Overt gastrointestinal bleeding secondary to left inferior phrenic artery pseudoaneurysm postgastric bypass surgery.

Bleeding from a visceral artery pseudoaneurysm (VAPA) is a rare but significant complication of bariatric surgery. Patients may present with gastrointestinal (GI) haemorrhage in the forms of haematemesis, melaena, haematochezia or haemodynamic compromise. Although CT angiogram, endoscopy and laparoscopy form essential parts of diagnostic assessment, small pseudoaneurysms with intermittent bleeding may be overlooked. We report the case of a man in his 40s who presented to the emergency department with massive GI bleeding and subsequent haemodynamic instability, secondary to a pseudoaneurysm from a vascular injury during a recent bariatric procedure. This case highlights the diagnostic challenges of obscure, intermittent bleeding involving the bypassed stomach with unremarkable investigation findings, and aims to raise awareness among clinicians in considering the less common postgastric-bypass complications.

Massive mixed epithelial-stromal tumour of seminal vesicle requiring challenging abdominoperineal resection: a case report and review of literature.

Mixed epithelial-stromal tumours (MESTs) are a rare biphasic tumour that frequently arise in women from the renal and urogenital tract. They are also seen in men but are exceptionally uncommon with only few cases reported to originate from the seminal vesicles. Malignant transformation of its epithelial or stromal components is possible; however, by in large, these tumours are benign in nature. We report the case of a 48-year-old man with no remarkable medical or surgical history who presented with a huge expanding pelvic and intra-abdominal mass that required extensive surgical management including a pelvic exenteration. Histopathological analysis concluded the diagnosis of benign MEST originating from the seminal vesicles with no malignant features. No further systemic therapy was recommended for our patient. Given the technical intricacy in the operative resection of this tumour, we aim to present our findings and surgical management of this complex MEST.

Accuracy of deep neural learning models in the imaging prediction of pathological complete response after neoadjuvant chemoradiotherapy for locally advanced rectal cancer: a systematic review.

PURPOSE: Up to 15-27% of patients achieve pathologic complete response (pCR) following neoadjuvant chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC). Deep neural learning (DL) algorithms have been suggested to be a useful adjunct to allow accurate prediction of pCR and to identify patients who could potentially avoid surgery. This systematic review aims to interrogate the accuracy of DL algorithms at predicting pCR. METHODS: Embase (PubMed, MEDLINE) databases and Google Scholar were searched to identify eligible English-language studies, with the search concluding in July 2022. Studies reporting on the accuracy of DL models in predicting pCR were selected for review and information pertaining to study characteristics and diagnostic measures was extracted from relevant studies. Risk of bias was evaluated using the Newcastle-Ottawa scale (NOS). RESULTS: Our search yielded 85 potential publications. Nineteen full texts were reviewed, and a total of 12 articles were included in this systematic review. There were six retrospective and six prospective cohort studies. The most common DL algorithm used was the Convolutional Neural Network (CNN). Performance comparison was carried out via single modality comparison. The median performance for each best-performing algorithm was an AUC of 0.845 (range 0.71-0.99) and Accuracy of 0.85 (0.83-0.98). CONCLUSIONS: There is a promising role for DL models in the prediction of pCR following neoadjuvant-CRT for LARC. Further studies are needed to provide a standardised comparison in order to allow for large-scale clinical application. PROPERO REGISTRATION: PROSPERO 2021 CRD42021269904 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021269904 .

Immune mediated colitis: a surgical perspective.

BACKGROUND: This study aims to review and summarize the current up to date literature that explore the current treatment approaches to immune mediated colitis and the role of surgical specialties in the landscape of management. METHODS: A narrative review of papers was performed following a literature search through Medline, EMBASE and Cochrane Central databases pertaining to immune mediated colitis as an adverse event of cancer immunotherapy. RESULTS: Current guidelines for the diagnosis and treatment of immune mediated colitis mirror the approach to the workup of inflammatory bowel disease and guided by treating oncology and gastroenterology specialties. Immune mediated colitis however relies on surgical specific skills as a consequence of obtaining a diagnosis as well as in the management of complications that may arise. CONCLUSION: Immune mediate colitis management has largely been under the purview of medical specialties. This review explores the current landscape of managing immune mediated colitis from a surgical perspective and highlights key areas in which surgeons can engage in the multidisciplinary care of this condition. To facilitate prompt diagnosis and management of immune-mediated colitis, there is an increasing necessity for surgeons to become familiar with the latest multidisciplinary approaches and recommendations.

