30-day Morbidity and Mortality after Cholecystectomy for Benign Gallbladder Disease (AMBROSE): A Prospective, International Collaborative Cohort Study.

OBJECTIVE: This study aimed to assess 30-day morbidity and mortality rates following cholecystectomy for benign gallbladder disease and identify the factors associated with complications. SUMMARY BACKGROUND DATA: Although cholecystectomy is common for benign gallbladder disease, there is a gap in the knowledge of the current practice and variations on a global level. METHODS: A prospective, international, observational collaborative cohort study of consecutive patients undergoing cholecystectomy for benign gallbladder disease from participating hospitals in 57 countries between January 1 and June 30, 2022, was performed. Univariate and multivariate logistic regression models were used to identify preoperative and operative variables associated with 30-day postoperative outcomes. RESULTS: Data of 21,706 surgical patients from 57 countries were included in the analysis. A total of 10,821 (49.9%), 4,263 (19.7%), and 6,622 (30.5%) cholecystectomies were performed in the elective, emergency, and delayed settings, respectively. Thirty-day postoperative complications were observed in 1,738 patients (8.0%), including mortality in 83 patients (0.4%). Bile leaks (Strasberg grade A) were reported in 278 (1.3%) patients and severe bile duct injuries (Strasberg grades B-E) were reported in 48 (0.2%) patients. Patient age, ASA physical status class, surgical setting, operative approach and Nassar operative difficulty grade were identified as the five predictors demonstrating the highest relative importance in predicting postoperative complications. CONCLUSION: This multinational observational collaborative cohort study presents a comprehensive report of the current practices and outcomes of cholecystectomy for benign gallbladder disease. Ongoing global collaborative evaluations and initiatives are needed to promote quality assurance and improvement in cholecystectomy.

Early-onset aggressive oesophageal carcinoma in Down's syndrome - a coincidence or a game of extra genes?

Patients with Down's syndrome exhibit a unique pattern for a number of malignant conditions but there is inconsistent data for the risk of oesophageal cancer. We present a case of early-onset aggressive oesophageal carcinoma in a young male patient diagnosed with Trisomy 21, who presented with complaints of progressive dysphagia, vomiting, voice change and weight loss. Barium swallow showed shouldering sign at distal oesophagus. GI Endoscopy revealed an irregular growth at 20cm from incisors obstructing the lumen. Histopathology confirmed well-differentiated adenocarcinoma. CT scan unmasked a circumferential mass involving the dorsal oesophagus with multiple enlarged nodes along with infiltration of basal segments of left lung staging the tumour as T3N1M0. A metallic stent was placed endoscopically through the stenotic tumour and the patient was referred for chemoradiotherapy. Contrary to the literature proposing a decreased incidence of solid tumours, this is a case reporting early-onset aggressive oesophageal carcinoma in a patient with Down's syndrome.

Subacute Infective Endocarditis of Aortic Valve During Pregnancy.

Bacterial infective endocarditis is a rare but a life-threatening infection during pregnancy. Infective endocarditis during pregnancy is often associated with a congenital heart condition or an earlier history of rheumatic heart disease. In pregnant women with infective endocarditis, the maternal and fetal mortality rate can reach as high as 33% and 29%, respectively. In most cases, infective endocarditis runs a subacute course and involves the mitral valve, nonetheless, rarely it can involve the aortic valve as well. We are documenting a rare case of subacute infective endocarditis in a 26-year-old pregnant female with severe aortic stenosis with associated multiple systemic emboli. The patient was managed by urgent cesarean section at 35 weeks of gestation followed by aortic valve replacement; there was no maternal or fetal mortality. This case report highlights the importance of early diagnosis, and timely management of infective endocarditis in pregnant women to prevent maternal and fetal death.

Double Trouble - Severe Hypernatremia Secondary to Central Diabetes Insipidus Complicated by Hypercalcemic Nephrogenic Diabetes Insipidus: A Case Report.

BACKGROUND Patients with malignancies often have electrolyte abnormalities. We present a case of a patient with central diabetes insipidus secondary to metastatic pituitary invasion complicated by hypercalcemic nephrogenic diabetes insipidus. CASE REPORT We present a case of 40-year-old female with a history of stage IV breast cancer with skeletal and leptomeningeal metastasis, who was admitted with polyuria, polydipsia, and recent onset of confusion. The patient was found to have profound hypernatremia and severe hypercalcemia with normal parathyroid and vitamin D serum levels. Urine studies showed low urine osmolality and high urine output, despite the higher serum osmolality. The patient received 5% dextrose for rehydration, 1 dose of intravenous (IV) pamidronate, 1 dose of IV desmopressin, and 4 days of subcutaneous calcitonin 200 international units Q12H. Initially, her urine output in the hospital was in the range of 350-400 milliliters/hour, which responded well to 1 dose of 1-desamino-8d-arginine vasopressin (DDAVP). In the subsequent days, her confusion resolved with normalization of serum sodium and calcium, but she died because of the extensive malignancy. CONCLUSIONS Our case emphasizes the importance of identification of causes and complications of electrolyte abnormalities associated with metastatic cancers. These electrolyte abnormalities can be primary or paraneoplastic and should be actively pursued and treated in such cases.