Severe Adhesions Research Articles

Severe Flexor Digitorum Profundus Muscular Adhesion by Pseudo-Volkmann's Contracture without Fracture: A Case Report and Literature Review

AbstractVolkmann's ischemic contracture is a condition characterized by permanent ischemic damage to muscles and nerves due to vascular insufficiency, resulting in flexion contractures of the affected limb. In contrast, pseudo-Volkmann's contracture presents with similar clinical features but lacks ischemic damage and has the potential for complete recovery. We report a case of a 39-year-old man who developed failure of extension in the middle and ring fingers of the left hand following blunt forearm trauma from a rolling machine. Despite no skin breakage or fracture, his symptoms progressively worsened over 2 months without treatment. Surgical exploration 2 years later revealed severe adhesions of the flexor digitorum profundus muscle at the myotendinous junction to the ulnar periosteum, with immediate recovery after release. This case highlights pseudo-Volkmann's contracture in an adult without fracture, likely due to blunt trauma causing delayed adhesion formation.

Treatment of Severe and Moderate Intrauterine Adhesions: Results of PREG2 International RCT on the Effectiveness of Womed Leaf Barrier Film

Treatment of Severe and Moderate Intrauterine Adhesions: Results of PREG2 International RCT on the Effectiveness of Womed Leaf Barrier Film

014. Localized Meconium Peritonitis Due to Perforation of Ileum Atresia: Case Report

Background: Ileal atresia is a congenital disorder that can cause serious complications such as intestinal obstruction, intestinal ischemia, and intestinal rupture. The worldwide incidence rate is 1 in 5,000 - 10,000 births, which can be influenced by various factors such as the use of certain drugs during pregnancy, a family history of similar complaints, and premature birth which can increase the risk. One of the rare features is spontaneous walling off of the abdominal wall which resembles a cyst. From this case we found a patient who had this rare clinical presentation. Case: 3 days old baby was referred to Dr. Kariadi Semarang with a greenish lump in the epigastric region since birth, accompanied by the appearance of small intestinal obstruction. The patient was born via vaginal delivery at 39 weeks' gestation with a normal Apgar score and weight. From the history and examination that had been carried out, it was concluded that there was ileal atresia and an exploratory laparotomy was performed. A green mass was obtained which was the walling off of the ileal perforation. During the operation, another finding was found, ileal perforation caused by atresia and severe adhesions (Grade IV). The patient then underwent the Santulli procedure and laceration repair. Conclusion: Ileal atresia is diagnosed from anamnesis taking from baby has signs of obstruction such as flatulence and vomiting. The incidence of ileal atresia associated with perforation and causing peritonitis is still rare due to lack of reporting of these cases. Peritonitis, which occurs due to intestinal perforation in the jejunoileal segment, can cause the release of intestinal products, meconium, into the intra-abdominal cavity. Spontaneous walling off in this case is quite rare, and because the perforation product is sterile, it does not give a picture of inflammation.

Surgical Outcomes after Laparoscopic Repairs of Para-colostomy Hernia and Para-ileal-conduit Hernia: A Comparative Study.

The aim of the study was to investigate the differences in clinical characteristics and surgical outcomes between para-colostomy hernia (PCH) and para-ileal-conduit hernia (PICH) after laparoscopic repairs. We retrospectively analyzed data from 41 laparoscopic parastomal hernia repairs performed at the Jikei University Daisan Hospital between June 2012 and September 2023. The data were divided into PCH (n=31) and PICH (n=10) groups and compared. The comparison of patient backgrounds and hernia characteristics showed no significant differences between PCH and PICH groups. Surgical procedures included laparoscopic Sugarbaker repair (LSB) for PCH (29 cases) and PICH (8 cases), and endoscopic Pauli repair (ePauli) for both PCH (2 cases) and PICH (2 cases). Intraoperative findings indicated a significantly higher rate of severe intra-abdominal adhesions (Zühlke index III/IV) in the PICH group (60%) compared to the PCH group (23%) (p=0.0485). The median operation time was significantly longer for PICH (223 [120-423] minutes) than for PCH (158 [48-386] minutes) (p=0.0467). Perioperative complications occurred in 1 PCH case (3%) and 2 PICH cases (20%), with no significant difference in postoperative hospital stay (9 [4-19] vs. 9 [6-14] days). With the follow-up period of 57 [2-110] months for PCH and 52 [20-104] months for PICH, recurrence was observed in 4 PCH cases (12%) but not statistically significant. The comparison of PCH and PICH suggests that PICH is associated with more severe intra-abdominal adhesions and longer operation times, indicating higher operative difficulty. Therefore, it would be advisable to discuss the surgical outcomes of repair for these stomas separately.

