Spontaneous periduodenal hematoma: a rare surgical and radiological conundrum.

This is a case of a 68-year-old female with spontaneous and rare periduodenal hematoma of unknown origin without any signs or symptoms of duodenal stenosis. All causes of known precipitating factors, such as trauma, intervention, anticoagulation, pancreatitis or malignant processes, were ruled out. She was managed conservatively, with a series of radiological investigations performed throughout her 7-day admission to further define stability and investigate the possible cause for the periduodenal hemorrhage. A repeat magnetic resonance imaging 4 weeks later showed near resolution of the hematoma. The underlying cause in this case remains unclear.

Outcome Comparison of Totally Implantable Venous Access Device Insertions Between Surgeons and Radiologists in Australia.

Background The need for chemotherapy treatment is increasing with the growing incidence of cancer worldwide. The insertion of totally implantable venous access devices (TIVADs) is commonly performed by surgeons and radiologists, but the procedures are not without complications. The primary outcome of this review outlines TIVAD insertion success and complication rates between general surgeons and radiologists. The secondary goal of this study is to help identify areas for improvement and consideration when performing TIVAD insertion. Methodology This was a descriptive, three-year, retrospective multicentre study of oncological patients who underwent TIVAD insertion by either general surgeons or radiologists at two peripheral Brisbane hospitals. Results Surgeons performed 61 percutaneous subclavian vein cannulations, 29 ultrasound-guided internal jugular veins, and seven open cephalic veins cut-down TIVAD insertions (n=97). Overall surgical success was 81.4%, with the internal jugular (89.7%) having the highest success rate followed by the open cut-down (85.7) and subclavian approaches (77.0%). The overall surgical complication rate was 16.4%, with five pneumothorax, five port malfunctions, three haemorrhages, two infections, one thrombus, and one mediastinal injury. Each pneumothorax was associated with subclavian cannulation attempts. Two haemorrhages were associated with both open cephalic and subclavian attempts. Radiologists performed 248 ultrasound-guided internal jugular vein TIVAD insertions (n=248) with 247 successful first attempts (99.5%). Within the radiology group, there was an overall complication rate of 15.3% with 22 infections, 14 port malfunctions, one haemorrhage, and 1 mediastinal injury. Conclusion Ultrasound-guided internal jugular vein TIVAD insertion had the highest first attempt success rate in both the surgical and radiology groups.

It's not you, it's me: a descriptive study of patient complaints and surgeon understanding.

BACKGROUND: Patient complaints are an underutilized and under-addressed issue in general surgery. They represent a unique sphere of interaction for surgeons and patients to understand motivations and failures in the delivery of healthcare. The aims of this study were to identify motivators of patient complaints and understand surgeon's awareness of this issue. METHODS: A retrospective review of patient complaint data in a single regional general surgical department was undertaken between the periods October 2017 to June 2020 and June 2018 to October 2020 relating to patient demographics and subject of complaint. Secondly, an anonymous survey was conducted across the same department and results tabulated by seniority. RESULTS: Two hundred and nineteen complaints were received during the study period. One hundred and thirteen were made by patients, while 56 were made by family members. One hundred and fifty-nine complaints were related to an inpatient episode of care, and 152 were made in writing. The majority of complainants were female, with a mean age of 52. The most common reason for complaint was "treatment" (n = 102), followed by communication (n = 48), and humaneness/caring (n = 44). Consultant surgeons and surgical trainees placed communication, humaneness/caring, and professionalism as most likely to incite complaints, while interns were more likely to prioritize other measures such as patient healthcare rights and medications. CONCLUSION: Patient complaints remain a relatively under-utilized resource in addressing the downfalls of general surgical departments. This study reports patient demographics that are congruent with the literature and highlights that surgeons prioritize many non-technical skills in the maintenance of the doctor-patient relationship, in contrast to preconceptions.

An incarcerated Spigelian hernia with the appendix in the sac passing though all layers of the abdominal wall: an unusual cause for chronic right iliac fossa pain.

Abdominal wall hernias are a common pathology and source of morbidity including chronic pain. They occur in various anatomical areas; amongst the rarest locations is the Spigelian hernia accounting for <2% of all abdominal hernias. We present a case report of a patient with chronic right iliac fossa pain caused by an incarcerated Spigelian hernia containing her appendix within the hernial defect. Rarer still is that her hernial defect penetrated all three layers of anterior abdominal wall, typically a Spigelian hernia would only pass through transversus abdominis and internal oblique layers.

