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Background: Gallbladder torsion is very rare and easily misdiagnosed as biliary disease. It is defined as the rotation of the gallbladder along the axis of the cystic pedicle on the mesentery. As gallbladder rotation involves the gallbladder artery, the blood supply is blocked, resulting in gallbladder ischemia and eventual necrosis. If misdiagnosis occurs and treatment is delayed, gallbladder torsion can develop into a lethal disease. The typical imaging features of gallbladder torsion in this case are a good learning resource for our young physicians, as well as providing a rare, unusual and typical case for our current literature database. Case Description: We present a rare case of gallbladder torsion in a 19-year-old man. The patient complained of sudden recurrent pain and discomfort in the right upper abdomen with vomiting for 12 hours. Abdominal ultrasound and computed tomography (CT) scan showed gallbladder enlargement and signs of acute cholecystitis in emergency examination, and there were no signs of cholecystolithiasis. Considering that the patient was a young male and the patients prefer conservative treatment, symptomatic treatment was given. However, there was no obvious effect after 1 day of medical treatment, but severe abdominal pain in the upper right quadrant continues to progress. Finally, the patient underwent laparoscopic cholecystectomy, and the gallbladder was found to be enlarged with ischemic necrosis, which was caused by gallbladder torsion. The patient recovered 2 days after surgery and was discharged without complications. Conclusions: Although the clinical manifestation is similar to that of typical acute calculous cholecystitis, gallbladder torsion can be diagnosed early through some special signs on imaging examination, such as distorted cystic duct signs ("beak and whirl" sign), gallbladder dilatation with gallbladder fossa effusion, and gallbladder in the horizontal position. These signs can help primary surgical treatment and prevent fatal complications such as gallbladder gangrene, perforation, and biliary peritonitis. Therefore, for inexperienced doctors, careful imaging features are required for the correct diagnosis of rare gallbladder torsion. Keywords: Gallbladder torsion; acute abdominal disease; cholecystitis; case report.
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Background: The risk of post-hepatectomy liver failure (PHLF) is difficult to predict preoperatively. Accurate preoperative assessment of residual liver volume is critical in PHLF. Three-dimensional (3D) imaging and intra-operative ultrasound (IOUS) offer significant advantages in calculating liver volume and have been widely used in hepatectomy risk assessment. Our research aimed to explore the accuracy of 3D imaging technique combining IOUS in predicting PHLF after hepatectomy. Methods: We used a retrospective study design to analyze patients who underwent hepatectomy with 3D imaging combined with IOUS between 2017 and 2020. Utilizing 3D reconstruction, the patient's residual liver volumes (PRLVs) and ratio of PRLV to standard liver volume (SLV) were calculated preoperatively. Hepatectomy were performed and actual hepatectomy volume (AHV) were measured. Consistency between preoperative planned hepatectomy volume (PPHV) and AHV was quantified postoperatively by Bland-Altman analysis. Multiple logistic regression and receiver-operating characteristic (ROC) curves were utilized to discuss the predictive value of PRLV/SLV in PHLF. Results: Among the 214 included patients, 58 (27.1%) had PHLF. Patients with PHLF had significantly higher residual rates of ICG-R15 (%) (P=0.000) and a lower PRLV/SLV ratio (P=0.000). Bland-Altman analysis showed that PPHV was consistent with AHV (P=0.301). Multivariate analysis confirmed that PRLV/SLV ratio >60% (OR, 0.178; 95% CI: 0.084-0.378; P<0.01) was a protective factor for PHLF. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75.8% (95% CI: 64.5.3-87.2%), 66.6% (95% CI: 59.1-74.1%), 45.8%, and 88.1%, respectively. The area under the ROC curve (AUC) was 73.7% (95% CI: 65.7-85.8%) and the diagnostic accuracy of PRLV/SLV for PHLF was moderate (P<0.001). These results were validated in the validation cohort perfectly. The primary cohort included 214 patients with a PHLF rate of 27.1% (n=58, 28 grade B and 13 grade C). The validation cohort included 135 patients with a PHLF rate of 35.6% (n=48, 24 grade B and 11 grade C). Conclusions: The calculation of PRLV/SLV has predictive value in PHLF and can be exploited as a predictive factor. The 3D imaging technique combined with IOUS may be useful for PHLF risk assessment in hepatectomy patients.