Umbilical port versus epigastric port for gallbladder extraction in laparoscopic cholecystectomy: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis.

BACKGROUND: After laparoscopic cholecystectomy, gallbladder can be extracted either from epigastric/subxiphoid port or umbilical port. We conducted systematic review of randomized controlled trials comparing the two. METHODS: PRISMA-compliant systematic review and meta-analysis was conducted with pre-specified study protocol registered on PROSPERO (CRD42019128662). Multiple databases were searched from inception till 14 September 2019 using search terms "gallbladder", "specimen", "extraction', "extract", "cholecystectomy", "epigastric port", "subxiphoid port" "umbilical port". Outcomes assessed were postoperative pain (visual analog scale at 24 h postoperatively), port-site hernia, port-site infection, operative time and gallbladder retrieval time. Data were analyzed using random-effects models with risk ratios (RR) for dichotomous variables and mean difference (MD) for continuous variables. RESULTS: Of 280 articles retrieved, 9 RCT's with 1036 participants were included. Quality of included studies was judged to be "moderate" to "low". There was no difference in postoperative pain at 24 h (p = 0.76), total operative time (p = 0.11), gallbladder retrieval time (p = 0.72) or surgical site infection (p = 0.93). Umbilical port retrieval was associated with significantly higher risk of port-site herniae (RR 2.68, 95%CI:1.06-6.80, p = 0.04). After sensitivity analysis, operative time was significantly shorter with epigastric retrieval (p = 0.0007). Trial sequential analysis showed that current studies were successful in achieving optimum information size for primary outcome. CONCLUSIONS: There was no difference in postoperative pain and infections between umbilical and epigastric port retrieval. Umbilical port retrieval was associated with significantly higher risk of developing port-site hernia and could also be associated with longer operative time. Epigastric port may be favorable for gallbladder retrieval in multiport laparoscopic cholecystectomy.

Flowfields produced by a robotic sea lion foreflipper starting from rest.

Sea lions swim using primarily their foreflippers, which is uncommon among aquatic mammals. While a significant body of literature exists which investigates the hydrodynamics of body-caudal swimming, relatively little research has looked at sea lion propulsion. In this work, particle imaging velocimetry is used to observe the flow around a robotic model sea lion flipper. The model flipper was cast in silicone from a high-resolution scan of a sample sea lion foreflipper. The model flipper was actuated at the root, and its motion was controlled by a programmable servomotor. It was observed that the thrust-producing clapping motion of the flipper entrained significant fluid momentum on the suction side of the flipper, which developed into a shed vortex and contributed to downstream momentum (and therefore thrust). Rotating the robotic flipper more quickly produced greater downstream jet velocities, but at a lower conversion of rotational velocity, suggesting that this mechanism of propulsion can be optimized based on the system needs.

Parastomal Evisceration: A Report of Two Cases and Review of Literature.

Intestinal stomas have been performed for hundreds of years for both benign and malignant disorders of the large and small bowel. Complications of stomas like stomal prolapse, parastomal hernia, and retraction are well-known. The evisceration of intra-abdominal contents is a very rare occurrence, carrying a high burden of morbidity. The etiology, timing, and treatment of this complication are not adequately described in the literature. We report two patients who were operated and in whom ostomy was fashioned; parastomal evisceration occurred in the early postoperative period in both cases. Both of these patients were operated emergently, and reduction of eviscerated contents followed by stoma refashioning was performed. One patient survived; whereas, the other patient who presented with septic shock expired due to multiorgan dysfunction syndrome. This report describes a rare and possibly fatal complication of ostomy and highlights the importance of meticulous operative technique in ensuring safety in this procedure.

Gastric Conduit Perforation: A Late Fatal Complication after Esophagectomy.

With an increasing number of long-term survivors of carcinoma esophagus, it is important to be vigilant about postoperative complications related to gastric tubes. Perforation of the gastric conduit has been rarely seen, with very few case reports in the literature. We report a rare case of perforation of the gastric tube conduit in a patient who had previously undergone esophagectomy for squamous cell carcinoma of esophagus five years ago. The patient presented with diffuse peritonitis in an emergency. On exploration, a large perforation was present on the anterior wall of the gastric conduit. This was closed with primary suture repair. Histopathology revealed nonspecific inflammatory changes. Unfortunately, the patient succumbed to severe sepsis and multiorgan dysfunction despite early surgical intervention and critical care management. Conduit perforation can be a major source of morbidity and mortality. Although gastric conduit is predisposed to ulcer formation due to multiple reasons, conduit perforation may occur only in rare cases. We recommend that surveillance endoscopy for conduit ulcer should be performed in long-term survivors after esophagectomy. Patients with conduit ulcers would benefit from long-term acid suppression with proton-pump inhibitors.

