Fibrous Adhesions Research Articles

Association of LIN28B Gene Polymorphisms with Intrauterine Adhesions in Patients after Curettage Abortion.

Background/Objectives: Intrauterine adhesion (IUA) is characterized by endometrial fibrocyte hyperplasia. The LIN28B gene is associated with many proliferative diseases. However, its association with IUA is entirely unknown. We hypothesized that LIN28B gene polymorphisms are responsible for IUA susceptibility after curettage abortion. Methods: In this genetic association study, We genotyped two common polymorphisms (rs369065 C>T and rs314280 A>G) in 107 patients with IUA and 270 controls without IUA after curettage abortion from a Chinese population between July 2022 and May 2023 and analyzed their associations with IUA risk using multiple logistic regression models. Results: The carriers of genotype rs314280 AA of the LIN28B gene showed an increased risk of IUA (AOR [adjusted odds ratio] = 2.12, 95% CI [confidence interval] = 1.151-3.903), compared to GG+GA genotypes. Further stratification analyses showed that the deleterious role of the rs314280 AA genotype was more evident in patients with fewer than four pregnancies (AOR = 2.740, 95% CI = 1.355-5.540), fewer than two births (AOR = 2.676, 95% CI = 1.300-5.509), and fibrous (AOR = 2.082, 95% CI = 1.084-3.997) and muscular adhesions (AOR = 3.887, 95% CI = 1.116-13.540). However, the rs369065 T>C polymorphism of the LIN28B gene was not significantly associated with the occurrence of IUA. Conclusions: The rs314280 AA genotype of the LIN28B gene is associated with an increased risk of IUA in patients after curettage abortion, especially in those with fewer pregnancies or parities and higher disease severity. Our findings implicate a precise choice of clinical counseling and decision-making of IUA, thereby protecting female reproduction.

Amino acid-crosslinked 4arm-PLGA Janus patch with anti-adhesive and anti-bacterial properties for hernia repair

Presently, the non-biodegradable polypropylene (PP) patches frequently used for hernia repair can cause fibrous tissue growth and adhesions. This study created a Janus Patch with anti-adhesion and antimicrobial properties to improve hernia repair while promoting tissue repair. The biologically active 4arm-PLGA-BLPD was initially synthesized through the modification of 4arm-PLGA with lysine, followed by the fabrication of a Janus patch using a layer-by-layer electrostatic spinning technique. This patch consisted of three layers: a repair layer composed of 4arm-PLGA-BLPD/PCL fiber membrane, a mechanical layer of 4arm-PLGA/PCL fiber membrane, and an antimicrobial layer of EMO-4arm-PLGA/PCL fiber membrane loaded with Emodin (EMO). The results showed that Janus patch exhibited notable tensile strength and elongation at break, enabling it to offer enhanced mechanical reinforcement for abdominal wall defects. In addition, it slowly releases lysine for repair and inhibits bacterial growth with EMO. In vivo experiments demonstrated that the patch effectively induced neovascularization, reduced collagen ac-cumulation, and stabilized the expression of relevant proteins through the up-regulation of MMP1 and MMP9. This facilitated successful repair of the abdominal wall defect model and prevented adhesions. In summary, the Janus patch offers both practical application and theoretical insight for hernia repair.

The regulatory effect of electroacupuncture on endometrial M1-type macrophages in rats with intrauterine adhesions.

