Partial cholecystectomy as a safe and viable option in the emergency treatment of complex acute cholecystitis: a case series and review of the literature

Partial cholecystectomy (PC) is an alternative choice to standard cholecystectomy in situations with increased risk of Calot's components injury. We reported our experience with the patients treated with PC and reviewed the literature. Fifty-four patients with complex acute cholecystitis underwent PC, including conventional partial cholecystectomy (CPC; n = 48) and laparoscopic partial cholecystectomy (LPC; n = 6). The clinical diagnosis was verified by ultrasonography. In addition, we reviewed 1190 published cases (1972-2005) who underwent a "nonconventional" surgery for severe cholecystitis, including cholecystostomy, CPC, or LPC. Review of the literature, including our cases, showed a male:female ratio of 1.3:1. The major operative indication was severe acute cholecystitis. Procedures included cholecystostomy (65.8%) and PC (34.2%). In the follow-up (n = 1190), biliary leak (4.8%), retained stones (4.6%), recurrent symptoms (2.3%), wound infections (1.9%), persistent biliary fistula (0.9%), and prolonged biliary drainage (0.2%) were found, with an overall mortality rate of 9.4 per cent. In 133 patients, because of postoperative complications (e.g., recurrent symptoms, remaining common bile duct stones, or persistence of bile fistula), reoperation was necessary, including 121 cases (90.1%) of cholecystectomy, whereas the other 11 patients underwent other procedures such as common bile duct exploration or closure of the fistula. The surgical trend for complex acute cholecystitis treatment has been changed from only cholecystostomy to a spectrum of cholecystostomy, CPC, and LPC with the progressive increase of PC. The proportion of the LPC compared with CPC has also increased during recent years. It seems that PC is a safe procedure for treating complicated acute cholecystitis. Whether the indication and need for alternative techniques to standard cholecystectomy is changing should be evaluated in future studies.     

Distinct effects of surgical denervation on hepatic perfusion, bowel ischemia, and oxidative stress in brain dead and living donor porcine models.

The liver function and perfusion following brain death is mainly influenced by the sympathetic nerves and hormones. We examined the specific influence of surgical liver denervation on systemic and hepatic perfusion parameters, bowel ischemia and oxidative stress in hemodynamically stable BD and control (living donor [LD]) pigs. Brain death was induced in 8 pigs via saline infusion into the balloon of an epidural Tieman-catheter (1 mL/15 minutes) and compared to the control group (n = 6) over 4 hours. At 2 hours postoperatively, complete liver denervation was initiated. We analyzed systemic cardiocirculatory parameters (mean arterial pressure, aortic flow, bowel ischemia (endotoxin, and endotoxin-neutralizing capacity) and oxidative stress (total glutathione in erythrocytes [tGSH(E)]) and compared them to local/hepatic perfusion parameters (hepatic artery and portal venous flow, liver blood flow index, and microperfusion), local bowel ischemia (intramucosal pH [pHi] of stomach [pHi(S)]/colon[pHi(C)]), and liver oxidative stress (glutathione [rGSH(L), GSSG(L)]). Following brain death, the parameters including mean arterial pressure, aortic flow, pHi, endotoxin, and tGSH(E) showed no significant changes at 2 hours. Portal venous flow and microperfusion were decreased significantly and hepatic arterial buffer response was ineffective. Hepatic oxidative stress was increased in BD animals (decrease rGSH(L), increase GSSG(L)). Surgical denervation/manipulation increased portal venous flow significantly, hepatic arterial buffer response became effective, and stomach pHi decreased (BD and LD groups). Hepatic oxidative stress was reduced in the BD group (increase rGSH(L)/GSSG(L); P < 0.001) while it was increased in the LD group (decrease rGSH(L)/GSSG(L); P < 0.001). In conclusion, denervation reduces hepatic oxidative stress in BD only in contrast to the LD. The reciprocal effect of denervation depends on the state of neural activation and postulates a potential benefit of surgical denervation before organ harvesting in brain death.     

