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ACS Case Reviews in Surgery Author Instructions

General considerations.

ACS Case Reviews in Surgery will publish educational materials in various surgical specialties. To be eligible for peer review, all submissions must meet at least one of the following requirements:

• Describes a topic of interest or important education value to practicing surgeons
• Describes experiences that may not be routinely seen or that were uniquely treated
• Involves patients with common surgical problems where the clinical presentation and/or challenges of management produced knowledge and insights that have significant educational value

Submissions will be reviewed with the understanding that they have not been published by and are not under consideration at any other publication venue. Additionally, all submissions must strictly adhere to the ACS Case Reviews Author Instructions, SCARE Guidelines , and all legal and ethical considerations as noted below in this instructions document.

Submitting Manuscripts

• Review the ACS Case Reviews Author Instructions and the SCARE Guidelines.
• Ensure that the submission fully satisfies all requirements.
• Submit online

Please note: Medical students and residents are encouraged to submit to ACS Case Reviews ; however, to do so, a practicing surgeon or attending surgeon must be included as one of the authors.

Upon completion of the peer-review process and the decision to accept the manuscript for publication, a non-negotiable publication processing fee of $1250 must be paid in full prior to publication.

Case Report Requirements

ACS Case Reviews in Surgery publishes case reports in various surgical specialties. All case reports must meet at least one of following requirements:

• Focus on a topic of interest and especially educational value to practicing surgeons
• Describe experiences that may not be routinely seen or that were treated in a unique way.
• Involve patients with common surgical problems where the clinical presentation and/or challenges of management produced knowledge and insights that have substantial educational value

Only original, previously unpublished case report manuscripts should be submitted. All submissions will be reviewed with the understanding that the submitted work has not been published by and is not currently under publication consideration at any other journal, website, or any other content platforms. Additionally, all manuscripts will be peer-reviewed.

Authors are encouraged to review the author instructions in their entirety as well as the published articles that appear on the ACS Case Reviews in Surgery Issue Page .

Submitted case reports should be approximately 1,000 words (excluding the reference list). All manuscript formatting requirements must be strictly followed, and all designated manuscript sections must be included. Failure to strictly follow the author instructions may result in the immediate rejection of the paper.

Medical students and residents are encouraged to submit to ACS Case Reviews in Surgery; however, to do so, a practicing surgeon/attending surgeon must be included as one of the authors.

Please note: On receiving a written acceptance for publication notification via e-mail, the corresponding author will be required to pay a nonnegotiable $1,250 publication fee; to complete this process, an ACS username and password are required.

If you have any questions, please contact the ACS Case Reviews in Surgery editorial team at [email protected] .

How to Submit

After ensuring that the manuscript adheres to all stated requirements, submit online .

Editors of ACS Case Reviews in Surgery will review each submission and decide if it is appropriate for publication in this journal. All case reports will be checked for plagiarism. If accepted for peer evaluation, any recommended edits will be sent to the authors, along with a request for changes. Once the paper is accepted for publication, the case report will be considered the property of the American College of Surgeons, subject to all applicable copyright laws, and not publishable again in any form.

SCARE Checklist

The Surgical Case Report (SCARE) checklist is structured to correspond with key components of a case report and capture useful clinical information (including "meaningful use" information mandated by some insurance plans).

Although case reports are popular and are frequently published, there are minimal instructions on the most essential elements to be reported for publication. According to reported evidence, incomplete description of methodologies and clinical details can lead to incomplete understanding and erroneous conclusions. To further help create a foundation for the more effective reporting of surgical case studies, the   SCARE Checklist was developed through a Delphi consensus exercise, published in 2016, and updated in 2020 (Agha RA, Franchi T, Sohrabi C, Mathew G, Kerwan A; SCARE Group. The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines. Int J Surg. 2020 Dec;84:226-230. doi: 10.1016/j.ijsu.2020.10.034. Epub 2020 Nov 9. PMID: 33181358.).

The ACSCRS editorial team requires all authors to review the below checklists prior to creating their case reports and to attest that all guidelines have been entirely fulfilled. Failure to do so will result in the immediate rejection of the submission.

Corresponding Author

Clearly indicate the author designated to handle all correspondence at all stages of review. Only one author is allowed to be designated as the corresponding author, with the following contact details provided:

• Complete postal address
• Valid e-mail address
• Valid phone number (with country and area code)

The corresponding author must confirm that all authors have reviewed and agree regarding any and all indicated revisions.

Manuscript Format

All case report submissions will include the following sections, and all sections will be completed as thoroughly and thoughtfully as possible (all sections should at least contain no less than 50 words and not contain language that is copied word for word from other sections (e.g., the Conclusion and Lessons Learned sections should be distinct from each other). Failure to provide this information will result in immediate rejection of the submission.

The title page must be the first page of the manuscript; all pages should be numbered. The title of manuscript should include the report's key concepts so that search engines will locate the manuscript. No abbreviations are allowed in the titles unless they are standard acronyms (for example, NSQIP).

Author Names and Affiliations

List the name(s) of all authors beginning with the last name and followed by the first initials of the first and middle name. No more than five names should appear.

Present the authors' affiliation addresses (where the actual work was done) below the names, including department and institution, city, state, and country. Indicate all affiliations with a lower-case superscript letter immediately after the author's name and in front of the appropriate affiliation.

Smith GH a ; Elliot QL ab ; Hill BC ac

Author Affiliations

• Department of Surgery, Loyola University Medical Center, Maywood, IL, 60153
• Burn Shock Trauma Institute, Loyola University Medical Center, Maywood, IL 60153
• Surgical Service Line, Edward Hines, Jr. VA Hospital, Hines IL 60141

As previously noted, clearly indicate who will handle correspondence at all stages of review, revision, publication, and post-publication.  

Gerald H. Smith, MD, FACS Department of Surgery Loyola University Medical Center 2160 S First Avenue Maywood, IL, 60153 Phone: (xxx) xxx-xxxx E-mail: [email protected]

Acknowledgements

Additional contributors should be listed in an acknowledgments section on the title page (for example, people who provided purely technical help/writing assistance, department chairs who provided only general support, etc.)

