The degree of gallbladder wall thickness and its impact on outcomes after laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy is the gold-standard procedure for management of symptomatic gallstone disease. Increased rates of conversion to an open procedure, increased postoperative complications, and longer lengths of stay are seen in thick-walled gallbladders. Previous studies have only evaluated gallbladder walls as being thick or not thick, without looking at the degree of thickness. We hypothesized that, the more severe the wall thickening, the greater the chance of conversions and complications, and the longer the lengths of stay.

Methods

All attempted laparoscopic cholecystectomies in our institution between 2006 and 2009 were retrospectively reviewed. Patients undergoing cholecystectomy for reasons other than gallstones (e.g., polyps or cancer) and those without preoperative ultrasounds were excluded. Patients were divided into four groups based on the degree of gallbladder wall thickness: normal (1–2?mm), mildly thickened (3–4?mm), moderately thickened (5–6?mm), and severely thickened (7?mm and above). Outcomes were compared amongst the groups.

Results

874 patients were included in the study. There were 68 conversions (7.8?%) and 58 complications (6.6?%). The incidence of conversions was 3.1, 5.1, 14.9, and 16.8?% in the four groups, respectively (p?<?0.001, χ ²), and the incidence of complications was 1.8, 6.7, 9.1, and 13.1?%, respectively (p?=?0.001, χ ²). The mean (±?standard deviation, SD) length of stay in days was 1.09?±?1.42, 1.83?±?3.24, 2.54?±?3.40 and 3.54?±?4.61, respectively [p?<?0.001, analysis of variance (ANOVA)].

Conclusions

A greater degree of gallbladder wall thickness is associated with an increased risk of conversion, increased postoperative complications, and longer lengths of stay. Classifying patients according to degree of gallbladder wall thickness gives more accurate assessment of the risk of surgery, as well as potential outcomes.     

Williams syndrome in a preterm infant with phenotype of Alagille syndrome

We report on a preterm infant born at 31 weeks of gestation with a phenotype suggestive of Alagille syndrome, yet microarray analysis identified a deletion on 7q11.23 at the Williams syndrome locus. The infant died on day 18 of life with overwhelming sepsis. This case illustrates the importance of microarray analysis in diagnosing genetic conditions, especially in preterm babies whose facial and other clinical manifestations have not fully developed.     

Minimum 2-year follow-up of mid-urethral slings, effect on quality of life, incontinence impact and sexual function

Introduction and hypothesis  

In this study, the impact of mid-urethral slings (MUS) on incontinence-related distress, quality of life and sexual function is assessed at a minimum 2 years.     

Fusarium falciforme vertebral abscess and osteomyelitis: case report and molecular classification

Fusarium is a ubiquitous mold that can cause superficial infections such as keratitis and onychomycosis in immunocompetent humans; however, infections in immunocompromised hosts can be fatal. We report an unusual case of epidural abscess and vertebral osteomyelitis in a patient with an autoimmune disorder who was on long-term glucocorticoids. Multilocus DNA sequence-based typing revealed that the infection was caused by a novel three-locus haplotype of Fusarium falciforme designated FSSC 3+4qqq.     

Endoscopic excision of an eroding calcified mesh sling, 10 years after primary surgery

Management of urethral erosion typically entails two options: sling incision (in the early postoperative period) or excision of the suburethral part of the sling (urethrolysis). This paper describes a different endoscopic technique. A forty-year-old woman with a synthetic sling implanted 10 years prior presented with persistent lower urinary tract symptoms. A kidney ureter bladder X-ray showed a stone at the level of the bladder neck. Disintegration of the stone revealed eroding mesh embedded in the urethral wall. Complete resection of the mesh using an electrocautery knife was performed. Two months since the procedure, the patient has had an uneventful course. Both vaginal and urethral walls are intact, and she is capable of normal voiding with some stress incontinence. Although it is unusual, a sling eroding the urethra is a diagnosis that needs to be considered even 10 years after surgery. Endoscopic management is feasible and can be successful.     

Urethral pressure measurement in stress incontinence: does it help?

Introduction and objectives  The resting urethral pressure profile (UPP), used for the assessment of women with stress incontinence, is routine in many urodynamic units. It is time- and effort-consuming, and its diagnostic value is controversial, as well as its value in the prediction of outcome of anti-incontinence surgery. Herein, we assessed its value in the prediction of the outcome of surgery. Patients and methods  Sixty women were randomized to fascial sling or TVT. Urodynamics were performed preoperatively, 6 months and annually thereafter. After filling and voiding cystometry, resting UPP was performed while sitting. Automated catheter pulling, at a rate of 1 mm/s, was adopted. Averaged readings were obtained. Comparison of maximum urethral closure pressure (MUCP) in success and failure, as well as in sling and TVT, was performed, utilizing ANOVA. Results  Preoperative MUCP and functional urethral length (FUL) were 72.9 ± 27.9 cmH2O and 2.4 ± 0.7 cm. At last follow-up, they were 71.1 ± 20.7 cmH2O and 2.7 ± 0.7 cm, respectively. The differences between sling and TVT as regards value of MUCP and FUL were not significant. The relationship of the outcome of surgery and UPP parameters showed no statistical difference. No significant effect was shown for the success of surgery, duration of follow-up, and interaction of outcome and time over MUCP (P = 0.82, 0.56 and 0.69, respectively) or FUL (P = 0.82, 0.11 and 0.67, respectively). Conclusion  The routine use of resting UPP has no added value in terms of the prediction of success of incontinence surgery. It does not help with follow-up and adds to the time and cost of the examination.     

Cardiac manifestations of parasitic infections part 1: overview and immunopathogenesis

Parasitic infections produce a wide spectrum of cardiac manifestations. They may involve various anatomic structures of the heart and are manifested clinically as myocarditis, cardiomyopathies, pericarditis, or pulmonary hypertension in many resource-constrained settings. However, many parasitic infections involving the heart may also be currently diagnosed in developed countries due to growing worldwide travel, blood transfusions, and increasing numbers of immunosuppression states such as organ transplantation, use of immunosuppressive agents, or HIV/AIDS. Clinicians anywhere in the globe need to be aware of the potential cardiac manifestations of parasitic diseases. This is part one of a three-part series discussing parasites of the heart. In this section, we provide a general overview and immunopathogenesis of parasitic infections of the heart.