Predictive factors of smell recovery in a clinical series of 288 coronavirus disease 2019 patients with olfactory dysfunction.

BACKGROUND AND PURPOSE: The aim was to evaluate potential predictive factors of smell recovery in a clinical series of 288 patients presenting olfactory dysfunction (OD) related to coronavirus disease 2019 (COVID-19). Potential correlations were sought between epidemiological, clinical and immunological characteristics of patients and the persistence of OD at 60 days. METHODS: COVID-19 positive patients presenting OD were prospectively recruited from three European hospitals. Baseline clinical and olfactory evaluations were performed within the first 2 weeks after OD onset and repeated at 30 and 60 days. In a subgroup of patients, anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies were measured in serum, saliva and nasal secretions at 60 days. RESULTS: A total of 288 COVID-19 patients with OD were included in the study. Two weeks after the onset of the loss of smell, 52.4% of patients had OD on psychophysical tests, including 113 cases (39.2%) of anosmia and 38 cases (13.2%) of hyposmia. At 60-day follow-up, 25.4% of the patients presented persistent OD. There was no significant correlation between sex, age, viral load on nasopharyngeal swab or COVID-19 severity and poor olfactory outcome. In a subgroup of 63 patients, it was demonstrated that patients with poor olfactory outcomes at 60 days had lower levels of salivary and nasal immunoglobulin G (IgG) and IgG1, but similar levels of antibodies in the serum. CONCLUSIONS: No clinical markers predicted the evolution of OD at 60 days. Patients with poor olfactory outcome at 60 days had lower saliva and nasal antibodies, suggesting a role for local immune responses in the persistence of COVID-19 related OD.

Neutrophilic Dermatosis of Hands as Oncological Finding: Importance of Follow-Up.

Neutrophilic febrile dermatosis (NFD) is a rare paraneoplastic syndrome that may be found in patients with head and neck cancer. NFD may appear before the neoplasia and may only concern the dorsal faces of the hands. This article reports the NFD findings of a patient with pharyngeal cancer, which was developed 2 years after the occurrence of NFD. The development of NFD in patient with alcohol and tobacco consumption should lead otolaryngologists and dermatologists to suspect head and neck malignancy. In cases of normal otolaryngological examination, patients have to be followed.

Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study.

OBJECTIVE: To investigate the occurrence of olfactory and gustatory dysfunctions in patients with laboratory-confirmed COVID-19 infection. METHODS: Patients with laboratory-confirmed COVID-19 infection were recruited from 12 European hospitals. The following epidemiological and clinical outcomes have been studied: age, sex, ethnicity, comorbidities, and general and otolaryngological symptoms. Patients completed olfactory and gustatory questionnaires based on the smell and taste component of the National Health and Nutrition Examination Survey, and the short version of the Questionnaire of Olfactory Disorders-Negative Statements (sQOD-NS). RESULTS: A total of 417 mild-to-moderate COVID-19 patients completed the study (263 females). The most prevalent general symptoms consisted of cough, myalgia, and loss of appetite. Face pain and nasal obstruction were the most disease-related otolaryngological symptoms. 85.6% and 88.0% of patients reported olfactory and gustatory dysfunctions, respectively. There was a significant association between both disorders (p < 0.001). Olfactory dysfunction (OD) appeared before the other symptoms in 11.8% of cases. The sQO-NS scores were significantly lower in patients with anosmia compared with normosmic or hyposmic individuals (p = 0.001). Among the 18.2% of patients without nasal obstruction or rhinorrhea, 79.7% were hyposmic or anosmic. The early olfactory recovery rate was 44.0%. Females were significantly more affected by olfactory and gustatory dysfunctions than males (p = 0.001). CONCLUSION: Olfactory and gustatory disorders are prevalent symptoms in European COVID-19 patients, who may not have nasal symptoms. The sudden anosmia or ageusia need to be recognized by the international scientific community as important symptoms of the COVID-19 infection.

Clinical and Acoustical Voice Quality Evolutions Throughout Empirical Treatment for Laryngopharyngeal Reflux Disease According to Gender: A Preliminary Study.