Present/Permanent Address

If an author has moved since the work described in the article was done, or was visiting at the time, a "Present address" (or "Permanent address") may be indicated as a footnote to that author's name. The address at which the author actually did the work must be retained as the main affiliation address.

Meeting Presentations

Include meeting presentation information: the name (spelled out) of the sponsoring organization, city and state, and month and year of the meeting.

Disclosure of Conflicts

All relevant conflicts of interest and sources of funding should be included on the title page of the manuscript with the heading "Conflicts of Interest and Source of Funding." See Conflict of Interest below for further details.

Financial Relationships

All relevant conflicts of interest and sources of funding should be included on the title page of the manuscript with the heading "Conflicts of Interest and Source of Funding." See Conflict of Interest below for further details. If there are no financial relationships to disclose, please include the sentence "The authors have no financial relationships or in-kind support to disclose."

Structured abstracts are required. Abstract should contain about 300 to 500 words. Briefly summarize the article by stating the clinical challenge(s), the results/findings, problems presented by the case, conclusion(s), recommendations, lessons learned, and, in retrospect, what alternative steps the authors would have taken. Do not cite references in the abstract. The format for the abstract is:

Immediately after the conclusion, provide a maximum of six (6) keywords. These keywords will be used for indexing and searching purposes.

Case Description

Abbreviations

Abbreviations/acronyms should be in parentheses immediately after the words for which they stand and must be spelled out completely at first use in the abstract and again at first use in the text. Abbreviations/acronyms used in figures must be spelled out in the figure legend. Up to 10 abbreviations of common terms (for example, DCIS, HBV, TIA) or acronyms (for example, SPECT, TRISS, SEER) may be used throughout the manuscript. On a separate page after the abstract, list the selected abbreviations and their definitions (for example, DCIS, ductal carcinoma in situ ). The editors will determine which lesser-known terms should not be abbreviated.

Units and Drug Names

Follow internationally accepted rules and conventions: use the international system of units (SI). If other units are mentioned, please give their equivalent in SI. Whenever possible, generic names should be used for drugs or materials (e.g., for sutures); if a proprietary (trade) name must be used, please include in parentheses the company, city, state, and country associated with the product, if necessary. Do not use patient names, initials, or hospital numbers.

This section should include a brief review of the literature as well as a discussion of the management and decision making involved in the case. Demonstrating an understanding of the existing literature related to the case study topic is also highly encouraged but should not be exhaustive. The discussion section should also evaluate the patient case for accuracy, validity, and uniqueness; compare the case report with the published literature; derive new knowledge; summarize the essential features of the report; and draw recommendations. If, in retrospect, any decisions made were not optimal, or were wrong, this information must be indicated in this section as well as in the Lessons Learned section for the sake of optimal surgical educational value.

Briefly reiterate evidence-based recommendations and applicability to surgical practice.

Lessons Learned

Authors must provide a summary of essential points, statements, or facts (minimum 100 words) summarizing both the findings of their manuscript as well as what the authors would have done differently regarding treatment steps if presented with the opportunity to revisit the presented case. As previously stated above, if any decisions made were not optimal, or were wrong, this information must be indicated in this section as well as in the Discussion section for the sake of optimal surgical educational value.

If automated reference numbering software (such as EndNote) or bibliography software is used, turn it off before submitting the manuscript.

Citation in Text

Please ensure that every reference cited in the text is also present in the reference list (and vice versa). Any references cited in the abstract must be given in full. Unpublished results and personal communications are not recommended in the reference list, but they may be mentioned in the text. Citation of a reference as 'in press' implies that the item has been accepted for publication. In-text citations should appear as superscript numbers. Please do not cite published abstracts, including those that have been published in meeting program books.

Reference Links

Increased discoverability of research and high-quality peer review are ensured by online links to the sources cited. In order to allow us to create links to abstracting and indexing services, such as Scopus, CrossRef, and PubMed, please ensure that data provided in the references are correct. Please note that incorrect surnames, journal/book titles, publication year and pagination may prevent the creation of a usable link. When copying references, please be careful as they may already contain errors. Use of the DOI is encouraged.

Reference Style

All references should follow the AMA format.

Number consecutively in the order mentioned in text. The citation number is placed in the text after the name when the reference is cited; if no name is mentioned, the citation is placed in the text at the end of the material referred to (for example, "Meakins and Jones 13 have shown that..." and "A group of oncologists has proved that if…. 13 "). When referring to an article by the names of the author(s), if there are two authors, both names should be used; if there are more than six authors, then the first author should be named followed by the phrases "et al" or "and colleagues." References to manuscripts accepted but not published at time of submission can be designated in the format shown in this example: " J Am Coll Surg . In press 2008." Please also include the DOI if at all possible. Any personal communication must be cited within the text (and followed with the phrase "personal communication") , not in the reference list . Authors must obtain written permission and confirmation of accuracy from the source of personal communication before submission. References must be verified against original documents; authors are responsible for completeness and accuracy of all citations.

The reference list should follow the text, and begin on a separate page, double-spaced and numbered consecutively. If there are more than six authors, list only the first three authors, followed by "et al." If there are six authors or fewer than six, list all authors.

Order of reference parts for a journal article: [Authors]. [Title]. [Journal name] [Year];[Volume]:[Pages].

Example: Valabussa P, Bonadonna G, Veronesi U. Patterns of relapse and survival following radical mastectomy. Cancer . 1978;41:1170-1178.

Figures, Tables, Images, Artwork, Etc

All images should be high-quality, original works or reproductions with appropriate permissions obtained. Adjustments to a figure may not highlight, misrepresent, obscure, or eliminate specific elements in the original figure, including the background.

Photographs, clinical images, micrographs, etc. must include arrows, as appropriate, or other markers to point out and elucidate important findings. Any violation of this requirement will be subject to penalties to include artwork removal, immediate rejection of the submission, banishment from submitting articles in the futures, etc.

Figure 1 . Left Hydroureteronephrosis and Suspicious Mass within the Pelvis. Published with Permission

Left image description details. Right image description details.

Previously published illustrations may be included if scientifically appropriate and permission has been obtained from the owner of the copyright, the publisher, and, ideally, the original author. Any violation of this requirement will be subject to penalties to include artwork removal, immediate rejection of the submission, banishment from submitting articles in the futures, etc.

