Accuracy of Preoperative MDCT in Patients With Penetrating Abdominal and Pelvic Trauma.

PURPOSE: This study aims to evaluate the overall diagnostic accuracy of preoperative multidetector computed tomography (MDCT) in penetrating abdominal and pelvic injuries (PAPI). METHOD AND MATERIALS: We used our hospitals' trauma registry to retrospectively identify patients with PAPI from January 1, 2006, to December 31, 2016. Only patients who had a 64-MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in our study cohort. Each finding noted on MDCT was rated using a 5-point scale to indicate certainty of injury, with a score of 0 being definitive. Using surgical findings as the gold standard, the accuracy of radiology reports was analyzed in 2 ways. A κ statistic was calculated to evaluate each pair of values for absolute agreement, and ratings for all organ systems were analyzed using a repeated measures analysis of variance (ANOVA) to determine whether radiology and surgical findings were similar enough to be clinically meaningful. Qualitative review of the radiology and surgical reports focused on the gastrointestinal (GI) tract was conducted. RESULTS: Our cohort consisted of 38 males and 4 females with a median age of 29 years and a median injury severity score of 15.6. For this study, 12 different organ groups were categorized and analyzed. Of those organ groups, absolute agreement between MDCT and surgical findings was found only for liver and spleen (κ values ranging from 0.2 to 0.5). Additionally, the ANOVA revealed an interaction between finding type and organ system (F 1, 33 = 7.4, P < .001). The most clinically significant discrepancies between MDCT and surgical findings were for gallbladder, bowel, mesenteric, and diaphragmatic injuries. Qualitative review of the GI tract revealed that radiologists can detect significant findings such as presence of injury, however, localization and extent of injury pose a challenge. CONCLUSION: The detection of clinically significant injuries to solid organs in trauma patients with PAPI on 64-MDCT is adequate. However, detection of injury to the remaining organ groups on MDCT, especially bowel, mesentery, and diaphragm, remains a challenge.

Isolated gallbladder injury from blunt abdominal trauma: A rare co-incidence.

Gallbladder injury resulting from blunt abdominal trauma is a rare entity and generally associated with other intra-abdominal injuries. Incidence of isolated gallbladder injury has not been reported yet. The most common mechanism of injury reported is road traffic accident. Diagnosis is usually made on imaging as clinical presentation may vary from no symptoms to peritonitis due to extravasation of bile in the abdominal cavity. Cholecystectomy is the treatment of choice and minimally invasive approach can be considered in haemodynamically stable patients.

A Case Report of Isolated Blunt Traumatic Gallbladder Perforation and Review of the Literature.

INTRODUCTION: Gallbladder trauma is an uncommon occurrence, most commonly found incidentally at the time of laparotomy for associated injuries following abdominal trauma. It is even more rare in blunt abdominal trauma, with one of the rarest forms being an isolated injury to the gallbladder. Awareness for this type of injury should not be forgotten by emergency personal when evaluating someone with a history of recent trauma. CASE DESCRIPTION: A 44-year-old male who works as a construction worker fell from a roof, landing on his right side. Upon evaluation by the emergency department, emergency personnel combined the history, abnormal laboratory values and imaging including ultrasound (U/S) and computed tomography (CT) to assess and diagnose a concern for gallbladder perforation. He was treated with a diagnostic laparoscopy, laparoscopic cholecystectomy, and intraoperative choleangiogram. The patient tolerated the procedure well and discharged home on postoperative day 1. DISCUSSION: Gallbladder trauma can be seen in all population types. As the gallbladder is fairly protected, it is rare to have an isolated injury. A detailed history as described can tip off practitioners to the diagnosis, but is also missed or delayed due to occasionally vague symptoms. Imaging studies can be used adjunctively to assist in diagnosis and may include CT, U/S, color Doppler, or HIDA scans. These can also fail to give a diagnosis leading to a missed injury and further morbidity and mortality. Perforated gallbladders can safely be treated laparoscopically as well as other options depicted. CONCLUSION: Awareness of isolated and rare injuries in trauma, such as those to the gallbladder, enables many types of emergency personnel to recognize and treat patients and consequently prevent the morbidity and mortality of a missed injury.

In vivo 1 H MRS of human gallbladder bile in understanding the pathophysiology of primary sclerosing cholangitis (PSC): Immune-mediated disease versus bile acid-induced injury.

