Laparoscopic subtotal cholecystectomy after percutaneous transhepatic gallbladder drainage for grade II or III acute cholecystitis.

BACKGROUND: Severe adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies. METHODS: This retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013-2017, n = 17) and post-TG18 group (2018-2020, n = 27). Patients' background demographics, surgical method, surgical results, and postoperative complications were compared. RESULTS: The interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9-42] days vs. 8 [4-11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group. CONCLUSIONS: For grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.

Effect of the Thermal History on the Crystallinity of Poly (L-lactic Acid) During the Micromolding Process.

The micromolding process using biocompatible thermoplastic polymers is highly attractive as a fabrication process of microdevices in biomedical applications. In this study, we investigated the effect of the thermal history in the micromolding process on the crystallinity of semi-crystalline polymers, such as poly (L-lactic acid) (PLLA), during their crystallization from the amorphous and molten states. In particular, the thermal history in the micromolding process using poly(dimethylsiloxane) replica mold embedded with a thermocouple was recorded. The crystallinity of PLLA constructs fabricated using the micromolding process was measured via wide-angle X-ray scattering, and crystallization kinetics was analyzed based on the Kolmogorov-Johnson-Mehl-Avrami equation. A crystallization rate of k = 0.061 min-n was obtained in the micromolding process of PLLA crystallization from the amorphous state, accompanied by the quenching operation, forming a large number of crystal nuclei. Finally, the fabrication of PLLA microneedles was performed using micromolding processes with different thermal histories. The information about the thermal history during the micromolding process is significant in the development of polymer microdevices to achieve better material properties.

Successful treatment of a bowel fistula in the open abdomen by perforator flaps and an aponeurosis plug.

In this report, we present a case of successful treatment of a bowel fistula in the open abdomen by perforator flaps and an aponeurosis plug. A 70-year-old man underwent total gastrectomy and developed anastomotic leakage and dehiscence of the abdominal wound a week later. He was dependent upon extracorporeal membrane oxygenation, continuous hemodiafiltration, and a respirator. Bowel fluids contaminated the open abdomen. Two months after the gastric operation, a plastic surgery team, in consultation with general surgeons, performed perforator flaps on both sides and constructed, as it were, a bridge of skin sealing the orifice of the fistula. The aponeurosis of the external oblique muscle was elevated with the flap to be used as a plug. The perforators of the flaps were identified on preoperative and intraoperative ultrasonography. This modality allowed us to locate the perforators precisely and to evaluate the perforators by assessing their diameters and performing a waveform analysis. The contamination decreased dramatically afterwards. The bare areas were gradually covered by skin grafts. The fistula was closed completely 18 days after the perforator flap. An ultrasoundguided perforator flap with an aponeurosis plug can be an option for patients suffering from an open abdomen with a bowel fistula.

Emphysematous cholecystitis successfully treated by laparoscopic surgery.

Emphysematous cholecystitis (EC) is an uncommon variant of acute cholecystitis, which is caused by secondary infection of the gallbladder wall with gas-forming organisms. The mortality rate of EC is still as high as 25%. Emergency surgical intervention is indicated. Open cholecystectomy has been traditionally accepted as a standard treatment for EC. We present a case of EC successfully treated by laparoscopic surgery. Laparoscopic cholecystectomy for EC is considered to be safe and effective when indicated.

Superior mesenteric venous thrombosis after laparoscopic exploration for small bowel obstruction.

Mesenteric venous thrombosis is a rare cause of intestinal ischemia which is potentially life-threatening because it can lead to intestinal infarction. Mesenteric venous thrombosis rarely develops after abdominal surgery and is usually associated with coagulation disorders. Associated symptoms are generally subtle or nonspecific, often resulting in delayed diagnosis. A 68-year-old woman underwent laparoscopic exploration for small bowel obstruction, secondary to adhesions. During the procedure, an intestinal perforation was identified and repaired. Postoperatively, the abdominal pain persisted and repeat exploration was undertaken. At repeat exploration, a perforation was identified in the small bowel with a surrounding abscess. After the second operation, the abdominal pain improved but anorexia persisted. Contrast enhanced abdominal computed tomography was performed which revealed superior mesenteric venous thrombosis. Anticoagulation therapy with heparin was started immediately and the thrombus resolved over the next 6 days. Although rare, this complication must be considered in patients after abdominal surgery with unexplained abdominal symptoms.