Interval cholecystectomy following drainage procedures for acute cholecystitis: percutaneous transhepatic vs endoscopic transpapillary gallbladder drainage.

BACKGROUND: Gallbladder drainage procedures are often considered for acute cholecystitis (AC) patients with significant peri-operative risks. While percutaneous transhepatic gallbladder drainage (PTGBD) has been evaluated in previous studies, there is scarce data on the feasibility and efficacy of endoscopic transpapillary gallbladder stenting (ETGBS) in patients with AC. This study aimed to compare the characteristics of interval cholecystectomy following ETGBS and PTGBD. METHODS: This retrospective descriptive study included patients who underwent ETGBS and/or PTGBD for AC and subsequently underwent interval cholecystectomy between 2018 and 2023. Demographics, operative technique, and postoperative complications of patients with ETGBS and PTGBD were compared. RESULTS: A total of 59 patients were included (14 ETGBS and 45 PTGBD). The median days between ETGBS and cholecystectomy were significantly longer than the PTGBD group (64 [45-150] days vs. 16 [10-42] days, p=0.045). The median operation time was significantly longer in the ETGBS group.　Among 33 patients who underwent subtotal cholecystectomy, the ERGBS group more frequently required closure of the gallbladder stump due to the difficulty in ligating the cystic duct compared to the PTGBD group (75.0% vs. 28.0%, p=0.035). Similarly, the fundus-first approach was more commonly selected in the ERGBS group (62.5% vs. 28.0%, p=0.01). No significant differences in the incidence of postoperative complications were observed between the two groups. CONCLUSIONS: Interval cholecystectomy following ETGBS is more technically demanding compared to PTGBD. Laparoscopic subtotal cholecystectomy following ETGBS could be a potential treatment option for patients who are unfit for early surgery, with the recognition of the difficulty in ligating the cystic duct.

Combined stepladder incision and Sistrunk procedure for en bloc resection of supraclavicular thyroglossal duct cysts.

The accurate diagnosis and therapeutic strategies of thyroglossal duct cysts (TGDCs) are challenging for surgeons if the opening with exudate is far from the hyoid bone. A 7-year-old boy presented with a right supraclavicular mass and persistent pus. Ultrasonography and magnetic resonance imaging revealed the fistula to the hyoid bone. Suspecting a TGDC, we combined the stepladder incision technique and the Sistrunk procedure. The first skin incision cut through the opening in a spindle shape, and the second incision was made in the skin just above the hyoid bone. This combined technique allowed en bloc resection of the TGDC and the hyoid bone to the base of the tongue. Cervical masses are commonly encountered in surgical clinics, and even distant openings off the midline must be considered in the differential diagnosis of TGDCs. This treatment strategy is essential for preventing the recurrence of TGDCs and ensures optimal cosmetic outcomes.

Management of Perforated Sigmoid Colon Cancer in an Incarcerated Inguinal Hernia Using a Combined Abdominal and Inguinal Approach.

The ideal management of perforated colorectal cancer in the hernia sac remains a challenge for general surgeons. We report such a case requiring a combined-incision surgical approach and two-stage operation. A male patient in his 80s presented with fatigue and a bulge in his left groin. Contrast-enhanced CT scan revealed a sigmoid colon perforation within the left inguinal hernia sac. A combination of midline abdominal and inguinal incisions was performed for the iliopubic tract repair and Hartmann procedure. Six months later, the recurrent inguinal hernia was repaired using the Kugel mesh. The treatment strategy for colonic perforation into the inguinal hernia remains nonstandardized, compared to those for nonperforated cases. Combined inguinal and midline abdominal incisions might be necessary for infected lesion removal and colon mesentery resection; using mesh to repair hernia is a rare option. Hernia repair using mesh can be performed in two stages when recurrence occurs.

Which factors influence the decision to perform Hartmann's reversal in various causative disease situations? A retrospective cohort study between 2006 and 2021.