Authors are responsible for:

• obtaining and including permission letters with their accepted manuscript in advance of publication
• providing publication-quality electronic files of the previously published illustrations.

Previously published, low-resolution images downloaded from the Internet are not acceptable for publication. Redrawing a figure does not change copyright; if the original author would recognize the figure as his/hers, permission to adapt/modify the figure must be obtained.

If a figure has been previously published, by you or by others, obtain permission from the copyright owner and state the permission fully in the figure legend. Upload the permission letter with the signed project agreement form.

Legal and Ethical Considerations

Statement on duplicate publication.

Submission of an article implies that the work described has not been published previously, that it is not under consideration for publication elsewhere, that its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere including electronically in the same form, in English or in any other language, without the written consent of the copyright holder (i.e., ACS Case Reviews in Surgery ).

When submitting a manuscript, the author must always make a complete statement to the editor about all submissions and previous reports (including meeting presentations and posting of results in registries) that might be regarded as redundant or duplicate publication. The author must alert the editor if the manuscript includes subjects about which the authors have published a previous report or have submitted a related report to another publication. Any such report must be referred to and referenced in the new paper. Copies of such material should be included with the submitted manuscript to help the editor decide how to handle the matter.

If redundant or duplicate publication is attempted or occurs without such notification, corrective action will be taken to remedy this policy violation, including the following steps: the submitted manuscript will be promptly rejected, the copyright owner of the original work will be notified, and all submission authors will be banned from submitting articles to ACS Case Reviews in Surgery in the future. If the editor was not aware of the violations and the article has already been published, then a notice of redundant or duplicate publication will likely be published with or without the author's explanation or approval.

Confidentiality

In order to protect and maintain the confidentiality of any ACS projects, authors will agree not to make copies of, disclose, discuss, describe, distribute, or disseminate in any manner whatsoever, including in any oral, written, or electronic form, any information discussed, developed, or disseminated in conjunction with the case report. Case report content will not be used for personal or professional benefit or for any other reason, except directly in conjunction with the terms of the ACS Project Agreement. Authors will take reasonable steps to protect the confidential nature of this matter and to dispose of all materials and notes regarding such confidential information in a manner consistent with confidential information. In the event that the authors receive questions about the ACS project, the author will agree to direct all questions, concerns, or inquiries to the College's staff. The author will acknowledge that ACS will be irreparably harmed and that the author shall have no adequate remedy at law for any breach of this provision.

In accordance with the Consensus Statement on Surgery Journals Authorship (2006), all authors should have made substantial contributions to all three of the following : (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted, including any revision.

Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. Allowing one's name to appear as an author without having contributed substantially to the study or adding the name of an individual who has not contributed or who has not agreed to the work in its current form is considered a breach of appropriate authorship.

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If the work involves the use of human subjects, the author should ensure that the work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; Uniform Requirements for manuscripts submitted to Biomedical journals . Authors should include a statement in the manuscript that informed consent was obtained for experimentation with human subjects. The privacy rights of human subjects must always be observed.

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• Case Report
• Open access
• Published: 05 April 2019

Laparoscopic cholecystectomy for acute cholecystitis in a patient with left-sided gallbladder: a case report

• Ryosuke Hirohata 1 ,
• Tomoyuki Abe 1 ,
• Hironobu Amano 1 , 2 ,
• Tsuyoshi Kobayashi 2 ,
• Masahiro Nakahara 1 ,
• Hideki Ohdan 2 &
• Toshio Noriyuki 1 , 2  

Surgical Case Reports volume  5 , Article number:  54 ( 2019 ) Cite this article

10k Accesses

5 Citations

Metrics details

Left-sided gallbladder is a relatively rare anatomical variation that is frequently associated with a biliary system anomaly. Here, we describe a case of left-sided gallbladder with acute cholecystitis treated by laparoscopic cholecystectomy.

Case presentation

An 86-year-old man with acute upper abdominal pain was admitted to our hospital. Computed tomography demonstrated that the gallbladder was centrally dislocated and the wall enhancement was discontinued. Magnetic resonance cholangiopancreatography showed that the gallbladder wall was thickened and abnormally swollen. A laparoscopic cholecystectomy was performed. The round ligament was attached to the right side of the gallbladder, and the left-sided gallbladder was diagnosed by intraoperative findings. The patient was discharged 5 days after surgery without postoperative complications.

Conclusions

A flexible and optimal port site should be inserted in cases of left-sided gallbladder with acute cholecystitis. An assessment of the extra- and intrahepatic biliary system is essential to avoid biliary injury in cases of left-sided gallbladder with acute cholecystitis.

Left-sided gallbladder (LSG) is defined as a gallbladder whose floor is located on the left side of the round ligament of the liver [ 1 ]. Laparoscopic cholecystectomy (LC) is the current gold standard treatment for acute cholecystitis. The 2018 Tokyo guidelines demonstrated that early cholecystectomy under strict criteria could lead to good surgical outcomes [ 2 ]. Our previous data showed that early LC within 7 days after symptom onset is a feasible and safe treatment option [ 3 ]. It is important to evaluate the preoperative biliary system to prevent intraoperative biliary injury. Of note, the intraoperative biliary injury rate in cases of LSG was around 7% [ 4 ], which is extremely high. It is well known that portal and biliary system variations are strongly associated with LSG. Detecting preoperative LSG is difficult due to its rarity and the similarity of its radiological findings to those of gallbladder torsion including gallbladder dislocation and cystic duct twisting [ 5 ]. Here, we present a case of acute cholecystitis with LSG following LC with a literature review.

An 86-year-old man was admitted to our hospital with a 3-day history of acute abdominal pain. The patient had no previous medical history. A physical examination revealed marked right upper quadrant pain with normal bowel sounds. Murphy’s sign was positive. His vital signs were within the normal range. Abdominal ultrasonography revealed an enlarged gallbladder with surrounding fatty tissue inflammation. The blood biochemistry was essentially normal, including C-reactive protein (1.9 mg/dL) and total bilirubin (1.4 mg/dL) levels. An enhanced computed tomography examination revealed an enlarged gallbladder and incarcerated gallstone. Gallbladder wall enhancement was discontinued, and the fundus of the gallbladder was located centrally beyond the round ligament (Fig.  1 ). The round ligament was attached to the right umbilical portion, which was associated with the anomaly of the intrahepatic portal vein system (Fig.  2 ). Magnetic resonance cholangiopancreatography demonstrated the root of the cystic duct, while the middle portion of the cystic duct was unclear (Fig.  3 ).