Immunoglobulin G4-related disease mimicking gallbladder cancer with associated choledochal cyst: A case report of a malignant masquerade.

Immunoglobulin G4 (IgG4)-related disease is a recently described autoimmune disease that can involve diverse organ systems, causing pancreatitis, cholangitis, retroperitoneal fibrosis, and thyroiditis to name a few. Key histological features include storiform fibrosis, obliterative venulitis, and intense inflammatory infiltrate composed of lymphoplasmacytic cells. The disease has a tendency to present with mass-forming lesions, often difficult to differentiate from malignant processes. We report the case of a 48-year-old male from an area endemic for gallbladder cancer (north India). He presented with a short history of abdominal pain and was found to have asymmetric thickening of the gallbladder wall with a soft-tissue mass invading the adjacent liver. In addition, the bile duct was dilated throughout its extent. A clinical and radiological diagnosis of gallbladder cancer with choledochal cyst was made, and the patient underwent radical cholecystectomy with bile duct excision. Histopathology surprisingly demonstrated IgG4-related disease with no evidence of malignancy. Notably, serum levels of immunoglobulins were found to be normal. Preoperative diagnosis was challenging due to the absence of other manifestations. IgG4-related disease is a possible diagnostic pitfall and should be included as a possible differential diagnosis for gallbladder masses.

Predrainage and Postdrainage Prognostic Nomograms to Predict Outcome of Percutaneous Drainage for Infected Pancreatic and Peripancreatic Necrotic Collections.

OBJECTIVES: This study aimed to identify factors affecting outcome of percutaneous catheter drainage (PCD) in management of infected pancreatic necrosis treated with step-up approach. METHODS: This was a single-center retrospective cohort study that included patients with infected necrosis undergoing PCD as initial intervention. Patients who did not respond underwent necrosectomy. Predictors of PCD failure (ie, mortality or need for necrosectomy) were analyzed. Models were constructed for predrainage and postdrainage use and were internally validated. RESULTS: Of 304 patients included, catheter drainage was successful in 59.8%, with overall mortality of 22%. Predrainage model consisted of Acute Physiologic and Chronic Health Evaluation II score at admission, early organ failure, and pancreatic necrosis of greater than 50%. Postdrainage model consisted of Acute Physiologic and Chronic Health Evaluation II at first PCD, early organ failure, pancreatic necrosis of greater than 50%, sepsis reversal within 1 week of PCD and Escherichia coli in PCD culture. Both models were internally validated with area under receiver operating characteristics curve of 71.2% for pre-PCD and 81.2% for post-PCD model. Prognostic nomograms were constructed using the models. CONCLUSIONS: Percutaneous catheter drainage alone was successful in 59.8% with mortality of 22%. The nomograms can help in guiding treatment strategy and referral of high-risk cases.

A Robotic Platform to Study the Foreflipper of the California Sea Lion.

The California sea lion (Zalophus californianus), is an agile and powerful swimmer. Unlike many successful swimmers (dolphins, tuna), they generate most of their thrust with their large foreflippers. This protocol describes a robotic platform designed to study the hydrodynamic performance of the swimming California sea lion (Zalophus californianus). The robot is a model of the animal's foreflipper that is actuated by motors to replicate the motion of its propulsive stroke (the 'clap'). The kinematics of the sea lion's propulsive stroke are extracted from video data of unmarked, non-research sea lions at the Smithsonian Zoological Park (SNZ). Those data form the basis of the actuation motion of the robotic flipper presented here. The geometry of the robotic flipper is based a on high-resolution laser scan of a foreflipper of an adult female sea lion, scaled to about 60% of the full-scale flipper. The articulated model has three joints, mimicking the elbow, wrist and knuckle joint of the sea lion foreflipper. The robotic platform matches dynamics properties-Reynolds number and tip speed-of the animal when accelerating from rest. The robotic flipper can be used to determine the performance (forces and torques) and resulting flowfields.