Gallbladder Perforation Research Articles

S1690 A Slow Gut Can Hold up Recovery for Cholecystectomy-Induced Bile Leak

Introduction: Bile leak (BL) can occur in up to 0.5% of open cholecystectomies (CCY) and up to 2.7% of laparoscopic CCY. Strasberg types A and D post-CCY BL can be treated with endoscopic retrograde cholangiopancreatography (ERCP) with excellent success rates > 90%. ERCP interventions can decrease the pressure gradient between the bile duct and duodenum and facilitate transpapillary flow of bile. Case Description/Methods: An 81-year-old woman with dementia, recurrent deep vein thrombosis and coronary artery disease presented to an outside hospital with severe abdominal pain and was diagnosed with acute cholecystitis. CCY was delayed by 6 days because she was on ticagrelor and rivaroxaban. Intraoperatively, a gangrenous perforated gallbladder was found, and a surgical drain (SD) was left in-situ. Post CCY she had persistent output from her SD and was transferred to our center for ERCP evaluation of suspected BL. On initial ERCP we found a high-grade Strasberg type A BL from the cystic duct (Figure A). Her major papilla was entirely located within a large duodenal diverticulum. Due to difficulty identifying safe cutting margins within the diverticulum, biliary sphincterotomy (Bsc) was not performed, and a 7 Fr plastic biliary stent was placed which resulted in good flow of bile into the duodenum. Her SD output decreased, and she was discharged the next day. Unfortunately, she was re-admitted to another hospital 3 days later with bile leakage around her SD, vomiting and constipation. An upper gastrointestinal (GI) series excluded a gastric outlet obstruction (Figure B). She was transferred back to our center for ERCP. The scout film showed that oral contrast that was ingested 3 days prior was still present within the proximal jejunum (Figure C). The biliary stent was patent and in good position, but a persistent high-grade BL was seen. Bsc was performed, and an 8mm by 6 cm fully covered self-expanding metal stent (FCSEMS) was placed. The patient was started on an aggressive bowel regimen with resolution of ileus. The SD output ceased, and the SD was removed 3 days later. Unfortunately, patient passed away in hospice before her follow-up ERCP from other causes. Discussion: Despite successful diversion of bile to the duodenum via a biliary stent, small bowel ileus can increase the pressure gradient across the major papilla, resulting in a persistent BL. More aggressive ERCP interventions using FCSEMS, along with aggressive medical treatment of ileus, allowed the BL to heal expeditiously.Figure 1.: A: High-grade cystic duct bile leak on initial ERCP evaluation. B: Contrast flowing from stomach to duodenum in upper gastrointestinal series. The plastic biliary stent is in-situ. C: the oral contrast ingested approximately 3 days prior is still visible within the proximal jejunum on ERCP scout film.

An Audit of Laparoscopic Cholecystectomy; at a Tertiary Care Hospital in Islamabad

Background: Laparoscopic Cholecystectomy is a commonly performed surgery and is a gold standard for the treatment of cholelithiasis as it has fewer side effects. This study was conducted to determine indications and complications of this surgery at a tertiary care hospital in Islamabad.
 Methodology: This retrospective study was conducted in the department of Surgery, Maroof International Hospital from March 2017 to March 2019. A total of 250 patients who underwent laparoscopic cholecystectomy were included through consecutive sampling technique. The data regarding age, gender, mode of presentation, types of presentation, per operative findings, operative complications and duration of hospital stay was collected from patients’ medical record. Statistical Package for Social Sciences SPSS version 23 was used to analyze data.
 Results: Mean age of the participants was 46.24 ± 14.13 years. Female to male ratio was 2.73:1. Almost 38.4% patients had chronic cholecystitis, 35.2% had symptomatic gallstone disease, 24.8% had acute cholecystitis and 1.6% had gallbladder polyps. No major vascular or common bile duct injury were noted. 27.2% patients had per operative gallbladder perforation. Stone spillage occurred in 8.8% patients with retrieval in all of them. 75.2% patients were discharged on day 1. Per operatively, 98.4% patients had cholelithiasis, 59.6% had adhesions, 9.6% had mucocele, 1.6% had empyema and 0.8% patients had collections.
 Conclusion: Laparoscopic cholecystectomy is a safe procedure in all types of gallstone disease presentations with low complication rate.
 Key words: Cholelithiasis, Gallstones, Laparoscopic Cholecystectomy, Per-operative complications

Contralateral gallbladder perforation and hemoperitoneum caused by an electrocautery-enhanced lumen-apposing metal stent during endoscopic ultrasound-guided gallbladder drainage.