Abdominal contrast-enhanced computed tomography findings. The fundus of the gallbladder was located centrally beyond the round ligament (white arrow)

Abdominal contrast-enhanced computed tomography findings. The intrahepatic portal vein formed the right umbilical portion (black arrow)

Magnetic resonance cholangiopancreatography findings. The cystic duct (black arrow) branched from the common bile duct (white arrow). The cystic duct was unclear in the middle (black arrowhead)

With the preoperative diagnosis of grade II acute gangrenous cholecystitis according to the 2018 Tokyo guidelines or gallbladder torsion, LC was planned. The first port was inserted into the umbilicus, and an enlarged and reddish gallbladder was observed. The gallbladder was swollen; however, torsion was not detected intraoperatively. The second port was placed in the epigastric area, while others were at the right hypochondriac and right lumbar regions. The gallbladder was attached to the left side of the hepatic round ligament (Fig.  4 ). The cystic duct and the cystic artery were located in the normal positions. Severe inflammation and the narrow working space between the epigastric port and the gallbladder made it difficult to dissect Calot’s triangle; however, the cystic duct and the cystic artery were resected after the critical view of safety was confirmed. Due to the severe inflammation, a subtotal cholecystectomy was finally performed. The operative time was 178 min, and intraoperative blood loss was 50 mL. The pathological diagnosis was acute cholecystitis with a mucosal ulcer. The patient was discharged on the fifth day after surgery without postoperative complications.

Intraoperative findings. The gallbladder is attached to the liver at the left side of the round ligament

LSG is defined as a rare right-sided round ligament associated with intrahepatic biliary and portal system variations [ 1 ]. The incidence of LSG without situs inversus is reportedly 0.2% [ 6 ]. Several reports showed that intrahepatic portal vein and biliary system anomalies are rather common in cases of LSG [ 1 , 7 ]. Attention should be paid to the intrahepatic portal and biliary system as well as cystic duct variations. In our case, the portal vein formed the right umbilical portion, to which the round ligament was attached.

From the hypothesis of LSG occurrence, two types of cystic duct anomalies have been reported [ 1 ]: (1) a gallbladder that migrated to the left lobe, that is, a normal cystic duct location, and (2) a gallbladder that formed directly from the left hepatic duct and the cystic duct joining the common bile duct of the left hepatic duct from the left side [ 1 ]. In our case, the cystic duct was recognized at the right side of the common bile duct, corresponding to the gallbladder migration type.

The preoperative diagnostic difficulty is due to its rarity and similar radiological findings to those of gallbladder torsion. Gallbladder torsion is highly associated with the floating gallbladder. Gross classified gallbladder torsion into two types: type I is associated with local attachment between the gallbladder and the liver, while type II is complete floating gallbladder [ 1 ]. Type I gallbladder torsion can present radiological findings such as central dislocation of the gallbladder fundus and expansion and tapering of the cystic duct on the right side of the common bile duct, which are similar to the radiological findings of our case.

Our previous report demonstrated that the preoperative detection of LSG is important for avoiding biliary injury in cases of hepatectomy [ 8 ]. In our case, the anomaly of the intrahepatic portal system was detected preoperatively, but the diagnosis of LSG was made according to intraoperative findings. In cases of acute cholecystitis, it is important to pay attention to the formation of a right umbilical portion as well as the preoperative location of a round ligament to distinguish between LSG and gallbladder torsion.

Patients with acute cholecystitis are generally good candidates for LC as recommended by the 2018 Tokyo guidelines under strict conditions [ 2 ]. Several reports have shown the efficacy of early versus delayed cholecystectomy due to the shorter hospital stays, fewer postoperative complications, and higher LC completion rate [ 2 , 3 ]. Avoiding biliary duct injury (BDI) is a cause for concern when performing cholecystectomy, and it is important to detect an ectopic biliary system in the emergent setting. Clearly detecting Calot’s triangle is essential for avoiding BDI. Regarding the LSG hypothesis, the cystic duct frequently branches from the left hepatic duct, an anomaly that leads to BDI.

Nastos et al. reviewed 18 previous surgical cases of LSG and reported that it can be safely managed by devising of the port arrangement and the use of intraoperative cholangiography [ 9 ]. In the literature, the use of an additional retracting port [ 10 ] and the fundus first approach [ 11 ] have been described. In our case, the distance between the round ligament and the epigastric port was so short that they interfered with each other. It is important to create an adequate workspace between the round ligament and the gallbladder for safe processing of Calot’s triangle. Some reports have stated that manipulation of the falciform ligament is useful [ 10 ]. Lifting the falciform and the round ligaments to the body wall using a surgical suture may be an easy approach and enable surgery with a clearer view. In addition, positioning the port more caudally or using an additional port to attract the round ligament would be useful for avoiding obstruction by the round ligament. Here, we performed a conventional American-style LC and attracted the round ligament using the epigastric port. Adopting additional ports or using energy devices may be helpful for ensuring surgical safety and shortening operative time.

In conclusion, LSG is associated with an intrahepatic biliary system anomaly. Here LC was successfully performed. Radiological findings are similar to gallbladder torsion, but identification of the round ligament is useful for the diagnosis of LSG. When LSG is diagnosed, the optimal port site should be determined to ensure safe cholecystectomy.

Abbreviations

Biliary duct injury

• Laparoscopic cholecystectomy
• Left-sided gallbladder

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Acknowledgements

The authors thank all individuals who contributed to this work.

The authors declare that this work was not supported by any grants or funding

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Department of Surgery, Onomichi General Hospital, 1-10-23, Onomichi, Hiroshima, 722-8508, Japan

Ryosuke Hirohata, Tomoyuki Abe, Hironobu Amano, Masahiro Nakahara & Toshio Noriyuki

Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan

Hironobu Amano, Tsuyoshi Kobayashi, Hideki Ohdan & Toshio Noriyuki

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RH and TA wrote the manuscript. The remaining authors contributed to the data collection, analysis, and interpretation. RH, TA, HA, MN, and TN performed the surgery. All authors conceived of the study, participated in its design and coordination, and helped draft the manuscript. All authors read and approved the final manuscript for publication.