To observe the effect of electroacupuncture(EA) on endometrial fibrosis and M1-type macrophages in rats with intrauterine adhesions(IUA), so as to explore the possible mechanism of EA in the treatment of IUA. Fifteen female SD rats were randomly divided into blank group, model group and EA group, with 5 rats in each group. The IUA rat model was established by double damage method using mechanical scraping combined with lipopolysaccharide infection. Rats in the EA group were treated with acupuncture at "Guanyuan"(CV4), and EA at bilateral "Zusanli"(ST36) and "Sanyinjiao"(SP6)for 20 minutes each time, once a day, for 3 consecutive cycles of estrus. Five rats in each group were sampled during the estrous period, and the endometrial morphology, endometrial thickness and the number of blood vessels and glands were observed after HE staining. The fibrotic area of the uterus was observed after Masson staining. The positive expressions of Runt-related transcription factor(RUNX1), transforming growth factor-β1(TGF-β1), connective tissue growth factor(CTGF), α-smooth muscle actin(α-SMA), collagen type I(Col-Ⅰ), cluster of differentiation 86(CD86), interleukin-1β(IL-1β), and tumor necrosis factor-α(TNF-α) in endometrial tissue were detected by immunohistochemistry. Western blot was used to detect relative protein expressions of RUNX1, TGF-β1, α-SMA, CD86, and TNF receptor 2 (TNFR2), and real-time fluorescence quantitative PCR was used to detect mRNA expressions of RUNX1, TGF-β1, α-SMA, CD86, and TNF-α in the endometrium. During the estrous phase, the endometrial layer in the model group was damaged, with reduced folds, disordered arrangement of epithelial cells, loose fibrous connective tissue, significant narrowing and adhesions in the uterine cavity, interstitial congestion, edema, and a significant infiltration of inflammatory cells with sparse glands. While uterine tissue structure of the EA group was basically intact, resembling a normal uterus, with more newly formed glands and a small amount of inflammatory cell infiltration. In comparison with the blank group, the endometrial thickness, the number of blood vessels, and the number of glands were significantly decreased(P<0.001) in the model group, while the ratio of uterine fibrosis area, the positive expressions of RUNX1, TGF-β1, CTGF, α-SMA, Col-Ⅰ, CD86, IL-1β, and TNF-α, the protein relative expressions of RUNX1, TGF-β1, α-SMA, CD86 and TNFR2, and the mRNA relative expression levels of RUNX1, TGF-β1, α-SMA, CD86 and TNF-α in the endometrium were significantly increased (P<0.001, P<0.01). Compared to the model group, the endometrial thickness, the number of blood vessels, and the number of glands were significantly increased(P<0.01, P<0.05) in the EA group, while the ratio of uterine fibrosis area, the positive expressions of RUNX1, TGF-β1, CTGF, α-SMA, Col-Ⅰ, CD86, IL-1β and TNF-α in the endometrial tissue, the protein expressions of RUNX1, TGF-β1, α-SMA, CD86 and TNFR2, and the mRNA relative expressions of RUNX1, TGF-β1, α-SMA, CD86 and TNF-α in the endometrium were significantly decreased (P<0.001, P<0.01, P<0.05). EA can improve endometrial fibrosis in IUA rats, which may be related to its function in decreasing the level of endometrial M1-type macrophages and the secretion of related inflammatory factors.

A Rare Presentation of Primary Thymic Small Cell Carcinoma Found after Trauma: A Case Report

Thymic small cell carcinoma is an exceedingly rare diagnosis with undefined treatment options and, typically, poor prognosis. A 69-year-old female presented to the Emergency Department with chest pain and was found on Computed Tomography (CT) to have a multilobulated cystic mass in the anterior mediastinum. Magnetic Resonance Imaging (MRI) demonstrated a 7 x 8 x 8 cm mediastinal mass suspicious for thymoma. Biopsies of enlarged lymph nodes in levels 4L and 7 were negative for malignancy. The patient was taken for surgical resection of the mediastinal mass. After standard sternotomy, the mass was noted to be contiguous with the thymus. The specimen was removed en bloc and surgical pathology revealed high grade neuroendocrine carcinoma, measuring 9.0 cm in greatest dimension, consistent with small cell carcinoma of the thymus. Fibrous adhesions to the lung were noted but all margins and lymph nodes were negative for malignancy. Brain MRI was unremarkable and multidisciplinary tumor board decided to proceed with adjuvant chemotherapy. Patient is currently doing well without symptoms of recurrence one year post-operatively.

Torsion of the caudate lobe of the liver and concurrent necrohemorrhagic typhlocolitis in a zoo-housed Patagonian mara.

