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Background Completion cholecystectomy (CC) is performed for recurrent or persistent biliary symptoms following subtotal cholecystectomy (STC) or incomplete cholecystectomy (IC). Due to its complexity, cases are often referred to hepato-pancreato-biliary (HBP) surgeons. There is little published literature on indications or outcomes of CC. Methods Completion cholecystectomy cases performed between 2016 and 2021 by the sole HPB surgeon covering a rural referral base of >250-mile radius in West Texas were included. Primary variables of interest include indications and outcomes of CC. Results Of the eleven patients included, 5 (45.5%) had laparoscopic STC, 3 patients (27.3%) had laparoscopic converted to open STC, and 2 (18.2%) had laparoscopic IC. Most STC cases (6/9, 66.6%) were reconstituting, while 3 STC cases were fenestrating (all had persistent bile leak). For reconstituting STC, indications were symptomatic cholelithiasis in 5 patients (45.5%), and choledocholithiasis in 3 patients (27.3%). The median (IQR) duration between index procedure and subsequent CC was 15 (1.4-92) months. The median (IQR) remnant gallbladder length was 4 (3-4.5) cm. Completion cholecystectomy was performed robotically in 8 cases (72.7%). Post-CC complications occurred in 3 patients (27.3%); these were 1 superficial surgical site infection, 1 hepatic abscess requiring percutaneous drainage, and lastly atrial fibrillation. Conclusions All patients requiring CC had residual gallbladder remnant >2.5 cm; this is longer than recommended for STC. Completion cholecystectomy is a complex operation that carries significant morbidity, even when performed using minimally invasive techniques. As bailout procedures become more common in severely inflamed cholecystitis, it is important to collate more data on the outcomes of requiring CC.

Incidental appendectomy (IA) is sometimes performed in patients undergoing abdominal operations to prevent subsequent development of appendicitis. Patients who undergo laparotomy for major abdominal trauma are at high risk of developing dense adhesions, increasing the risk of future operations. Therefore, there is a potential benefit to IA for patients undergoing trauma laparotomy. We performed a retrospective review of patients who underwent IA during laparotomy for abdominal trauma at a Level 1 trauma center between January 2010, and June 2020. Twenty-three patients underwent IA; they tended to be young (33.7 ± 18.9 years) and male (87%) with 12 penetrating and 11 blunt injuries. Regarding indications, 13 had no documented intra-operative abnormalities of the appendix, 6 patients had a fecalith, and 3 had trauma to the appendix. One patient’s appendix was adhered to the peritoneum and one patient had unusual anatomic location. Only one patient developed an appendiceal stump leak after IA.

Background Liver cirrhosis is associated with increased mortality in trauma victims. We stratified the impact of cirrhosis on trauma mortality by Model for End-stage Liver Disease (MELD) score. Methods Trauma center database was accessed for patients with established diagnosis of cirrhosis presenting 2014 - 2018, matched to control patients without cirrhosis in a 2:1 ratio by age, sex, and TRISS. Primary outcome was mortality, secondary outcomes were length of stay, intensive care unit days, and ventilator dependent days. Results Cirrhosis was present in 182 (1.5%) trauma patients. Mortality difference between 12 (7%) deaths in cirrhosis cohort versus 14 (4%) in control was not statistically significant (p = 0.38). No difference was found in secondary outcomes. Categorization of cirrhosis severity by MELD score range (MELD 6-7, 8-10, 11-14, 15-20, 21-30) showed a 1.9 fold increase in the odds of mortality for every increase in MELD score category (OR = 1.91, p = 0.03, 95% CI = 1.08 – 3.37). Conclusion Mortality effects of cirrhosis in trauma patients can be estimated using MELD score.

Background As Acute Care Surgery and shift-based models increase in popularity, there is evidence of better outcomes for many types of emergency general surgery patients. We explored the difference in outcomes for patients with acute biliary disorders, treated by either Acute Care Surgery (ACS) model or traditional call model (TRAD) during the same period. Methods Retrospective review of patients undergoing laparoscopic cholecystectomy for acute biliary disease 2017-2018. Demographics, clinical presentation, operative details, and outcomes were compared. Results Demographics, clinical presentation, and complication rates were similar between groups. Time from surgical consult to operating room (Δ = −15.34 hours [−24.57, −6.12], P = .001), length of stay (Δ = −1.4 days [−2.45, −.35], P = .009), and total charges were significantly decreased in ACS group compared to TRAD (Δ$2797.76 [−4883.12, −712.41], P = .009). Conclusions Acute biliary disease can be managed successfully in an ACS shift-based model with reduced overall hospital charges and equivalent outcomes.