The complication profile of low Hartmann's in rectal cancer: a systematic review and meta-analysis.

BACKGROUND: Non-restorative options for low rectal cancer not invading the sphincter includes low Hartmann's procedure (LH) and inter-sphincteric abdominoperineal resection (ISAPR). There is currently little comparative data to differentiate these options. OBJECTIVES: The aim of this review was to assess the peri-operative morbidity of LH, and then to compare it to that of ISAPR. DATA SOURCES: An up-to-date systematic review was performed on the available literature between 2000-2020 on PubMed, EMBASE, Medline, and Cochrane Library databases. STUDY SELECTION: All studies reporting on non-restorative surgeries for rectal cancer were analysed. Outcomes were firstly analysed between LH and non-LH groups, with further sub-analysis comparing the LH and ISAPR groups. MAIN OUTCOME MEASURE: The main outcome measures were the rates of pelvic sepsis, rates of overall post-operative complication rates, oncological outcomes, and survival. RESULTS: A total of 12 observational studies were included. There were 3526 patients (61.1%) in the LH group, and 2238 patients (38.9%) in the non-LH group, which included 461 patients who underwent ISAPR. The LH group had a higher rate of pelvic sepsis as compared to the non-LH group (OR: 1.79, 95% CI: 1.39-2.29, P < 0.001). The difference is more marked in the sub-analysis comparing LH and ISAPR alone (OR: 3.94, 95% CI: 1.88-7.84, P < 0.01) corresponding to a higher rate of unplanned re-intervention. LH was associated with a higher rate of short-term post-operative mortality as compared to the non-LH group. CONCLUSION: ISAPR is the preferred option for non-restorative rectal surgery, with a more favourable peri-operative morbidity and short-term mortality profile as compared to LH.

Defining the learning curve of transanal total mesorectal excision: a systematic review and meta-analysis.

BACKGROUND: Transanal total mesorectal excision (taTME) represents a novel approach to rectal dissection. Although many structured training programs have been developed worldwide to assist surgeons in implementing this new technique, the learning curve (LC) of taTME has yet to be conclusively defined. This is particularly important given the concerns regarding the complication profile and oncological safety of taTME. The aim of this review was to provide an up-to-date systematic review and meta-analysis of the LC for taTME, comparing the difference of outcomes between the LC and after learning curve (ALC) groups. METHODS: An up-to-date systematic review was performed on the available literature between 2010-2020 on PubMed, EMBASE, Medline and Cochrane Library databases. All studies comparing taTME procedures before and after LC were analysed. RESULTS: Seven retrospective studies of prospectively collected databases were included, comparing 333 (51.0%) patients in the LC group and 320 (49.0%) patients in the ALC group. There was a significantly reduced number of adverse intra-operative events, anastomotic leaks and improved quality of mesorectal excision in the ALC group. CONCLUSION: This review shows that there is a significant improvement in clinical outcomes between the LC and ALC groups which supports the need for careful mastery and ongoing technical refinement during the LC in taTME. This procedure should be performed on a subset of carefully selected patients in the hands of experienced and well-trained teams dedicated to ongoing audit.

Appendicitis in Far North Queensland: a new take on an old story.

BACKGROUND: Appendicitis is a leading cause of surgical hospital admission. To date, there have been no published epidemiological studies describing appendicitis in tropical and remote Australia and none specifically documenting appendicitis in Indigenous Australians. This descriptive study used available state data to investigate appendicitis across Far North Queensland (FNQ). METHODS: Queensland Health hospital admission data for FNQ was analysed to explore appendicitis epidemiology and outcomes in FNQ, 2012-2018. Population data for the same time period provided rates. RESULTS: Over the study period, 3458 hospital presentations for appendicitis were available for analysis. Mean incidence was 178 per 100 000/yr. Median age was 27 years with 50.1% female patients. The annual rate of appendicitis was higher in the Indigenous population. Most patients had a laparoscopic procedure with a low rate of conversion to open surgery (2.6%). More than 80% of patients were discharged from hospital in less than 3 days. Intensive care (ICU) admission rate was low overall (1.1%) although higher for Indigenous people (2.4%). Following discharge, the hospital re-admission rate was 3.8% and all-cause mortality was 0.03%. CONCLUSION: The incidence of appendicitis in FNQ is higher than that reported in the rest of Australia in both Indigenous and non-Indigenous populations. Despite logistical challenges of health care, clinical outcomes are in line with best practice across the country. Clinicians in FNQ should maintain a high index of suspicion for diagnosing appendicitis in rural and remote settings.