Primary sclerosing cholangitis (PSC) has been considered to be either an "autoimmune disease" or a "bile acid-induced injury." In vitro MRS studies on PSC patients have limitations due to the contamination of bile with contrast agent (commonly administered during endoscopic retrograde cholangiopancreatography) and/or the use of patient cohorts with other diseases as controls. The objective of this study was to quantify biliary metabolites using in vivo 1 H MRS and gain insight into the pathogenesis of PSC. Biliary metabolites in 10 PSC patients and 14 healthy controls were quantified in vivo using 1 H MRS on a 3 T MR scanner. The concentrations of total bile acids plus cholesterol, glycine-conjugated bile acids, taurine-conjugated bile acids, and choline-containing phospholipids (chol-PLs) were compared between the two groups. There were statistically significant decreases in the levels of the above mentioned biliary metabolites in the PSC patients compared with controls. The reduction in bile acid secretion in bile of PSC patients indicates accumulation of bile acids in hepatocytes. Moreover, reduction in the levels of chol-PLs in bile may increase the toxic effects of bile acids. Our findings suggest that the bile duct injury in PSC patients is most likely due to "bile acid-induced injury."

10-mm Laparo-Endoscopic Single-Site Cholecystectomy Using Multiple Magnetically Anchored and Controlled Instruments.

BACKGROUND: To study the feasibility of laparo-endoscopic single-site (LESS) cholecystectomy through a 10-mm incision using a miniature magnetically anchored and controlled laparoscopy system and a grasper system. METHODS: The miniature magnetically anchored and controlled laparoscopy system consisted of a miniature magnetically anchored camera (MMAC), an external magnetic anchoring unit, and a vision output device. The camera weighed 9.8 g and measured Φ10 mm × 50 mm. The magnetically anchored and controlled grasper system consisted of a magnetically anchored grasper (MAG), an external magnetic anchoring unit, and a push-pull device. The MAG had a titanium alloy clip head and a magnetic tail. The laparoscopy system and grasper system were used simultaneously to perform LESS cholecystectomy through a single 10-mm incision in model canines. RESULTS: LESS cholecystectomy through a 10-mm incision using the MMAC and MAG was attempted in six dogs. The mean operative time was 85.75 ± 7.14 min. The operation was completed successfully in four cases, with failure occurring in one case due to gallbladder rupture and in another due to bile duct injury. The MMAC provided clear imaging, and the MAG provided sufficient exposure to perform the cholecystectomy. The use of multiple magnetically anchored and controlled instruments did not result in notable collisions. CONCLUSIONS: The designed MMAC and MAG system could be easily maneuvered. LESS cholecystectomy may be feasible through a single 10-mm incision with the simultaneous use of multiple magnetically anchored and controlled instruments.

Intraoperative bile spillage is associated with worse survival in gallbladder adenocarcinoma.

BACKGROUND: Gallbladder adenocarcinoma is often incidentally identified following cholecystectomy. We hypothesized that intraoperative bile spillage would be a negative prognostic factor. METHODS: A retrospective review of patients treated at a cancer center with histologically confirmed gallbladder adenocarcinoma, 2009-2017, was performed. Patient, disease, and treatment factors were analyzed in terms of progression-free survival (PFS) and overall survival (OS). RESULTS: Sixty-six patients were identified. Tumor stage was T1 (n = 8, 12%), T2 (n = 23, 35%), T3 (n = 35, 53%). Node stage was N0 (n = 22, 33%), N1+ (n = 26, 39%), Nx (n = 18, 27%). Operations included cholecystectomy alone (n = 27, 36%), cholecystectomy and partial hepatectomy (n = 30, 45%), or hepaticojejunostomy (n = 9, 14%). Median PFS was 7 months (interquartile range [IQR], 2-19); median OS was 16 months (IQR, 10-31). Subset multivariate proportional hazards regression of 41 patients who underwent initial cholecystectomy showed decreased PFS was associated with intraoperative spillage (n = 12, 29%; hazard ratio [HR], 5.5; P = .0014); decreased OS was associated with drain placement (n = 21, 51%; HR, 8.1; P = .006). CONCLUSIONS: Intraoperative bile spillage and surgical drain placement at initial cholecystectomy are negatively associated with PFS and OS in gallbladder adenocarcinoma. Explicit documentation of spillage and drain placement rationale is critical, possibly indicating locally advanced disease and prompting stronger consideration of systemic therapy before definitive resection.

Green dialysate and gallbladder perforation in a peritoneal dialysis patients: a case report and literature review.