A rare case of mesenteric heterotopic pancreas presenting as an inflammatory mass.

Heterotopic pancreas (HP) is a rare condition, is commonly asymptomatic and found incidentally at autopsy or during abdominal surgery. HP is usually found in the upper gastrointestinal tract, particularly in the stomach, duodenum and jejunum. Mesenteric heterotopic pancreas (MHP) has been rarely described in the literature, and there has been no reported case under ten years of age. We report a unique case of a 7-year-old African boy who presented with clinical appendicitis and intraoperatively was found to have a necrotic nodular mass in the jejunal mesentery which required segmental small bowel resection. Histology revealed mesenteric heterotopic pancreas with normal pancreatic tissue. As pre-operative diagnosis of MHP is difficult; we encourage a heightened awareness of this condition as a differential diagnosis in children presenting with abdominal pain and an inflammatory mass, which will subsequently aid in the management of these patients.

Incidental leiomyosarcoma within an ischaemic gut: a review of the management of visceral sarcoma.

Leiomyosarcomas are rare, primary malignancies that can be found in the small bowel in a minority of cases. The management of these visceral sarcomas remains controversial, with surgical resection forming the mainstay, being optimally achieved in a unit familiar with the management of sarcomas. These tumours are difficult to diagnose based on history and are challenging to localize on conventional imaging modalities. We report a case of a 61-year-old female who proceeded to emergent laparotomy with imaging suggestive of small bowel ischaemia secondary to portal venous thrombosis. Incidental leiomyosarcoma was noted on histology and was discussed at local multidisciplinary meeting regarding further management.

A rare presentation of an ectopic kidney with pyelonephritis mimicking appendicitis.

Acute appendicitis is one of the top differential diagnoses of right lower quadrant pain in the emergency department. There are many other conditions that may mimic appendicitis such as diverticulitis, colitis and gynecological conditions. We report a rare diagnosis of a patient who presents with characteristic clinical and laboratory features of appendicitis with severe sepsis, but later showed acute pyelonephritis of a malrotated right ectopic kidney on computer tomography. An ectopic kidney is very rare with an incidence of 1 in 3000. It is usually asymptomatic, although it may also associate with obstruction, infection and urolithiasis. This case report raises the importance of early recognition of the correct diagnosis using imaging in appropriate clinical settings, and prompt antibiotic treatment can avoid unnecessary surgical intervention, preserve renal function and prevent a life-threatening catastrophe.

Intra-abdominal tuberculosis masquerading as ovarian carcinoma.

Intra-abdominal tuberculosis (TB) is rare in Australia, but it can be found in those who emigrate from endemic areas. We report a rare case of a 28-year-old lady from the Philippines who presented with abdominal pain, ascites and an elevated cancer antigen (CA) 125 with an initial concern of ovarian malignancy. She underwent a diagnostic laparoscopy which revealed typical features of intra-abdominal TB and histological features of granulomatous inflammation. The symptoms and signs of intra-abdominal TB are non-specific and can mimic many other conditions. The gold-standard mode of diagnosis in intra-abdominal TB is laparoscopy with tissue biopsy. Ovarian malignancy is relatively rare in pre-menopausal women; hence an elevated CA 125 warrants a broader differential diagnosis. It is important to have intra-abdominal TB as a differential even in the non-endemic settings to avoid delay in diagnosis and appropriate management.

Facing the faceless patients - the emerging challenges of identity fraud in general surgery: A case series.

INTRODUCTION: This case series highlights the challenges faced in general surgery when encountering patients who use multiple false identities and provide unreliable histories. PRESENTATION OF CASES: We present two patients both with a background of mental health disorders and previous abdominal surgeries. After extensive workup with one patient almost proceeding to surgery, it was noted that these patients have had multiple presentations under different aliases to multiple different hospitals and had given inconsistent medical and surgical histories. DISCUSSION: In such patients, history and clinical examinations are unreliable. Medical records are also not helpful given the patients' multiple aliases. Particularly in surgery, inaccurate knowledge of the patients' previous operative details can lead to significant harms. Extensive investigations are usually performed in assessing these patients, resulting in excessive radiation exposure and incurring significant costs to the health system. It is also important to recognise the potential legal repercussions and harms to the patients who have had their identities stolen. CONCLUSION: Identity fraud poses significant challenges to patient care, vigilance from clinicians and implementing strategies to reduce system error can help to limit harms to the patient and the health care system.

