Importance of high suspicion of intestinal perforation in blunt abdominal injury in patients with inflammatory bowel disease.

Estimated to affect 3 million individuals in Europe alone, Crohn's disease is an inflammatory bowel disease causing transmural inflammation throughout the gastrointestinal tract. We describe the case of a patient with a known background of Crohn's disease who presented with abdominal pain following blunt abdominal trauma after a hit and run where initial diagnosis of perforation was missed on pan-computed tomography, however, diagnosis was made early due to high clinical suspicion of perforation. This suggests that current diagnostic imaging can be inaccurate, leading to delays where urgent surgery is otherwise indicated which is a cause for concern. Herein, we emphasize the importance of a high index of suspicion for perforation in patients with blunt abdominal trauma, especially where there is underlying bowel disease.

Laparoscopic treatment of an unruptured cystic artery pseudo-aneurysm in the presence of calculous emphysematous cholecystitis.

Cystic artery pseudoaneurysm is a rare complication of invasive biliary procedures or of acute or chronic cholecystitis and pancreatitis. Emphysematous cholecystitis is an acute inflammatory process of the gallbladder due to gas forming organisms such as Escherichia coli and Clostridium perfringens. We report the case of a 34-year-old gentleman admitted with a 3-day history of generalized abdominal pain, vomiting and markedly raised inflammatory markers. A computed tomography scan demonstrated acute calculus cholecystitis and an incidental CAP. This was successfully treated with an emergency laparoscopic cholecystectomy. CAPs are reported in the literature as rare and are usually diagnosed after rupture with severe haemorrhage. In this report, we highlight that a non-ruptured CAP identified preoperatively can be safely managed simultaneously with a laparoscopic approach, thus avoiding the need for invasive angiographic procedures or open surgery.

A ruptured ovarian cystadenofibroma presenting with life-threatening sepsis and an incidental synchronous endometrial stromal sarcoma.

A woman in her 60s presented with a rare complication of an ovarian cyst which many clinicians may not consider at first presentation. She was admitted with life-threatening staphylococcus aureus sepsis. She presented shocked with a collapse following a 2-day history of diarrhoea, vomiting and pain in the right iliac fossa. She was taken to theatre where a ruptured, widely infarcted left ovarian serous cystadenofibroma was discovered with over 2 litres of purulent fluid exuding from the cyst into the abdomen. She had a left cyst removal, hysterectomy and bilateral salpingo-oophorectomy performed. Histological analysis and molecular gene testing of an incidentally discovered uterine neoplasm revealed an undifferentiated uterine sarcoma. She successfully recovered as an inpatient and was discharged under the care of an oncology team for ongoing management.

The weekend effect - How can it be mitigated? Introduction of a consultant-delivered emergency general surgical service.

BACKGROUND: Poorer patient outcomes for emergency general surgery have been observed in patients admitted to hospital over the weekend. This paper reports the outcomes of a Consultant-delivered service model for weekend admissions and its impact for patients undergoing emergency laparotomy. METHODS: Operative data was analysed from a prospectively collected database over 5-years. Primary outcome measures were 30-day all-cause mortality and Clavien-Dindo class ≥2 morbidity. Secondary outcomes included time from admission to diagnostic imaging and time to surgery, post-operative length of stay and requirement for Intensive Care Unit admission. RESULTS: 263 patients underwent an emergency laparotomy. Overall 30-day mortality was 4.6% and all-cause morbidity was 55.9%. The most common indications for laparotomy were mechanical small bowel obstruction (32.7%) and hollow viscus perforation (30.4%) of the 263 emergency laparotomies, 92 patients in the cohort were weekend admissions (Saturday or Sunday). There was no significant difference amongst patients admitted during the weekend in ASA grade, age, gender, or proportion of patients receiving a pre-operative computed tomography scan, when compared to those during the week. Compared to weekdays, weekend admission was not associated with a significant difference in mortality (5.3% and 3.3%, respectively p = 0.458), all-cause morbidity (p = 0.509), post-operative length of stay (p = 0.681), or Intensive Care Unit admission (p = 0.761). CONCLUSION: A Consultant Surgeon delivered emergency service can avoid the poor patient outcomes associated with weekend admissions and the 'weekend effect'.

Adult Presentations of Congenital Midgut Malrotation: A Systematic Review.