Cannonball appearance,a tricky yet underrated imaging manifestation of COVID-19

Emergency Radiology - Spreading swiftly across the borders and over the seas, severe acute respiratory syndrome–related coronavirus-2 (SARS-COV-2), as causative pathogen of coronavirus...     

Transplantation of a severely lacerated liver – a case report with review of the literature

Abstract:  Using lacerated livers for liver transplantation (LTx) can add an option to the extended donor criteria. We present an LTx case using a severely lacerated liver and review of the literature for reported cases. We used a high-grade lacerated liver from a 19-yr-old brain-dead patient caused by traffic accident. The liver had grade IV and II lacerations in the right and left lobe, respectively. Lacerations were managed by sealants, stitching and perihepatic packing. The liver was transplanted to a 49-yr-old man suffering from hepatocellular carcinoma on hepatitis C-induced liver cirrhosis. The two-yr follow-up was uneventful. All published LTx cases using traumatized livers (n = 18) were analyzed. The liver injury ranged from subcapsular hematoma to deep ruptures. Most reported lacerations were in the right lobe, which were managed by digital compression, suturing, electrocautery, and perihepatic packing. The reported complications were primary non- (18%), or poor function, liver abscess, bilioma, and subhepatic hematoma each in one case (5.5%). Six-month graft and patient survival were 71% and 88%, respectively. With meticulous management lacerated livers can be transplanted successfully. Because of complexity of the management, procurement and transplantation should be done by experienced liver surgeons. These organs are marginal grafts and should be offered to selected patients.     

Crush syndrome due to drug-induced compartment syndrome: A rare condition not to be overlooked

Purpose  The crush syndrome caused by drug-induced compartment syndrome (DCS) is a challenge for surgeons because it is regularly associated with potentially fatal complications. Drug-induced compartment syndrome can often be distinguished from other forms of compartment syndrome by the presence of severe rhabdomyolysis with kidney crush and severe postoperative complications such as local and generalized infection, persistent nerve damage, coagulopathy, and multiorgan failure. Methods  In the past 15 years, eight prospectively documented, operatively managed, DCS with subsequent crush syndrome cases were recorded. Results  All of the patients required renal replacement therapy. The creatine kinase (CK) values in the context of rhabdomyolysis reached an average of 86 (range 47–144) kU/l. The renal function recovered in all surviving patients. The analysis showed that the diagnosis of a DCS is usually made after an average of 13 h. It then took an average of an additional 7 h before a fasciotomy was performed. Six operational revisions were necessary. In three out of eight patients the extremities had to be amputated. Conclusions  In DCS the decision to open the compartment should be made immediately upon the clinical diagnosis. A protracted intensive phase is expected. The benefit to patients is closely associated with surgical wound debridement along with rigorous intensive therapy. M. Golling and H. Fonouni contributed equally to this work.     

Successful treatment of a patient with multicolored nevus of Ota using a combination of 1064 and 532 nm Q-switched Nd:YAG lasers

ABSTRACT

Nevus of Ota (NO) is a hamartoma of dermal melanocytes usually presents as unilateral blue, gray or brown macules or patches. It can impose a high burden of cosmetic and psychological disturbances in affected individuals. Q-Switched lasers appear to be an effective treatment for this kind of dermal melanocytosis. Multicolored Ota nevus is a rare variant of this kind of nevus and its treatment may be more challenging compared with unicolor lesions. Herein we report a 21-year-old woman with a multicolored nevus of Ota (blue and brown), which showed a dramatic response to a combination of 1,064 nm and 532 nm Q-Switched Nd:YAG lasers. We also discuss different aspects of the Q-switched laser application of Ota nevus treatment. We also focus on laser combination therapy to treat the nevus of Ota.     

Priming Global Processing Strategy Improves the Perceptual Performance of Children with Autism Spectrum Disorders

Journal of Autism and Developmental Disorders - We investigated (1) if the perceptual integration performance is different in children with ASD in comparison with their typically developed (TD)...