Ruptured salpingitis isthmica nodosa: a rare cause for spontaneous haemoperitoneum.

Salpingitis isthmica nodosa (SIN) is the nodular swelling or diverticulum of the isthmus of the fallopian tube. It is most commonly identified when investigating female infertility or in association with ruptured ectopic pregnancies. We experienced a rare and atypical presentation of SIN. A 33-year-old woman presented with a 1-hour history of acute lower abdominal pain associated with nausea and vomiting. CT and pelvic ultrasound revealed haemoperitoneum with no radiological evidence for its aetiology. Initial beta-human chorionic gonadotropin excluded ectopic pregnancy. A diagnostic laparoscopy was performed following clinical deterioration of the patient. Active bleeding of the right fallopian tube was identified and managed with a right partial salpingectomy, with subsequent histopathology revealing ruptured SIN. There have been no reported cases of SIN being a primary cause for an acute abdomen or haemoperitoneum in the absence of an ectopic pregnancy, making this case a surgical novelty.

Large intra-abdominal cystic lymphangioma managed by laparoscopic partial excision and modified drain with no need for open resection.

A 57-year-old woman was referred to the emergency department after a CT scan ordered by her general practitioner to investigate her abdominal pain showed a large cystic mass. The simple cystic appearance with its location in the small bowel mesentery prompted a provisional diagnosis of cystic lymphangioma. However, concerns regarding the size, location and local involvement of neurovascular structures presented a technical surgical challenge. Here we present a case of minimally invasive laparoscopic drainage using a modified Jackson-Pratt drain that avoided a laparotomy and open resection.

Recurrent unilateral cellulitis: is it May-Thurner syndrome (MTS)?

May-Thurner syndrome (MTS) is a differential diagnosis to be considered in a patient with recurrent unilateral cellulitis. A 73-year-old woman initially presented with recurrent unilateral cellulitis of her left lower limb. A CT scan demonstrated a stenosed left common iliac vein (CIV) narrowed at its origin by the proximal right common iliac artery consistent with MTS. The chronicity of the condition at the time of diagnosis made attempts to recanalise the CIV unsuccessful. A diagnosis of MTS should be considered in a patient with chronic unilateral limb oedema/cellulitis as it represents a potentially treatable condition if detected early.

Pilonidal disease practice points: An update.

BACKGROUND: Chronic pilonidal disease is a common debilitating condition often seen in general practice. It is a cause of considerable morbidity and social embarrassment, but recent developments in treatment options provide promising solutions to this problem.  OBJECTIVE: This article recaps pilonidal sinus development and presentation, details methods of treatment in the primary care setting and explores new specialist management options available in Australia. DISCUSSION: As a chronic condition, the devastation of recurrence with further pain, embarrassment and time off work - added to the prospect of more surgery - is still common for patients with chronic pilonidal disease. This can be avoided with correct management and timely counselling regarding surgical options available.

Fungal appendicitis in a non-immunocompromised woman.

We describe a previously fit and well 54-year-old woman who presented with 3 weeks of right-sided lower abdominal pain with CT showing a non-specific thickening of the caecal/appendiceal wall. Although initially concerning for a neoplastic process, histology demonstrated yeast-like organisms colonising and invading into the appendiceal wall, confirming the diagnosis of fungal appendicitis. Fungal appendicitis is an important clinical entity that has previously been reported to affect immunocompromised individuals. Although uncommon among the non-immunocompromised individuals, it should not be neglected as a possible diagnosis in patients presented with non-specific abdominal pain.