Introduction The majority of trauma-related deaths occur within the first 24 h of injury, and time elapsed until intervention for an injury is one of the greatest causes of preventable death in mature trauma centers. This study seeks to determine if there is a correlation between time spent in the trauma bay and mortality outcomes. Methods A retrospective analysis of Level 1 trauma patients from 1 January 2010 to 1 January 2016 in a single center. Results Charts from 1678 Level 1 trauma patients with 1290 (76.9%) blunt and 388 (23.1%) penetrating injuries were analyzed. Of these, 345 patients died and 237 (68.7%) died within the first 24 h. Multivariate analysis yields an inverse correlation between increased times spent in the trauma bay and mortality, with controls for injury severity, age, and race/ethnicity and with deaths in the trauma bay excluded ( p Conclusion Reduced time spent in trauma bay was not correlated with improved mortality outcomes in Level 1 trauma patients. Findings do not necessarily suggest that increased trauma bay time would reduce mortality, but rather current evaluation procedures may prioritize trauma patients appropriately. Instinctive adjustment by emergency care providers to move more severely injured patients out of the trauma bay quicker and other additional variables could account for the measured phenomena. This is the first study to examine trauma bay times and mortality outcomes.

Pneumomediastinum (PM) is an uncommon finding after blunt trauma to the neck or chest. Motor vehicle collisions are the most common cause in adults, while falls are the most common in children. The majority of traumatic PM results from medial tracking of air from a concomitant pneumothorax. The Macklin effect, of air tracking medially along peribronchial sheaths from alveolar rupture, is responsible for most other cases. Chest pain is the most common symptom, and crepitus the most common sign. The majority of PM will resolve spontaneously, and requires no specific intervention. Only 1—6% of cases result from rupture of the larynx, trachea, bronchi or oesophagus. Hoarseness, dyspnea, persistent lung collapse or air leak should increase suspicion for aerodigestive injury. Computed tomography (CT) can help differentiate benign etiology from those that require surgical correction. High suspicion for aerodigestive injury based on clinical and/or CT findings should prompt diagnostic bronchoscopy and/or oesophagram.

We present our experience during the past 5 years with isolated penetrating flank trauma. We examined the evaluation process, treatment plan, length of stay, outcome, and complications of patients with isolated penetrating injuries to the flank. There were four patient groups: 1) laparotomy (n = 5); 2) local wound exploration (n = 1); 3) laparoscopy (n = 8); and 4) observation and triple contrast CT scan (n = 9). All patients were male. The mean length of stay was 15 days for group 1, one day for group 2, two days in group 3, and 1.5 days in group 4. Three patients had diaphragmatic injuries, which were repaired laparoscopically. One patient with local wound exploration re-presented with a diaphragm hernia. A negative triple contrast CT scan resulted in no subsequent intervention. There were no missed injuries or complications from CT scan + observation or from diagnostic laparoscopy. We believe that laparoscopy may emerge as a useful adjunct in the treatment of patients with flank trauma. We present an algorithm for the management of penetrating flank trauma.

We present a case of a patient sustaining an isolated injury to the right main branch of the cysterna chyli due to a high-speed motor vehicle accident. A 42-year-old man presented after a high-speed collision. CT revealed a collection of hypodense fluid in the gallbladder fossa, which was the clue to take him to the OR. We proceeded to laparoscopic exploration, and based on the milky white color of the fluid, identified a chyle leak. In an open fashion, the retroperitoneum was explored and the injury was identified as disruption of the right lumbar branch entering the cisterna chyli, and this was ligated with silk ties. Chyle duct injury secondary to blunt trauma is a rare finding. The use of CT imaging can identify this injury. Laparoscopy can confirm the injury. Open ligation of the injured duct is the best treatment.