Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis.

BACKGROUND: Laparoscopic cholecystectomies continue to pose trouble for surgeons in the face of severe inflammation. In the advent of inability to perform an adequate dissection, a "bailout cholecystectomy" is advocated. Conversion to open or subtotal cholecystectomy is among the standard bailout procedures in such instances. METHODS: We performed a retrospective single institution review from January 2016 to August 2019. All patients who underwent a cholecystectomy were included, while those with a concurrent operation, malignancy, planned as an open cholecystectomy, or performed by a low volume surgeon were excluded. Patient characteristics, operative reports, and outcomes were collected, as were surgeon characteristics such as years of experience, case volume, and bailout rate. Univariable and multivariable analysis were performed. RESULTS: 2458 (92.6%) underwent laparoscopic total cholecystectomy (LTC) and 196 (7.4%) underwent a bailout cholecystectomy (BOC). BOC patients tended to be older (p < 0.001), male (p < 0.001), have a longer duration of symptoms (p < 0.001), and higher ASA class (p < 0.001). They also had more signs of biliary inflammation, as evidenced by increased leukocytosis (p < 0.001), tachycardia (p < 0.001), bilirubinemia (p = 0.003), common bile duct dilation (p < 0.001), and gallbladder wall thickening (p < 0.001). The BOC cohort also had increased rates of complications, including bile leak (16%, p < 0.001), retained stone (5.1%, p = 0.005), operative time (114 min vs 79 min, p < 0.001), and secondary interventions (22.7%, p < 0.001). Male gender (aOR = 2.8, p < 0.001), preoperative diagnosis of acute cholecystitis (aOR = 2.2, p = 0.032), right upper quadrant tenderness (aOR = 3.0, p = 0.008), Asian race (aOR = 2.7, p = 0.014), and intraoperative adhesions (aOR = 13.0, p < 0.001) were found to carry independent risk for BOC. Surgeon bailout rate ≥ 7% was also found to be an independent risk factor for conversion to BOC. CONCLUSIONS: Male gender, signs of biliary inflammation (tachycardia, leukocytosis, dilated CBD, and diagnosis of acute cholecystitis), as well as surgeon bailout rate of 7% were independent risk factors for BOC.

Endovascular Treatment of Intracavernous Internal Carotid Aneurysm Secondary to Pituitary Infection.

BACKGROUND: Intracavernous internal carotid artery (ICICA) aneurysm secondary to pituitary infection is exceedingly rare. CASE DESCRIPTION: We report an unusual case of a 63-year-old man who presented with acute left blepharoptosis and imaging findings of a pituitary infection. Interestingly, sudden onset of right blepharoptosis occurred after anti-infective therapy for 10 days. Digital subtraction angiography revealed a right ICICA aneurysm. After 6 months of follow-up visits, enlargement of the ICICA aneurysm was observed, and the endovascular technique of a low-profile visualized intraluminal support stent combined with 5 detachable coils was successfully performed to treat the ICICA aneurysm, with preservation of the internal carotid artery. CONCLUSION: This rare case highlights a life-threatening complication of a pituitary infection. Moreover, enlargement of the infected ICICA aneurysm could not be relieved by conservative anti-infective therapy. Endovascular treatment may be an alternative therapy for an infected ICICA aneurysm.

Infarto de epiplón mayor. Caso clínico / Infarction of the greater omentum. Case report

No disponible

Diagnostic accuracy of leukocytosis in prediction of acute appendicitis.

An analytical study was conducted to find out the diagnostic accuracy of leukocytosis in predicting acute appendicitis in patients undergoing emergency appendicectomy. The degree of inflammation of the resected specimens was grossly assessed and graded into acute inflammation, acute inflammation with complications (such as gangrene, perforation, abscess) and un-inflamed appendix. The operative findings were correlated with leukocyte counts using 2 x 2 table. Out of 233 appendicectomies, with exclusion of the negative appendicectomies (17.59%, n = 41), there were 67.38% patients (n = 157) with elevated leukocyte count. The overall sensitivity, specificity, positive predictive value and negative predictive value of elevated leukocyte counts for inflamed appendix were 91.81%, 43.55%, 81.77% and 65.85% respectively.