Successful ROTEM-guided transfusion therapy in a case of rural paediatric trauma.

Massive transfusion therapy in severe paediatric trauma is a challenge. When this occurs in a rural setting, the potential delays in accessing medical services can lead to worse coagulopathy on presentation. We report successful treatment of a child post-traumatic lower limb amputation where treatment was only initiated 3 hours postinjury due to difficulties in access/retrieval. Rotational thromboelastometry (ROTEM)-guided, goal-directed haemostatic therapy perioperatively utilising a blood product ratio of 2:2:1 units of red blood cell:free frozen plasma:platelet reverted his coagulopathy. This report aims to raise awareness of the utility of ROTEM in paediatric trauma.

Dyspnoea and constipation: rare case of large bowel obstruction secondary to an incarcerated Morgagni hernia.

Incarcerated diaphragmatic hernias are often challenging to diagnose. 1 Patients often present with non-specific abdominal symptoms, and barring an imaging modality that confirms herniation of intra-abdominal contents, there is no investigation sensitive or specific enough to identify it. It is a rare cause of mechanical bowel obstruction that clinicians should be aware of. This report describes a case of an 81-year-old man who presented to the emergency department with ongoing dyspnoea and constipation secondary to a partial large bowel obstruction due to an incarcerated Morgagni hernia. This case highlights the non-specific symptoms of this condition that often leads to a delayed diagnosis and aims to increase the awareness among clinicians.

Small bowel volvulus versus adhesive small bowel obstruction: a diagnostic dilemma in a 19-year-old woman.

Small bowel volvulus (SBV) is often challenging to diagnose. Research suggests that the clinical presentation of this disease is often very similar to other more common causes of small bowel obstruction (SBO) such as intraabdominal adhesions and no single preoperative diagnostic study is sensitive or specific enough to identify this rare cause of mechanical SBO. This report describes a case of a 19-year-old woman who presented with irretractable vomiting and abdominal pain secondary to SBV. This case is unusual as her history of recurrent adhesive SBO presented a diagnostic dilemma that required a higher degree of clinical suspicion to tease these differential diagnoses apart. She underwent laparoscopy which facilitated successful detorsion and resection of the floppy tongue of jejunum. This report aims to increase the awareness among surgeons.

Appendiceal fat stranding on CT: a red herring in a post-caesarean section woman with Ogilvie's syndrome (OS).

A 30-year-old woman was referred for a surgical review with abdominal pain and distension 2 days post-caesearean section. Abdominal X-ray showed dilated bowel loops. CT of her abdomen however showed fat stranding around a thickened appendix, suggesting a differential diagnosis of acute appendicitis on top of a postoperative ileus. Failure to respond to intravenous antibiotics led to an emergent surgical exploratory laparotomy, by which time the progressive caecal dilatation had led to patchy necrosis and perforation of the right hemicolon intra-operatively. The patient required a right hemicolectomy and histological examination of the excised bowel supported the diagnosis of Ogilvie's syndrome. This case highlights the red herrings that one can encounter when faced with a woman with post-caesarean section abdominal pain and aims to raise awareness among clinicians of this condition-where timely diagnosis and management is key.

An Exceptional Case of Ileocolic Intussusception Secondary to Burkitt's Lymphoma: What Variations Are There in the Presentation and Management of Those Patients Who Approach Adolescence?

Intussusception is a common cause of abdominal pain among the paediatric population with up to 10% of cases occurring secondary to a pathological lead point. Burkitt's lymphoma (BL) is a highly malignant and rapidly growing B-cell neoplasm which in extremely rare cases can present as intussusception. We report a case in an otherwise healthy 15-year-old male who presented with atypical abdominal pain. Imaging subsequently indicated an ileocolic intussusception, and given that the suspicion of a pathological lead point mandates a laparotomy and bowel resection, he proceeded to surgery. The histopathology confirmed Burkitt's lymphoma as the aetiology responsible for this intussuscepted mass. A detailed discussion including a systematic review of all previous case reports explore the diagnostic dilemma of intussusceptions secondary to BL. This case report aims to highlight the clinical challenges in establishing such a diagnosis and an appreciation for the subtle variations in clinical features, as well as the differences in management between infants and adolescents.