BACKGROUND: Gallbladder perforation is a rare but lethal condition and its diagnosis is usually difficult and delayed. Frequently, gallbladder rupture is associated with cholecystitis, but spontaneous perforation was ever described. However, spontaneous rupture of gallbladder has never been reported in patients underwent peritoneal dialysis. CASE PRESENTATION: We report a 62-year-old man who presented with abdominal pain for 2 days to clinic. Peritoneal dialysis-related peritonitis was diagnosed initially. It was followed by spontaneous gallbladder perforation with greenish dialysate. The patient was managed successfully by antibiotic treatment and primary closure of gallbladder perforation with external drainage. He recovered from this critical condition and stayed on dialysis. CONCLUSIONS: Early diagnosis and timely surgical intervention yields a good prognosis in PD patients with gallbladder perforation. Surgical intervention and antibiotic treatment are the mainstay of treatment. Both of them should take place promptly.

Life Threatening Complications Post-Liposuction.

BACKGROUND: Liposuction is one of the most commonly performed aesthetic procedures. It is performed worldwide as an outpatient procedure. However, the complications are underestimated and underreported by caregivers. We present a case of delayed diagnosis of bilothorax secondary to liver and gallbladder injury after tumescent liposuction. METHODS: A 26-year-old female patient was transferred to our emergency department from an aesthetic clinic with worsening dyspnea, tachypnea and fatigue. She had undergone extensive liposuction of the thighs, buttocks, back and abdomen 5 days prior to presentation. RESULTS: A chest X-ray showed significant right-sided pleural effusion. Thoracentesis was performed and drained bilious fluid. CT scan of the abdomen revealed pleural, liver and gall bladder injury. An exploratory laparoscopy confirmed the findings, the collections were drained; cholecystectomy and intraoperative cholangiogram were performed. The patient did very well postoperatively and was discharged home in 2 days. CONCLUSION: Even though liposuction is considered a simple office-based procedure, its complications can be fatal. The lack of strict laws that exclusively place this procedure in the hands of medical professionals allow these procedures to still be done by less experienced hands and in outpatient-based settings. Our case serves to highlight yet another unique but potentially fatal complication of liposuction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Efficacy and Safety of Radiofrequency Ablation for Focal Hepatic Lesions Adjacent to Gallbladder: Reconfiguration of the Ablation Zone through Probe Relocation and Ablation Time Reduction.

PURPOSE: To evaluate the safety and efficacy of radiofrequency (RF) ablation for treatment of focal hepatic lesions adjacent to the gallbladder with electrode relocation and ablation time reduction. MATERIALS AND METHODS: Thirty-nine patients who underwent RF ablation for focal hepatic lesions adjacent to the gallbladder (≤ 10 mm) were evaluated retrospectively from January 2011 to December 2014 (30 men and 9 women; age range, 51-85 y; mean age, 65 y). Of 36 patients with hepatocellular carcinoma, 3 had a second treatment for recurrence (mean tumor size, 15 mm ± 6). Patients were divided into 2 subgroups based on lesion distance from the gallbladder: nonabutting (> 5 mm; n = 19) and abutting (≤ 5 mm; n = 20). Electrodes were inserted parallel to the gallbladder through the center of a tumor in the nonabutting group and through the center of the expected ablation zone between a 5-mm safety zone on the liver side and the gallbladder in the abutting group. Ablation time was decreased in proportion to the transverse diameter of the expected ablation zone. RESULTS: Technical success and technical effectiveness rates were 89.7% and 97.4%, respectively, with no significant differences between groups (P = 1.00). Local tumor progression was observed in 3 patients (1 in the nonabutting group and 2 in the abutting group; P = 1.00). There were no major complications. The gallbladder was thickened in 10 patients, with no significant difference between groups (P = .72). Biloma occurred in 1 patient in the nonabutting group. CONCLUSIONS: RF ablation with electrode relocation and reduction of ablation time can be a safe and effective treatment for focal hepatic lesions adjacent to the gallbladder.

Gallbladder perforation after closed thoracoabdominal trauma, diagnosed and treated by ERCP.

Single gallbladder injury after abdominal trauma is a rare finding. Early diagnosis of this disease is often difficult due to the variability of symptoms and unspecific results in the usual radiological tests. The usual management in patients with vesical trauma is surgery. We report a case of a patient with a gallbladder perforation after closed thoracoabdominal trauma diagnosed and treated with ERCP and a conservative management with good clinical evolution.

Right Retroperitoneal and Subhepatic Abscess; Late Complications Due to Spilled Stones During Laparoscopic Cholecystectomy - Case Report.