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Hirohata, R., Abe, T., Amano, H. et al. Laparoscopic cholecystectomy for acute cholecystitis in a patient with left-sided gallbladder: a case report. surg case rep 5 , 54 (2019). https://doi.org/10.1186/s40792-019-0614-9

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Optimizing Surgical Planning for Epilepsy Patients With Multimodal Neuroimaging and Neurophysiology Integration: A Case Study

Affiliations.

• 1 Department of Neurology, School of Medicine, Emory University, Atlanta, Georgia, U.S.A.
• 2 Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, U.S.A.
• 3 The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, U.S.A. ; and.
• 4 School of Medicine Columbia, University of South Carolina, Columbia, South Carolina, U.S.A .
• PMID: 38376938
• PMCID: PMC11073903 (available on 2025-05-01 )
• DOI: 10.1097/WNP.0000000000001071

Current preoperative evaluation of epilepsy can be challenging because of the lack of a comprehensive view of the network's dysfunctions. To demonstrate the utility of our multimodal neurophysiology and neuroimaging integration approach in the presurgical evaluation, we present a proof-of-concept for using this approach in a patient with nonlesional frontal lobe epilepsy who underwent two resective surgeries to achieve seizure control. We conducted a post-hoc investigation using four neuroimaging and neurophysiology modalities: diffusion tensor imaging, resting-state functional MRI, and stereoelectroencephalography at rest and during seizures. We computed region-of-interest-based connectivity for each modality and applied betweenness centrality to identify key network hubs across modalities. Our results revealed that despite seizure semiology and stereoelectroencephalography indicating dysfunction in the right orbitofrontal region, the maximum overlap on the hubs across modalities extended to right temporal areas. Notably, the right middle temporal lobe region served as an overlap hub across diffusion tensor imaging, resting-state functional MRI, and rest stereoelectroencephalography networks and was only included in the resected area in the second surgery, which led to long-term seizure control of this patient. Our findings demonstrated that transmodal hubs could help identify key areas related to epileptogenic network. Therefore, this case presents a promising perspective of using a multimodal approach to improve the presurgical evaluation of patients with epilepsy.

Copyright © 2024 by the American Clinical Neurophysiology Society.

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Conflict of interest statement

The authors have no conflicts of interest to disclose.

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• Long-term seizure outcome in frontal lobe epilepsy surgery. Morace R, Casciato S, Quarato PP, Mascia A, D'Aniello A, Grammaldo LG, De Risi M, Di Gennaro G, Esposito V. Morace R, et al. Epilepsy Behav. 2019 Jan;90:93-98. doi: 10.1016/j.yebeh.2018.10.033. Epub 2018 Dec 3. Epilepsy Behav. 2019. PMID: 30522059
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• Gleichgerrcht E, Keller SS, Drane DL, et al. Temporal lobe epilepsy surgical outcomes can be inferred based on structural connectome hubs: a machine learning study. Annals of neurology. 2020;88(5):970–983. - PMC - PubMed
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Case study: surgical oncology, renal retroperitoneal mass adherent to the inferior vena cava with blood conservation by cell saver and intraoperative normovolemic hemodilution (ianh).

A 68-year old woman who is one of Jehovah’s Witnesses presented with general malaise and some left upper quadrant pain and nausea. Her history was significant for a right nephrectomy for renal cell carcinoma 15 years ago. A CT scan revealed a heterogeneous mass located in the right-sided retroperitoneal space measuring 8 by 11 cm with compression of the inferior vena cava (IVC) and effacement of the gallbladder. In addition, she had a pacemaker implant 3 years prior, for the treatment of sick sinus syndrome. 

Two surgeons, Dr. James Black from vascular surgery, and Dr. Mohamed Allaf from Urology as well as Dr. Steven Frank, the Medical Director of the Center for Bloodless Medicine and Surgery  were consulted. Drs. Frank and Allaf saw her at the same time together, along with her family members, to map out an intraoperative plan. On reviewing the CT scans, the three physicians decided that a surgical resection would be high-risk, given the involvement of the vena cava, and that the risk of bleeding was significant. The risks and benefits of the procedure, as well as the available blood conservation techniques were discussed with the patient and her family. It was decided that by using autologous blood salvage (Cell Saver), along with a special leukoreduction filter, the risks would be minimized and the planned procedure could be accomplished. Intraoperative autologous normovolemic hemodilution (IANH) was also discussed as a blood conservation technique and the patient agreed this was acceptable to minimize risks.

The preoperative hemoglobin level was 14.7 g/dL, which was thought to be adequate for this surgical procedure. The anesthesia plan was developed by Dr. Frank, which included a thoracic epidural to minimize both postoperative pain and the requirement for narcotic pain medications. Large bore venous access was placed after induction of general anesthesia, using three 8.5 French introducers, 2 in the right and 1 in the left internal jugular veins. An intra-arterial catheter was also placed in the radial artery for continuous blood pressure monitoring. This degree of venous access would allow for veno-veno bypass from the iliac vein to the right atrium, if a vena cava cross clamp was necessary to remove the tumor. Prior to incision, 2 units of fresh whole blood were removed into CPDA anticoagulant bags, but remained in continuity with the patient’s circulation (via IV tubing) at all times. A volume expander (albumin) along with 2 liters of crystalloid solution were given for the hemodilution technique. Phenylephrine was given to maintain blood pressure during the IANH phlebotomy to allow the safe removal of autologous blood. 

The surgery was performed through a right-sided thoraco-abdominal incision, and the diaphragm was taken down to provide access to the tumor. The tumor was identified and was adherent to the vena cava, but appeared to be resectable. A sidebiting cross clamp was applied to the cava, the tumor was removed, and the cava was repaired. There was no need for veno-veno bypass as the patient tolerated the partial cross clamp with hemodynamic stability. The blood loss was substantial (1,200 mLs) which for her body mass (50kg) was about 1/3 of her entire blood volume (calculated as 70 mL per kg or 3,500 mLs). The shed blood was processed through the Cell Saver and returned to the patient using the leukoreduction filter to minimize and chances of spreading tumor cells. The 2 units of autologous whole blood were given back to her near the end of the procedure. The closure included repair of the diaphragm and no chest tube was required. 