Double-Layer Traction Method for Treating Severe Upper Auricular Adhesion Malformation in Infants: A Prospective Randomized Controlled Study.

Severe upper auricular adhesion malformation poses a significant challenge for complete correction through ear molding. This prospective randomized controlled study aimed to assess the efficacy of a new method in addressing severe upper auricular adhesions. In this non-blinded randomized controlled study, we enrolled 72 infants with severe upper auricular adhesion malformation who underwent treatment with the EarWell system. They were randomly assigned to either the double-layer traction (DLT) group or the control group. We compared the effectiveness of treatment, treatment duration, and potential complications between the two groups. All 72 infants completed the treatment and follow-up, with 38 (52.8%) in the DLT group and 34 (47.2%) in the control group. The DLT group exhibited significantly shorter treatment times and a lower incidence of pressure sores than the control group. The DLT method, along with unilateral malformation, independently predicted positive long-term outcomes. The DLT method demonstrated superior effectiveness, shorter treatment duration, and lower complication rates than traditional methods when treating severe upper auricular adhesion malformation in infants. The DLT method is safe and effective and merits broader adoption in clinical practice. 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.

Vascular complications during appendectomy: severe adhesion of the appendix to the right iliac artery: a case report

IntroductionAppendicitis is a common cause of acute abdomen. Rarely, it may form adhesions to nearby structures, complicating surgeries, especially when involving vascular structures such as the internal iliac artery, potentially causing severe intraoperative hemorrhage.Case presentationA 65-year-old Middle Eastern male presented with abdominal pain and anorexia for 5 days. Examination and imaging confirmed acute appendicitis with complications. Additionally, a large pelvic mass was noted. During surgery, severe bleeding was encountered due to an adhesion between the appendix and the right internal iliac artery, managed by ligating the artery. The patient recovered well and was discharged in stable condition. Histopathology confirmed the diagnosis.ConclusionThis case highlights a rare vascular complication of appendectomy due to abnormal adhesions between the appendix and the internal iliac artery, associated with a large pelvic mass. This study emphasizes the need for thorough preoperative evaluation and careful surgical planning in patients with unusual anatomical variations or specific underlying conditions such as neurofibromatosis. Early recognition and strategic management of vascular adhesions are essential to optimize patient outcomes in appendectomies complicated by such rare scenarios.

Giant gallbladder cyst with acute cholecystitis: a case report

BackgroundGallbladder cysts are rare diseases with very few reported cases, and no clinical or histological definition has been established. Furthermore, cases of giant cysts outside the gallbladder wall are extremely rare. We report a rare case of giant gallbladder cyst with acute cholecystitis.Case presentationAn 85-year-old woman with appetite loss and right lower abdominal pain lasting 2 days presented to our hospital. At first, the patient’s abdominal pain was mild to moderate with no fever. Blood tests revealed a white blood cell count of 10,950/mm3, and the C-reactive protein (CRP) level was 14.35 mg/dl. A contrast-enhanced computed tomography (CT) scan of the abdomen revealed a grossly distended gallbladder (14.5 × 14.5 × 8.7 cm) with an incarcerated stone in the cystic duct. The patient was treated by percutaneous transhepatic gallbladder drainage (PTGBD) with 735 ml of drainage fluid. Oral contrast magnetic resonance cholangiopancreatography (MRCP) revealed that gallbladder swelling remained (14.0 × 6.5 cm) 3 days after PTGBD. We performed laparoscopic cholecystectomy 6 days after PTGBD. Because of the severe adhesion around the junction of the cystic and common bile ducts, we performed open cholecystectomy.The resected specimen was 14 × 11 cm in size and consisted of a gallbladder (6 × 7 cm) with a stone (2.4 × 1.8 cm) in the gallbladder and a large cystic lesion (18 × 18 cm) outside the gallbladder wall. The cystic lesion had a wall thickness of 6 to 12 mm and internal septal structures and contained hemorrhagic and necrotic tissue.Histological examination revealed that the specimens showed a mildly swollen gallbladder and a cystic lesion on the outside of the gallbladder wall, adjacent to the gallbladder wall, with wall thickening and inflammation. The cystic lesion suggested gallbladder duplication, gallbladder diverticulum or extension of the Rokitansky-Aschoff sinus (RAS). There was no malignancy. The patient’s postoperative course was uneventful, and she was discharged 5 days after the operation.ConclusionWe present a very rare case of giant gallbladder cyst with acute cholecystitis revealed by cholecystectomy.