Contralateral gallbladder perforation and hemoperitoneum caused by an electrocautery-enhanced lumen-apposing metal stent during endoscopic ultrasound-guided gallbladder drainage.

Evaluation of the safety of using harmonic scalpel during laparoscopic cholecystectomy in children: A preliminary report.

Background and objectiveIn spite of being one of the most common surgical procedures performed in adults, laparoscopic cholecystectomy (LC) is relatively uncommon in the pediatric age group. Most surgeons prefer to dissect the cystic duct using a monopolar electrosurgical hook and occlude it with simple metal clips. Although the safety of using the ultrasonically-activated shears, e.g., harmonic scalpel for dissection of the gallbladder is confirmed in many studies, its efficacy in the closure of the cystic artery and duct in adults is still debatable. Furthermore, very few reports studied its safety in children during LC. The aim of our work is to study the safety and efficacy of ultrasonic shears in controlling the cystic duct and artery during LC in children.Materials and methodsA prospective study was conducted from May 2017 to April 2020, where all children having symptomatic gallbladder stone disease were included in the study. HS was used as a sole instrument in gallbladder dissection as well as in controlling cystic duct and artery. No metal clips or sutures were used throughout the procedure.ResultsA total of forty-two children having symptomatic gallstone disease were included in the study. The main indication for LC was hemolytic anemia. Their age ranged from 3 to 13 years with a mean of 8.4 ± 3.25 years. All operations were completed laparoscopically, i.e., no conversion to open surgery was needed. The mean operative time was 40 ± 10.42 min. There were no intraoperative complications apart from gall bladder perforation in two cases during dissection from the liver bed while the postoperative recovery was smooth in all patients. Patients started oral feeding after 11.30 ± 3.01 h. The mean time for discharge was 25.47 ± 7.49 h, ranging from 14 to 48 h. Postoperative ultrasound for all cases showed no evidence of minor or major bile leaks or CBD injuries.ConclusionThis is the first report to evaluate the use of HS as a sole instrument during LC in the pediatric age group. HS is a safe and efficient instrument that can be used alone in gallbladder dissection as well as in controlling cystic duct and artery during LC in children.

The Prevalence and Outcome of Bile Spillage during Elective Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy (LC) has a low risk for postoperative infective complications. The incidence of iatrogenic gall bladder perforation leading to spillage of bile and stones seems to be higher ranging between 5 and 40%. Studies have also shown an increased incidence of complications like surgical site infection (SSIs) after bile spillage. This study aims to assess the prevalence and outcome in bile spillage during LC. Methods: A cross-sectional study was conducted at KIST Medical College and Teaching Hospital. All the patients who underwent elective LC from February 2018 to March 2020 were studied. A total of 187 patients were enrolled. The required data was entered in the proforma by reviewing the patient’s medical records. The data was entered and analyzed using the SPSS version 26. Descriptive statistics and chi-square test were carried out. Results: The prevalence of bile spillage was 29.4%. The prevalence of SSIs among the bile spillage and non-bile spillage groups was 10.9% and 8.3% respectively. There was no significant association between SSIs and bile spillages (p value 0.584). There is no significant association post operative use of antibiotics and SSIs among patients with bile spillage (p value = 0.163). Conclusion: The prevalence of bile spillage during LC was higher when compared to other national and international studies. However, the rate of SSIs among bile spillage was lower. Bile spillage during LC doesn’t cause SSIs post-operatively and use of postoperative antibiotics among bile spillage patients doesn’t prevent SSI during elective LC thus use of antibiotics in such cases should be limited.