Synchronous bilateral breast cancer: A case report of heterogeneous estrogen receptor status.

INTRODUCTION: Tumour heterogeneity is important in the management of breast cancer. Hormone receptors are established biomarkers for treatment and prognosis of patients with breast cancer. There are three immunohistochemical biomarkers: estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor 2 (HER2). We explore whether heterogeneity in hormone receptor status in synchronous bilateral breast alters therapeutic management. CASE PRESENTATION: This case details a 54 year old woman who was referred to our clinic by her general practitioner for investigation of bilateral breast pain that she had for 6 months. On clinical examination pathological nodes were palpated in bilateral axilla. There was left sided nipple inversion with a palpable mass in the upper outer quadrant of approximately 3 cm diameter. On examination of the right breast there was skin tethering of the nipple and 3 masses were palpated, the largest being in the upper inner quadrant at 5 cm diameter. Ultrasound and mammography of bilateral breasts demonstrated advanced bilateral breast cancer with axillary node metastases. Core biopsies demonstrated invasive carcinoma. The right breast lesion was ER negative whilst the left breast lesion was ER positive. DISCUSSION: In patients with synchronous bilateral breast cancer ER discordance in patients have been associated with higher mortality than ER concordant positive patients and lower mortality than ER concordant negative patients within the first 5 years of surveillance [1]. CONCLUSION: Heterogeneity in hormone receptor status alters the therapeutic management of patients with synchronous bilateral breast cancer. Both hormone therapy and chemotherapy should be considered in these patients. It is of utmost importance to evaluate the tumor receptor status in cases of synchronous bilateral breast tumour and to assess for change in relation to tumour progression or treatment. Further study in the status change of receptors could open up new treatment modalities.

Dilemma of mucosal appendicitis: a clinico-pathological entity? A retrospective cohort study.

BACKGROUND: The presence of mucosal inflammation within appendicectomy specimens is poorly described in the literature, and there is debate regarding the clinical significance of this histological finding. The aim of this study is to correlate clinical and radiological data with histologically confirmed acute mucosal appendicitis (MA). METHODS: A retrospective cohort study was performed to identify all patients who underwent appendicectomy over 5 years at Caboolture Hospital. Data were collected in regards to clinical Alvarado score, pathological specimen findings, radiological findings and coincidental conditions, and comparison made between MA and negative appendicectomy groups. RESULTS: A total of 1347 appendicectomy specimens and data were reviewed. Of these, 219 (16%) specimens were microscopically confirmed to have acute mucosal inflammation, 150 (68%) were females. Median age was 19 ± 14 years. A total of 243 (18%) were histologically negative. There was a statistically significant difference in mean Alvarado score in the MA group (5.0 ± 1.9 versus 4.3 ± 1.8, P = 0.0002). Patients with MA are more likely to report migratory pain (48.4 versus 31.4%, P = 0.0001) and rebound tenderness (24.9 versus 14.6%, P = 0.002). Computed tomography and ultrasound scans were negative in 74.1 and 72.6%, respectively, in patients with MA. More MA patients benefited from appendicectomy compared with the negative appendicectomy group (82 versus 63%, P = <0.0001). CONCLUSION: There is a subgroup of patients with MA who are young females with have low Alvarado scores, have non-diagnostic imaging, and may represent almost one-fifth of appendicectomy specimens. This study supports the probability that MA is a pathological entity.

Sigmoid endometriosis in a post-menopausal woman leading to acute large bowel obstruction: A case report.

INTRODUCTION: Endometriosis is usually a disease involving women of reproductive age. Colonic endometriosis is a rare sequelae. It usually presents vaguely with nonspecific abdominal pain, dyspareunia, fecal tenesmus, rectal bleeding or painful defecation. There are very few case reports of sigmoid endometriosis in the literature, more so ones involving post-menopausal women. Our report highlights such a case, mimicking a malignant rectosigmoid stricture leading to a large bowel obstruction. CASE PRESENTATION: A 63year old lady was referred by her General Practitioner for further investigation of recent altered bowel habit. She underwent an incomplete colonoscopy due to stricturing in the sigmoid. She subsequently was admitted with abdominal pain, distension and vomiting, with imaging consistent with a large bowel obstruction secondary to a stricturing mass within the rectosigmoid which was suspicious for malignancy. An emergency laparotomy and Hartmann's procedure was performed. She had an uncomplicated post-surgical recovery. Histology revealed no underlying malignancy, but confirmed colonic endometriosis. CONCLUSION: This case report shows that colonic endometriosis, although rare, can be significantly infiltrative and lead to complications such as a large bowel obstruction. Diagnosing this condition can be challenging and usually requires histological confirmation.