Sequence variants underlying severe combined immunodeficiency and leukocyte adhesion deficiency type 1 in six consanguineous families.

Inborn errors of immunity (IEI) are defined as genetic disorders affecting the immune system and resulting in diverse clinical signs and symptoms. Despite the lack of diagnosis and unavailability of IEI estimation in the Pakistani population, consanguinity is exacerbating its prevalence. The current study focuses on severe combined immunodeficiency (SCID) and leukocyte adhesion deficiency type 1 (LAD1). SCID is associated with the life-threatening symptoms developing at post-birth. LAD1 is clinically characterized by recurrent bacterial infections related to the skin, mouth, and respiratory tract owing to impaired leukocytes. Herein, in six consanguineous families, flow cytometry was used to evaluate the patient's immune status. Whole-exome sequencing (WES) was then conducted to search for the causative variations in immunodeficiency genes. Sanger sequencing was used to assess the segregation of the variants with the disorder within the families. Sequence analysis revealed five homozygous variants in four different causative genes. This included four novel nonsense variants in CD70 p.(Thr126Profs*33), CD3e p.(Trp151*), IL7R p.(Val138Ilefs*10), and ITGB2 p.(Ser627Valfs*61), and one previously reported in ITGB2 p.(Cys62*). In one of the families, two variants in two different genes, including DNAH6 p.(Tyr2653His) and NIPAL4 p.(Gly121Ser), were detected in an unclassified patient. All the identified variants were found in a homozygous state in the patient but in a heterozygous state in the available parents. The study will facilitate the diagnosis and management of IEI patients.

A systematic study on wear behavior of TiCrNbTaWx refractory high-entropy alloy: Inducing amorphization to achieve anti-wear

Refractory high-entropy alloys (RHEAs) possess exceptional properties at elevated temperatures. However, their limited wear resistance at room temperature (RT) hinders their widespread application. In this work, based on compositional modulation and surface engineering strategies, two TiCrNbTaWx (x = 0, 0.5) RHEAs were prepared using spark plasma sintering. The results show that the addition of W can effectively improve the hardness (10.3 GPa) and deformation resistance of the BCC matrix, alleviating the severe adhesion and the fracture behavior. In addition, the friction-induced oxidized amorphous layer with high hardness (12.3 GPa) can further improve the anti-wear properties. Because of these, the TiCrNbTaW0.5 alloy has a low wear rate of 9 × 10−5 mm−3·N−1·m−1, which is 67 % lower than the pristine TiCrNbTa alloy. In conclusion, our design strategy provides a new idea for designing RT wear-resistant RHEAs.

Nomogram for predicting intolerable postoperative early enteral nutrition following definitive surgery for small intestinal fistula: a cohort study.

