricular ejection fraction (LVEF), coronary vessel involvement, and STEMI-related complications. Intergroup comparisons used the Fisher-Freeman-Halton exact test and the Kruskal-Wallis test. Associations between risk category and in-hospital outcomes were assessed using Fisher’s exact test (p < 0.05). Regional findings were compared with global data to identify population-specific trends.ResultsA total of 461 patients met the inclusion criteria and were stratified by risk group. The cohort was predominantly male (98%) and South Asian (86.3%), with a median age of 40 years. Most had ≥1 cardiovascular risk factor: dyslipidemia (59.7%), smoking (55.5%), diabetes (47.5%), hypertension (33%), and a family history of premature CAD (9.5%). The left anterior descending artery was the most common culprit artery (60.3%), and single-vessel disease predominated (48.8%). Most had an uncomplicated hospital course (84.8%), while 15.2% experienced complications-mainly arrhythmias (10%), followed by death, cardiogenic shock, and others. Risk group distribution was as follows: low (70.1%), intermediate (27.5%), and high (2.4%). Significant associations were found between risk categories and dyslipidemia (p = 0.026), age (p = 0.010), eGFR (p = 0.0125), and factors used in stratification: LVEF and vessel count (p < 0.001). Higher risk groups were linked to an increase in in-hospital complications and death (p < 0.001).ConclusionsYoung adults presenting with STEMI in Dubai tend to exhibit shared demographic and anatomical characteristics. Increasing age and dyslipidemia are associated with a higher likelihood of in-hospital complications and adverse outcomes. While some findings, such as the associations with LVEF, eGFR, and extent of coronary disease, aligned with global data, traditional risk factors like diabetes and hypertension showed no significant associations, possibly reflecting population-specific patterns. Although not directly tested, public health strategies targeting smoking cessation and early detection of lipid disorders may help mitigate the burden of premature STEMI. Further research into genetic and metabolic predispositions is warranted to refine risk assessment and improve preventive efforts in this population.

Toxic epidermal necrolysis caused by etonogestrel implantation: A rare presentation

A Combination of Type A Aortic Dissection and COVID-19: Operative Mortality of 33%?

Introduction: Patients with prior instrumentation or biliary surgery may not present with classic laboratory changes associated with ascending cholangitis. Here we describe two cases of acute cholangitis in patients with normal bilirubin levels.Table 1: Laboratory Values at PresenationFigure 3Case 1: A 29 year old female was admitted with acute onset of fever, tachycardia, progressive right upper quadrant abdominal pain and nausea for several weeks. She had undergone laparoscopic cholecystectomy 9 years previously. Admission labs showed a leukocytosis, mildly elevated alkaline phosphatase (ALP) with normal transaminases and bilirubin (table 1). MRCP showed intrahepatic biliary duct dilation affecting the right system with a stricture at the site of the cholecystectomy clip. She was started on antibiotics, but her clinical status worsened over 24 hours and her labs remained unchanged. Urgent ERCP also showed the same findings and a plastic stent was placed with drainage of pus (figure 1). She subsequently improved and 10 days later underwent Roux-en-Y hepaticojejunostomy and subsequently recovered completely.Figure 1Case 2: A 77 year old female with chronic pancreatitis and recently placed covered metal stent placement for biliary stricture presented with a four days of diffuse abdominal pain, emesis, and chills. ALP, transaminases, and bilirubin were all within normal limits. She had a leukocytosis and elevated lactate (table 1). CT of the abdomen and pelvis was notable for pneumobilia and prominence of a poorly-defined pancreatic head. ERCP demonstrated that the metal stent was occluded with purulent material and was replaced with a plastic stent (figure 2). She clinically improved and one week later the temporary stents were removed. She was discharged to a skilled nursing facility for acute physical rehabilitation without recurrence.Figure 2Discussion: Ascending cholangitis with normal bilirubin has been described in primary sclerosing cholangitis (PSC) and biliary atresia (BA), but has not been reported in patients with prior biliary instrumentation or surgery. A review of the literature using the PubMed database with the search terms ‘cholangitis' and ‘normal bilirubin' found a total of 161 articles after excluding those associated with PSC and BA. No relevant reports were found. Conclusion: Physicians should have a high index of suspicion for acute cholangitis even when liver function tests are normal in patients with prior biliary tract intervention.