BACKGROUND: Adult midgut malrotation is a rare cause of an acute abdomen requiring urgent intervention. It may also present in the non-acute setting with chronic, non-specific symptoms. The objective of this study is to identify the clinical features, appropriate investigations and current surgical management associated with adult malrotation. METHODS: A systematic review was conducted according to PRISMA guidelines, identifying confirmed cases of adult malrotation. Patient demographics, clinical features, investigation findings and operative details were analysed. RESULTS: Forty-five reports met the inclusion criteria, totalling 194 cases. Mean age was 38.9 years (n = 92), and 52.3% were male (n = 130). The commonest presenting complaints were abdominal pain (76.8%), vomiting (35.1%) and food intolerance (21.6%). At least one chronic symptom was reported in 87.6% and included intermittent abdominal pain (41.2%), vomiting (12.4%) and obstipation (11.9%). Computerised tomography scanning was the most frequent imaging modality (81.4%), with a sensitivity of 97.5%. The whirlpool sign was observed in 30.9%; abnormalities of the superior mesenteric axis were the commonest finding (58.0%). Ladd's procedure was the most common surgical intervention (74.5%). There was no significant difference in resolution rates between emergency and elective procedures (p = 0.46), but length of stay was significantly shorter for elective cases. (p = 0.009). There was no significant difference in risk of mortality, or symptom resolution, between operative and conservative management (p = 0.14 and p = 0.44, respectively). CONCLUSION: Malrotation in the adult manifests with chronic symptoms and should be considered as a differential diagnosis in patients with abdominal pain, vomiting and food intolerance.

Primary Gallbladder Lymphoma in a Male Patient with No Risk Factors Detected Incidentally by CT Colonography.

Primary gallbladder lymphoma, although rare, usually presents in females with symptoms mimicking cholecystitis. We present a rare case of primary gallbladder in an 81-year-old male with no risk factors whose only symptom was weight loss. Routine blood tests including liver function tests were unremarkable. A CT colonography was carried out to exclude colonic malignancy. Unilateral gallbladder wall thickening and lymphadenopathy were incidentally detected and confirmed by ultrasound and a decision for the patient to undergo laparoscopic cholecystectomy and intraoperative cholangiogram was made. Histology confirmed extranodal marginal zone lymphoma with follow-up staging and biopsy of the bone marrow not demonstrating spread. Cholecystectomy was therefore deemed curative and no adjuvant therapy was necessary. Thickening of the gallbladder wall on any imaging with or without symptoms should not be ignored or assumed to be cholecystitis, even in males with no risk factors. In these patients urgent cholecystectomy with intraoperative cholangiogram is indicated with histology and haematology follow-up.

Unemployment, public-sector healthcare spending and stomach cancer mortality in the European Union, 1981-2009.

OBJECTIVES: We sought to determine the association between changes in unemployment, healthcare spending and stomach cancer mortality. METHODS: Multivariate regression analysis was used to assess how changes in unemployment and public-sector expenditure on healthcare (PSEH) varied with stomach cancer mortality in 25 member states of the European Union from 1981 to 2009. Country-specific differences in healthcare infrastructure and demographics were controlled for 1- to 5-year time-lag analyses and robustness checks were carried out. RESULTS: A 1% increase in unemployment was associated with a significant increase in stomach cancer mortality in both men and women [men: coefficient (R)=0.1080, 95% confidence interval (CI)=0.0470-0.1690, P=0.0006; women: R=0.0488, 95% CI=0.0168-0.0809, P=0.0029]. A 1% increase in PSEH was associated with a significant decrease in stomach cancer mortality (men: R=-0.0009, 95% CI=-0.0013 to -0.005, P<0.0001; women: R=-0.0004, 95% CI=-0.0007 to -0.0001, P=0.0054). The associations remained when economic factors, urbanization, nutrition and alcohol intake were controlled for, but not when healthcare resources were controlled for. Time-lag analysis showed that the largest changes in mortality occurred 3-4 years after any changes in either unemployment or PSEH. CONCLUSION: Increases in unemployment are associated with a significant increase in stomach cancer mortality. Stomach cancer mortality is also affected by public-sector healthcare spending. Initiatives that bolster employment and maintain public-sector healthcare expenditure may help to minimize increases in stomach cancer mortality during economic downturns.

Hepatic portal venous gas: comparison of two cases.