AIM: Our aim was to investigate the predictive factors for Hartmann's reversal and to describe the differences in the rates and timings of Hartmann's reversal for various causative diseases. METHOD: In this multicentre retrospective cohort study patients who underwent Hartmann's procedure (HP) between 2006 and 2018 were enrolled. To describe the demographic patterns of Hartmann's reversal through to 2021, we analysed the cumulative incidence rate of Hartmann's reversal over time based on the Kaplan-Meier failure estimate. Multivariable Cox proportional hazard analysis was performed with cluster-adjusted robust standard errors to calculate hazard ratios (HRs) for the assessment of variables associated with colostomy reversal. RESULTS: Of 250 patients who underwent the index HP and survived to discharge, 112 (45%) underwent subsequent Hartmann's reversal (36% for malignant and 51% for benign disease). The causative diseases with the highest probability of colostomy reversal were trauma (85%) and diverticular disease (73%). Conversely, colostomy reversal was performed in only 16% for colonic volvulus and 17% for bowel ischaemia. Home discharge after index HP (HR 5.22, 95% CI 3.31-8.23) and a higher body mass index (HR 1.03, 95% CI 1.01-1.04) were associated with a higher probability of Hartmann's reversal, whereas older age, malignant disease and a history of cardiovascular and psychoneurological diseases were independently associated with a lower probability of colostomy reversal. CONCLUSION: The probability and timing of Hartmann's reversal varied considerably with the surgical indications for colostomy creation. Our results could help surgeons counsel patients and their families regarding stoma closure surgery to set realistic expectations.

Intrauterine intestinal volvulus without malrotation presenting neonatal abdominal compartment syndrome.

INTRODUCTION: Fetal intestinal volvulus without malrotation is extremely rare, and early prenatal diagnosis is challenging because the signs and symptoms are non-specific. However, without proper management, it can cause massive bowel necrosis. PRESENTATION OF CASE: A woman experienced a dilated fetal bowel at 34 weeks of pregnancy and noticed a decrease in fetal movements at 36 weeks; however, she did not visit a hospital. Her newborn developed severe abdominal distension and was diagnosed with neonatal abdominal compartment syndrome with respiratory distress immediately after emergency caesarean section at 36 weeks and 5 days of pregnancy. The neonate underwent emergency exploratory laparotomy. This revealed a volvulus of the small bowel with extensive necrosis and no findings of congenital malrotation. While the patient required massive necrotic bowel resection, 80 cm of the small intestine was preserved. DISCUSSION: Fetal intestinal volvulus without malrotation can cause abdominal compartment syndrome with rapid respiratory distress. Therefore, it should be considered in the differential diagnosis of fetal intestinal dilatation. Volvulus exacerbation risk increases from 30 weeks of pregnancy to late preterm delivery. However, the time lag between the mother's awareness of decreased fetal movement and caesarean section makes early diagnosis challenging, resulting in a life-threatening condition for the neonate. CONCLUSION: When a fetal ultrasound examination shows intestinal dilatation between gestational week 30 and late preterm, the mother must be fully informed about the possibility that the foetus has intestinal volvulus and the potential risk of massive fetal intestinal necrosis.

Laparoscopic subtotal cholecystectomy after percutaneous transhepatic gallbladder drainage for grade II or III acute cholecystitis.

BACKGROUND: Severe adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies. METHODS: This retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013-2017, n = 17) and post-TG18 group (2018-2020, n = 27). Patients' background demographics, surgical method, surgical results, and postoperative complications were compared. RESULTS: The interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9-42] days vs. 8 [4-11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group. CONCLUSIONS: For grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.

The use of warm fresh whole blood transfusion in the austere setting: A civilian trauma experience.