INTRODUCTION: Drug-induced liver injury is an uncommon but a life-threatening entity. Sunitinib, a tyrosine kinase inhibitor (TKI), is used for advanced and imatinib-refractory gastrointestinal stromal tumors. It causes a transient elevation of liver enzymes in about 39% of patients while grade 3 and 4 hepatotoxicities in 3 % of patients. The incidence of fatal acute liver failure is rare. The incidence of acute cardiomyopathy is seen in 10% of patients. We present a case of fatal acute liver failure and cardiomyopathy within two weeks of sunitinib therapy initiation for advanced pancreatic neuroendocrine carcinoma. CASE DESCRIPTION/METHODS: A 64-year-old male with stage IV high grade pancreatic neuroendocrine carcinoma with metastasis to the liver, spleen, and left adrenal gland, presented with right upper quadrant abdominal pain, nausea, and lethargy. The patient was started on Sunitinib, a month prior to presentation. It was discontinued two weeks before admission due to severe fatigue, decreased oral intake, and dehydration. Physical exam was positive for jaundice, disorientation to time, place, and person and asterixis. The trend of liver function tests during the course of hospitalization is presented in Table 1. The workup to determine other causes of acute liver failure was unremarkable. The patient was started on N-acetylcysteine protocol for acute liver failure and lactulose and rifaximin for suspected hepatic encephalopathy. The patient was not a candidate for a transplant due to stage IV cancer. Transthoracic echocardiography showed new-onset severe acute cardiomyopathy with an ejection fraction of 20–25%. The patient's mental status did not improve despite 3–4 bowel movements per day. Despite aggressive supportive care, his liver failure was irreversible and the patient passed away on day 5 of hospitalization. DISCUSSION: Sunitinib causes time and concentration-dependent cellular injury. The pattern of liver injury is typically hepatocellular. Definitive management of organ dysfunction includes withholding of sunitinib along with supportive care. This case emphasizes that overt liver failure and systolic cardiac dysfunction are infrequent but possibly fatal complications of Sunitinib therapy. We recommend periodic monitoring of baseline liver function and cardiac function status for patients on Sunitinib therapy, especially within the first year of treatment.Table 1.: The trend of liver function tests during the course of hospitalization.

Introduction: Intrahepatic gallbladders, a rare anatomical variant, usually have impaired functionality and do not empty completely. This stasis leads to the formation of gallstones which in turn leads to an increased risk of developing associated complications with increased morbidity and mortality. We illustrate this point with a case of a male with a history of partial cholecystectomy who presented with sepsis from cholecystitis within an intrahepatic gallbladder. Case Report: A 31-year-old male presented with complaints of right upper quadrant abdominal pain, nausea and vomiting. His past medical history included cholelithiasis with elective open partial cholecystectomy a few months prior for biliary cholic. His postoperative course had been complicated by stump leakage requiring an ERCP with stent placement. On this admission, the patient presented with hypotension and tachycardia, elevated WBC count of 12.6 K/mL, total bilirubin of 1.4, and direct bilirubin 0.56. Blood cultures were positive for gram-negative bacilli. CT scan was significant for a fluid collection in the gallbladder fossa (Figure 1). MRCP revealed an intrahepatic gallbladder with dark signal representing possible calculi (Figure 2). The patient was admitted to SICU on IV antibiotics and vasopressors. The patient had 15cc of purulence drained by interventional radiology. GI was then consulted for an ERCP. The prior stent was removed, sphincterotomy performed, a cholangiogram did not reveal any bile leaks or filling defects in the common bile duct, and a new stent was placed. The patient's vital signs improved and he no longer required vasopressors within 24 hours after the ERCP. Discussion: Intrahepatic gallbladders are predisposed to develop cholelithiasis, which presents a significant cause of morbidity. A delay in diagnosis leads to inappropriate management and increases in morbidity and mortality. In our case, the patient likely required earlier stent placement because the entirety of the gallbladder was not removed during his initial surgery. The remaining portion of the gallbladder remained at risk of developing further cholelithiasis due to its anatomical position if the original gallstone was not removed during the initial cholecystectomy. Intrahepatic gallbladders should be identified early as they have a higher propensity for developing gallstones, which can lead to other complications such as cholecystitis, cholangitis, perforation, abscess formation and even death.Figure 1Figure 2