Context. Hepatic portal venous gas (HPVG) is a rare and sinister finding. Its mortality is associated with the underlying causative condition. When secondary to bowel ischaemia, mortality rates exceed 50%. Case Report. Two cases of HPVG are described. One case describes HPVG in association with gastric ischaemia, with complete resolution following conservative management. The second case describes HPVG in association with widespread intra-abdominal ischaemia, with resultant mortality. Conclusion. A "watch and wait" management of HPVG associated with gastric ischaemia is suggested in certain patients, with a low threshold for surgical intervention. HPVG associated with bowel ischaemia is an absolute indication for surgical intervention, where intervention may change the clinical course.

Spontaneous intraperitoneal rupture of a hepatic hydatid cyst with subsequent anaphylaxis: a case report.

Hydatid cyst rupture into the abdomen is a serious complication of cystic hydatid disease of the liver (Cystic Echinococcosis) with an incidence of up to 16% in some series and can result in anaphylaxis or anaphylactoid reactions in up to 12.5% of cases. At presentation, 36-40% of hydatid cysts have ruptured or become secondarily infected. Rupture can be microscopic or macroscopic and can be fatal without surgery. Hydatid disease of the liver is primarily caused by the tapeworm Echinococcus granulosus and occurs worldwide, with incidence of up to 200 per 100,000 in endemic areas. Our case describes a 24-year-old Bulgarian woman presenting with epigastric pain and evidence of anaphylaxis. Abdominal CT demonstrated a ruptured hydatid cyst in the left lobe of the liver. A partial left lobe hepatectomy, cholecystectomy, and peritoneal washout was performed with good effect. She was treated for anaphylaxis and received antihelminthic treatment with Albendazole and Praziquantel. She made a good recovery following surgery and medical treatment and was well on follow-up. Intraperitoneal rupture with anaphylaxis is a rare occurrence, and there do not seem to be any reported cases from UK centres prior to this.

Glycine maintains mitochondrial activity and bile composition following warm liver ischemia-reperfusion injury.

BACKGROUND AND AIM: Experimental studies have shown protective effect by the non-essential amino acid glycine to liver ischemia-reperfusion (I/R) injury but the mechanism of action is unknown. METHODS: A rabbit model of hepatic lobar I/R was used. Three groups of animals (n=6) were studied: Sham group (laparotomy alone), ischemia reperfusion (I/R) group (1 h of liver lobar ischemia and 6 h of reperfusion), and a glycine I/R group (intravenous glycine 5 mg/kg prior to the I/R protocol). Systemic and hepatic hemodynamics, degree of liver injury (bile flow, transaminases), hepatic microcirculation, mitochondrial activity (redox state of cytochrome oxidase), bile composition and cytokines (tumor necrosis factor-α and interleukin-8) were measured during the experiment. RESULTS: Glycine administration increased portal blood flow, bile production, hepatic microcirculation and maintained cytochrome oxidase activity as compared with the I/R group during reperfusion. Glycine also reduced bile lactate surge and stimulated acetoacetate release in bile during reperfusion versus the I/R group. Cytokine levels (tumor necrosis factor-α, interleukin-8) and hepatocellular injury (aspartate aminotransferase and alanine aminotransferase) were significantly reduced by glycine administration. CONCLUSION: Intravenous glycine administration reduces liver warm I/R injury by reducing the systemic inflammatory response, and maintaining cellular energy production.

WITHDRAWN: Methods of vascular occlusion for elective liver resections.