SP8.1.4 Iatrogenic gallbladder perforation during laparoscopic cholecystectomy and outcomes: a systematic review and meta-analysis

Abstract Aims to compare the outcomes of iatrogenic gallbladder perforation versus no gallbladder perforation in patients undergoing laparoscopic cholecystectomy. Methods In compliance with PRISMA statement standards, electronic databases were searched to identify all studies comparing the outcomes of iatrogenic gallbladder perforation versus no gallbladder perforation in patients undergoing laparoscopic cholecystectomy. The outcome of interest included surgical site infection (SSI), postoperative collection, operative time and length of hospital stay. Random effects modelling was applied to calculate pooled outcome data. The certainty of evidence was assessed using GRADE system. Results A total of 5366 patients from 11 studies were included. Analysis of 5366 patients from 11 observational studies suggested that iatrogenic gallbladder perforation during laparoscopic cholecystectomy does not increase the risk of SSI (OR 1.48, 95% CI 0.57–3.86, P=0.42) and postoperative collection (RD 0.00, 95%CI -0.00–0.01, P=0.41) but may result in longer operative time (MD 10.28, 95% CI 7.40–13.16, P <0.00001) and length of hospital stay (MD 0.51, 95%CI 0.15–0.87, P=0.005). The results remained consistent through sensitivity analyses. The quality of available evidence was judged to be moderate and the GRADE certainty of the evidence was judged to be high. Conclusions Relatively robust evidence with high level of certainty suggests that iatrogenic gallbladder perforation during laparoscopic cholecystectomy may not increase the risk of SSI and postoperative collection but may result in longer operative time and length of hospital stay. Whether prompt retrieval of spilled stones, adequate peritoneal irrigation, and intraoperative use of prophylactic antibiotic contribute to the above findings remains unknown.

TH2.3 Elective versus emergency management of gallstone disease at a tertiary referral centre amidst the COVID-19 pandemic - should the protocol be altered?

BackgroundGallstones are a common pathology affecting approximately 15% of the population in UK, 20% of which are symptomatic. It is suggested symptomatic patients undergo cholecystectomies. Guidelines recommend this is performed within one week of initial emergency presentation or 52 weeks for elective case. Surgical capacity to manage emergency cholecystectomies was limited due to the COVID pandemic. We assessed wait time discrepancy between elective and emergency cholecystectomies.MethodsA retrospective review of all patients undergoing cholecystectomies between January and November 2021 in a major tertiary referral centre in London was undertaken. Initial pathology at the time of presentation, elective vs emergency presentation, pre-surgical biliary complications along and wait times were reviewed.Results219 (74 elective, 145 emergency) patients underwent surgery, mean age 48 years (23% Male and 77% Female). Average wait times for elective cholecystectomies were 69.7 days (min 0, max 246) in comparison to 68.9 days (min 1, max 253) for emergency surgery. 22 (15%) of the patients of initial emergency presentation re-attended hospital and 6 (4%) had adverse events such as gallbladder perforation or pancreatitis due to delayed treatment. Comparatively, 9 (12%) elective patients attended A&E due to pain, with no adverse outcomes.ConclusionsOverall wait time of emergency vs elective cholecystectomies were similar. This review indicates emergency cases require prioritisation over elective cholecystectomies due to the higher number of re-attendance and adverse events. Emergency cases need to be prioritised to meet guidelines, which could also reduce complication rates whilst awaiting surgery and lead to fewer adverse outcomes.

Artificial intelligence for phase recognition in complex laparoscopic cholecystectomy

BackgroundThe potential role and benefits of AI in surgery has yet to be determined. This study is a first step in developing an AI system for minimizing adverse events and improving patient’s safety. We developed an Artificial Intelligence (AI) algorithm and evaluated its performance in recognizing surgical phases of laparoscopic cholecystectomy (LC) videos spanning a range of complexities.MethodsA set of 371 LC videos with various complexity levels and containing adverse events was collected from five hospitals. Two expert surgeons segmented each video into 10 phases including Calot’s triangle dissection and clipping and cutting. For each video, adverse events were also annotated when present (major bleeding; gallbladder perforation; major bile leakage; and incidental finding) and complexity level (on a scale of 1–5) was also recorded. The dataset was then split in an 80:20 ratio (294 and 77 videos), stratified by complexity, hospital, and adverse events to train and test the AI model, respectively. The AI-surgeon agreement was then compared to the agreement between surgeons.ResultsThe mean accuracy of the AI model for surgical phase recognition was 89% [95% CI 87.1%, 90.6%], comparable to the mean inter-annotator agreement of 90% [95% CI 89.4%, 90.5%]. The model’s accuracy was inversely associated with procedure complexity, decreasing from 92% (complexity level 1) to 88% (complexity level 3) to 81% (complexity level 5).ConclusionThe AI model successfully identified surgical phases in both simple and complex LC procedures. Further validation and system training is warranted to evaluate its potential applications such as to increase patient safety during surgery.