BACKGROUND: Gallbladder perforation with gallstone spillage during laparoscopic cholecystectomy is usually an event with no consequences. CASE REPORT: We report the case of a 66 year-old female admitted in our hospital with severe large abscess in the right lumbar region. Her medical history reveals a laparoscopic cholecystectomy for acute gallstone cholecystitis. Emergent abscess incision and drainage are performed, noticing a mass of stone outline. The abdominal CT scan shows fluid, air-bubbled collection with biloculate walls located in the right retroperitoneal subhepatic region. Laparoscopic procedure is performed, the subhepatic abscess is located and drained, the abscess cavity containing 19 gallstones. OUTCOME: The post-operative evolution was favourable. The patient was discharged on the 6th post-operative day. CONCLUSIONS: The stones left in the peritoneal cavity during laparoscopic cholecystectomy may be sometimes the cause of severe late complications.

Isolated gallbladder rupture following blunt abdominal injury.

Isolated traumatic gallbladder rupture subsequent to blunt abdominal injury is rare. Most literatures on the subjects consist of case reports. We reported a rare case of isolated gallbladder rupture and discussed the possible predisposing factors to gallbladder rupture.

Gallbladder perforation: a rare complication of postoperative chemotherapy of gastric cancer.

A middle-aged man presented 1 day after being discharged from hospital with completing the first course of postoperative chemotherapy. He suffered a sudden persistent high fever and chills. It was noted that he had a history of a total gastrectomy (with D2 lymphadenectomy) 1 month ago. His admission bloods revealed total bilirubin was 142.2 umol/L, indirect bilirubin of 107.6 umol/L and white cell count of 20.05×10(9)/L. A color doppler ultrasound scan confirmed fluid and gas around liver and hilus lienis while the gallbladder cannot be detected. During Computed Tomography (CT) guided puncture positioning technology and setting a three-channel tube, about 400 ml of foul smell hazel turbid liquid was drained out. He was diagnosed as gallbladder perforation and he was underwent conservative treatment consist of drainage, banning diet, total parenteral nutrition and intravenous antibiotics. Then he recovered well within the subsequent 10 days and was discharged.

Giant biloma as a result of a blunt abdominal trauma: A case report.

A 58-year-old man with a history of a heavy alcohol intake was admitted to hospital for a 3-weeks history of abdominal discomfort, nausea, vomiting and an increased abdominal girth that appeared progressively after an abdominal trauma due to an accidental fall. On physical examination, jaundice was present and the abdomen was distended with no tenderness on palpation. Laboratory studies showed an increased white-cell count, an elevated C-reactive protein and abnormal liver-function tests. Abdominal ultrasonography showed a large fluid collection in the right side of the abdomen. An abdominal computed tomography scan revealed a gallbladder perforation communicating to a big subcapsular hepatic biloma of 9.5 by 25.0 by 35.0 centimeters, which was compressing the liver and other intraabdominal organs. Finally, our patient underwent an open cholecystectomy with drainage of the biloma, and a partial resection of the Glisson's capsule. Macroscopic and microscopic examination of the resected specimens confirmed the diagnosis of traumatic gallbladder perforation. Gallbladder traumatic injury is a rare entity. The diagnosis represents a challenge because of its low incidence, its association with other lesions of vital organs and the nonspecific and insidious symptoms that can produce. Treatment depends on the type and severity of the damage caused; nevertheless, cholecystectomy remains the treatment of choice in patients with rupture or avulsion of the gallbladder. To our knowledge, this is the first report in the English literature of an isolated blunt traumatic gallbladder injury that was associated with the development of a large biloma.

Outcomes of antibiotic prophylaxis in acute cholecystectomy in a population-based gallstone surgery registry.

BACKGROUND: The aim of this study was to assess the effect of antibiotic prophylaxis (AP) on postoperative infections in acute cholecystectomy. METHODS: The study was based on acute cholecystectomies registered in the nationwide Swedish Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) between 2006 and 2010. The association between AP and the risk of postoperative infectious complications was tested in a multivariable regression analysis, with stepwise addition of age, sex, duration of operation, indication for surgery, surgical approach (laparoscopic versus open) and American Society of Anesthesiologists (ASA) fitness grade as co-variables. Postoperative infections requiring antibiotic treatment and postoperative abscesses were defined as outcome measures. RESULTS: AP was given to 9549 (68.6 per cent) of 13 911 patients. Postoperative infections requiring antibiotic treatment occurred following 1070 procedures (7.7 per cent), including 805 patients (8.4 per cent) who received AP (P < 0.001 versus patients without AP). Postoperative abscesses developed after 273 procedures (2.0 per cent), including 208 patients (2.2 per cent) who received AP (P = 0.007). In univariable analysis, the odds ratio for development of infectious complications necessitating treatment with antibiotics was 1.42 (95 per cent confidence interval 1.23 to 1.64) for those who received AP versus those who did not, and for postoperative abscesses it was 1.47 (1.11 to 1.95). In multivariable analysis, adjusting for confounders, the odds ratios were 0.93 (0.79 to 1.10) and 0.88 (0.64 to 1.21) respectively. CONCLUSION: The present study suggests that AP provides no benefit in acute cholecystectomy.