Liver lobe torsion has been reported in many species, with frequent reports in rabbits. Here we describe caudate liver lobe torsion and concurrent necrohemorrhagic typhlocolitis in a Patagonian mara (syn: Patagonian cavy, Patagonian hare, Dolichotis patagonum). Following acute death, postmortem examination findings included torsion of the hepatic caudate process, which had fibrous adhesions to the pancreas indicating chronicity. The cecal apex and proximal 30 cm of colon had regionally reddened serosa and diffusely roughened and reddened mucosa with brown-red and granular luminal contents. Key histologic findings included massive necrosis of the torsed hepatic caudate lobe, consistent with infarction, necrotizing hepatitis in remaining areas of liver, necrohemorrhagic typhlocolitis, adrenocortical necrosis and hemorrhage, and renal tubular degeneration and necrosis with tubular casts. Bacterial culture of cecal contents yielded pure growth of Salmonella spp. Death was attributed to toxemia or bacteremia resulting from Salmonella spp. infection, as the hepatic lobe torsion appeared chronic. It was undetermined if the liver lobe torsion predisposed to gastrointestinal compromise and infection. Patagonian maras have some anatomical similarities to rabbits and are highly cursorial, not dissimilar to hares, Lepus spp. We speculate that these characteristics may increase the likelihood of hepatic caudate lobe torsion in this species.

Bioglass/ceria nanoparticle hybrids for the treatment of seroma: a comparative long-term study in rats.

Background: Seroma formation is a common postoperative complication. Fibrin-based glues are typically employed in an attempt to seal the cavity. Recently, the first nanoparticle (NP)-based treatment approaches have emerged. Nanoparticle dispersions can be used as tissue glues, capitalizing on a phenomenon known as 'nanobridging'. In this process, macromolecules such as proteins physically adsorb onto the NP surface, leading to macroscopic adhesion. Although significant early seroma reduction has been shown, little is known about long-term efficacy of NPs. The aim of this study was to assess the long-term effects of NPs in reducing seroma formation, and to understand their underlying mechanism. Methods: Seroma was surgically induced bilaterally in 20 Lewis rats. On postoperative day (POD) 7, seromas were aspirated on both sides. In 10 rats, one side was treated with NPs, while the contralateral side received only NP carrier solution. In the other 10 rats, one side was treated with fibrin glue, while the other was left untreated. Seroma fluid, blood and tissue samples were obtained at defined time points. Biochemical, histopathological and immunohistochemical assessments were made. Results: NP-treated sides showed no macroscopically visible seroma formation after application on POD 7, in stark contrast to the fibrin-treated sides, where 60% of the rats had seromas on POD 14, and 50% on POD 21. At the endpoint (POD 42), sides treated with nanoparticles (NPs) exhibited significant macroscopic differences compared to other groups, including the absence of a cavity, and increased fibrous adhesions. Histologically, there were more macrophage groupings and collagen type 1 (COL1) deposits in the superficial capsule on NP-treated sides. Conclusion: NPs not only significantly reduced early manifestations of seroma and demonstrated an anti-inflammatory response, but they also led to increased adhesion formation over the long term, suggesting a decreased risk of seroma recurrence. These findings highlight both the adhesive properties of NPs and their potential for clinical therapy.

A Unique Case of Appendiceal Intussusception (Inversion): A Case in Bloom.

A 40-year-old female patient presented to a secondary facility with dull lower abdominal pain and a persistent low-grade fever. Her laboratory results showed elevated inflammation markers. A CT scan revealed two abscesses in the lesser pelvic region in direct contact with the apex of the appendix, the posterior wall of the uterus, and the right-side appendages. The patient responded well to intravenous antibiotics, and an MRI scan revealed the cause to be an appendiceal rupture. The patient was scheduled for an appendectomy. The procedure started laparoscopically but had to be converted to an open one with a midline infra-umbilical incision in order to protect the right appendages. A standard appendectomy was conducted, and the histology report revealed rupture of the appendix with concomitant wall inversion in the context of fibrous adhesions as well as obstruction due to a fecalith. Patient recovery and follow-up were excellent. Acute appendicitis, while frequently encountered in surgical practice, can present a diagnostic conundrum when it manifests in an atypical manner. This unique form of inversion appeared to confer a protective role against peritonitis, primarily through the mechanism of obstruction occurring centrally to the rupture. We suggest that this case should be included in current classifications as a partial inversion of the appendix after rupture and inflammation.