This study was designed to develop and validate a nomogram for predicting intolerable early enteral nutrition (EEN) following definitive surgery (DS) for small intestinal fistula. A total of 377 patients, recruited from January 2016 to September 2023, was randomly allocated into development ( n =251) and validation ( n =126) groups in a 2:1 ratio. Risk factors were identified using the nomogram. Its performance was assessed based on calibration, discrimination, and clinical utility, with validation confirming its effectiveness. Of the 377 patients, 87 (23.1%) were intolerant to EEN, including 59 (23.1%) in the development cohort and 28 (22.1%) in the validation cohort ( P =0.84). Four factors were identified as predictive of intolerable EEN: severe abdominal adhesion, deciliter of blood loss during DS, human serum albumin (Alb) input >40g during and within 48h post-DS, and the visceral fat area (VFA)/total abdominal muscle area index (TAMAI) ratio. The model demonstrated excellent discrimination, with a C-index of 0.79 (95% CI: 0.74-0.87, including internal validation) and robust calibration. In the validation cohort, the nomogram showed strong discrimination (C-index=0.77; 95% CI: 0.64-0.87) and solid calibration. Decision curve analysis affirmed the nomogram's clinical utility. This research introduces a nomogram that enables the individualized prediction of intolerable EEN following DS for small intestinal fistula, demonstrating a possible clinical utility.

Characterization of MoS2:Nb sputtered thin films. An application as hole transport layer in Cu2ZnSnS4/Si tandem solar cells

MoS2:Nb films deposited by radio-frequency magnetron sputtering are investigated in view of their application in infrared (IR)-transparent contacts for tandem photovoltaic devices.This material is already known to give a good electrical contact with p-type chalcogenide semiconductors, which are typically grown onto opaque molybdenum metallic contacts and a MoS2 layer spontaneously forms at the back interface during the on-top semiconductor growth. Our study explores a different approach, which involves the direct growth of IR-transparent MoS2:Nb films via sputtering inside complete photovoltaic devices, like Cu2ZnSnS4 (CZTS)-based single junction solar cells and CZTS/Si tandem devices. Films deposited at different sputtering pressures are compared by analysing their microstructure, morphology, chemical composition, optical and electrical properties. The effects of post-deposition sulfurization treatments are also investigated. We find that MoS2:Nb films deposited at around 0.1 Pa exhibit compactness but show a notable sulfur deficit ([S]/[Mo]≈1.4), a significant sub-bandgap optical absorptance and lack of crystallinity. Increasing the Ar pressure to 1 Pa raises the [S]/[Mo] ratio to 2.2, yielding crystalline films with good IR-transparency, although with a porous morphology. Despite 0.5 wt% Nb-doping of the sputtering target, the as-deposited films demonstrate n-type conductivity likely due to uncontrolled impurities and intrinsic defects. Ultraviolet Photoemission Spectroscopy measurements suggest that films’ work function higher than 5 eV can be obtained with a post-deposition sulfurization, making these materials suitable as Hole Transport Layer in photovoltaic applications. A similar increase in work function is expected in the CZTS/MoS2 junctions, since the sputtered MoS2:Nb films undergo a sulfurization process needed to obtain the overlying polycrystalline CZTS absorber.CZTS solar cells produced with sputtered MoS2 and Transparent Conductive Oxides contacts on glass substrates, despite plagued by severe adhesion problems, show the potentiality to give efficiencies comparable to reference devices with standard Mo back contact. Fabrication of CZTS/Si tandem devices on textured silicon bottom cells yields a maximum efficiency of 4.4 %, primarily hindered by the low quality of the CZTS film on textured substrates. Nonetheless, optoelectronic characterizations based on both spectrophotometric and quantum efficiency measurements confirm a good IR transparency of the MoS2-based intermediate contacts and the desired electrical behaviour.

Laparoscopic Sacrohysteropexy for the Management of Uterovaginal Prolapse: a Pilot, Single-Center Experience from Saudi Arabia.