On postoperative day #1 she was sitting up in a chair and on postoperative day #2 she was walking. A duplex ultrasound exam of the vena cava and iliac veins revealed good blood flow, and no narrowing or thrombosis. Pain scores and narcotic requirements were minimal due to the thoracic epidural. The pathology report came back as recurrent papillary renal cell carcinoma, with clean margins, indicating the tumor was completely resected. She was discharged to home on postoperative day #7 to be followed up by Oncology.

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A prosthesis driven by the nervous system helps people with amputation walk naturally

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State-of-the-art prosthetic limbs can help people with amputations achieve a natural walking gait, but they don’t give the user full neural control over the limb. Instead, they rely on robotic sensors and controllers that move the limb using predefined gait algorithms.

Using a new type of surgical intervention and neuroprosthetic interface, MIT researchers, in collaboration with colleagues from Brigham and Women’s Hospital, have shown that a natural walking gait is achievable using a prosthetic leg fully driven by the body’s own nervous system. The surgical amputation procedure reconnects muscles in the residual limb, which allows patients to receive “proprioceptive” feedback about where their prosthetic limb is in space.

In a study of seven patients who had this surgery, the MIT team found that they were able to walk faster, avoid obstacles, and climb stairs much more naturally than people with a traditional amputation.

“This is the first prosthetic study in history that shows a leg prosthesis under full neural modulation, where a biomimetic gait emerges. No one has been able to show this level of brain control that produces a natural gait, where the human’s nervous system is controlling the movement, not a robotic control algorithm,” says Hugh Herr, a professor of media arts and sciences, co-director of the K. Lisa Yang Center for Bionics at MIT, an associate member of MIT’s McGovern Institute for Brain Research, and the senior author of the new study.

Patients also experienced less pain and less muscle atrophy following this surgery, which is known as the agonist-antagonist myoneural interface (AMI). So far, about 60 patients around the world have received this type of surgery, which can also be done for people with arm amputations.

Hyungeun Song, a postdoc in MIT’s Media Lab, is the lead author of the paper , which appears today in Nature Medicine .

Sensory feedback

Most limb movement is controlled by pairs of muscles that take turns stretching and contracting. During a traditional below-the-knee amputation, the interactions of these paired muscles are disrupted. This makes it very difficult for the nervous system to sense the position of a muscle and how fast it’s contracting — sensory information that is critical for the brain to decide how to move the limb.

People with this kind of amputation may have trouble controlling their prosthetic limb because they can’t accurately sense where the limb is in space. Instead, they rely on robotic controllers built into the prosthetic limb. These limbs also include sensors that can detect and adjust to slopes and obstacles.

To try to help people achieve a natural gait under full nervous system control, Herr and his colleagues began developing the AMI surgery several years ago. Instead of severing natural agonist-antagonist muscle interactions, they connect the two ends of the muscles so that they still dynamically communicate with each other within the residual limb. This surgery can be done during a primary amputation, or the muscles can be reconnected after the initial amputation as part of a revision procedure.

“With the AMI amputation procedure, to the greatest extent possible, we attempt to connect native agonists to native antagonists in a physiological way so that after amputation, a person can move their full phantom limb with physiologic levels of proprioception and range of movement,” Herr says.

In a 2021  study , Herr’s lab found that patients who had this surgery were able to more precisely control the muscles of their amputated limb, and that those muscles produced electrical signals similar to those from their intact limb.

After those encouraging results, the researchers set out to explore whether those electrical signals could generate commands for a prosthetic limb and at the same time give the user feedback about the limb’s position in space. The person wearing the prosthetic limb could then use that proprioceptive feedback to volitionally adjust their gait as needed.

In the new Nature Medicine study, the MIT team found this sensory feedback did indeed translate into a smooth, near-natural ability to walk and navigate obstacles.

“Because of the AMI neuroprosthetic interface, we were able to boost that neural signaling, preserving as much as we could. This was able to restore a person's neural capability to continuously and directly control the full gait, across different walking speeds, stairs, slopes, even going over obstacles,” Song says.

A natural gait

For this study, the researchers compared seven people who had the AMI surgery with seven who had traditional below-the-knee amputations. All of the subjects used the same type of bionic limb: a prosthesis with a powered ankle as well as electrodes that can sense electromyography (EMG) signals from the tibialis anterior the gastrocnemius muscles. These signals are fed into a robotic controller that helps the prosthesis calculate how much to bend the ankle, how much torque to apply, or how much power to deliver.

The researchers tested the subjects in several different situations: level-ground walking across a 10-meter pathway, walking up a slope, walking down a ramp, walking up and down stairs, and walking on a level surface while avoiding obstacles.

In all of these tasks, the people with the AMI neuroprosthetic interface were able to walk faster — at about the same rate as people without amputations — and navigate around obstacles more easily. They also showed more natural movements, such as pointing the toes of the prosthesis upward while going up stairs or stepping over an obstacle, and they were better able to coordinate the movements of their prosthetic limb and their intact limb. They were also able to push off the ground with the same amount of force as someone without an amputation.

“With the AMI cohort, we saw natural biomimetic behaviors emerge,” Herr says. “The cohort that didn’t have the AMI, they were able to walk, but the prosthetic movements weren’t natural, and their movements were generally slower.”

These natural behaviors emerged even though the amount of sensory feedback provided by the AMI was less than 20 percent of what would normally be received in people without an amputation.

“One of the main findings here is that a small increase in neural feedback from your amputated limb can restore significant bionic neural controllability, to a point where you allow people to directly neurally control the speed of walking, adapt to different terrain, and avoid obstacles,” Song says.

“This work represents yet another step in us demonstrating what is possible in terms of restoring function in patients who suffer from severe limb injury. It is through collaborative efforts such as this that we are able to make transformational progress in patient care,” says Matthew Carty, a surgeon at Brigham and Women’s Hospital and associate professor at Harvard Medical School, who is also an author of the paper.

Enabling neural control by the person using the limb is a step toward Herr’s lab’s goal of “rebuilding human bodies,” rather than having people rely on ever more sophisticated robotic controllers and sensors — tools that are powerful but do not feel like part of the user’s body.