Percutaneous cryoablation of hepatic tumors adjacent to the gallbladder: assessment of safety and effectiveness.

PURPOSE: To assess safety and effectiveness of percutaneous image-guided cryoablation of hepatic tumors adjacent to the gallbladder. MATERIALS AND METHODS: Twenty-one cryoablation procedures were performed to treat 19 hepatic tumors (mean size, 2.7 cm; range, 1.0-5.0 cm) adjacent to the gallbladder in 17 patients (11 male; mean age, 59.2 y; range, 40-82 y) under computed tomography (n = 15) or magnetic resonance imaging (n = 6) guidance in a retrospective study. All tumors (mean size, 2.67 cm; range, 1.0-5.0 cm) were within 1 cm (mean, 0.4 cm) of the gallbladder; seven (33%) were contiguous with the gallbladder. Primary outcomes included complication rate and severity and postprocedure gallbladder imaging findings. Secondary outcomes included technical success and technique effectiveness at 6 months. RESULTS: Complications occurred in six of 21 procedures (29%); one (5%) was severe. Ice balls extended into the gallbladder lumen in 20 of 21 procedures (95%); no gallbladder-related complications occurred. The most common gallbladder imaging finding was mild, asymptomatic focal wall thickening after nine of 21 procedures (42%), which resolved on follow-up. Technical success was achieved in 19 of 21 sessions (90%). Six-month follow-up was available for 16 tumors; of these, all but two (87%) had no imaging evidence of local tumor progression. CONCLUSIONS: Percutaneous cryoablation of hepatic tumors adjacent to the gallbladder can be performed safely and successfully. Although postprocedural gallbladder changes are common, they are self-limited and clinically inconsequential, even when the ice ball extends into the gallbladder lumen.

Trauma Whipple: do or don't after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB).

BACKGROUND: Pancreaticoduodenectomy for trauma (PDT) is a rare procedure, reserved for severe pancreaticoduodenal injuries. Using the National Trauma Data Bank (NTDB), our aim was to compare outcomes of PDT patients to similarly injured patients who did not undergo a PDT. METHODS: Patients with pancreatic or duodenal injuries treated with PDT (ICD-9-CM 52.7) were identified in the NTDB 2008­2010 Research Data Sets. We excluded those who underwent delayed PDT (>4 days). The PDT group (n = 39) was compared to patients with severe combined pancreaticoduodenal injuries (grade 4 or 5) who did not undergo PDT (non-PDT group, n = 38). Patients who died in the emergency department or did not undergo a laparotomy were excluded. Our primary outcome was death. Secondary outcomes were intensive care unit length of stay (LOS), hospital LOS, and total ventilator days. A multivariate model was used to determine predictors of in-hospital mortality within each group and in the overall cohort. RESULTS: The non-PDT group had a significantly lower systolic blood pressure and Glasgow Coma Scale values at baseline and more severe duodenal, pancreatic, and liver injuries. There were no significant differences in outcomes between the two groups. The Injury Severity Score was the only independent predictor of mortality among PDT patients [odds ratio (OR) 1.12, 95 % confidence interval (CI) 1.01­1.24] and in the entire cohort (OR 1.06, 95 % CI 1.01­1.12). The operative technique did not influence any of the outcomes. CONCLUSIONS: Compared to non-PDT, PDT did not result in improved outcomes despite a lower physiologic burden among PDT patients. More conservative procedures for high-grade injuries of the pancreaticoduodenal complex may be appropriate.

A case of gallbladder perforation detected by sonography after a blunt abdominal trauma.

Gallbladder (GB) perforation is a very rare posttraumatic abdominal injury. It is potentially life-threatening, and good outcome requires early diagnosis. We present a case of isolated posttraumatic GB perforation in which the precise sonographic (US) diagnosis led us to apply proper management. Color Doppler US showed a clear to-and-fro flow signal passing through the perforation site, and contrast-enhanced US confirmed the presence of a small defect in the GB wall. When examining posttraumatic patients, the possibility of GB perforation must be kept in mind. Color Doppler US and contrast-enhanced US are the examinations of choice to detect the perforation site and show bile movement through the perforation.