Laparoscopic sacrohysteropexy is an emerging uterine-preserving strategy for management of uterovaginal prolapse (UVP). The literature on laparoscopic sacrohysteropexy for management of UVP is very scarce from Saudi Arabia. This research examined the feasibility, clinical utility, and safety of laparoscopic sacrohysteropexy in a Saudi setting. A retrospective study was conducted, including all patients who met the inclusion criteria. The laparoscopic sacrohysteropexy technique was adapted with modifications from the "Oxford hysteropexy". The primary endpoint was overall success, defined as anatomical success in all vaginal compartments (UVP grade 0 or 1 postoperatively). The secondary endpoint was the mean change in point C. Descriptive data were summarized with numbers and percentages, while numerical data used means ± standard deviations. Fisher's exact and Student's t tests were used for univariate analyses. Significant surgical outcome predictors were identified via logistic regression, with p <0.05 considered statistically significant. Overall, 21 patients met the inclusion criteria. The most frequent indication for laparoscopic sacrohysteropexy was UVP without anterior or posterior wall prolapse (n = 15, 71.4%), whereas the most frequent grade of UVP was grade III (n = 13, 61.9%). One patient (4.8%) required switch to laparotomy due to severe adhesions. No perioperative complications were recorded. The mean change in point C and hospital stay were 5.8 ± 2.1 (range: 0-8) and 1.4 ± 0.6 days (range: 1-3), respectively. Surgical success was achieved in 18 patients (85.7%). Only three patients experienced recurrences (one, two, and six months postoperatively). The mean change in point C was significantly higher in successful cases contrasted with the failed cases (6.5 versus 1.3). Laparoscopic sacrohysteropexy for management of uterovaginal prolapse revealed technical feasibility, safety, and beneficial utility of the procedure. Further large-sized and multicentric investigations are important to gather additional pertinent information on laparoscopic sacrohysteropexy.

Investigating precise control pathway for haemostatic clip usage in laparoscopic cholecystectomy based on patient clinical variations: an exploratory retrospective observational study

ObjectivesTo explore a precise control pathway based on patient clinical variations for haemostatic clip usage in laparoscopic cholecystectomy (LC) through on-site research data from a teaching hospital. Specifically, the study...

Establishment of a postoperative bowel adhesion model in Rats

Postoperative adhesive bowel obstruction is a frequent cause of hospital admission in a surgical department. Emergency surgery is needed in a majority of patients with bowel ischemia or peritonitis; most adhesive bowel obstruction can be managed non-operatively. Many studies have investigated benefits of using oral water-soluble contrast to manage adhesive bowel obstruction. Treatment recommendations are still controversial. Intestinal adhesions commonly occur in patients after abdominal surgery, often between intestines, between intestines and the abdominal wall, or within the peritoneum. Adhesions can lead to symptoms such as abdominal pain, constipation, and bloating, and may result in serious complications such as intestinal obstruction, bowel necrosis, acute peritonitis, and sepsis, which can be life-threatening. Therefore, reducing the occurrence of intestinal adhesions is crucial for abdominal surgery. To minimize adhesions, endoscopic techniques can be employed to reduce the abdominal opening area and thus decrease the probability of adhesion formation. However, this approach requires specialized equipment and surgical skills, making it somewhat challenging. Alternatively, anti-adhesion products can be used to lower the risk of adhesion formation. In this study, a murine cecal abrasion adhesion model was established and will be simulated common adhesion scenarios observed in patients after abdominal surgery. The efficacy of anti-adhesion gel materials will be then evaluated to assess their anti-adhesion properties. The record of gross adhesion severity assessment was performed. The adhesion status between the cecum and abdominal wall was observed on postoperative days 3 and 14. The results was shown that three days post-surgery operation, the group exhibited more severe adhesions upon gross examination. By day 14 post-surgery operation (at animal sacrifice), the histopathological analysis revealed that the group exhibited thicker fibrous tissue thickness, increased neovascularization, and higher collagen accumulation in the peritoneum. Therefore, based on the results of this experiment, a postoperative bowel adhesion rat is reliable and can be safely used to test the efficacy of novel anti-adhesive formulations to prevent intra-abdominal adhesions by using this model.

Investigation on the machining characteristics of AZ91 magnesium alloy using uncoated and CVD-diamond coated WC-Co inserts

An investigation has been performed to study the compatibility of machining AZ91 magnesium alloy in dry conditions using uncoated and CVD diamond-coated WC-Co inserts. The machining characteristics such as built-up edge (BUE) formation, surface roughness, cutting forces and chip morphology were studied at the cutting speeds, 350, 650 and 950 m/min. The results revealed severe adhesion of the AZ91 Mg alloy on the uncoated WC-Co inserts with increasing cutting speed and contributed to an increase in surface roughness and cutting forces. The CVD diamond-coated inserts have shown negligible built-up edges at various cutting speeds due to their unique properties like low coefficient of friction, low chemical affinity and high thermal conductivity. Snarled types of long continuous chips were observed while machining with CVD diamond-coated WC-Co inserts, whereas short continuous chips were observed with uncoated WC-Co inserts.