Temporomandibular joint ankylosis - An anesthesiologist’s nightmare: Case series

Temporomandibular joint (TMJ) ankylosis is defined as bony or fibrous adhesion of the anatomic joint components accompanied by a limitation in opening the mouth. Airway management is a grueling task and has confronted anesthesiologists ever since. The challenge is even more exaggerated when it is a pediatric patient. We present a case series of five pediatric patients with TMJ ankylosis with age 7 years or less, who were posted for its corrective surgery. Although all patients belonged to the pediatric age group, the challenges faced and techniques employed to overcome them were different partly because of different age groups and partly the nature of the airway, with tailoring of each technique accordingly. Pediatric airway management is no less than waging a war as all necessary skills and expertise are put to the test. It combines fortuity with skills. We have to be prepared for the worst in any unforeseen scenario.

In Vitro Assessment of Bacterial Adhesion and Biofilm Formation on Novel Bioactive, Biodegradable Electrospun Fiber Meshes Intended to Support Tendon Rupture Repair.

The surgical repair of a ruptured tendon faces two major problems: specifically increased fibrous adhesion to the surrounding tissue and inferior mechanical properties of the scar tissue compared to the native tissue. Bacterial attachment to implant materials is an additional problem as it might lead to severe infections and impaired recovery. To counteract adhesion formation, two novel implant materials were fabricated by electrospinning, namely, a random fiber mesh containing hyaluronic acid (HA) and poly(ethylene oxide) (PEO) in a ratio of 1:1 (HA/PEO 1:1) and 1:4 (HA/PEO 1:4), respectively. Electrospun DegraPol (DP) treated with silver nanoparticles (DP-Ag) was developed to counteract the bacterial attachment. The three novel materials were compared to the previously described DP and DP with incorporated insulin-like growth factor-1 (DP-IGF-1), two implant materials that were also designed to improve tendon repair. To test whether the materials are prone to bacterial adhesion and biofilm formation, we assessed 10 strains of Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Enterococcus faecalis, known for causing nosocomial infections. Fiber diameter, pore size, and water contact angle, reflecting different degrees of hydrophobicity, were used to characterize all materials. Generally, we observed higher biofilm formation on the more hydrophobic DP as compared to the more hydrophilic DP-IGF-1 and a trend toward reduced biofilm formation for DP treated with silver nanoparticles. For the two HA/PEO implants, a similar biofilm formation was observed. All tested materials were highly prone to bacterial adherence and biofilm formation, pointing toward the need of further material development, including the optimized incorporation of antibacterial agents such as silver nanoparticles or antibiotics.

A Rare Case of Inflammatory Myofibroblastic Tumor Mimicking Fibrous Adhesions Resulting in Bowel Obstruction

Inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal tumors of unknown etiology composed of myofibroblastic cells admixed with inflammatory cells. Presented is a 72‐year‐old male hospitalized for severe abdominal pain and hematochezia with onset of associated symptoms of fever and sweats a few hours prior to abdominal pain. A computed tomography (CT) demonstrated left colonic thickening interpreted as partial obstruction, gross adhesions, and ischemia. At surgery, marked bowel ischemia from the distal transverse to proximal sigmoid colon was seen with extensive gross adhesions. Histopathology revealed a mesenteric mass chiefly composed of stellate‐to‐spindled myofibroblastic cells and fibrous adhesions, intermixed with lymphocytes, histiocytes, and plasma cells. The tumor was positive for desmin, smooth muscle actin, and keratin; tumor staging, grade, and postsurgical follow‐up were not completed as the patient expired postoperatively. Illustrated is a rare pathologic mimic of ischemic colitis with fibrous adhesions, IMT. Thus, it should not be assumed that fibrous adhesions are always the etiology of obstruction when “adhesions” between sections of bowel are noted radiologically or surgically.

Ab. No. 161 An Immediate Effect of Active Release Technique [ART] Versus Graston Technique [GT] on Neck Pain in Individuals Having Myofascial Trigger Point of Upper Trapezius

