Background
Subtotal cholecystectomy is an effective surgical method to decrease the risk of complications for gallbladders that are difficult to remove. However, there is a risk for postoperative refractory bile leakage through the gallbladder stump. Here, we report a new management technique involving the use of argon plasma coagulation (APC) to stop bile leakage after a subtotal cholecystectomy.
Case presentation
A 74-year-old man was referred to our hospital for abdominal pain and fever. Contrast-enhanced computed tomography of the abdomen showed fluid collection, such as an abscess, surrounding the gallbladder and hepatic flexure colon. The patient was diagnosed with colonic perforative peritonitis, and he underwent emergency surgery. On laparotomy, the abscess was observed outside of the hepatic flexure colon and gallbladder necrosis was detected. The neck of the gallbladder and the area close to the hepatoduodenal ligament was severely inflamed prohibiting dissection. The hepatic flexure colon was part of the abscess wall, and resection was needed. A subtotal cholecystectomy and right hemicolectomy confirmed peritonitis caused by cholecystic perforation. The mucous membrane of the gallbladder neck that remained was necrotic or detached. Therefore, the stump of the gallbladder was closed by primary sutures without cauterization of the mucosa. On postoperative day 6, bile leakage from the gallbladder stump was revealed. Percutaneous and endoscopic retrograde cholangiography drainage were performed. However, the liquid, which seemed to be secreted from the mucosa of the remnant gallbladder, was continuously obtained. We used APC to cauterize the gallbladder mucosa through the fistula of the abdominal drainage tube. Bile leakage and mucus discharge were improved after three rounds of APC cauterization.
Conclusions
APC effectively treated refractory bile leakage from a gallbladder stump after subtotal cholecystectomy for severe cholecystitis.
BackgroundThe safety and feasibility of laparoscopic colectomy for T4 colorectal cancer remain controversial. We believe that setting a “Goal” that will guide the surgeons in returning from the deep layer could be the key to safe en bloc resection of neighboring organs. For descending colon cancer, the cranial-first approach makes it possible to clearly visualize the pancreas and origin of the transverse mesocolon, leading to safe splenic flexure mobilization and complete mesocolic excision, which is the strongest advantage of this approach.Case presentationA 75-year-old woman was diagnosed with T4 descending colon cancer invading the Gerota’s fascia. We performed laparoscopic left colectomy using the cranial-first approach to set a “Goal” at the inferior border of the pancreas for safe resection of the Gerota’s fascia. The total operative time was 233 min, and the estimated blood loss was 98 ml. She was discharged after surgery without postoperative complications. Pathological findings revealed the invasion into the Gerota’s fascia, and the resection margin was negative for cancer.ConclusionsThe cranial-first approach of laparoscopic left colectomy appears to be safe and feasible and could be a promising method for selected patients with T4 descending colon cancer invading the Gerota’s fascia.
An80-year-oldwomanwasreferredtoourhospitalforgallbladdertumorswhichweredetectedvia abdominalsonographyatamedicalcheckup.Acontrast-enhancedCTscanrevealedswellingofthegallbladder fundus containing multiple protruding lesions. Magnetic resonance cholangiopancreatography showed localized constriction of the gallbladder body with cystic structures, which was associated with segmentaladenomyomatosis.Therefore,gallbladdercarcinomawithsegmentaladenomyomatosiswasdiagnosed. We performed cholecystectomy with lymphadenectomy of the hepatoduodenal ligament. The postoperativecoursewasuneventful,andthepatientwasdischargedonpostoperativeday6.Postoperativepathologicalfindingsshowedthatthereweremultiplepapillarytumorsinthegallbladderfundus.Almostallofthecancercellshadspreadonlyontheepitheliummicroscopically.However,itpartlyinfiltrat-edintothesubserosallayeralongtheRokitansky-Aschoffsinus.Thefundalsideofthegallbladderhada scatteredatypicalepithelium,suggestingthatthewholegallbladdermucosacouldhavebecomeprecancerous.Weexperiencedaveryrarecaseofmulticentricgallbladdercarcinomaaccompaniedbysegmental adenomyomatosis.
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