La leucocitosis extrema puede inducir a un diagnóstico erróneode hipoxemia severa. Descripción de un caso / Extreme leucocytosis can lead to an erroneous diagnosis of severe hypoxaemia. Description of a case

El diagnóstico y tratamiento de la insuficiencia respiratoria es parte de la prác-tica diaria del anestesiólogo, y la hipoxemia una de sus consecuencias fisiológicas y analíticas.Pacientes con una leucocitosis extrema secundaria a leucemia pueden sufrir un diagnósticoincorrecto de hipoxemia, llamada «seudohipoxemia». Esto se debe fundamentalmente al rápidoconsumo de oxígeno in vitro, y se caracteriza por una presión arterial de oxígeno (PaO2) bajaa pesar de tener una saturación de oxígeno (SpO2) normal medida por pulsioximetría. La seu-dohipoxemia se presenta en pacientes con trombocitosis o hiperleucocitosis por crisis blásticade una leucemia. Se debe sospechar en pacientes con una discrepancia entre la SpO2medidapor oximetría de pulso y la PaO2. En este contexto, el pulsioxímetro es el método más útil paraestablecer el diagnóstico y evitar actuaciones innecesarias. Presentamos el caso de un pacientecon leucemia mieloide crónica y extrema leucocitosis, intervenido de urgencia y diagnosticadode seudohipoxemia durante el período perioperatorio que conllevó un retraso en su extubación (AU)

The diagnosis and treatment of respiratory failure is a part of the anaesthesist’s dailypractice, as well as the hypoxaemia that is one of its physiological and analytical consequences.Patients with an extreme leucocytosis secondary to leukaemia can suffer an incorrect diagnosisof hypoxemia, called ‘‘pseudohypoxaemia’’. This is basically due to the rapid in vitro oxygenconsumption, and is characterized by a low partial pressure of oxygen in arterial blood (PaO2)despite a normal oxygen saturation (SpO2) measured by pulse oximetry. Pseudohypoxaemiaappears in patients with thrombocytosis or hyper-leucocytosis occurring during blastic crisis ofa leukaemia. It must be suspected in patients with a discrepancy between the SpO2measuredby oximetry and the PaO2. In this context, pulse oximetry is the most accurate way to establishthe diagnosis and to avoid unnecessary actions. We report the case of a patient with chronicmyeloid leukaemia and extreme leucocytosis requiring emergency surgery, and diagnosed with pseudohypoxaemia during the perioperative period that led to a delay in the extubation of thepatient (AU)

Primary squamous cell carcinoma of the stomach with paraneoplastic leukocytosis: a case report and review of literature.

Apparently pure, primary squamous cell carcinoma of the stomach is exceedingly rare. To date, less than 100 cases have been reported. Here, we describe a case of primary squamous cell carcinoma arising in the gastric antrum of an 83-year-old man with persistent leukocytosis, which resolved on resection of the tumor. No foci of squamous metaplasia or gland-forming elements were identified in the resection specimen, although there was marked chronic gastritis with intestinal metaplasia. There was no evidence of Helicobacter, fungal, or parasitic infection. Immunohistochemical and in situ hybridization studies for human papillomavirus and Epstein-Barr virus were negative. This case suggests that gastric squamous cell carcinoma likely arises in the setting of long-standing, chronic inflammation, and like squamous cell carcinoma in other organ systems, may be associated with paraneoplastic leukocytosis.

[Leukemoid reaction with uncommonly high leucocytosis in the course of serious infection]. / Odczyn bialaczkowy z niespotykanie wysoka leuko- cytoza w przebiegu ciezkiego zakazenia.

We present a case of 51-year old female patient with gastrointestinal perforation and septic shock leading to leukemoid reaction with WBC 155 x 109/l. Leukemoid reaction in neoplasms and infections can mimic chronic myelogenous leukaemia and is an important diagnostic problem.