Introduction: Myofascial trigger points (MTrPs) are hyperirritable, palpable nodules found along taut bands of muscle fibers. It has been estimated that 85% of people who come to pain in clinics have trigger points in the neck, and they occur more often in women than in men. MTrPs are classified clinically into active and latent. latent trigger points produce pain when palpated and cause restriction of movement. ART can identify and reduce fibrous adhesions, microscopic tissue injury and inflammation. Graston technique is an Instrument assisted soft Tissue Mobilization method. It helps the healing process by intentional micro-trauma, breaking down collagen cross-linkage, increasing blood flow and cellular regeneration. The purpose is to compare the immediate Effect of Active Release Technique Methods: 30 participants age (18-34) years were included, 15 per group. Ethical approval was taken. Groups A received ART &amp; Group B - Graston technique. Pre and post evaluation was done using pain pressure threshold (PPT) and Visual Analogue Scale (VAS) for pain. Result: Within group analysis showed Group A PPT (p&gt;0.05), VAS (p&lt;0.05) and Group B PPT p&gt;0.05), VAS (&lt; 0.05). Between group showed statistical significance in PPT (p&lt;0.05) but did not in VAS (p&gt;0.05). Conclusion: Graston technique is more effective in increasing PPT. Implications: Graston technique can be used to get faster results.

Diagnosis and Management of Tethered Cord Syndrome.

Tethered cord syndrome is a condition in which the spinal cord is tethered by pathological structures such as a tight filum terminale, intradural lipomas with or without a connecting extradural component, intradural fibrous adhesions, diastematomyelia, and neural placode adhesions following closure of a myelomeningocele.It usually occurs in childhood and adolescence as the spine grows in length, but it can also develop in adulthood. Symptoms of tethered cord syndrome are slowly progressive and varied. Incorrect diagnosis and inappropriate treatment may be provided if the physician lacks knowledge and understanding of this disease.This chapter aims to describe the pathophysiology, syndromes, diagnostic imaging, surgical treatment, and prognosis of tethered cord syndrome to enhance the understanding of this condition.

Full-Length Endoscopic Adhesiolysis of the Achilles Tendon and Triceps Surae

Fibrous adhesions of the Achilles tendon and triceps surae can cause calf and heel cord pain, limited ankle dorsiflexion, and even equinus deformity. The purpose of this technical note is to describe the technical details of full-length endoscopic adhesiolysis of the Achilles tendon and triceps surae. This minimally invasive approach has the advantage of allowing immediate postoperative vigorous mobilization and stretching exercise, which can reduce formation of peritendinous adhesions as compared to immobilization.

S2418 It is Not Just Fibrous Adhesions

S2418 It is Not Just Fibrous Adhesions

Small bowel obstruction in infants due to complicated Meckel’s diverticulum: A case series

Objectives: Our purpose is to illustrate the radiological aspects of Meckel’s diverticulum as an etiology of small bowel obstruction in infants. Material: We report a group of 4 patients with Meckel’s diverticulum complicated with small bowel obstruction that underwent surgery. We reviewed patient records, clinical presentation, ultrasound and CT imaging and intraoperative findings. Results: All included patients presented symptoms of bowel obstruction, one patient presented acute abdomen symptoms. The median age of our group was 5 years, all patients were males. All patients underwent radiological explorations. Ultrasound showed small bowel dilatation in all cases, and CT scan confirmed small bowel obstruction with ischemic complications in one patient. All of the 4 patients had laparotomy with the finding of MD responsible of small bowel obstruction in all cases, with on case of perforated loop and latero-caecal abscess. The obstruction was secondary to fibrous adhesions in three cases and the omphalomesenteric duct in one cases. All the patients had normal evolution with no post-operative complications. Conclusion: Meckel’s diverticulum represents a rare embryological remnant. It is a differential diagnosis in pediatric bowel obstruction and remains an intraoperative surprise despite the very abvanced imaging studies.

Laparoscopic Reduction of Sigmoidorectal Intussusception by a Modified Hutchinson’s Maneuver

