Benign Multicystic Peritoneal Mesothelioma Presenting as Appendiceal Abscess: A Diagnostic and Therapeutic Challenge.

Primary peritoneal tumors are rarely encountered and their management is usually challenging for the clinicians. Especially when the patients with advanced peritoneal malignancy present as surgical emergencies, usually with symptoms of obstruction, perforation or gross space-occupying lesions, the on-call surgical team has to weigh the pros and cons of urgent versus delayed treatment and plans a safe and simultaneously oncologically beneficial therapeutic approach. Herein, we present a case of a Caucasian man who was referred as suspected complicated appendicitis by his primary care physician, with the final diagnosis being benign multicystic mesothelioma. We describe the challenges of the clinical decision making for the emergency general surgeon and relevant diagnostic and therapeutic pitfalls, which can be potentially minimized by early liaison with tertiary units specializing in the treatment of disseminated peritoneal malignancy.

Diagnostic performance of EUS in non-jaundiced patients with an incidental finding of double duct sign on cross-sectional imaging: A systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: Dilatation of the pancreatic duct and common bile duct, known as double duct sign (DDS), suggests sinister pathology at the periampullary region. Non-jaundiced patients with incidental DDS and otherwise normal cross-sectional imaging present a diagnostic dilemma to the multidisciplinary team (MDT). The primary aim of this review was to assess the diagnostic yield of endoscopic ultrasound (EUS) in detecting causal pathology in this patient population. METHODS: A systematic literature search (Medline, EMBASE, Google Scholar, Cochrane database and PROSPERO) was performed to identify original studies that reported EUS findings in patients with incidental DDS. Primary outcome was detection of a periampullary tumour. Secondary outcome was detection of benign causal pathology. Meta-analysis was used to calculate an absolute measure (pooled proportion) of pathology detection. RESULTS: Four studies (177 patients) were included. EUS detection rate for a periampullary tumour was 5% (95% CI, 0-10%) including both adenocarcinomas and adenomas. EUS detection rate for benign causal pathology was 22% (95% CI, 10-34%), the most common being chronic pancreatitis CONCLUSION: Non-jaundiced patients with incidental DDS on cross-sectional imaging have a 5% risk of a periampullary tumour that can be detected by EUS.

Bariatric Surgery in Cirrhotic Patients: Is It Safe?

INTRODUCTION: Ten percent of cirrhotic patients are known to have a high risk of postoperative complications. Ninety percent of bariatric patients suffer from non-alcoholic fatty liver disease (NAFLD), and 50% of them may develop non-alcoholic steatohepatitis (NASH) which can progress to cirrhosis. The aim of this study was to assess whether the presence of cirrhosis at the time of bariatric surgery is associated with an increased rate and severity of short- and long-term cirrhotic complications. METHODS: A cohort of 110 bariatric patients, between May 2003 and February 2018, who had undergone liver biopsy at the time of bariatric surgery were reassessed for histological outcome and divided into two groups based on the presence (C, n = 26) or absence (NC, n = 84) of cirrhosis. The NC group consisted of NASH (n = 49), NAFLD (n = 24) and non-NAFLD (n = 11) liver histology. Medical notes were retrospectively assessed for patient characteristics, development of 30-day postoperative complications, severity of complications (Clavien-Dindo (CD) classification) and length of stay. The C group was further assessed for long-term cirrhosis-related outcomes. RESULTS: The C group was older (52 years vs 43 years) and had lower BMI (46 kg/m2 vs 52 kg/m2) and weight (126 kg vs 145 kg) compared to the NC group (p < 0.05). The C group had significantly higher overall complication rate (10/26 vs 14/84, p < 0.05) and severity of complications (CD class ≥ III, 12% vs 7%, p < 0.05) when compared to the NC group. The length of stay was similar between the two groups (5 days vs 4 days). The C group had significant improvement in model end-stage liver disease scores (7 vs 6, p < 0.01) with median follow-up of 4.5 years (range 2-11 years). There were no long-term cirrhosis-related complications or mortality in our studied cohort (0/26). CONCLUSION: Bariatric surgery in cirrhotic patients has a higher risk of immediate postoperative complications. Long-term cirrhosis-related complications or mortality was not increased in this small cohort. Preoperative identification of liver cirrhosis may be useful for risk stratification, optimisation and informed consent. Bariatric surgery in well-compensated cirrhotic patients may be used as an aid to improve long-term outcome.

Successful non-heart-beating donor organ retrieval in a patient with a left ventricular assist device.

Non-heart-beating donors (NHBD) represent an option to expand the organ supply with good results. We report a donor patient with a left ventricular assist device (LVAD) due to dilated cardiomyopathy in which controlled NHBD was performed. Due to the LVAD, a modified procurement technique was utilized. The liver and kidneys were procured and successfully transplanted. Patients and grafts are alive and well. Successful organ retrieval can be achieved on selected cases of NHBD with LVADs in which modifications of the procurement technique are implemented without jeopardizing the procurement and not increasing preservation injury.