“The problem with that long-term approach is that the user would never feel embodied with their prosthesis. They would never view the prosthesis as part of their body, part of self,” Herr says. “The approach we’re taking is trying to comprehensively connect the brain of the human to the electromechanics.”

The research was funded by the MIT K. Lisa Yang Center for Bionics and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

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MIT scientists have conducted a trial of a brain controlled bionic limb that improves gait, stability and speed over a traditional prosthetic, reports Hannah Devlin for The Guardian . Prof. Hugh Herr says with natural leg connections preserved, patients are more likely to feel the prosthetic as a natural part of their body. “When the person can directly control and feel the movement of the prosthesis it becomes truly part of the person’s anatomy,” Herr explains. 

The Economist

Using a new surgical technique, MIT researchers have developed a bionic leg that can be controlled by the body’s own nervous system, reports The Economist . The surgical technique “involved stitching together the ends of two sets of leg muscles in the remaining part of the participants’ legs,” explains The Economist . “Each of these new connections forms a so-called agonist-antagonist myoneural interface, or AMI. This in effect replicates the mechanisms necessary for movement as well as the perception of the limb’s position in space. Traditional amputations, in contrast, create no such pairings.”  

The Boston Globe

Researchers at MIT and Brigham and Women’s Hospital have created a new surgical technique and neuroprosthetic interface for amputees that allows a natural walking gait driven by the body’s own nervous system, reports Adam Piore for The Boston Globe . “We found a marked improvement in each patient’s ability to walk at normal levels of speed, to maneuver obstacles, as well as to walk up and down steps and slopes," explains Prof. Hugh Herr. “I feel like I have my leg — like my leg hasn’t been amputated,” shares Amy Pietrafitta, a participant in the clinical trial testing the new approach.

Researchers at MIT have developed a novel surgical technique that could “dramatically improve walking for people with below-the-knee amputations and help them better control their prosthetics,” reports Timmy Broderick for STAT . “With our patients, even though their limb is made of titanium and silicone, all these various electromechanical components, the limb feels natural, and it moves naturally, without even conscious thought," explains Prof. Hugh Herr. 

Financial Times

A new surgical approach developed by MIT researchers enables a bionic leg driven by the body’s nervous system to restore a natural walking gait more effectively than other prosthetic limbs, reports Clive Cookson for the Financial Times . “The approach we’re taking is trying to comprehensively connect the brain of the human to the electro-mechanics,” explains Prof. Hugh Herr.  

The Washington Post

A new surgical procedure and neuroprosthetic interface developed by MIT researchers allows people with amputations to control their prosthetic limbs with their brains, “a significant scientific advance that allows for a smoother gait and enhanced ability to navigate obstacles,” reports Lizette Ortega for The Washington Post . “We’re starting to get a glimpse of this glorious future wherein a person can lose a major part of their body, and there’s technology available to reconstruct that aspect of their body to full functionality,” explains Prof. Hugh Herr. 

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Surgical strategies in reoperation of the proximal aorta and arch for patients with previous frozen elephant trunk.

1. Introduction

2. basics of the fet procedure, 3. further planned reintervention in patients with fet, 4. indications for redo fet, 4.1. endoleak with sac expansion, 4.2. pseudoaneurysm/anastomotic leaks, 4.3. infections including fistulae formation, 4.4. requirement for additional procedures in the ascending aorta/root/valves/coronaries, 5. general considerations for redo aortic surgery, 6. specific considerations for redo frozen elephant trunk technique, 6.1. peripheral cannulation option, 6.1.1. axillary artery cannulation, 6.1.2. femoral artery cannulation, 6.1.3. carotid artery cannulation, 6.2. preoperative considerations when assessing peripheral cannulation options, 6.3. fail-safe measures for unforeseen complications, 6.4. handling existing stent–grafts, 7. a case of complex redo frozen elephant trunk surgery, 7.1. case background, 7.2. operative approach, 8. current evidence on redo fet, 8.1. reoperation rates and causes, 8.2. mortality rates, 9. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Arjomandi Rad, A.; Ansaripour, A.; Magouliotis, D.E.; Abbasciano, R.G.; Koulouroudias, M.; Viviano, A.; Rosendahl, U.; Athanasiou, T.; Kourliouros, A. Surgical Strategies in Reoperation of the Proximal Aorta and Arch for Patients with Previous Frozen Elephant Trunk. J. Clin. Med. 2024 , 13 , 4063. https://doi.org/10.3390/jcm13144063

Arjomandi Rad A, Ansaripour A, Magouliotis DE, Abbasciano RG, Koulouroudias M, Viviano A, Rosendahl U, Athanasiou T, Kourliouros A. Surgical Strategies in Reoperation of the Proximal Aorta and Arch for Patients with Previous Frozen Elephant Trunk. Journal of Clinical Medicine . 2024; 13(14):4063. https://doi.org/10.3390/jcm13144063

Arjomandi Rad, Arian, Ali Ansaripour, Dimitrios E. Magouliotis, Riccardo G. Abbasciano, Marinos Koulouroudias, Alessandro Viviano, Ulrich Rosendahl, Thanos Athanasiou, and Antonios Kourliouros. 2024. "Surgical Strategies in Reoperation of the Proximal Aorta and Arch for Patients with Previous Frozen Elephant Trunk" Journal of Clinical Medicine 13, no. 14: 4063. https://doi.org/10.3390/jcm13144063

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Adherence to presurgical antibiotic protocols found to be low in Brazilian study

In only 20.7% of surgeries, prescribers followed surgical antibiotic prophylaxis (SAP) protocols for procedures performed at a university hospital in Sao Paulo, Brazil, finds a study published yesterday in the American Journal of Infection Control .

University of Sao Paulo researchers assessed prescriber adherence to SAP protocols and contributing factors among surgeries performed by cardiologists, urologists, neurologists, and gastrointestinal specialists. They compared SAP prescriptions to hospital protocols on surgical indication and antibiotic choice, dosage, and duration.

"Surgical antibiotic prophylaxis (SAP) is an important preventive measure, aiming to minimize surgical site infections," the study authors wrote. "However, despite evidence-based guidelines, adherence to SAP protocols remains suboptimal in clinical practice."