A retrospective cohort study on the optimal interval between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) are the most important procedures for patients with choledocholithiasis and gallstones. Many studies recommend early LC after ERCP; however, there is still no consensus on the optimal interval between the two. The purpose of this study was to investigate the appropriate timing of LC after ERCP in patients with choledocholithiasis and cholecystolithiasis.We retrospectively reviewed all ERCPs in our institution from November 2014 to August 2021. All eligible 261 patients were divided into ERCP-LC1 (≤3 days), ERCP-LC2 (3–7 days), and ERCP-LC3 (>7 days). We also reviewed 90 patients with elective LC as the LC group. Procedures, treatment outcomes, and postoperative adverse events were evaluated.In a total of 1642 ERCPs, 261 eligible patients were divided into ERCP-LC1 (n = 102), ERCP-LC2 (n = 113), and ERCP-LC3 (n = 46). The ERCP-LC groups had no difference in operation time, postoperative adverse events, and open conversion rate with the LC group, but the total hospital stay and hospital stay after LC were longer than the LC group. There were no differences between the ERCP-LC groups in operation time, hospital stay after LC, open conversion rate, postoperative adverse events, and efficacy. However, LC within 7 days and even 3 days after ERCP had significant advantages in improvement in total length of stay and medical expenses. Furthermore, we also found an increased risk of gallbladder gangrene and perforation in LC >7 days after ERCP.LC within 7 days and even 3 days after ERCP is a safe, effective, and economical method for patients with choledocholithiasis and gallstones.

Spontaneous acalculous gallbladder perforation mimicking duodenal stump leak after gastrectomy for gastric cancer: A case report.

Introduction and importanceSpontaneous gallbladder (GB) perforation is a rare and severe condition. Herein, we present a case of spontaneous acalculous gallbladder perforation mimicking duodenal stump leak after a subtotal gastrectomy for gastric cancer.Case presentationAn 83-year-old woman underwent a radical subtotal gastrectomy for advanced gastric cancer. On postoperative day 5, mild leukocytosis was observed. A computed tomography (CT) scan revealed a slightly distended non-thickened GB with minimal air and fluid collection near the duodenal stump, and fluid collection in the abdominal and pelvic cavities. We considered a duodenal stump leak. The effluent of the Barovac located in the abdominal cavity was serosanguinous and the patient was stable, thus we observed and continued using antibiotics. On day 13, the Barovac stopped functioning properly, so we replaced it with a percutaneous catheter drain (PCD) under ultrasonography guidance, aided by the Barovac tract. The PCD drained over 1000 cc of bile daily. On day 16, a follow-up CT showed an increased fluid collection in the abdominopelvic cavity. After comparing this with the previous CT, we rediagnosed as spontaneous GB perforation. An emergency cholecystectomy was performed. Postoperatively, the patient's condition returned to normal and antibiotic therapy continued until day 14. The patient recovered without other complications and was discharged on day 28.Clinical discussionSpontaneous GB perforation is a rare but serious complication immediately after gastrectomy which should be looked out for.ConclusionWe report a rare case of spontaneous GB perforation mimicking duodenal stump leak after radical subtotal gastrectomy in gastric cancer.