BACKGROUND: Vascular occlusion is used to reduce blood loss during liver resection surgery. There is considerable controversy regarding whether vascular occlusion should be used or not during elective liver resections. The method of vascular occlusion employed is also controversial. There is also considerable debate on the role of ischaemic preconditioning before vascular occlusion. OBJECTIVES: To assess the advantages (decreased blood loss and peri-operative morbidity) and disadvantages (liver dysfunction from ischaemia) of vascular occlusion during liver resections. To compare the advantages (in decreasing blood loss or decreasing ischaemia-reperfusion injury) and disadvantages of different types of vascular occlusion versus total, continuous portal triad clamping. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2007. SELECTION CRITERIA: We included randomised clinical trials comparing vascular occlusion versus no vascular occlusion during elective liver resections (irrespective of language or publication status). We also included randomised clinical trials comparing the different methods of vascular occlusion and those investigating the role of ischaemic preconditioning in liver resection. DATA COLLECTION AND ANALYSIS: We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, blood loss, blood transfusion requirements, liver function tests, markers of neutrophil activation, operating time, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each binary outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis. For continuous outcomes, we calculated the weighted mean difference (WMD) with 95% confidence intervals. MAIN RESULTS: We identified a total of 16 randomised trials. Five trials including 331 patients compared vascular occlusion (n = 166) versus no vascular occlusion (n = 165). Six trials including 521 patients compared different methods of vascular occlusion. Three trials including 210 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 105) versus no ischaemic preconditioning (n = 105). Two trials including 127 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 63) versus intermittent portal triad clamping (n = 64).The blood loss was significantly lower in vascular occlusion compared with no vascular occlusion. The liver enzymes were significantly elevated in the vascular occlusion group compared with no vascular occlusion. There was no difference in the mortality, liver failure, or other morbidities. Four of the five trials comparing vascular occlusion and no vascular occlusion used intermittent vascular occlusion. Trials comparing complete inflow and outflow occlusion to the liver, ie, hepatic vascular exclusion and portal triad clamping demonstrate significant detrimental haemodynamic changes in hepatic vascular exclusion compared to portal triad clamping. There was no significant difference in the number of units transfused and the number of patients needing transfusion. There was no difference in mortality, liver failure, or morbidity between total and selective methods of portal triad clamping. All four cases of mortality and liver failure in the comparison between the intermittent and continuous portal triad clamping occurred in the continuous portal triad clamping (statistically not significant). Intermittent portal triad clamping does not increase the total blood loss or operating time compared to continuous portal triad clamping.There was no statistically significant difference in the mortality, liver failure, morbidity, blood loss, or haemodynamic changes between ischaemic preconditioning versus no ischaemic preconditioning before continuous portal triad clamping. Liver enzymes used as markers of liver injury were significantly lower in the early post-operative period in the ischaemic preconditioning group. The intensive therapy unit stay and hospital stay were statistically significantly lower in the ischaemic preconditioning group than in the no ischaemic preconditioning group.There was no statistically significant difference in the mortality, liver failure, morbidity, intensive therapy unit stay, or hospital stay between ischaemic preconditioning before continuous portal triad clamping and intermittent portal triad clamping. The blood loss and transfusion requirements were lower in the ischaemic preconditioning group. Aspartate aminotransferase level was lower in the intermittent portal triad clamping group than the ischaemic preconditioning group on the third post-operative day. There was no difference in the peak aspartate aminotransferase levels or in the aspartate aminotransferase levels on first or sixth post-operative days of aspartate aminotransferase . AUTHORS' CONCLUSIONS: Intermittent vascular occlusion seems safe in liver resection. However, it does not seem to decrease morbidity. Among the different methods of vascular occlusion, intermittent portal triad clamping has most evidence to support the clinical application. Hepatic vascular exclusion cannot be recommended routinely. Ischaemic preconditioning before continuous portal triad clamping may be of clinical benefit in reducing intensive therapy unit and hospital stay.

Methods of vascular occlusion for elective liver resections.

BACKGROUND: Vascular occlusion is used to reduce blood loss during liver resection surgery. Various methods of vascular occlusion have been suggested. OBJECTIVES: To compare the benefits and harms of different methods of vascular occlusion during elective liver resection. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2008. SELECTION CRITERIA: We included randomised clinical trials comparing different methods of vascular occlusion during elective liver resections (irrespective of language or publication status). DATA COLLECTION AND ANALYSIS: Two authors independently assessed trials for inclusion and independently extracted the data. We calculated the risk ratio or mean difference with 95% confidence intervals using fixed-effect and random-effects models based on intention-to-treat or available data analysis. MAIN RESULTS: Ten trials including 657 patients compared different methods of vascular occlusion. All trials were of high risk of bias. Only one or two trials were included under each comparison. There was no statistically significant differences in mortality, liver failure, or other morbidity between any of the comparisons.Hepatic vascular occlusion does not decrease the blood transfusion requirements. It decreases the cardiac output and increases the systemic vascular resistance. In the comparison between continuous portal triad clamping and intermittent portal triad clamping, four of the five liver failures occurred in patients with chronic liver diseases undergoing the liver resections using continuous portal triad clamping. In the comparison between selective inflow occlusion and portal triad clamping, all four patients with liver failure occurred in the selective inflow occlusion group. There was no difference in any of the other important outcomes in any of the comparisons. AUTHORS' CONCLUSIONS: In elective liver resection, hepatic vascular occlusion cannot be recommended over portal triad clamping. Intermittent portal triad clamping seems to be better than continuous portal triad clamping at least in patients with chronic liver disease. There is no evidence to support selective inflow occlusion over portal triad clamping. The optimal method of intermittent portal triad clamping is not clear. There is no evidence for any difference between the ischaemic preconditioning followed by vascular occlusion and intermittent vascular occlusion for liver resection in patients with non-cirrhotic livers. Further randomised trials of low risk of bias are needed to determine the optimal technique of vascular occlusion.