Enfermedad de Crohn apendicular / Crohn’s disease of the appendix

La enfermedad de Crohn limitada al apéndice es una entidad clínica poco frecuente que se asemeja a un cuadro de apendicitis aguda. Afecta principalmente a individuos jóvenes, y el diagnóstico definitivo es anatomopatológico. Presentamos una serie de 7 casos de enfermedad de Crohn apendicular intervenidos en nuestro servicio de cirugía en los últimos 12 años. Los 7 pacientes presentaron dolor en la fosa ilíaca derecha y, con sospecha de apendicitis aguda, se intervinieron quirúrgicamente; en todos ellos se realizó apendicectomía. El diagnóstico se confirmó con estudios anatomopatológicos. Un enfermo fue diagnosticado en el postoperatorio de enfermnedad de Crohn cólica y en la actualidad evoluciona favorablemente con tratamiento médico. Aunque la enfermedad de Crohn limitada al apéndice es una entidad clínica rara, debe considerarse en el diagnóstico diferencial preoperatorio de pacientes con dolor en la fosa ilíaca derecha y un curso preoperatorio tórpido que se asemeja a una apendicitis aguda. La recurrencia de la enfermedad en otro lugar del tracto digestivo es poco frecuente (AU)

Crohn's disease limited to the appendix is uncommon. Clinically, it is likely to mimic acute appendicitis. It is more frequent in young people and definitive diagnosis is histological. We present a series of seven cases of Crohn's disease of the appendix that were treated in our surgery service over the past 12 years. The seven patients had pain in the lower right quadrant. In all patients, the preoperative diagnosis was acute appendicitis and appendectomy was performed. Histopathological evaluation was required for diagnosis. In the postoperative course, one patient was diagnosed with colonic Crohn's disease, and outcome was favorable with medical treatment. Although isolated Crohn's disease of the appendix is a rare entity, it should be considered in the preoperative differential diagnosis of patients with right lower quadrant pain and a protracted preoperative course mimicking acute appendicitis. Disease recurrence elsewhere in the alimentary tract is uncommon (AU)

Tumoral calcinosis after an injection of recombinant human erythropoietin in a dialysis patient.

Tumoral calcinosis is a rare form of soft tissue calcifications, initially described as an idiopathic condition, which could occur in uremic patients. Despite its distinct clinical and morphologic presentations, the underlying pathogenesis is unknown. We present a dialysis patient who developed tumoral calcinosis over the right shoulder after receiving a misplaced injection of human recombinant erythropoietin probably into the periarticular tissue. This case serves as an example highlighting the importance of periarticular inflammatory reaction in precipitating the development of the lesion in predisposed patients.

Gastrointestinal manifestations of Henoch-Schönlein purpura.

We report a case of the intestinal lesion in Henoch-Schönlein purpura, presented with an acute abdomen in a 4 year old boy. Five days after sudden colicky abdominal pain, skin purpura and painful joint swelling developed. These manifestations were associated with abdominal distension, hematemesis, hematochezia and hematuria. Exploratory laparotomy revealed a marked bowel distension with edema and patchy dark reddish discoloration of the jejunum and ileum. These patchy areas showed transmural hemorrhage and necrosis associated with characteristic leukocytoclastic vasculitis in and around the hemorrhagic lesions. These vasculitis was thought to be related to Henoch-Schönlein purpura.

Necrotizing fasciitis.

Necrotizing infections of soft tissues are rapidly progressive infections accompanied by a high mortality. Clinical presentation involves fever, cellulitis, edema, crepitus, bullae, necrosis and sepsis. Operative findings include fascial and subcutaneous tissue necrosis with or without myonecrosis. The treatment is prompt surgical debridement. Delay in treatment results in decreased survival time. The mortality in our study was 30 per cent (20 of 33). The time from recognition of an infection by the patient or physician until operative debridement averaged three and one-half days for survivors compared with 11.7 days for nonsurvivors. These infections frequently occur in compromised hosts and the mortality is greatly increased in these patients. Patients with diabetes had a mortality of 63 per cent (five of eight). The mortality for infections of the abdomen (44 per cent) and perineum (38 per cent) is greater than for the extremities (18 per cent). The bacteriologic findings of these infections involved three combinations of organisms. We had 30 mixed infections involving two or more organisms. In addition, three patients had identical signs and symptoms caused by infection with a single organism--Vibrio species. These patients all had some type of contact with a marine environment as a predisposing cause. We also applied both the APACHE and SIS systems to these patients to evaluate the severity of the illness. Nonsurvivors presented with a mean SIS score of 8.64 compared with survivors with 3.82. Initial scores with the APACHE system for nonsurvivors was 12.0 compared with 2.14 for survivors. In both systems, scores rapidly increased at three and seven days in nonsurvivors as compared with a rapid decline in the survivors. We suggest that the best descriptive system is to simply identify the organisms and tissues involved.