OBJECTIVE: To compare symptoms, signs, and acoustical voice quality changes throughout the 6-month course of empirical treatment between laryngopharyngeal reflux (LPR) males and females. MATERIALS AND METHODS: Forty clinically diagnosed LPR females and 40 males with a reflux finding score (RFS) >7 and a reflux symptom index (RSI) >13 were treated with pantoprazole and diet recommendations during 3 or 6 months according to their evolution. RSI, RFS, and acoustic parameters were assessed at baseline and 3 and 6 months posttreatment. A correlation analysis between videolaryngostroboscopic findings and acoustic measurements was performed. RESULTS: RSI, RFS, and many acoustic measurements (i.e., percent jitter, percent shimmer, phonatory fundamental frequency range, fundamental frequency variation, and peak-to-peak amplitude variation) significantly improved from baseline to 3 months posttreatment in male group. In female group, RSI and RFS total score significantly improved along the 3 first months of treatment. However, some clinical outcomes (i.e., RSI total score, hoarseness, cough, and globus) continued to improve from 3 to 6 months of treatment. We did not identify significant improvement of acoustic measurements in female group. The correlation study did not reveal significant correlation between videolaryngostroboscopic findings and acoustic measurements. CONCLUSION: This preliminary study suggests the occurrence of gender-related differences in the LPR therapeutic response. Further studies need to clarify whether females require a longer course of therapy than males.

Pancreaticoduodenectomy in the Middle East: Achieving optimal results through specialization and standardization.

BACKGROUND: Pancreaticoduodenectomy is a challenging surgical intervention that remains the cornerstone in the treatment of localized peri­ampullary pathologies. The concept of treatment standardization has been well-established in many high-volume centers in the world. Here, we present our experience in pancreaticoduodenectomy from 1994 to 2015. METHODS: We performed a retrospective review of the medical charts of patients who underwent pancreaticoduodenectomy at our institution. Data was entered to SPSS statistical software and analyzed. The Mann-Whitney U and Fisher's exact tests were used to report statistical differences between groups. RESULTS: Of the 370 patients who underwent pacreaticoduodenectomy, 300 were analyzed. The 1-, 3-, 5- and 10-year survival rates were 85%, 35%, 15%, and 7%, respectively with a 30-day mortality rate of 5.0% (15 patients). The median age of the patients was 61 (13-84) years, with 193 (64.3%) males and 107 (35.7%) females. The median operative time was 300 (130-570) min. The median postoperative length of hospital stay was 12 (5-76) days. Thirty-two patients required re-laparotomies; 10 for pancreatic leak, 7 for biliary leak and 15 for control of bleeding. Seventy-five (25.0%) patients developed pancreatic fistulae. Delayed gastric emptying was present in 31 (10.3%) patients. A significant improvement in surgical outcome was observed in cases done after 2008 which indicates the important role of specialized team in surgical management. CONCLUSIONS: The number of patients undergoing pancreaticoduodenectomy has been increasing annually over the past twenty-two years in our institution with results comparable to published series from high-volume centers. Through standardization of surgical techniques and perioperative management carried out by a specialist team, our results continue to improve despite the increasing complexity of cases referred to our unit.

Gender differences in the presentation of dysphonia related to laryngopharyngeal reflux disease: a case-control study.

OBJECTIVE: To investigate the voice quality impairments in patients with laryngopharyngeal reflux (LPR) according to the gender. DESIGN: Controlled multi-center study. MATERIALS AND METHODS: 80 LPR patients (40 males and 40 females) with reflux finding score (RFS) > 7 and reflux symptom index (RSI) > 13 were included and clinically compared according to gender. To be considered as LPR patients, subjects responded to an empiric therapeutic trial based on pantoprazole intake and diet recommendations for 3 months or had positive pH/Impedance metry. Voice Handicap Index (VHI); Short Form Healthy Survey 36 (SF36), blinded Grade, Roughness, Breathiness, Asthenia, Strain and Instability (GRBASI); aerodynamic and acoustic measurements were assessed in all patients and compared with 80 healthy controls (40 males and 40 females) according to gender. RESULTS: The most common reasons for the consultation were, respectively, globus sensation in males (22.5%) and dysphonia (27.5%) in female who complained more of breathing difficulties and choking episodes related to LPR than males (p = 0.024). From a quality of life standpoint, female had increased significant impact of LPR disease on vitality and mental health than male. Compared to healthy subjects, both LPR male and female patients had stronger values of G, R, B, S, I, VHI, percent jitter, percent shimmer, and soft palate index than controls. In addition, LPR female had stronger values of lowest fundamental frequency and all aerodynamic measurements than controls. CONCLUSION: As showed in many other laryngeal conditions, voice quality of female could be more impaired by LPR than male. Some anatomical, histological and functional factors can be suspected and need additional future researches.