A case of paraneoplastic cerebellar ataxia secondary to renal cell carcinoma.

A 64-year-old female patient presented with acute cerebellar ataxia. After ruling out vascular, infectious, metastatic, demyelinating, and medication etiologies, a paraneoplastic origin for her illness was determined. A renal mass was discovered and found to be renal cell carcinoma. Her symptoms resolved after a radical nephrectomy. Physicians should consider the diagnosis of paraneoplastic neurologic syndromes whenever a thorough evaluation fails to explain neurologic abnormalities.

Formation and role of plasma S-nitrosothiols in liver ischemia-reperfusion injury.

Plasma S-nitrosothiols (RSNOs) may act as a circulating form of nitric oxide that affects vascular function and platelet aggregation. Their role in liver ischemia/reperfusion (I/R) injury is largely unknown. The aim of the present study was to investigate the changes in plasma RSNOs following liver I/R injury. Two groups of New Zealand white rabbits were used (n=6, each): the I/R group underwent 60 min lobar liver ischemia and 7 h reperfusion, while the sham group underwent laparotomy but no liver ischemia. Serial RSNO levels were measured in plasma by electron paramagnetic resonance (EPR) spectrometry, nitrite/nitrates by capillary electrophoresis, hepatic microcirculation by laser Doppler flowmetry, redox state of hepatic cytochrome oxidase by near-infrared spectroscopy, liver iNOS mRNA expression by reverse transcription-polymerase chain reaction (RT-PCR) and the oxidation of dihydrorhodamine to rhodamine by fluorescence. The effect of the antioxidant N-acetylcysteine (NAC) on RSNOs formation and DHR oxidation was tested in a third group of animals (n=6) undergoing lobar liver I/R. Hepatic I/R was associated with a significant increase in plasma RSNOs, plasma nitrites, hepatic iNOS mRNA expression, impairment in hepatic microcirculation, decrease in the redox state of cytochrome oxidase, and significant production of rhodamine. The changes were more obvious during the late phase of reperfusion (>4 h). NAC administration decreased plasma RSNOs and oxidation of DHR to RH (P<0.05, 5 and 7 h postreperfusion, respectively). These results suggest that significant upregulation of nitric oxide synthesis during the late phase of reperfusion is associated with impairment in microcirculation and mitochondrial dysfunction. Plasma S-nitrosothiols are a good marker of this nitric oxide-mediated hepatotoxicity.

N-Acetylcysteine ameliorates the late phase of liver ischaemia/reperfusion injury in the rabbit with hepatic steatosis.

Steatotic livers are highly susceptible to I/R (ischaemia/reperfusion) injury and, therefore, the aim of the present study was to evaluate the in vivo effect of NAC (N-acetylcysteine) on hepatic function in the early and initial late phase of warm liver I/R injury in steatotic rabbits. Twelve New Zealand White rabbits were fed a high-cholesterol (2%) diet. The control group (n=6) underwent lobar liver ischaemia for 1 h, followed by 6 h of reperfusion. In the treated group receiving NAC (n=6), an intravenous infusion of NAC was administered prior to and during the 6 h reperfusion period. Systemic and hepatic haemodynamics were monitored continuously. ALT (alanine aminotransferase) activity and bile production were measured. NMR spectroscopy was used to analyse bile composition. Oxidation of DHR (dihydrorhodamine) to RH (rhodamine) was used as a marker of production of reactive oxygen and nitrogen species. Moderate centrilobular hepatic steatosis was demonstrated by histology. The results showed that NAC administration significantly improved portal flow, hepatic microcirculation, bile composition and bile flow after 5 h of reperfusion. NAC administration was also associated with less hepatocellular injury, as indicated by ALT serum activity, and decreased the oxidation of DHR to RH. In conclusion, NAC administration decreased the extent of I/R injury in the steatotic liver, particularly during the late phase of reperfusion.