基于轻量化的YOLOv8小麦籽粒自动计数研究

In order to accurately and quickly achieve wheat grain detection and counting, and to efficiently evaluate wheat quality and yield, a lightweight YOLOv8 algorithm is proposed to automatically count wheat grains in different scenarios. Firstly, wheat grain images are collected under three scenarios: no adhesion, slight adhesion, and severe adhesion, to create a dataset. Then, the neck network of YOLOv8 is modified to a bidirectional weighted fusion BiFPN to establish the wheat grain detection model. Finally, the results of wheat grain counting are statistically analyzed. Experimental results show that after lightweight improvement of YOLOv8 with BiFPN, the mAP (mean Average Precision) value of wheat grain detection is 94.7%, with a reduction of 12.3% in GFLOPs. The improved YOLOv8 model now requires only 9.34ms for inference and occupies just 4.0MB of memory. Compared with other models, the proposed model in this paper performs the best in terms detection accuracy and speed comprehensively, better meeting the real-time counting requirements of wheat grains.

Anatomical biliary reconstruction as an ultimum refugium for selective cases-History and current state of knowledge.

Reconstruction of extrahepatic bile ducts is a staple procedure of HPB surgery. The current standard for most cases is a nonanatomical bilioenteric reconstruction, a satisfactory option for the majority of patients. However, it cannot be used for a small number of selective cases (short bowel syndrome, severe abdominal adhesions), where an anatomical reconstruction with or without an interponate can be used. This review summarizes current knowledge about tissue and material usage for experimental and clinical anatomical bile duct reconstruction in the last 100 years. A Pubmed database was searched for published articles about anatomical extrahepatic bile duct reconstruction in experimental and clinical settings ranging from 1920 to 2022. To date, the truly optimal interponate material has not yet been found. However, evidence reveals important properties of such material, most importantly its biodegradability and neovascularization in the recipient's body. The role of internal bile duct stenting for anatomical reconstruction seems important for the outcome. Anatomical reconstruction of extrahepatic bile ducts is an uncommon but usable technique in unique cases when a nonanatomical reconstruction cannot be done. The optimal properties of interponate material for anatomical bile duct reconstruction have been more clarified, although further research is required.

Visceral to subcutaneous fat area ratio predicts severe abdominal adhesions in definitive surgery for anastomotic fistula after small intestine resection

Abdominal adhesions manifests following abdominal infections triggered by intestinal fistulas. The severity of such adhesions depends on the extent of fiber deposition and peritoneal fibrinolysis following peritoneal injury, which may be influenced by sustained inflammation within the abdominal cavity. In this regard, the visceral-to-subcutaneous fat area (VFA/SFA) ratio has been implicated as a potential marker of inflammation. This study aimed to explore the relationship between VFA/SFA and abdominal adhesions. This multicenter study was conducted across four tertiary institutions and involved patients who had undergone definitive surgery (DS) for intestinal fistula from January 2009 and October 2023. The presence of abdominal adhesions was determined intraoperatively. VFA/SFA was investigated as a potential risk factor for severe adhesions. The study comprised 414 patients with a median age of 50 [interquartile range (IQR) 35–66] years and a median body mass index of 20.0 (IQR 19.2–22.4) kg/m2, including 231 males with a median VFA/SFA of 1.0 (IQR 0.7–1.2) and 183 females a median VFA/SFA of 0.8 (0.6–1.1). VFA/SFA was associated with severe abdominal adhesions in males [odds ratio (OR) = 3.34, 95% CI 1.14–9.80, p = 0.03] and females (OR = 2.99, 95% CI 1.05–8.53, p = 0.04). J-shaped association between VFA/SFA ratio and severe adhesions was revealed in both sex. The increasing trend can be revealed when OR more than 0.8, and 0.6 in males and females respectively. Preoperative VFA/SFA demonstrates predictive value for statues of severe abdominal adhesions in DS for anastomotic fistula after small intestine resection.

