Challenges, Preoperative Assessment, and Surgical Strategies for the Left-Sided Gallbladder.

Left-sided gallbladder positioning, or sinistroposition, is a rare anatomical variation that poses challenges during surgical intervention due to associated vascular and biliary anomalies. While existing literature suggests an incidence of approximately 0.04-1.1%, it remains an underreported phenomenon that falls well outside the realm of "expected" anatomical variation and are rarely identified on preoperative imaging. Here, we present a case of acute cholecystitis in a patient with unexpected left-sided gallbladder, highlighting the associated challenges and outlining both preoperative and intraoperative strategies for managing this rare but consequential anatomical variant. In this case, a 49-year-old woman with a prior history of bilateral ovarian cysts presented with clinical, laboratory, and imaging findings consistent with acute cholecystitis. She underwent laparoscopic cholecystectomy and was found to have a severely inflamed left-sided gallbladder that was obscured by omentum. Her gallbladder was found in the midline immediately beneath the falciform ligament, with most of the gallbladder body and fundus attached to liver segment III, situated to the left of the midline. An additional left-sided mid-abdominal port was required to enhance retraction, and an intraoperative cholangiogram (IOC) was performed given the elevated risk of structural injury. This case underscores the heightened intraoperative risk associated with deviations in vascular and biliary anatomy and provides recommendations for intraoperative adaptations to mitigate these risks.

Mirizzi syndrome complicated by type IV cholecystobiliary fistula to the right hepatic duct.

Mirizzi syndrome is a rare complication of long-term chronic cholecystitis, characterized by extrinsic compression of the common hepatic duct that may progress to development of cholecystobiliary fistula. Here we report a case of a 38-year-old female patient who underwent laparoscopic cholecystectomy with intraoperative cholangiogram for acute cholecystitis and choledocholithiasis. Intraoperatively, the patient was found to have a Mirizzi syndrome complicated by cholecystobiliary fistula to the right hepatic duct. The gallbladder was successfully removed, cholelithiasis cleared and a ureteral stent was used in reconstruction. The patient was discharged on postoperative two and was doing well on routine follow-up. Ultimately, Mirizzi syndrome is a rare clinical entity that requires careful consideration during preoperative workup and a high suspicion when abnormal anatomy is encountered intraoperatively.

Automatic acoustic gunshot sensor technology's impact on trauma care.

INTRODUCTION: As cities nation-wide combat gun violence, with less than 20% of shots fired reported to police, use of acoustic gunshot sensor (AGS) technology is increasingly common. However, there are no studies to date investigating whether these technologies affect outcomes for victims of gunshot wounds (GSW). We hypothesized that the AGS technology would be associated with decreased prehospital transport time. METHODS: All GSW patients from 2014 to 2016 were collected from our institutional registry and cross-referenced with local police department data regarding times and locations of AGS alerts. Each GSW incident was categorized as related or unrelated to an AGS alert. Admission data, trauma outcomes, and prehospital time were then compared. RESULTS: We analyzed 731 patients. Of these, 192 were AGS-related (26%) and 539 were not (74%). AGS-related patients were more likely to be female (p < 0.01), have a higher injury severity score (ISS) (p < 0.01), and require an operation (p = 0.03). Ventilator days (p < 0.05) and hospital length of stay (p < 0.01) was greater in the AGS cohort. Mortality, however, did not differ between groups (p = 0.5). On multivariable analysis, both total prehospital time and on-scene time were lower in the AGS group (p < 0.01). CONCLUSION: Our study suggests reduced transport times, decreased prehospital and emergency medical service on-scene times with AGS technology. Additionally, despite higher ISS and use of more hospital resources, mortality was similar to non-AGS counterparts. The potential of AGS technology to further decrease prehospital times in the urban setting may provide an opportunity to improve outcomes in trauma patients with penetrating injuries.

Rapid Implementation of Intraoperative Ultrasonography to Reduce Wire Localization in The Permanente Medical Group.

CONTEXT: Preoperative wire localization (WL), the most common localization technique for nonpalpable breast lesions, has drawbacks including scheduling constraints, cost, and patient discomfort. OBJECTIVE: To reduce WL use in our health care system, we investigated using hydrogel clips to facilitate intraoperative ultrasonography-guided lumpectomies. DESIGN: We retrospectively reviewed electronic medical records of patients with nonpalpable, ultrasound-visible breast lesions who underwent lumpectomy by 7 surgeons at 4 pilot sites in Kaiser Permanente Northern California between January 2015 and October 2015. Hydrogel clips, used for several years before the study period, were placed routinely during core-needle biopsy in all patients with nonpalpable, ultrasound-visible breast lesions. MAIN OUTCOME MEASURES: Localization method, lesion size, margin positivity, and receipt of neoadjuvant therapy. RESULTS: One hundred forty-three patients underwent hydrogel clip placement and lumpectomy by pilot-site surgeons. Localization consisted of intraoperative ultrasonography alone, preoperative skin marking, or WL. Of the 143 patients, 71.3% did not need WL (60.8% ultrasonography alone and 10.5% skin marking). The non-WL and WL groups had similarly sized lesions, and the positive margin rate was 7.2% overall, with no significant difference between the non-WL and WL groups (5.9% vs 11.5%, p = 0.33). Of the 12 patients who underwent neoadjuvant chemotherapy, 8 (67%) did not require WL. CONCLUSION: A multifacility protocol using intraoperative ultrasonography to visualize hydrogel clips was implemented, which decreased WL procedures and produced no significant difference in margin positivity between the WL and non-WL groups. This technique can be a cost-effective alternative to WL in patients who are candidates for hydrogel clip placement.