Traditionally, adult intestinal intussusception is treated using Hutchinson’s maneuver, i.e., manual proximal bowel compression and reduction of intussusception. However, the lack of manual contact in laparoscopic surgery limits the application of Hutchinson’s maneuver. Moreover, when the lead point is located distal to the peritoneal refection, and the intussusception cannot be reduced prior to bowel resection, stoma construction (e.g., Hartmann surgery or abdominoperineal resection) becomes necessary. Here, we report a case of sigmoidorectal intussusception treated laparoscopically using a modified Hutchinson’s maneuver. A 74-year-old man was diagnosed with sigmoidorectal intussusception caused by sigmoid colon cancer. Colonoscopy revealed a malignant-appearing obstructing mass telescoping into the rectum, with the lead point at 3 cm from the anal verge. During the endoscopic examination, the lead point did not move. A biopsy of the mass showed adenocarcinoma, leading to a diagnosis of sigmoid cancer with sigmoidorectal intussusception. Since the patient had no symptoms of intestinal ischemia, and defecations were observed, elective laparoscopic surgery was planned. Intraoperatively, an attempt was made to pull out the intussuscepted segment proximally, but the presence of fibrous adhesions made the intussusception irreducible. Therefore, the rectum and mesorectum were mobilized completely up to the level of the levator ani so that the lower rectum could be wrapped with gauze on the anal side of the lead point of the intussusception. The gauze was then pulled up to the oral side and simultaneously, a surgeon pushed the distal end of the intussuscepted segment up using a laparoscopic bowel grasper, with another surgeon pushing the lead point through the anus with fingers. Thereby, the intussusception was reduced to some extent, allowing for low anterior resection. The resected specimen contained an ulcerated moderately differentiated adenocarcinoma of the sigmoid colon measuring 3.5 cm × 3.0 cm, combined with circumferential ischemia with mucosal loss and necrosis over an 8 cm length on the distal side of the tumor. The tumor was stage III (T3 N1). We provide a laparoscopic approach for treating intussusception using a modified Hutchinson’s maneuver. This method will be useful in reducing the intussuscepted segment while avoiding stoma construction.

Dance Around the Fibula with a Twisted Plate: A Technical Note.

Nowadays, there is a better understanding of the role of the posterior malleolar fragment in trimalleolar ankle fractures. Not fragment size, but rather fragment morphology should guide the management of the posterior malleolar fracture (PMF). Anatomical reduction and fixation of the PMF is important, as an intra-articular step-off will eventually lead to osteoarthritis. Incongruency of the incisura fibularis tibia is associated with fibular dislocation, syndesmotic insufficiency, and poor functional outcomes. Open reduction and internal fixation through a posterior approach leads to ankle joint mobility restriction (i.e., dorsal flexion deficiency) due to arthrofibrosis of the ankle joint, fibrous adhesions and secondary shortening of the flexor muscles. In this technical note, we describe a surgical technique to fixate unstable ankle fractures with a combined PMF and a high supra-syndesmotic fibular fracture through two small surgical windows using a twisted one-third tubular plate. By reducing the size of the posterolateral window, fibrous adhesions and secondary flexor muscle shortening are diminished, favoring ankle joint mobility.

State of the Art in Temporomandibular Joint Arthrocentesis-A Systematic Review.

Temporomandibular joint disorders are a heterogenic group of clinical conditions, which impair physiological functioning of the masticatory system. Arthrocentesis of the temporomandibular joint has become a widely approved method for non-invasive treatment, bridging the gap between conservative and surgical approaches. Regardless of technique, treatment is based upon joint lavage and lysis of the inflammatory fibrous tissue adhesions, which, in turn, improves joint mobility and reduces pain and closed lock. Recently, approaches for intra-articular injections have been proposed as adjuvant or replacement therapy. The aim of this study was to assess the most efficient technique of arthrocentesis. A systematic search based on PRISMA guidelines, including a computer search with specific keywords, a reference list search and a manual search, was performed. Relevant articles were selected after three search rounds for final review. The studies pulled for the analysis presented information about the relevant predictors, including the technique of arthrocentesis (single- or two-needle method), fluid used for lavage (Ringer lactate or saline), volume of the fluid, application of the injectable, number of interventions, pain (VAS) and mouth opening scores (MMO) and follow-up. All cohorts showed improvement in mouth opening, but significant pain reduction was observed only in cohorts treated either by arthrocentesis alone or arthrocentesis followed by intra-articular injectables. Intra-articular injectables used alone failed to reduce pain post-operatively when compared to other cohorts. We concluded that both double-needle and single-puncture arthrocentesis techniques are equally efficient. Application of the adjuvant injectable did not improve the outcomes of arthrocentesis performed alone. The volume of the fluid used for joint lavage and its chemical composition were not significant in clinical outcomes. However, due to the lack of homogeneity in the study settings, a meta-analysis could not be applied and a systematic review was conducted. We still, however, state that there is a knowledge gap in the current literature regarding the use of injectables alone, as well as a longitudinal follow-up, which provides information about treatment efficiency. More high-quality and randomized controlled trials are required to shed light on this subject.