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 .

Impact of age on laryngopharyngeal reflux disease presentation: a multi-center prospective study.

The objective is to assess the differences in the severity of symptoms, signs, voice quality, and quality of life before and after treatment according to age in suspected laryngopharyngeal reflux (LPR) patients. The design used in this paper is prospective multi-center study. Eighty clinically diagnosed LPR patients with a reflux finding score (RFS) >7 and a reflux symptom index (RSI) >13 were treated with pantoprazole and diet recommendations for 3 months. Patients were subdivided into three groups according their age: group 1 (18-39 years, N = 21), group 2 (40-59 years, N = 31), and group 3 (≥60 years, N = 28). RSI, RFS, Voice Handicap Index (VHI), Short Form 36 questionnaire (SF36), aerodynamic, and acoustic measurements were evaluated at baseline and after treatment. The response to the empiric treatment was also assessed. Significant improvements in RSI, RFS, and VHI were found in all patient groups. The elderly patients showed a significantly lower RSI score than younger subjects (p = 0.035) without RFS difference among groups. At baseline, the SF36 score was better in group 3 with respect to social functioning (p = 0.049). At the 3-month follow-up, we found significant improvement of acoustic parameters only in the younger age groups (group 1 and group 2). The rate of resistant patients to the empiric treatment was higher in the younger group than in the elderly patient group (42.9 versus 28.6%). Age appears to reduce the subjective LPR symptom perception, leading to a lower rate of uncured patients. The utilization of acoustic parameters as an indicator of treatment effectiveness seems less useful for elderly subjects, probably due to an overlap between an aging voice and LPR.

Spontaneous nosocomial Proteus mirabilis meningitis in a Human Immunodeficiency Virus (HIV)-infected adult patient: a case report.

BACKGROUND: Gram-negative bacillary meningitis remains a rare occurrence, even in patients with human immunodeficiency virus. Current literature only describes anecdotal cases of spontaneous nosocomial Proteus mirabilis meningitis. This report describes the clinical manifestations and management of a patient with healthcare-associated spontaneous Gram-negative bacillary meningitis in a patient with advanced human immunodeficiency virus disease. CASE PRESENTATION: A 23-year-old Congolese female was hospitalized in a human immunodeficiency virus specialized center for ongoing weight loss, chronic abdominal pain, and vomiting 9 months after initiation of treatment for tuberculosis meningitis. Hospitalization was complicated by healthcare-associated Gram-negative bacillary meningitis on day 18. Blood and cerebrospinal fluid cultures confirmed Proteus mirabilis. Antibiotic susceptibility testing showed extended spectrum beta-lactamase resistant to common antibiotics, and sensitive to meropenem. Despite initiation of high-dose meropenem by intravenous infusion (2 g every 8 hours), the patient did not improve, and died after 4 days of meropenem treatment. Gram-negative bacillary meningitis remains rare and is associated with an unfavorable prognosis. CONCLUSIONS: This case report highlights the importance of microbiological identification of pathogens in resource-limited settings. As Gram-negative bacillary meningitis does not present with pleocytosis in patients with advanced human immunodeficiency virus, a negative lumbar puncture cannot exclude this diagnosis. Access to clinical bacteriology in resource-limited settings is essential to enable correct antibiotic treatment and avoid overuse of antibiotics to which there is already resistance. It further plays an essential role in public health by identifying antibiotic susceptibilities. Infection prevention and control measures must be reinforced in order to protect patients from such avoidable healthcare-associated infections.