Case PresentationA 61-year-old female presented to the emergency department with right upper quadrant abdominal pain following a cholecystectomy 18 days prior. Computed tomography (CT) of her abdomen demonstrated a large abscess in her post-hepatic fossa. She was admitted to the general surgery service and received an image-guided percutaneous drain placement with interventional radiology with immediate return of purulent material. She was discharged home after a three-day hospital course with outpatient antibiotics and follow-up.DiscussionPatients may have multiple complications following cholecystectomy, including infection, bleeding, biliary injury, bowel injury, or dropped stone. The emergency clinician must consider cholecystectomy complications including gallbladder fossa abscess in patients presenting with abdominal pain in the days to weeks following cholecystectomy, especially if they present with signs of sepsis. Critical actions include obtaining CT and/or ultrasonography, initiating broad spectrum antibiotics, and obtaining definitive source control by either surgery or interventional radiology.

Background:Fluorescent cholangiography using intravenous indocyanine green (ICG) is a noninvasive technique that enables real-time intraoperative imaging of biliary anatomy. The objective of this study was to visualise the biliary anatomy in routine and complicated cases of laparoscopic cholecystectomy (LC).Methods:This was a prospective observational study of patients undergoing LC for various indications. After obtaining consent, 5 mg/1 ml of ICG dye was administered intravenously in each patient, 2 h before the incision time. LC was performed by standard critical view of the safety technique. The biliary tree was visualised using near-infrared (NIR) view before clipping any structure. Intra-operative findings, visibility of ducts in the NIR view, conversion, adverse reactions to ICG and post-operative outcomes in all patients were recorded.Results:Out of 43 patients undergoing LC, 24 had cholelithiasis, 10 had acute cholecystitis, 3 had chronic cholecystitis, 1 had mucocele of the gall bladder, 1 had gall bladder polyp and 4 cases had common bile duct (CBD) stone clearance with endoscopic retrograde cholangiopancreatography. Cystic duct (CD) and CBD were visualised in 100% of cases among all groups except for those with acute cholecystitis where CD and CBD were visualised in 90% and 80% of cases, respectively, and in chronic cholecystitis CD and CBD were visualised in 66.6% and 80% of patients, respectively. There was one elective conversion in the chronic cholecystitis group due to dense adhesions and non-progression. Only the CBD was visualised in this case. There were no cases of CBD injury or any allergic reactions to the dye.Conclusions:Fluorescent cholangiography during LC is a safe and non-invasive method, allowing superior anatomical visualisation of the biliary tree in comparison to simple laparoscopy. This method can correct misinterpretation errors and detect aberrant duct anatomy, thus increasing the confidence of the operating surgeon enabling safe dissection. This simple technique has the potential to become standard practice to avoid bile duct injury during LC.

Spontaneous biliary perforation: biloma resembling a small bowel duplication cyst.

A 50 year old woman with a 6 year history of right upper quadrant abdominal pain and obstructive liver biochemistry had imaging of her biliary tract carried out using ultrasonography, the recently described technique of Helical CT scan after administration of cholecystographic contrast material and ERCP. Ultrasound of abdomen showed dilatation beside the gall bladder and the common hepatic duct, but was unable to precisely define the exact abnormality. Pre and post-oral cholecystographic contrast helical CT scan of the biliary tree showed cystic dilatation of the cystic duct (choledochocele). ERCP showed dilatation of cystic duct, which was well separated from gall bladder confirming what was visualised at CT cholangiography but adding no extra information. This is a rare entity, with only 9 previous descriptions in the literature. This report demonstrates the value of non-invasive Helical CT cholangiography in the diagnosis of biliary tract abnormalities.