Subtotal Cholecystectomy in Preventing Major Complications in Difficult Cholecystectomy Cases: A Comprehensive Single Center Study

ABSTRACT Background: Cholecystectomy is a commonly performed laparoscopic surgery but because of variability in anatomy, surrounding inflammation and fibrosis because of recurrent attacks of cholecystitis, can be a potentially difficult surgery. Laparoscopic total cholecystectomy in difficult gall bladder cases sometimes can cause severe complications. Laparoscopic subtotal cholecystectomy can be a bridge and a safe and feasible option between open subtotal cholecystectomy and laparoscopic cholecystectomy. Aim: To study indications, morbidity and clinical outcomes in patients undergoing subtotal cholecystectomy with laparoscopy or with open surgery. Settings and Design: It was a prospective observational study. Patients presenting with signs and symptoms of cholecystitis in either OPD or IPD and in emergency were included in this study. Materials and Methods: Total 38 patients who presented to our institute with clinical and ultrasonographic evidence of acute cholecystitis were included in the study. All patients underwent detailed and thorough clinical examination, laboratory investigations, ultrasonographic, and contrast enhanced computed tomography scan in selected patients. Based on intraoperative findings, decision of subtotal cholecystectomy either by laparoscopy or via open method was made. Various outcomes like intraoperative complications, postoperative complications and need of postoperative interventions, hospital stay, and returning to daily activity were observed and charted. Statistical Analysis: The data obtained were tabulated in Microsoft Excel and analyzed using SPSS version 17.0. Continuous variables were expressed as mean ± standard deviation value. Probability value (P value) was used to determine the level of significance. P value &lt;.05 was considered as significant; P value &lt;0.001 was considered as highly significant. Results: The common indications for subtotal cholecystectomy were severe cholecystitis with dense fibrous adhesions (97.4%), empyema (34.2%) or gangrenous gallbladder (31.6%), and Mirizzi syndrome (2.6%). Conversion rate was 21.1%. Morbidity rates were relatively low with subtotal cholecystectomy (bile leak 21.1%, sub hepatic collections 10.5%, retained stones 5.3%, paralytic ileus 18.4%, wound infection 7.9%, and common bile duct stricture 2.6%). Postoperative interventions were necessary in 18.4% of the cases (retained stones 5.3%, bile leak 7.9%, common bile duct stricture 2.6%, and subhepatic collection 2.6%). Mean duration of hospital stay was 7.5 days and returning to routine daily activity was 11.05 days. Conclusion: Subtotal cholecystectomy is a safe and feasible method for difficult gallbladder cases with a positive outcome. Laparoscopic subtotal cholecystectomy decreases the conversion rate in difficult gallbladder cases but it is not a substitute to open conversion if deemed necessary.

Anatomical Relationship between the Inferior Temporal Septum and the Temporal Branch of the Facial Nerve for Clinical Applications.

The inferior temporal septum (ITS) is a fibrous adhesion between the superficial temporal fascia and the superficial layer of the deep temporal fascia. This study identified detailed the anatomical relationship between the ITS and the temporal branch of the facial nerve (TBFN) for facial nerve preservation during temple interventions. Among 33 Korean cadavers, 43 sides of TBFNs in temporal regions were dissected after identifying the ITS between the superficial temporal fascia and superficial layer of the deep temporal fascia through blunt dissection. The topography of the ITS and TBFN were investigated with reference to several facial landmarks. Regional relationships with the ITS and TBFN within the temporal fascial layers were histologically defined from five specimens. At the level of the inferior orbital margin by the tragion, the mean distances from the lateral canthus to the anterior and posterior branches of the TBFN were 5 and 6.2 cm, respectively. At the lateral canthus level, the mean distance from the lateral canthus to the posterior branch of the TBFN was similar to that to the ITS, at 5.5 cm. At the superior orbital margin level, the posterior branch of the TBFN ran cranial to the ITS adjacent to the frontotemporal region. The TBFN ran through the subsuperficial temporal fascia layer and the nerve fibers located cranially, and within the ITS meshwork in the upper temporal compartment. The area of caution during superficial temporal fascia interventions related to the TBFN was clearly identified in the upper temporal compartment, which is known to lack important structures.