The impact of temporal artery biopsy on surgical practice.

BACKGROUND: Giant cell arteritis (GCA) has the potential to cause irreversible blindness and stroke in affected patients [1-4]. Temporal artery biopsy (TAB) remains the gold standard test for GCA [6-8]. Recent literature suggests that TAB does not change management of patients with suspected GCA and that ultrasound scan (USS) may be sufficient enough alone to confirm the diagnosis [9-11,13]. The aim of this study is to therefore determine the impact of TAB on current surgical practice and emergency theatre services. MATERIALS AND METHODS: A retrospective clinical study was performed of patients who had undergone TAB at the Caboolture Hospital from January 2010 to September 2015. Demographic and clinical data was collected from patient's medical records in regards to GCA. RESULTS: A total of 55 TAB were performed on 50 patients. Only two TAB were positive for GCA. Thirty-eight (76%) patients had a pre-TAB ACR criteria score of ≥3. Pre-operative corticosteroids were administered in forty-five (90%) patients, on average 4 ± 10 days pre-TAB. Mean time to TAB was 1.6 ± 1.6 days following their booking. Ninety-one percent of TAB were performed by surgical registrars. All TAB were performed using local anaesthesia alone. CONCLUSIONS: TAB is an expensive procedure with a low positive yield. Recent evidence suggests promising results with USS in diagnosing GCA. With the exceedingly low positive TAB results found in this study, patients with suspected GCA should be investigated in accordance with the above algorithm. The routine use of USS will reduce the number of negative TAB performed.

A surgeon-led model to improve operating theatre change-over time and overall efficiency: A randomised controlled trial.

BACKGROUND: The non-operative time during the process of patient change-over between operating theatre cases is a significant source of delay and overall theatre inefficiency. The aim of this study was to integrate and trial a working strategy to improve this change-over time. METHOD: This was a single-blinded, randomised controlled intervention study comparing a surgeon-led, team-based model of strategies versus routine patient change-over. This model was trialled by a single surgeon, and the primary outcome was the difference in change-over times compared with 4 other surgeons who were blinded and served as controls. Secondary outcome measures included overall differences in complications between the groups, and the number and differences in operative case cancellations due to inadequate theatre time. RESULTS: 1265 patients were randomised into 5 general surgical lists, and included all major and minor cases. Median number of operative cases were 214 per surgeon, with an overall median change over time of 17.9 ± 3.7 min. Surgeon A in the intervention group had a median change-over time of 12.1 ± 5.4 min (p < 0.001), with a median difference of 8.5 min ± 21.4 min (p < 0.0001), translating to a 58% reduction in median change-over time between the intervention and control groups. There were no differences in complication rates amongst the groups. The intervention group had no cancellations due to lack of time, compared with 37 cancellations in the control group. CONCLUSION: This study demonstrates a statistically significant improvement in median change-over times using this model. This re-design can be implemented without incurring extra costs, staff, or operating theatres.

A diagnostic dilemma: Left-sided appendicitis in a 10 year old boy with previously undiagnosed intestinal malrotation. A case report.

INTRODUCTION: Intestinal malrotation is a congenital rotational anomaly that occurs as a result of an arrest of normal rotation of the embryonic gut, said to occur in 1 in 6000 live births. Due to the abnormal caecal and appendix position, diagnosis of acute appendicitis becomes more challenging, thus leading to diagnostic and operative intervention delays. Our aim is to highlight the diagnostic challenges in this clinical scenario. PRESENTATION OF CASE: We present a case of a 10 year old boy with previously undiagnosed intestinal malrotation with a left sided acute appendicitis. Initial symptoms lead to a treatment for gastroenteritis, however, due to ongoing pain a CT abdomen was done which showed the malrotation and appendicitis. He required a laparoscopy converted to open appendicectomy due to an appendicecal mass. DISCUSSION: Historically, intestinal malrotation was thought to be a disease of infancy with infrequent occurrence after the age of one year. However, recent analysis has shown an increase in presentations after one year of life into adulthood. Thus, the prevalence of malrotation in children and adults over the age of one year appear to be higher than initially presumed. CONCLUSION: Left sided acute appendicitis is a diagnostic dilemma, thus often leading to management delays. It is pertinent to remember that malrotation of the gut is more common than previously thought, and not just a disease of infancy. It is advisable to consider imaging studies while balancing the risk-benefit-ratio of radiation exposure, especially in paediatric cases to cinch the diagnosis.

