Predicting gangrenous cholecystitis.

BACKGROUND: Gangrenous cholecystitis (GC) is often challenging to treat. The objectives of this study were to determine the accuracy of pre-operative diagnosis, to assess the rate of post-cholecystectomy complications and to assess models to predict GC. METHODS: A retrospective single-institution review identified patients undergoing a cholecystectomy. Logistic regression models were used to examine the association of variables with GC and to build risk-assessment models. RESULTS: Of 5812 patients undergoing a cholecystectomy, 2219 had acute, 4837 chronic and 351 GC. Surgeons diagnosed GC pre-operatively in only 9% of cases. Patients with GC had more complications, including bile-duct injury, increased estimated blood loss (EBL) and more frequent open cholecystectomies. In unadjusted analyses, variables significantly associated with GC included: age >45 years, male gender, heart rate (HR) >90, white blood cell count (WBC) >13,000/mm(3), gallbladder wall thickening (GBWT) ≥ 4 mm, pericholecystic fluid (PCCF) and American Society of Anesthesiology (ASA) >2. In adjusted analyses, age, WBC, GBWT and HR, but not gender, PCCF or ASA remained statistically significant. A 5-point scoring system was created: 0 points gave a 2% probability of GC and 5 points a 63% probability. CONCLUSION: Using models can improve a diagnosis of GC pre-operatively. A prediction of GC pre-operatively may allow surgeons to be better prepared for a difficult operation.

Rare cases of colonic schwannomas.

Schwannomas of the gastrointestinal tract are rare spindle cell tumors that account for 2-6% of mesenchymal tumors. An elderly male was found to have a left colon mass on CT scan and colonoscopy with pathology of fibrotic tissue. A laparoscopic-assisted left hemi-colectomy with primary anastomosis was performed. Pathology demonstrated spindle cell neoplasm arranged in short fascicles that were strongly and diffusely positive for S100. An elderly female was found to have a submucosal lesion on surveillance colonoscopy in the proximal transverse colon. Biopsy with jumbo forceps revealed spindle cell neoplasm positive for S100. Patient underwent an uncomplicated limited non-oncologic segmental transverse colectomy. We report only the ninth case of left and sixth in the transverse colon described in the literature. As is true for other mesenchymal tumors, mucosal biopsy is usually inconclusive and deep biopsy or submucosal resection is required, making pre-operative surgical decision difficult.

Multidisciplinary Conservative Treatment Outcomes of in-Patient Physiotherapy Set-Up Among Patients with Lumbar Disc Herniation in Dhaka City, Bangladesh: A Retrospective, Cross-Sectional Study.

Background: The study aimed to determine the outcome of Multidisciplinary physiotherapist-led conservative treatment of lumbar disc herniation at an in-patient set-up of a specialized spine center in Dhaka, Bangladesh. Methods: This was a retrospective cross-sectional study of 228 cases completing treatment and follow-up sessions. The outcome was evaluated as pain at rest and five different functional positions, neurological recovery, and Magnetic resonance imaging (MRI) changes during discharge and follow-up. Results: 80.3% had a complete recovery with a typical motor and sensory status, no limitations in straight leg raise (SLR), no cauda equina symptom (CES), and no or <3 pain during more than 30 minutes of daily living activities. Statistically significant changes were noted at all outcome measures at the follow-up (day 90), compared to baseline (day 1) P<0.01. In the posthoc tests, pain, SLR, and CES had the most significant improvement at discharge (day 12) compared to the baseline (P < 0.01) and at follow-up compared to discharge (P < 0.01). No major adverse events noted. Conclusion: Physiotherapist-led in-patient treatment results in significant resting and functional pain outcomes in 12 days. Also, the improvements in neurological recovery and normalizing disc position are statistically significant in 90 days.

Lemierre's syndrome caused by Streptococcus pyogenes in an elderly woman.

Lemierre's syndrome is characterized by septic thrombophlebitis of the internal jugular vein. It typically presents in healthy adolescents or young adults, usually preceded by an oropharyngeal infection, with the most common offending pathogen being Fusobacterium necrophorum. We present a case of Lemierre's syndrome in an elderly woman without antecedent oropharyngeal infection, caused by Streptococcus pyogenes. She was successfully treated with combined surgical and medical management.

Age-related differences pre-, intra-, and postcholecystectomy: A retrospective cohort study of 6,868 patients.

BACKGROUND: Cholecystectomy (CCY) is increasingly performed in older individuals. We sought to examine age-related differences in pre-, intra-, and postoperative factors at a community hospital, using a very large, single-institution cholecystectomy database. MATERIALS AND METHODS: A retrospective review of 6868 patients who underwent CCY from 2001 to 2013 was performed. ROC analysis identified the optimal age cutoff when complications reached a significant inflection point (<55 and ≥55 years). Multiple clinical features and outcomes were measured and compared by age. Logistic regression was used to examine how well a set of covariates predicted postoperative complications. RESULTS: Older patients had significantly higher rates of comorbidities and underwent more extensive preoperative imaging. Intraoperatively, older patients had more blood loss, longer operative times, and more open operations. Postoperatively, older patients experienced more complications and had significantly different pathological findings. While holding age and gender constant, regression analyses showed that preoperative creatinine level, blood loss and history of previous operation were the strongest predictors of complications. The risk for developing complications increased by 2% per year of life. CONCLUSION: Older patients have distinct pre-, intra-, and postoperative characteristics. Their care is more imaging- and cost-intensive. CCY in this population is associated with higher risks, likely due to a combination of comorbidities and age-related worsened physiological status. Pathologic findings are significantly different relative to younger patients. While removing the effect of age, preoperative creatinine levels, blood loss, and history of previous operation predict postoperative complications. Quantifying these differences may help to inform management decisions for older patients.