Lower adherence for antibiotic choice, duration

Prescribers adhered to SAP protocols for only 20.7% of 1,864 surgeries. Lower adherence rates were observed for antibiotic choice and duration of prophylaxis, particularly for neurologic and urologic procedures. The researchers also said that prescribers used broad-spectrum antibiotics more than necessary.

Despite the relatively high adherence to antibiotic dosage, challenges persist in antibiotic choice and duration adjustment.

Risk factors for nonadherence were high preoperative blood glucose levels, prolonged hospitalization, and long surgeries. Surgical teams had significant influence over protocol adherence.

"Despite the relatively high adherence to antibiotic dosage, challenges persist in antibiotic choice and duration adjustment," the researchers concluded. "Poor glycemic control, prolonged surgery and surgical teams were variables associated with inappropriate practice."

Salmonella outbreak tied to raw milk products from often-implicated firm may have sickened 165

A four-state Salmonella outbreak linked to raw (unpasteurized) milk products has infected at least 165 people—many of them children—from fall 2023 to June 2024, Food Safety News (FSN)  reported today based on data it obtained from the  California Division of Communicable Disease Control (CDCDC) and the California Department of Health.

The median age of patients is 7 years.

Raw Farm (formerly Organic Pastures) of Fresno, California, has been linked to the outbreak, with 93% of those sickened reporting that they consumed the company's products. Raw Farm recalled the implicated products in October 2023 but resumed sales a week later.

Long history of outbreaks tied to raw-milk maker

Raw Farm has been tied to a series of outbreaks or recalls related to Salmonella , Campylobacter and Shiga toxin–producing Escherichia coli  bacteria, FSN noted. 

FSN noted that when Raw Milk operated under the name Organic Pastures, its milk and cream products were associated with eight outbreaks of E coli , Listeria , and Campylobacter from 2006 to 2016.

In  May 2023 , the California Department of Food and Agriculture recalled Raw Farm milk after routine sampling detected C jejuni , and in  August of that year, it announced a statewide recall of Salmonella -contaminated cheddar cheese from the company. In February 2024, the  CDC reported 11 E coli cases in five states, including five hospitalizations, linked to Raw Farm cheddar cheese.

While the most recent California public health report from the current outbreak was released in February, the latest outbreak case was recorded in June, according to FSN. The two reports obtained by FSN were partially redacted, the publication said.

"It is beyond me to comprehend why public health would remain mute in the face of at least 165 sick, 20 hospitalized, and 40 percent of the ill five years or younger—especially raw milk—a risky elixir," Bill Marler, JD, a Seattle food safety attorney and FSN publisher , said in the article.

Quick takes: Haemophilus influenzae spike in Europe, H5N1 in Cambodian poultry, hepatitis C self-test

• In an annual update on Haemophilus influenzae released today, the European Centre for Disease Prevention and Control (ECDC) reported that the invasive form of the bacterial disease rose sharply in 2022 compared to the previous 2 years, which coincided with the lifting of COVID-19 restrictions and measures. It said 3,967 confirmed cases of invasive H influenzae disease were reported in 2022, up from 1,694 in 2021 and 1,849 in 2020. Easing COVID measures likely came with microbe-causing diseases returning to circulation, suggesting a correlation between the two events, the ECDC said. Babies younger than 1 year old were most affected, followed by seniors. H influenzae type b (Hib) made up a slightly greater percentage of cases in 2022 compared to recent years. Infection can range from mild to severe, with meningitis and septicemia seen in invasive infections. In most countries, children receive the Hib vaccine before they are 6 months old and a booster dose when they are 1 year old.
• Cambodia's agriculture ministry has reported a highly pathogenic H5N1 avian flu outbreak in village birds from the same location where two human cases were recently reported, according to a notification from the World Organization for Animal Health (WOAH). The virus killed 474 of 1,168 susceptible birds, and the remaining ones were culled to curb the spread of the virus. The outbreak began on July 5, and the H5N1 findings were confirmed on July 7. The location of the poultry outbreak and the patients is Preah Bat Choan Chum commune in Takeo province. The clade wasn't noted WOAH report, but an older 2.3.2.1c clade is known to circulate in Cambodia and has been implicated in other recent human infections in the country.
• The World Health Organization (WHO) today announced that it has prequalified the first self-test for hepatitis C, which it said will help expand diagnosis and treatment, thus speeding global efforts to eliminate the disease. The OraQuick HCV self-test, made by OraSure Technologies, is an extension of the OraQuick HCV rapid antibody test that the WHO prequalified in 2017. The agency recommended hepatitis C self-testing in 2021 to complement existing diagnostic testing. WHO prequalification paves the way for low- and middle-income countries to receive the products.

In case you missed it

This week's top reads, cdc confirms 4th human case of h5n1 avian flu as more dairy herds in colorado hit.

The infected farm worker is from Colorado, which has had the most affected dairy herds in the past month.

Study shows abnormal immune-cell activity with long COVID

The researcher also found leftover SARS-CoV-2 RNA in the gut as long as 2 years after infection.

H5N1 confirmed in 5 more US dairy herds, more cats

The additional cat detections are from 2 states battling the virus in cows: Minnesota and Michigan.

Animal experiments shed more light on behavior of H5N1 from dairy cows

The authors say the virus can bind to both avian and human-type cell receptors but doesn't easily spread through respiratory routes.

NIH announces launch of clinical trial for nasal COVID vaccine

Nasal vaccines have the potential for reducing transmission and preventing milder illness.

HHS awards Moderna $176 million to develop mRNA H5 avian flu vaccine

Moderna's work on a prepandemic vaccine began last year, and the new award has an option for large-scale production, if needed.

H5N1 strikes dairy herd in Michigan, large poultry farm in Colorado

The outbreak at the poultry farm, with more than 1.7 million birds, prompted an emergency declaration from Colorado's governor. 

H5N1 avian flu infects 2 children in Cambodia

The patients are young cousins from the same household who had contact with dead poultry before they became ill. 

Study: Long-term post-COVID altered sense of smell in healthcare workers common

The authors found that 37% of the COVID-positive group suffered quantitative olfactory dysfunction.

New roadmap addresses Lassa fever, a growing threat to human health

Climate change threatens to create more endemic regions in Africa.  

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