BACKGROUND Biloma is the collection of bile outside the biliary tree as a result of visceral perforation. The most common site of disruption is the gallbladder, whereas common bile duct lesions usually occur following medical procedures or trauma. Spontaneous perforation of the common bile duct has been previously reported in the literature. Retroperitoneal biloma secondary to spontaneous perforation of the common bile duct is an extremely rare pathological entity. The purpose of this report is to inform clinical doctors of this rare entity, which can have fatal consequences for the patient. CASE REPORT We present the case of an 89-year-old man who was hospitalized with symptoms of vomiting, nausea, fatigue, and diffuse abdominal pain. The clinical examination and blood tests revealed peritonitis, a finding which was confirmed by the computed tomography of the abdomen as a retroperitoneal fluid collection, extending from the region posterior to the duodenum and head of the pancreas to the right inguinal fossa. As the patient\'s clinical status deteriorated, an urgent laparotomy was performed, revealing the presence of retroperitoneal biloma secondary to spontaneous perforation of the common bile duct. The operation was never completed as the patient died during the operation. CONCLUSIONS The diagnosis of this entity is difficult and is made during surgery. A large spectrum of treatment approaches has been used, but, regardless of the method, the goal is to halt the spreading abdominal contamination with bile and to treat the associated biliary pathology.

BACKGROUND: Spontaneous biliary system perforation is a rare presentation in clinical practice especially in adults. It is rarely suspected and diagnosed preoperatively due to small number of cases, vague sign and symptoms, and ambiguous presentation.
METHODS: We describe an interesting case of spontaneous perforation of the common bile duct in a 16 year-old female who presented a week after her first birth to the emergency department with complaints of diffuse abdominal pain, abdominal distention, fever, vomiting, and constipation. She was having generalized peritonitis but the etiology was unclear despite a thorough workup. She underwent exploratory laparotomy, and a perforation in the supra duodenal region of the common bile duct was found intraoperatively. The common bile duct was repaired over T-tube, and cholecystectomy was performed; the patient was recovered uneventfully.
CONCLUSIONS: Spontaneous biliary perforation is a rare cause of acute abdomen in adults and extremely rare in pregnancy. Its delayed diagnoses and management can lead to a high morbidity and mortality. All physicians, especially surgeons, should be aware of this possibility and consider it a cause of peritonitis on differential diagnosis particularly when there is no apparent etiology available for presentation.

BACKGROUND: Many patients with gastric cancer present with late stage disease. Palliative gastrectomy remains a contentious intervention aiming to debulk tumour and prevent or treat complications such as gastric outlet obstruction, perforation and bleeding.
METHODS: We conducted a systematic review of the literature for all papers describing palliative resections for gastric cancer and reporting peri-operative or survival outcomes. Data from peri-operative and survival outcomes were meta-analysed using random effects modelling. Survival data from patients undergoing palliative resections, non-resective surgery and palliative chemotherapy were also combined. This study was registered with the PROSPERO database (CRD42019159136).
RESULTS: One hundred and twenty-eight papers which included 58,675 patients contributed data. At 1 year, there was a significantly improved survival in patients who underwent palliative gastrectomy when compared to non-resectional surgery and no treatment. At 2 years following treatment, palliative gastrectomy was associated with significantly improved survival compared to chemotherapy only; however, there was no significant improvement in survival compared to patients who underwent non-resectional surgery after 1 year. Palliative resections were associated with higher rates of overall complications versus non-resectional surgery (OR 2.14; 95% CI, 1.34, 3.46; p < 0.001). However, palliative resections were associated with similar peri-operative mortality rates to non-resectional surgery.
CONCLUSIONS: Palliative gastrectomy is associated with a small improvement in survival at 1 year when compared to non-resectional surgery and chemotherapy. However, at 2 and 3 years following treatment, survival benefits are less clear. Any survival benefits come at the expense of increased major and overall complications.

BACKGROUND: Spontaneous intestinal perforation (SIP) is a devastating complication of prematurity, and extremely low birthweight (ELBW < 1000 g) infants born prior to 28 weeks are at highest risk. The role of nutrition and feeding practices in prevention and complications of SIP is unclear. The purpose of this review is to compile evidence to support early nutrition initiation in infants at risk for and after surgery for SIP. Methods: A search of PubMed, EMBASE and Medline was performed using relevant search terms according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Abstracts and full texts were reviewed by co-first authors. Studies with infants diagnosed with SIP that included information on nutrition/feeding practices prior to SIP and post-operatively were included. Primary outcome was time to first feed. Secondary outcomes were incidence of SIP, time to full enteral feeds, duration of parenteral nutrition, length of stay, neurodevelopmental outcomes and mortality. Results: Nineteen articles met inclusion criteria-nine studies included feeding/nutrition data prior to SIP and ten studies included data on post-operative nutrition. Two case series, one cohort study and sixteen historical control studies were included. Three studies showed reduced incidence of SIP with initiation of enteral nutrition in the first three days of life. Two studies showed reduced mortality and neurodevelopmental impairment in infants with early feeding. Conclusions: Available data suggest that early enteral nutrition in ELBW infants reduces incidence of SIP without increased mortality.