Bilateral Vocal Cord Abduction Paralysis after C1 Laminectomy in a Child with Type 1 Arnold Chiari Malformation.

Background: Type 1 Arnold Chiari is a neurological malformation that may be associated with vocal cord paralysis in Children. In most cases, the vocal cord paralysis is related to protrusion of medulla and cerebellum in the foramen magnum, which led to compression on the vagus nerve.Case report: A 12-year-old child underwent suboccipital decompression and C1 laminectomy for a symptomatic type 1 Arnold Chiari malformation. After the surgery, patient reported severe dyspnea, aphonia, and dysphagia. The videolaryngostroboscopy and neurological examinations reported a postoperative bilateral vocal cord abduction paralysis due to bilateral IX and X cranial nerve paralyzes and a bilateral paralysis of the tongue.Discussion: The type 1 Arnold Chiari malformation clinical picture may present with unilateral or bilateral vocal cord paralysis, which may resolve with an adequate management of the disease. However, the neurosurgical decompression and C1 laminectomy may result in bilateral lesion of the IX, X, and XII cranial nerves, and related severe swallowing, aspiration and vocal cord disorders.Conclusion: We reported the first case of bilateral vocal cord abduction paralysis occurring post-neurosurgical decompression and C1 laminectomy in a child with type 1 Arnold Chiari malformation. This case highlights the importance of surgical steps of the procedure in front of the C1 vertebrae where there are IX, X, and XII cranial nerves.

Extra-gastrointestinal stromal tumors (EGISTs): A case report for a mischief entity.

BACKGROUND: Extra-gastrointestinal stromal tumor is a rare subtype of soft tissue sarcomas with significantly variable presentation, management, and prognosis. This makes it crucial to report the different institutional experiences of encountering extra-gastrointestinal stromal tumors (EGIST). CASE PRESENTATION: We report 3 cases of EGIST diagnosis at American University of Beirut Medical Center for 2 males and 1 female in the 5th, 6th, and 7th decades of life, respectively. For the first case, the tumor was initially suspected to be ovarian cancer, but biopsy revealed a diagnosis of EGIST, and the patient was started on neoadjuvant therapy. In the second case, the tumor was retro-gastric and prelim diagnosis was gastric cancer but again biopsy revealed an EGIST histopathology, and the patient underwent surgery and adjuvant treatment. For the third case, a previous history of testicular cancer prompted an initial suspicion of recurrence with metastasis but biopsy and immunohistochemistry staining revealed EGIST with related markers. The patient underwent treatment at a different institution in his home country. CONCLUSION: This report sheds light on the importance of keeping EGIST amongst any differential list for abdominal and pelvic tumors. It also shows that EGIST-focused studies are needed to assess the effectiveness of the different treatment modalities available when utilized specifically for EGIST. This would allow for better oncological outcomes and improved quality of life.

Antimicrobial stewardship in primary health care programs in humanitarian settings: the time to act is now.

Fragile and conflict-affected settings bear a disproportionate burden of antimicrobial resistance, due to the compounding effects of weak health policies, disrupted medical supply chains, and lack of knowledge and awareness about antibiotic stewardship both among health care providers and health service users. Until now, humanitarian organizations intervening in these contexts have confronted the threat of complex multidrug resistant infections mainly in their surgical projects at the secondary and tertiary levels of care, but there has been limited focus on ensuring the implementation of adequate antimicrobial stewardship in primary health care, which is known to be setting where the highest proportion of antibiotics are prescribed. In this paper, we present the experience of two humanitarian organizations, Médecins sans Frontières and the International Committee of the Red Cross, in responding to antimicrobial resistance in their medical interventions, and we draw from their experience to formulate practical recommendations to include antimicrobial stewardship among the standards of primary health care service delivery in conflict settings. We believe that expanding the focus of humanitarian interventions in unstable and fragile contexts to include antimicrobial stewardship in primary care will strengthen the global response to antimicrobial resistance and will decrease its burden where it is posing the highest toll in terms of mortality.

Retroperitoneal desmoid-type fibromatosis: a case report.