The dilemma of stump appendicitis - A case report and literature review.

INTRODUCTION: Stump appendicitis is one of the rare delayed complications post appendectomy with a reported incidence of 1 in 50,000 cases. Stump appendicitis can present as a diagnostic dilemma if the treating clinician is unfamiliar with this rare clinical entity. A PubMed search was conducted to identify cases of stump appendicitis following appendectomy. Sixty one cases of SA that were reported in English medical literature were analyzed. PRESENTATION OF CASE: We report a case of stump appendicitis (SA) with a systematic review and challenges encountered during the management. DISCUSSION: The interval from original appendectomy to stump appendicitis ranged from 4 days to 50 years. SA followed appendectomy in 58% of open and 31.6% of laparoscopic procedures. SA was frequently misdiagnosed as constipation, gastroenteritis or right sided diverticulitis, therefore leading to a significant delay to surgery. Computerized Tomography diagnosed SA in 56.3% of cases. Perforation with gangrene of the stump occurred in 60%. CONCLUSION: Stump appendicitis can represent a diagnostic dilemma if the treating physician is unfamiliar with this uncommon clinical entity. Radiological imaging is required to aid diagnosis and a completion appendectomy is the modality of treatment.

"Less is more": Non operative management of short term superior mesenteric artery syndrome.

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a relatively rare aetiology of proximal intestinal obstruction. This is caused by narrowing of vascular angle of SMA and aorta compressing the third part of the duodenum (D3). Predisposing factors may include precipitous weight loss, corrective spinal surgery or repair of an aortic aneurysm. PRESENTATION OF CASE: A 53 year old male presented to our department with worsening post-prandial vomiting and epigastric pain for last three months. One examination, epigastric region was distended with succussion splash on abdominal auscultation. History did not include any predisposing factor. CT scan showed narrow angle of 12.77° between SMA and aorta owing to the compression of D3. Since onset of vomiting and resultant poor oral intake, he had lost 11 kg of his usual body weight. After gastric decompression, nasojejunal enteral feeding was started. Diet was progressed to oral feedings gradually and following return to his baseline weight, he continued to be free of symptoms in follow-up visits. DISCUSSION: Although there are recognised predisposing factors but sometimes aetiology remains idiopathic. SMA syndrome should initially be managed non-operatively with gastric decompression, correction of water and electrolyte imbalance, and hemodynamic instability. Regaining weight helps increasing vascular space between SMA and D3 thus relieving obstruction. Persistence of symptoms beyond 3-4 weeks warrants surgical intervention. CONCLUSION: Non operative management with nutritional supplementation remains the first line of therapy.

Cytomegalovirus enteritis with ischemia in an immunocompetent patient: A rare case report.

INTRODUCTION: Cytomegalovirus (CMV) is predominantly an opportunistic infection in the immunocompromised patients. Though, there are few cases of CMV colitis being reported in the immunocompetent individuals, CMV enteritis is exceedingly rare and enteritis leading into small bowel ischemia has never been reported yet. PRESENTATION OF CASE: A-78-year-old male patient presented with distal small obstruction for 4 days duration. Clinical examination revealed a distended abdomen and localised peritonism in right iliac fossa. An initial computed tomography (CT) scan revealed distended small bowel loops up to the thickened inflammed terminal illeum with no free fluid or gas and a normal appendix. No immunosuppressive risk factors such as human immunodeficiency virus, transplant procedures, or steroid therapy were present. Hematologic investigations showed leucocytosis with neutrophilia. Diagnostic laparoscopy confirmed a thickened terminal ileum causing small bowel obstruction. Laparoscopy converted to laparotomy and right hemicolectomy was performed. Histology showed isolated small bowel ischemia with ulcerative changes and cytomegalovirus inclusions. The patient was started on ganciclovir therapy and subsequently had an uneventful recovery and discharged after 16 days. DISCUSSION: Cytomegalovirus enteritis was initially not suspected in our patient. In this case CMV caused ischemia of the small bowel without evidence of colonic involvement. Even in elderly patients, the small bowel remains resilient to the ischemic changes because of the copious blood supply. CONCLUSION: We report possibly the first case of isolated small bowel ischaemia caused by cytomegalovirus in immunocompetent individuals, needed surgical resection.