Actinomyces species are gram-positive, facultative anaerobic bacilli. Infection caused by Actinomyces species is usually limited to cervicofacial, thoracic, and abdominopelvic regions. Infective endocarditis due to Actinomyces species is extremely rare with only 30 reported cases since 1939. We report a case of Actinomyces oris endocarditis in a 14-year-old boy who had a 2-week history of dyspnea on exertion without other constitutional signs. Transthoracic echocardiography was suggestive of perforation of the right coronary cusp of aortic valve. No organisms were isolated from blood cultures. The patient underwent surgical valve repair due to deteriorated cardiac function. Valve tissue culture did not initially identify the organism. However, the terminal subculture in a thioglycolate broth grew gram-positive bacilli. The matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) was compatible with Actinomyces oris. After 6 weeks of intravenous ampicillin, the patient remained well with improved cardiac function. We reviewed all reported cases of infective endocarditis caused by Actinomyces species, commenting on clinical characteristics and factors associated with unfavorable outcomes in infective endocarditis due to Actinomyces species. Although infective endocarditis caused by Actinomyces spp is rare, it could be considered in a case of culture-negative endocarditis since the clinical features might be indistinguishable from other bacterial endocarditis. Additionally, MALDI-TOF MS is a useful diagnostic tool for the identification of Actinomyces spp to improve the accuracy of diagnosis.

BACKGROUND: Spontaneous perforation of the common bile duct is rare. The cause is usually unknown, although it is sometimes related to the malformation of the bile duct.
METHODS: Female of 1 year, with abdominal distention, hyporexia and fever, tomography with ascites, surgical findings included retroperitoneal bilioma, peritonitis and perforation of common bile duct. Block resection and primary hepato-duodenal anastomosis were performed.
CONCLUSIONS: Spontaneous perforation of the common bile duct tend to evolve insidiously and delay in diagnosis is frequent. Surgical management is decisive, and there are different techniques described.
CONCLUSIONS: A high index of suspicion is important, treatment must be individualized according to each patient.
UNASSIGNED: La perforación espontánea del colédoco es rara. La causa generalmente se desconoce, aunque en ocasiones guarda relación con una malformación de la vía biliar.
UNASSIGNED: Niña de 1 año, con distensión abdominal, hiporexia y fiebre, tomografía con ascitis, se interviene y se encuentra bilioma retroperitoneal, peritonitis y perforación de colédoco. Se realiza resección en bloque y anastomosis hepatoduodenal primaria.
UNASSIGNED: La perforación espontánea del colédoco tiende a evolucionar insidiosamente y el retraso en el diagnóstico es frecuente. El manejo quirúrgico es resolutivo; existen distintas técnicas descritas.
UNASSIGNED: Es importante un alto índice de sospecha. El tratamiento se debe individualizar en cada paciente.

暂无摘要。

BACKGROUND: Non-traumatic biliary perforation other than the gallbladder is extremely rare and most commonly seen in children in association with congenital biliary anomalies. We present a rare case of choledocholithiasis that progressed to spontaneous perforation of the common hepatic duct probably from ischemic necrosis caused by impaction of large biliary stones.
UNASSIGNED: A 62-year-old female presented with diarrhea and jaundice. She was found to have two 2.5cm stones in the common hepatic duct. Stones could not be extracted by ERCP, and placement of biliary stent was done to restore patency. The patient was lost to follow up and returned after three months with a new onset of similar symptoms. At that time ERCP and a stent change were done without resolution of the symptoms. Patient then underwent an open exploration and was found to have a free perforation in the lateral aspect of the common hepatic duct just at the bifurcation of the right and left hepatic radicals. Through this perforation stones were both extracted and cholangiogram showed free flow with the distal biliary stent. The stent was nowhere near the site of perforation which appeared to be caused by pressure necrosis from the impacted stones.
CONCLUSIONS: Impacted stones in the biliary tree need to be extracted to avoid pressure necrosis and spontaneous perforation. ERCP and stent placement should be used only as temporizing measures to manage the acute obstructive phase. Definitive surgical intervention must follow initial biliary decompression to extract the impacted biliary stones and avoid complications.

BACKGROUND: Choledochal cysts are a congenital disorder of the common bile duct that can cause progressive biliary obstruction and biliary cirrhosis. They were classified by Todani into five types. Of these, type VI choledochal cysts are rarely reported in the literature.
UNASSIGNED: A 22-month-old girl presented with intermittent epigastralgia for approximately 10 days and fever for three days. Fasting and total parenteral nutrition were administered after admission. However, sudden onset of severe epigastric pain occurred. An abdominal sonogram showed turbid ascites and peritonitis was impressed.
UNASSIGNED: An emergent exploratory laparotomy was performed, and perforation of the posterior wall of types I and VI choledochal cysts was observed.
METHODS: Intraoperative cholangiography revealed concomitant types I and VI choledochal cysts with stricture of the distal common bile duct. Definite surgery for resection of the choledochal cysts and gallbladder was performed with Roux-en-Y choledochojejunostomy.
RESULTS: The patient had no evidence of ascending cholangitis at three years after the operation.
CONCLUSIONS: Type VI choledochal cysts are rarely reported in the literature. To our knowledge, this is the first reported pediatric case of concomitant types I and VI choledochal cysts complicated with acute pancreatitis and spontaneous perforation.

The authors describe a fatal case of gastric perforation secondary to an ulcerated metastasis in a woman with undiagnosed breast cancer. The 48-year-old woman, with no significant medical history, presented with weight loss, persistent dyspepsia and pain in the epigastric and mesogastric region. She was treated by her primary care physician with proton-pump inhibitors and antispasmodics. The following day she was found dead at her home. External examination showed a tumefaction in the lateral region of her left breast, near the axilla. Autopsy revealed 1000 ml of turbid, light-brown peritoneal fluid in the abdominal cavity and a perforated gastric wall. Histological examination of the breast mass showed an infiltrating, poorly-differentiated breast carcinoma. Microscopical analysis of the stomach wall revealed a perforated metastatic gastric ulcer. Immunohistochemistry was required to confirm the neoplastic involvement of the stomach due to metastatic breast cancer.