Shedding new light on rapidly resolving traumatic acute subdural hematomas.

BACKGROUND: Rapidly resolving acute subdural hematomas (RRASDHs) have been described in case reports and case series but are still poorly understood. We hypothesized that a cohort analysis would confirm previously reported predictors of RRASDH including coagulopathy, additional intracranial hemorrhage, and low-density band on imaging. We also hypothesized that rapid resolution would be associated with improved trauma outcomes. METHODS: We reviewed all nonoperative acute subdural hematomas (ASDHs) treated at our center from 2011 to 2015. Inclusion criteria were ASDH on computed tomography (CT), admission Glasgow coma score >7, and repeat CT to evaluate ASDH change. RRASDH was defined as reduced hematoma thickness by 50% within 72 h. Clinical data, CT findings, and trauma end points were analyzed for the RRASDH and nonresolving groups. RESULTS: There were 154 ASDH patients included, with 29 cases of RRASDH. The RRASDH group had a lower rate of comorbidities than the nonresolving group (58.6% versus 78.4%, P = 0.03) and a lower rate of prehospital anticoagulation (7.7% versus 37.1%, P = 0.004). Previously reported predictors of RRASDH did not differ between the groups, nor did any clinical outcome measures. When compared with patients who experienced rapid growth (>50% increased width in 72 h), the RRASDH group had lower mortality (3.4% versus 23.5%, P = 0.04). CONCLUSIONS: To our knowledge, this is the largest review of RRASDHs. We identified two previously unrecognized factors that may predict resolution; however, previously reported predictors were not associated with resolution. We also found no relationship between RRASDHs and improved standard trauma outcomes, calling into question the clinical significance of RRASDH.

Repeat computed tomography is highly sensitive in determining need for delayed exploration in blunt abdominal trauma.

BACKGROUND: Computed tomography (CT) imaging has an established role in the initial evaluation of blunt abdominal trauma. What is less clear is the role of CT in guiding delayed exploration in patients initially managed nonoperatively after blunt trauma. We hypothesized that a repeat CT would accurately identify the need for an exploratory laparotomy in this patient population. MATERIALS AND METHODS: From 2005 to 2014, we reviewed all blunt abdominal trauma patients at our institution who received an admission CT scan. We identified patients who underwent repeat CT of the abdomen within 72 h for the documented purpose of reevaluating potential intra-abdominal injuries. CT findings were categorized as either having a CT indication for exploration or not, allowing a sensitivity analysis. RESULTS: Of the 50 patients who met our inclusion criteria, 9 underwent surgical exploration of the abdomen and 41 did not. Admission clinical indicators such as Glasgow Coma Scale, Injury Severity Score, and vitals were similar between the operative and nonoperative groups (P > 0.05). When compared with initial CT scan, repeat scan was found to increase the sensitivity from 67% to 100%, while also improving the specificity to 86%, positive predictive value to 50%, and negative predictive value to 100%. CONCLUSIONS: Repeat CT scan of the abdomen may be useful in evaluating blunt trauma patients initially managed nonoperatively. The second CT scan increases the sensitivity of CT evaluation to 100% while also improving the specificity, positive predictive value, and negative predictive value.

Lactate predicts massive transfusion in hemodynamically normal patients.

BACKGROUND: Trauma patients at risk of deterioration because of occult injury may be hemodynamically normal on arrival. Early identification of these patients may improve care, especially for those who require massive transfusion (MT). We hypothesized that elevated admission lactate would predict the need for MT in hemodynamically normal patients. MATERIALS AND METHODS: All trauma patients treated at our university-based urban center over a 5-year period were reviewed. We included hemodynamically normal patients who had an admission lactate performed. First, a receiver-operating curve was used to determine the threshold lactate value. Subsequent analyses were then based on this value. Variables were analyzed using chi-square and unpaired t-tests, and univariable and multivariable regressions. RESULTS: There were 3468 hemodynamically normal patients with an admission lactate. Those who received MT (n = 19) had higher lactate than those who did not (n = 3449; 5.6 versus 2.6 mmol/L, P ≤ 0.001). Receiver-operating curve curve analysis revealed a threshold lactate value of 4 mmol/L with an area under the curve of 0.71. Patients with a lactate of >4 mmol/L had increased mortality (8% versus 2%), longer hospital length of stay (LOS, 6 versus 3 days), longer intensive care unit (ICU) LOS (6 versus 3 days), greater need for MT (2.8% versus 0.3%), and greater blood requirement (219 versus 38 mL; all P values < 0.001). After controlling for confounding variables, the predictive value of admission lactate >4 remained strong (odds ratio, 5.2; 95% confidence interval, 1.87-14.2). CONCLUSIONS: In hemodynamically normal trauma patients, the admission lactate of >4 mmol/L is a robust predictor of MT requirement and associated with poor outcomes.