Desmoid-type fibromatosis (DF) is a rare subtype of soft tissue sarcomas that most commonly occurs in the anterior abdominal wall. When occurring in the retroperitoneum, DF is usually part of familial syndromes while only rarely sporadic. This makes it imperative to report any instance of experience with DF and the oncological outcomes of the different approaches to management. We report two cases of sporadic and severe DF occurring in the retroperitoneum at our institution. Case presentation: The first case is a male that presented with urinary obstruction symptoms and underwent surgical resection of the tumor that extended into the left kidney. The second case is a female with a history of recurrent desmoid tumors of the thigh and was incidentally diagnosed with retroperitoneal DF on imaging. She underwent tumor resection and radiotherapy; however, the tumor recurred with urinary obstruction symptoms that required another surgical resection. Histopathological characteristics and radiological imaging of both cases are described below. Clinical discussion: Desmoid tumors often recur, thus significantly influencing the quality of life which is reflected in one of our cases. Surgery remains a mainstay treatment, and both cases presented in this report required surgical resection of the tumors as symptomatic and curative measures. Conclusion: Retroperitoneal DF is a rare entity, and our cases add to the scarce literature available on the topic, which may well contribute to the formulation of practice-changing recommendations and guidelines focused on this rare variant of DF.

Indirect ballistic injury to the liver resulting in retained bullet complicated with hepatic abscess: a case report.

Indirect and extraperitoneal penetrating liver injury is an extremely uncommon phenomenon. In this report, we highlight the case of an 18-year-old male patient that sustained a gunshot wound with an entry site through the right buttock and landed in the liver. He presented to us in sepsis due to developing a hepatic abscess at the site of the dislodged bullet that was confirmed with computed tomography. Interestingly, the ballistic missile did not cause any visceral injury due to its indirect and extraperitoneal trajectory. The patient underwent diagnostic laparoscopy, where the hepatic abscess was unroofed and evacuated. A free-floating bullet was found and extracted, and a small bile duct leak was repaired. The patient had an uneventful post-operative course and was duly discharged on an empiric course of antibiotics.

Metastatic melanoma to the small bowel causing intussusception: A case report.

INTRODUCTION AND IMPORTANCE: Melanoma is a malignant skin neoplasm with a high metastatic potential. Several reports have shown that metastatic melanoma has a predilection to metastasize to the GI tract; however, diagnosing metastatic melanoma as a cause of intussusception has been reported in only few cases with variable presentations. CASE PRESENTATION: We present the case of a 48-year-old woman with a long history of metastatic melanoma who presented with recurrent enteric intussusception due to a melanoma lesion acting as a pathologic lead point despite immunotherapy treatment. We contribute the management plan, diagnostic modalities, and surgical approach of this rare form of adult intussusception in guidance of future management plans. CLINICAL DISCUSSION: The variability in presentation of adult intussusception makes diagnosis difficult and the lack of consensus on management and surgical strategies poses challenging hurdles. A diagnostic laparoscopy followed by reduction and resection of the intussuscepted lesion in a small surgical field is an effective and beneficial palliative procedure with favorable outcomes. Our patient developed intussusception despite receiving a trial of dual immunotherapy after chemotherapy. CONCLUSION: It may be insufficient to control disease even with dual immunotherapy after chemotherapy. Further studies are needed to determine the optimal surgical and oncological management in treating gastrointestinal metastasis of malignant melanoma.

Management of ruptured hepatocellular carcinoma invading the gastrointestinal tract: A case report.

