INTRODUCTION: Subtotal cholecystectomies have become a viable alternative to converting laparoscopic cholecystectomies to open cholecystectomies in complicated gallbladder etiologies. There are two subtypes of subtotal cholecystectomies: fenestrating and reconstituting. Fenestrating subtotal cholecystectomy requires an internal suture of the cystic duct with removal of most of the gallbladder. Reconstituting subtotal cholecystectomy creates a gallbladder remnant. Bile leak is a common adverse outcome of subtotal cholecystectomies. ERCP is the standard intervention for high output bile leaks. METHODS: This was a retrospective analysis of patients at Coney Island Hospital who underwent any cholecystectomy during January 2010 to December 2018. The inclusion criterion was patients who underwent subtotal cholecystectomy. The exclusion criteria was any patient who underwent prior ERCP or sphincterotomy. We reviewed patient’s age, initial WBC, alkaline phosphatase, total bilirubin, AST, ALT, total output of JP drain, duration of JP drain, and hospitalization length. Data was analyzed using XTabs, ANOVA, and T-test using Prism and SAS software. RESULTS: 1423 cholecystectomies performed at Coney Island Hospital during this period. Of these, 106 were subtotal cholecystectomies: 11 were reconstituting and 96 were fenestrating. 34 subtotal cholecystectomies required ERCP intervention. Fenestrating subtotal cholecystectomies were associated with higher total bile output from JP drain and longer duration of JP drain. Cases requiring ERCP intervention were associated with larger bile output from JP drain, higher total bilirubin, and longer hospitalization duration. 68 of the fenestrated subtypes were left with an open cystic duct without internal closure. CONCLUSION: ERCP has been demonstrated to be an effective intervention in treating post operative bile leaks in cases showing large JP drain output and increased total bilirubin on initial presentation. However, a majority of subtotal cholecystectomies can be managed without intervention. We noted that 68 of the 96 fenestrating subtotal cholecystectomies had the cystic ducts remain open instead of the traditional internal suture. Cystic duct obliteration or severe inflammation may impede suturing. Regardless, close monitoring of JP drain output is recommended. Our research concludes that there are better outcomes with reconstituting subtotal cholecystectomies and fenestrating subtotal cholecystectomies in which there was an internal suture placed at the cystic duct.

INTRODUCTION: Adult gastric volvulus is generally diagnosed by the symptoms of abdominal or chest pain. Acute presentation include symptoms of pain, vomiting, and failure of placement of naso-gastric tube (NGT) also known as Borchardt Triad. Severity of sequelae is dependent on significance of the rotation with rotations of >180° causing possibly outlet obstruction, strangulation, necrosis leading to perforation and severe sepsis leading to death. CASE DESCRIPTION/METHODS: A 92 year old gentleman is admitted for UTI related sepsis and started on antibiotics. On day 8 of his admission, patient complained of abdominal epigastric pain and had two episodes of dark red colored particulate emesis. Hemoglobin was stable and physical exam showed mild distention and slight tenderness on palpation but was otherwise nonsignificant. Multiple attempts at nasogastric tube placement were difficult due to resistance during insertion at below oro-pharyngeal levels. Abdominal CT scan (Figures 2 and 3) was completed showing left diaphragmatic hernia with herniation of the stomach with upside down stomach is noted with partial gastric outlet obstruction with the distended stomach, indicating organo-axial volvulus. This was not obviously noted in the admission chest X-ray (Figure 1). Given requirement for gastrostomy, patient was transferred to hospital of their choice where he subsequently received surgery and was discharged 4 months later. DISCUSSION: The diagnosis of gastric volvulus in this patient was not initially apparent as his abdominal pain complaints were very mild, his labs were normal and stable, and his initial admission was for sepsis. It was primarily the resistance in the placement of the NGT and the coffee-ground emesis that raised suspicion and prompted the CT imaging scan, which revealed the diagnosis. Therefore, it is important to have medical professionals remain cognizant of the possibility of the diagnosis of gastric volvulus, no matter how rare, in an elderly patient with resistance to NGT placement. And although the Borchardt triad is apparent in 75% of acute gastric volvulus cases, it is important to remember that up to 25% of patients do not present classically, and therefore gastric volvulus should not be excluded as a possible diagnosis.

INTRODUCTION: Approximately 3-6% of patients with gastric carcinoma (GC) present with ascites at their initial presentation of GC. Many studies suggest that GC patients with ascites have poor prognosis due to ascites-related complications, like spontaneous bacterial peritonitis (SBP). CASE DESCRIPTION/METHODS: A 69 year-old Asian female active smoker presented with worsening abdominal pain and 10 lbs weight loss for 1 month. She reported one episode of coffee ground emesis. Physical examination revealed reticulated abdominal skin discoloration, right upper quadrant tenderness, and hypoactive bowel sounds. Laboratory studies: Hgb: 12.4 g/dL; MCV 92.3 fL; WBC: 14.2 K/mcL, Lactate: 1.3 mmol/L, BUN 13 mg/dL, Cr < 0.46 mg/dL. CT abdomen revealed distended small bowel loops, moderate ascites, omental caking and gastric thickening greatest at the gastric body with surrounding fat infiltration and tiny nodes. Paracentesis drained 3.8 L of cloudy yellow ascites fluid with a WBC of 385. The patient was started on treatment for SBP. Esophagogastroduodenoscopy was performed revealing a partially obstructing, ulcerating mass at the gastric cardia and gastric body (A). Biopsy confirmed the diagnosis of gastric adenocarcinoma (B). DISCUSSION: We present a patient who initially presented with symptoms suggestive of malignancy. Her labs revealed SBP although her presentation was asymptomatic. With only 3-6% of patients with gastric carcinoma (GC) presenting with ascites at their initial presentation of GC, ascites-related complications, like SBP, is associated with poorer prognosis. For this reason, current treatment for GC with ascites is palliation and prevention of ascites-related symptoms.