A case of Mirizzi syndrome accompanied by a pseudoaneurysm that ruptured into the gallbladder: successfully treated by embolization of aneurysm and sequential surgery

BackgroundAlthough visceral aneurysms are relatively rare, it can be life-threatening in case it ruptures. We report a case of Mirizzi syndrome accompanied by a pseudoaneurysm that ruptured into the gallbladder.Case presentationThe patient was a 73-year-old woman with persistent gastrointestinal bleeding and progressive jaundice. Examination revealed a pseudoaneurysm in the gallbladder artery or hepatic artery branch, and biliary hemorrhage due to gallbladder perforation was suspected. Urgent abdominal angiography revealed a pseudoaneurysm measuring 50 × 32 mm that had ruptured directly from the right hepatic artery or the cystic artery into the gallbladder. The pseudoaneurysm was successfully coiled and the bleeding was stopped. The presence of ongoing obstruction due to Mirizzi syndrome resulted in an emergency cholecystectomy being performed on the same day. On removing the impacted gallstone from the neck of the gallbladder, we found an obstruction between the lateral wall of the common bile duct and the gallbladder, this condition was diagnosed as Mirizzi syndrome with a biliobiliary fistula. After removing the impacted gallstone, a T-tube was inserted into the common bile duct. Bile leakage was observed postoperatively, but it improved with drainage. The patient fully recovered.ConclusionsWe present our experience with a case of Mirizzi syndrome accompanied by a ruptured pseudoaneurysm successfully treated with coil embolization followed by cholecystectomy. In this case, the pseudoaneurysm may have been caused by inflammation due to cholecystitis or compression of the arterial wall by a gallstone. To the best of our knowledge, Mirizzi syndrome associated with pseudoaneurysm rupture is rare. Our study suggested that cholecystectomy preceded by transcatheter arterial embolization is an effective strategy to control bleeding in patients with hemobilia due to aneurysm.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8–3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient’s clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Outcome of laparoscopic cholecystectomy in terms of complications in Lady Reading Hospital Peshawar.

Objective: To evaluate the outcome after laparoscopic cholecystectomy in terms of these complications in our setup. Study Design: Descriptive cross-sectional study. Setting: Department of General Surgery, MTI-Lady Reading Hospital Peshawar. Period: July 2018 to June 2019. Material & Methods: A total of 115 patients undergoing laparoscopic cholecystectomy were enrolled in this study and were assessed for the development of various postoperative complications. Results: The mean ± SD age of study participants was 45.92±5.41 years. Females (n=67; 58.2%) outnumbered males (n=48; 41.7%) in this study. Most common complication was port site infection noted in 7 patients (6.1%) with gall bladder perforation being second most common complication observed in 6 patients (5.2%). Post-operative fever was noted in 4 patients (3.5%). Conclusion: In our study the majority of patients undergoing laparoscopic cholecystectomy recovered uneventfully without any mortality. Port site infection was the most common complication and gall bladder perforation was found to have statistically significant association with all the complications.

Feasibility of a Single Pigtail Stent Made by Cutting a Nasobiliary Drainage Tube in Endoscopic Transpapillary Gallbladder Stenting for Acute Cholecystitis.

Background and objectiveIn this study, we aimed to evaluate the efficacy and safety of a single pigtail stent made by cutting a nasobiliary drainage tube (NBD stent) by comparing the clinical outcomes of using an NBD stent and those of using a ready-made double pigtail stent (RDP stent) in endoscopic gallbladder stenting (EGBS) for acute cholecystitis.Materials and methodsThis was a single-center retrospective study involving 20 cases that had technical success with EGBS for acute cholecystitis; the patients were divided into two groups: those using NBD stent (NBD group) and those using RDP stent (RDP group). The baseline characteristics and clinical outcomes were compared between the two groups.ResultsThere were 13 patients in the NBD group and seven in the RDP group. The rates of clinical success (NBD group: 92% vs. RDP group: 100%, p=0.45) did not differ significantly between the groups. Regarding adverse events, gallbladder perforation occurred in one case in the NBD group; however, no other adverse events occurred in either group (NBD group: 7.7% vs. RDP group: 0%, p=0.45). The stent patency periods did not differ significantly between the groups [NBD group: 43 (12-64) days vs. RDP group: 97 (58-215) days, p=0.17]. The stent patency period in cases of long-term stent placement after EGBS was 1,381 days and 1,579 days in the NBD group and 305 days in the RDP group, respectively.ConclusionNBD stents are considered as effective as RDP stents in EGBS for acute cholecystitis. They are highly versatile and can be used for both bridging to surgery and long-term stent placement.

