Small Bowel Perforation Secondary to Biliary Stent Migration in an Incarcerated Inguinal Hernia.

We describe the case of a 90-year-old female who presented with signs of a strangulated inguinal hernia. Further history revealed a paired biliary-pancreatic stent insertion three years prior for ascending cholangitis and a long-standing asymptomatic right inguinal hernia. Biochemistry revealed a slightly elevated C-reactive protein level of 65 mmol/L, but was otherwise unremarkable. Abdominal CT demonstrated two plastic biliary stents within an incarcerated right inguinal hernia. At the time of surgery, a 3-mm perforation due to the stents was identified in the small bowel within the hernia. The stents were retrieved via an enterotomy that was subsequently repaired with full-thickness interrupted sutures. A tissue-suture repair of the inguinal hernia was performed due to significant contamination of enteric contents in the operative field. The patient had an unremarkable recovery and was discharged four days after her operation. This is a very rare acute presentation of stent migration with only a handful of such reported cases in the literature. With the rising number of endoscopic biliary stenting procedures, these complications are likely to increase, and clinicians need to be aware of this possibility in patients with pre-existing hernias.

Synchronous Acute Appendicitis and Cholecystitis in a Paediatric Patient with Salmonella Enteritis.

We present the case of a 13-year-old male who presented with right upper quadrant pain and diarrhoea after recently travelling from Bali, Indonesia. He had a normal white cell count of 8x10^9/L and elevated c-reactive protein (CRP) of 205 mg/L with normal liver function tests. Originally thought to be appendicitis, given the rarity of cholecystitis in a child, he was commenced on broad-spectrum antibiotics and was taken to the operating theatre based on his clinical presentation. Diagnostic laparoscopy revealed inflammatory change in both the gallbladder and appendix and a laparoscopic cholecystectomy and appendicectomy were performed simultaneously. Histopathology results confirmed cholecystitis and appendicitis and a stool culture confirmed the presence of Salmonella serotype B. Synchronous cholecystitis and appendicitis is an exceedingly rare phenomenon with only a handful of cases reported in the literature. This is the first case in the literature of this phenomenon occurring in the paediatric population; surgeons need to be aware of this rare possibility even in the paediatric population and especially in those patients with an atypical presentation or in recent travellers experiencing gastroenteritis.

High Output Chylous Fistula Post First Rib Resection.

We present a patient who developed high output chyle leak post left first-rib resection for neurogenic thoracic outlet syndrome. The persistent high output chylorrhea was refractory to 3 surgical reexplorations attempting to ligate leaking branches, bed rest, nonfat diet, parenteral nutrition, octreotide administration, and vacuum-assisted closure (VAC) therapy. In addition, she developed hypovolemia, hyponatremia, and hypoalbuminemia. Control of the chylous fistula was achieved by reattaching the sternocleidomastoid muscle laterally to protect the phrenic nerve and brachial plexus in order to redirect chyle to the medial portion of the neck incision site. This was supported by the application of fibrin sealants in combination with VAC therapy. The patient was discharged after a 27-day hospital stay with complete resolution of her chylous fistula prior to discharge.

Primary Small Bowel Volvulus: An Unusual Cause of Small Bowel Obstruction.

We present the case of a 78-year-old female who presented to the emergency department with small bowel obstruction in a virgin abdomen. Although the patient did not have peritonism and biochemical investigations did not reveal alarming features of ischemia, an abdominal computed tomography (CT) scan was suggestive of small bowel volvulus (SBV), and operative exploration was pursued. No obvious cause was identified aside from hard stools throughout the colon and a diagnosis of primary SBV was determined. She was subsequently discharged symptom-free on day seven post-operatively. She re-presented on day 10 post-operatively with a similar history, examination, and abdominal CT findings suggestive of SBV recurrence. Her volvulus slowly resolved post administration of rectal enemas and did not require any further operative intervention; she was discharged on day eight of re-admission (day 19 post-operatively) with no recurrence of her symptoms on a regular diet. In this article, we discuss the management of SBV.

Long-term patient-related outcome measures of septoplasty: a systematic review.

PURPOSE: Septoplasty is a common rhinological procedure intended to relieve symptoms of chronic nasal obstruction. However, there remains a question as to whether patients obtain symptom improvement and are satisfied with surgical outcomes in the months and years after septoplasty. This review aims to evaluate the long-term efficacy of functional septoplasty for nasal septal deviation. METHODS: A systematic review of the literature was conducted from November 2014 to March 2016 using the Cochrane, EMBASE, and PubMed databases. Prospective trials concerning functional septoplasty, which assessed subjective outcomes and included long-term follow-up data (≥ 9 month post-septoplasty) were included. RESULTS: 2189 articles were screened with seven meeting the criteria for inclusion. Patient satisfaction was assessed in six studies, with rates of satisfaction provided in three of these, ranging from 69 to 100%. Two studies assessed the degree of patient satisfaction, with one study indicating that 88% of patients were moderately satisfied or better at 1 year post-op, and the other reporting that 50% of patients were satisfied. In assessing symptom relief, several methods were used, including validated questionnaires, with varying degrees of improvement in nasal obstruction reported. CONCLUSIONS: Septoplasty appears to be a far from perfect treatment for nasal obstruction due to septal deviation. However, given the heterogeneity of data and lack of randomized controlled trials (RCTs), future RCTs and use of validated questionnaires would enable generation of superior levels of evidence. We suggest future prospective trials evaluating prognostic factors in septoplasty, to better inform patients and facilitate the development of guidelines for surgical intervention.