Surgical approach for a refractory enterocutaneous fistula by combining laparoscopic surgery and a planned open conversion: a case report

BackgroundAn enterocutaneous fistula (ECF) is defined as an abnormal communication between the gastrointestinal tract and skin. ECFs are rarely encountered in clinical practice, yet are frequently difficult to treat. Few reports exist regarding the surgical techniques for the treatment of an ECF. Therefore, we report a case of refractory ECF with concomitant severe adhesions, in which we performed combined laparoscopic adhesiolysis and planned open conversion.Case presentationA 57-year-old female patient underwent a laparotomy for an ovarian cyst in her 20s. At 46 years, adhesiolysis without bowel resection was performed for adhesive small bowel obstruction (SBO). However, her symptoms did not improve. Eighteen days postoperatively, she underwent a reoperation and jejunostomy. An ECF developed post-reoperation; therefore, stoma closure and radical surgery for the ECF were planned. Due to the severe adhesions, only stoma closure was performed, based on intraoperative assessments. The patient was subsequently referred to our hospital. First, skin care around the fistula was provided during an outpatient visit. Appropriate sizing of the stoma pouch was performed, to improve erosions and ulcers. Thereafter, debridement of the perifistula skin and simple closure of the ECF outlet were attempted; however, the ECF recurred shortly thereafter. After 8 years of regular skin care, with the ECF remaining stable, however, manifesting as symptomatic SBO, she underwent laparoscopic adhesiolysis. This procedure was initiated in the epigastric region, where relatively fewer adhesions were anticipated. Post-open conversion, partial resection of the small intestine at four locations, including the fistula site, was performed. Postoperatively, jejunal edema and peristaltic dysfunction, due to narrowing of the superior mesenteric artery occurred. Regular drainage by percutaneous endoscopic gastrostomy was required. However, she improved and was discharged 3 months post-operatively. Three years post-operatively, the ECF and SBO did not recur.ConclusionsWe reported a case of refractory ECF in which we were able to safely perform surgery, by combining laparoscopic adhesiolysis and a planned open conversion. Therefore, the surgical approach used in this case may be an option for securing a safe surgical field, while avoiding collateral damage.

Cholecystocolonic Fistula (CCF) Case Report

Introduction: Gallbladder disease is one of the most common conditions affecting the digestive tract. Autopsy reports have shown a prevalence of gallstones ranging from 11-36%, with cholecystitis being one of the most prevalent complications. Although cholecystoenteric fistulas are rare, with an incidence of 0.15-0.5% among patients undergoing cholecystectomy, they can present significant diagnostic and therapeutic challenges. The transverse colon is the second most common site for these fistulas after the duodenum. A high degree of suspicion is required to diagnose it preoperatively. Here, we present a noteworthy case of a 65-year-old male patient with a fistula between the gallbladder and transverse colon, complicated by severe adhesions and a large stone, underscoring the complexities associated with this condition. Case Presentation: The patient had a history of hypertension and gallbladder stones when he was admitted during the COVID-19 pandemic with acute cholecystitis. Two years later, he had an elective laparoscopic cholecystectomy and, during surgery, the surgical team noticed significant adhesions around the gallbladder. Further inspection during dissection of the gallbladder bed revealed a fistula between the transverse colon and the gallbladder, and a single large stone was identified. The patient’s surgical procedure was successful, and his postoperative recovery was uncomplicated. Conclusion: A fistula between the gallbladder and transverse colon is a rare complication of gallbladder disease, and the transverse colon is the second most common cholecystoenteric fistula after the duodenum. The presence of a fistula is usually a late sequence of chronic gallstone disease that requires appropriate diagnosis and correct treatment. In this case, the surgery was complicated by extensive adhesions around the gallbladder with an adjacent colon and a large stone with a fistula noted between the transverse colon and the gallbladder. However, through careful planning, correct surgical procedures, and skilled surgical expertise, the patient’s condition after surgery lacked complications. This case focuses on the importance of addressing all possible complications of gallbladder disease and adjusting surgical procedures accordingly.