INTRODUCTION AND IMPORTANCE: Hepatocellular carcinoma (HCC) constitutes most of primary liver cancers. HCC invading the gastrointestinal tract (GIT) is considered a rare entity with limited reports in the literature. Management can either be palliative or curative such as transarterial chemoembolization (TACE) followed by definitive resection. Here, we present a case of direct HCC invasion of the GIT that was managed by surgical resection. CASE PRESENTATION: A 74-year-old male with a history of a liver mass, found to have HCC. Admitted for medical optimization prior to definitive resection, however his stay was complicated by hemorrhagic shock, with imaging findings of hemoperitoneum suggestive of spontaneous rupture of the mass. TACE was done to stabilize the patient prior to resection. Patient was taken immediately to the operating room for definitive resection. CLINICAL DISCUSSION: Most cases of direct HCC invasion into the GI tract present mainly with GI bleed. Some patients, present with abdominal pain without any warning signs of an occult GI bleed. Thus, absence of an occult GI bleeding does not exclude a GIT invasion. Management options are several, but in advanced stages, management is not limited to palliation. CONCLUSION: GIT invasion is a rare complication of HCC reported in scarcity in the literature. Most cases present with GI bleeding but with some rare cases, they present with more generalized symptoms like abdominal pain, weight loss or fatigue. Despite having a poor prognosis, complete surgical resection of the tumor may be a reassuring and life prolonging treatment option for these patients.

Hydatid Disease of the Liver in the Middle East: A Single Center Experience.

Background: Human cystic echinococcosis (CE), most commonly caused by echinococcosis granulosis, is the most common presentation of hydatid disease of the liver and is considered endemic in the Middle East region. Patients and Methods: This study is a retrospective single-center analysis of all patients with hepatic hydatid disease presenting for surgical management from 2001 to 2019. Results: From 2001 to 2019, 100 patients (54 males, 46 females) were diagnosed with hydatid disease of the liver with a mean age of 45 years (range, 19-82). The most common presenting symptom was right upper quadrant abdominal pain followed by incidental finding of cyst on imaging. Thirteen patients (13%) presented with signs and symptoms of obstructive jaundice. Of the 100 patients, 39 underwent laparoscopic surgery and 61 underwent open surgery. The most common complications were as follows: 16 bile leaks (16%), 14 intra-abdominal fluid collections (14%), 8 wound infections (8%), and 3 patients had biliary strictures (3%). Of the 100, 8 patients(8%) had recurrence of their hepatic hydatid disease. Conclusions: Hydatid disease of the liver is not a common disease, and its management can include medical, surgical, and interventional radiology. The decision depends on the size and complexity of the cyst and its location. Bile leak is a common complication and should be managed conservatively or through intervention by radiology or endoscopic retrograde cholangiopancreatography (ERCP).

Immunotherapy for metastatic liver disease from colorectal carcinoma: case series from the Middle East.

Immunotherapy poses new considerations and alterations to the management of metastatic colorectal carcinoma (mCRC), where chemotherapy achieves complete radiological response but yields complete pathological response in few patients only. Immunotherapy may be superior in the conversion of unresectable disease to resectable liver lesions from mCRC and downsizing borderline lesions for more feasible resectability and achieving complete pathologic response, with the potential for cure and to alter current, established guidelines for surgical resection with a shift from chemotherapy. We present two patients with hepatic lesions from mCRC characterized by deficient mismatch repair (dMMR) which were unresectable after traditional chemotherapy but were converted to resectable lesions with a complete histopathological response following immunotherapy. Complete histopathologic response and radiologic regression or disappearance of liver lesions was observed in patients with dMMR mCRC after pembrolizumab. Immunotherapy exhibits notable potential for cure, achieving complete, successful surgical resection and improving prognosis.

The implications and management of complex biliary injuries at a tertiary hepatobiliary specialty center.

Injuries of the biliary tract and complex injuries involving vascular and parenchymal tissue can be detrimental despite the improved use of laparoscopy. Complex biliary injuries are variable depending on the type of injury as well as patient and surgeon factors. We present four cases of complex biliary injuries at our tertiary referral center with hepatobiliary expertise: biliary stenosis with obstruction, double duct system anatomy, combined right hepatic arterial transection and biliary duct injury, and a complete pedicle injury. Early identification and specialized repair of complex biliary injuries is essential to minimize patient morbidity. Notably, consulting a specialist intraoperatively in case of difficult dissection and visualization or a suspected injury and considering bail-out strategies such as a subtotal cholecystectomy or conversion are safe approaches to minimize complex biliary injuries. Earlier recognition and repair of complex biliary injuries improves outcomes when immediate intraoperative repair can be performed rather than delayed postoperatively.