BACKGROUND: Hemostatic resuscitation strategy using blood components with a balanced ratio is adopted in the civilian trauma setting. However, there is usually limited availability of blood components in the austere setting. Warm fresh whole blood (WFWB) has been used for trauma patients with life-threatening hemorrhage necessitating massive transfusions in the Okinawa Islands, Japan. The purpose of this study was to evaluate the safety and feasibility of WFWB use in the austere civilian trauma setting. METHODS: We conducted a retrospective cohort study between January 1999 and June 2019, including trauma patients who received WFWB within 24 hours of admission. Immediately after WFWB was collected from blood donors, the sample was typed and screened for transmissible infectious diseases. Approximately half of the study population received irradiated WFWB to prevent graft versus host disease. We evaluated the incidence of transfusion-associated adverse events. Transfusion requirements and patient outcomes were compared between early and late WFWB use. RESULTS: A total of 28 patients from three civilian institutions were eligible. Of those, 93% sustained blunt trauma. The median Injury Severity Score was 37 (interquartile range, 32-49). All patients required operative hemostatic intervention, and half of the patients required both operative and endovascular hemostatic interventions. Patients received a median of 1,800 mL WFWB transfusions from seven volunteer blood donors. None of our subjects developed hemolytic reactions, transmissible infectious diseases, or graft versus host disease. Early WFWB use (within 4 hours of admission) was associated with a significant reduction in platelet transfusion requirement compared with the late WFWB group in univariate analysis (16 units vs. 47 units, p = 0.002). CONCLUSION: Warm fresh whole blood use is safe and feasible in an austere civilian trauma setting. Prospective studies with larger cohorts are necessary to determine whether early WFWB use will affect patient outcomes, transfusion requirement, and treatment cost. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Association between contrast extravasation on computed tomography scans and pseudoaneurysm formation in pediatric blunt splenic and hepatic injury: A multi-institutional observational study.

PURPOSE: We aimed to examine the association between contrast extravasation (CE) on initial computed tomography (CT) scan and pseudoaneurysm (PSA) development in pediatric blunt splenic and/or liver injury. METHODS: We conducted a multi-institutional retrospective study in cases of blunt splenic and/or hepatic injury who underwent an initial attempt of nonoperative management. A logistic regression model was used to compare PSA formation and CE on initial CT scan, and the area under the receiver operating characteristic curve (AUC) with and without CE was used to assess the predictive performance of CE for PSA formation. RESULTS: Of 236 cases enrolled from 10 institutions, PSA formation was observed in 17 (7.2%). Multivariate analysis showed a significant association between CE on initial CT scan and increased incidence of PSA formation (odds ratio, 4.96; 95% confidence interval, 1.37-18.0). There was no statistically significant association between the grade of injury and PSA formation. The AUC improved from 0.75 (0.64-0.87) to 0.80 (0.70-0.91) with CE. CONCLUSION: Active CE on initial CT scan was an independent predictor of PSA formation. Selective use of follow-up CT in children who showed CE on initial CT may provide early identification of PSA formation, regardless of injury grade. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

[Complete response of locally recurrent anorectal cancer to proton beam therapy alone--a case report].

We report a case of locally recurrent anorectal cancer treated with proton beam therapy (PBT) alone that led to a clinically complete response. A 70-year-old woman with paraparesis due to infantile paralysis underwent abdominoperineal resection (APR) and D3 lymphadenectomy for anorectal cancer (PERb, type 2, 50×40 mm, muc-tub1, M1a[lung], Stage IV a]. Three months after APR, right middle and right lower lobectomies were performed for synchronous lung metastases. Adjuvant chemotherapy was not administered. One year and 8 months after APR, computed tomography (CT) showed local recurrence of the tumor (29×28 mm), which contacted the right ischial spine. Pelvic exenteration combined with sacral resection was not performed because of the patient's poor performance status. PBT (70 Gy [RBE]/25 F/5 week) was administered for treatment of the recurred tumor. CT revealed that the tumor disappeared 1 year after PBT, which was defined as complete response. The patient is alive and has not experienced recurrence for 7 years.