To study the indications of cholecystectomy, types of surgery and complications of surgery in a tertiary care hospital in Nepal

Background: Cholelithiasis is a chronic recurrent disease of the hepatobiliary system and cholecystectomy is one of the commonly performed surgeries. This study intends to evaluate the demographic of patients with cholelithiasis, its various mode of presentation, surgical intervention, and its outcome. Methods: This was a quantitative retrospective cross-sectional study conducted in the College of Medical Sciences- a Superspeciality Tertiary Care Teaching Hospital in Bharatpur, Chitwan in central Nepal. All patients undergoing laparoscopic or open cholecystectomy in the department of GI and General Surgery at the College of Medical Sciences from 1st May 2017 to April 30, 2021were included in the study. Study tools were records of the patients retrieved from the medical record section. Results: A total of 355 patients data were analyzed. The mean age of the study samples was 46.43 +/- 16.47 years. Female predominance was seen at 76.18% with M: F ratio of 1:3.18. The most common presenting symptoms were pain abdomen (70.4%), bloating of the abdomen (63.9%), and fatty dyspepsia (46.8%). Acute cholecystitis was seen in 14.36%, biliary pancreatitis in 6.2%, and gallbladder perforation in 2.25% cases. Laparoscopic cholecystectomy was done in 269(83.94%), open cholecystectomy in 57(16.05%), and laparoscopic converted into open cholecystectomy 29 in (9.73%). Intra-operative complications like gallbladder perforation and controlled bleeding were seen in 10.14% and 4.23% of cases. Post-operative complications like bile leak and major bile duct injury were seen in 6.19% and 1.40% of cases. Regarding management of bile leak, conservative management was successfully done in 54.54% of cases while they were managed with ERCP in 27.27%, hepaticojejunostomy in 13.63%, and with T-tube repair in 4.5% cases. The overall mortality was 0.8%.

P042 Spontaneous gallbladder perforation: a rare complication of eosinophilic granulomatosis with polyangiitis

Abstract Background/Aims Gallbladder (GB) perforation is a serious clinical condition, caused by cholecystitis with or without cholelithiasis. Although there have been reports of bowel perforation in many cases of vasculitis, we report to the best of our knowledge, the first case of spontaneous gallbladder perforation following a diagnosis of EGPA. This alerts the clinician to a unique complication of EGPA. Methods A 48-year-old man presented initially to haematology with weight loss and marked eosinophilia, investigations (bone marrow aspirate and trephine, CT chest, abdomen and pelvis) at the time showed no evidence of haematological causes. Subsequently, he developed worsening weakness and paraesthesia of the upper and lower limbs, ongoing for 4 months. He had a background of asthma, and hay fever, which were well-controlled. On examination, he had progressive quadriparesis with extensive muscle wasting. His abdomen was soft non-tender, and he had no skin changes, although he later revealed a photograph of a vasculitic rash affecting the limbs when the symptoms initially presented. Results Laboratory findings revealed raised white blood cells of 46.9 (4-10 x109/L), raised eosinophils of 29.4 (0.01-0.5 x109/L), thrombocytosis of 757 (150-410 x109/L), raised CRP of 172 (0-10mg/L), raised IgE 179(<107 kU/L), and IgG 20.8(6-16 g/L). An extensive infectious screen was performed including HIV, and hepatitis (A-E), which were all negative. Vasculitic screen was negative for PR3 and MPO ANCA. However, nerve conduction studies showed evidence of confluent mononeuritis mimicking acute demyelinating sensory motor neuropathy. Following this, a CT scan was requested to exclude underlying neoplasms and infection which revealed a GB perforation with defect in the distended GB wall. He had no typical symptoms of cholecystitis, favouring an underlying gallbladder necrotizing vasculitis as the cause of GB perforation. The patient was commenced on IV cyclophosphamide and maintained on prednisolone, and azathioprine. A percutaneous cholecystostomy was inserted and immunosuppression continued with antibiotic cover. He had excellent response to therapy and his mobility improved following physiotherapy and rehabilitation. However, he continues to have significant residual weakness of the small muscles of his hand (median and ulnar nerve palsies). An MRCP was later requested, this revealed a contracted GB with no evidence of cholelithiasis or ongoing inflammation. He remained asymptomatic of GB perforation, and as a result, surgeons decided not to proceed with a cholecystectomy. Conclusion Gallbladder vasculitis (GV) can occur as a single organ vasculitis or as part of a systemic vasculitis. In the rare occasion of its occurrence, it mainly presents as symptoms of cholecystitis. Spontaneous GB perforation as a complication of GV has been noted in patients with other vasculitides like Henoch-Schonlein Purpura. However, this is the first report of a spontaneous gallbladder perforation in a patient with EGPA. Disclosure J. Ochogwu: None. A. Madathil: None. H. Mazin: None. D. Makkuni: None.

Gallbladder perforation in blunt traumatic injury

A 49-year-old man with a history of HIV presented to an urban level 1 trauma center as a pedestrian struck by a motor vehicle. In the trauma bay, the patient was hemodynamically stable (blood pressure 118/82 mm Hg) with sinus tachycardia (heart rate 107 beats/min). He was breathing comfortably with an SpO2 of 100% on room air, and he was alert and oriented with a Glasgow Coma Score of 15. The patient was in moderate distress, and complained of severe abdominal pain exacerbated by movement and transfer.

Spontaneous Gall Bladder Perforation Presenting as a Diagnostic Challenge: a Case Series

Spontaneous Gall Bladder Perforation Presenting as a Diagnostic Challenge: a Case Series

Pleural empyema caused by dropped gallstones after laparoscopic cholecystectomy for acute cholecystitis: a case report

BackgroundDropped gallstones during laparoscopic cholecystectomy (LC) sometimes induce postoperative infectious complications. However, pleural empyema rarely occurs as a complication of LC.Case presentationWe present the case of a 66-year-old woman with right pleural empyema. She previously underwent LC for acute gangrenous cholecystitis 11 months ago. The operative report revealed iatrogenic gallbladder perforation and stone spillage. The bacterial culture of the gallbladder bile was positive for Escherichia coli. Chest and abdominal computed tomography revealed right pleural effusion, perihepatic fluid collection, and multiple small radiopaque density masses. Although ultrasound-guided transthoracic drainage was performed, the drainage was incomplete, and systemic inflammatory reaction persisted. Consequently, thoracotomy and laparotomy with gallstone retrieval were performed, and the patient recovered completely. The patient has remained well without complications after 14 months of follow-up.ConclusionsWe report a rare case of pleural empyema caused by dropped gallstones after LC. This case emphasized the importance of completely retrieving the dropped gallstones to prevent late infectious complications after LC.

Post-operative complications rates in patients undergoing emergency laparotomy in tertiary care hospital

Background: Post-operative complication may occur after explorative laparotomy whether elective or emergency. This study was aimed to evaluate the cause in which emergency laparotomy has been done, the frequency of different types of surgical complications after laparotomy in KR hospital, Mysore Medical college and Research Institute, Mysore, Karnataka. Aims and Objective: This study aims to evaluate the post-operative complications in patients undergoing emergency laparotomies at K R Hospital, Mysore Medical College and Research Institute, Mysore. Materials and Methods: This prospective observational study was carried out at the Department of General Surgery in Mysore Medical College, Mysore, Karnataka, during the period of October 2020–June 2021. All the patients who underwent emergency laparotomy were included in the study. They were followed up in the post-operative period and all the complications/sequelae developed were recorded. Results: The primary indications for an exploratory laparotomy are perforation peritonitis constituted (58.8%) cases followed by intestinal obstruction (13%), gallbladder perforation (10%), blunt and penetrating trauma abdomen (9.2%), and appendicular abscess/perforation (4.8%). In this study, most of the patients (77.2%) were between 21 and 50 years of age. Out of these, maximum cases (age) were found in the 4th decade, that is, 107 cases (42.8%). In this study local complication, surgical site infection (47.2%) was the most common complication followed by respiratory infection (30%), fever (38%), nausea and vomiting (14%), paralytic ileus (12.8%), UTI (10%), and thrombophlebitis (10.8%). Mortality was 6%. Conclusion: Post-operative complications are more common after emergency laparotomy as compared to elective laparotomies. Post-operative surgical site infection, nausea and vomiting, and fever are the most common complications which need adequate management and post-operative care.