Percutaneous thrombolysis via cholecystostomy catheter to dissolve biliary clots causing obstructive jaundice.

Haemobilia, or bleeding within the biliary tree, is rare. It can cause biliary obstruction secondary to blood clots. A comorbid 87-year-old was admitted to hospital with acute cholecystitis, choledocholithiasis, and an Escherichia coli bacteremia. He had a partial pancreatectomy and gastrojejunostomy 35 years prior for severe pancreatitis. He was treated with antibiotics and a percutaneous cholecystostomy. He developed atrial fibrillation and was subsequently commenced on warfarin. He re-presented 5 days after discharge with abdominal pain and fevers. Liver function tests revealed cholestasis and a supratherapeutic international normalised ratio. Imaging showed cholecystitis, biliary obstruction, and extensive biliary blood clots. He improved with antibiotics, vitamin K, and alteplase flushes through the percutaneous cholecystostomy. Repeat cholangiogram demonstrated dissolution of the biliary clots. Due to altered anatomy and comorbidities, alteplase flushes were utilized to relieve this patient's biliary obstruction. Thrombolytics may assist in treating biliary clots when first-line options are not possible or favourable.

Perioperative Blood Transfusions and Anastomotic Leak After Colorectal Surgery for Cancer in an Australian Hospital.

PURPOSE: Peri-operative blood transfusion has been identified as a risk factor for anastomotic leak in recent studies, but little is known about which patients are at risk for blood transfusion. This study aims to assess the relationship between blood transfusion and anastomotic leak and factors predisposing to leak in patients undergoing colorectal cancer surgery. METHODS: This retrospective cohort study was conducted in a tertiary hospital in Brisbane, Australia, between 2010 and 2019. A total of 522 patients underwent resection of colorectal cancer with primary anastomosis with no covering stoma and the prevalence of anastomotic leak was compared between those who had had perioperative blood transfusion(s) and those who had not. RESULTS: A total of 19 of 522 patients undergoing surgery for colorectal cancer had developed an anastomotic leak (3.64%). 11.3% of patients who had had a perioperative blood transfusion developed an anastomotic leak whereas 2.2% of patients who had not had a blood transfusion developed an anastomotic leak (p = 0.0002). Patients undergoing procedure on their right colon had proportionally more blood transfusions and this approached statistical significance (p = 0.06). Patients who received a greater quantity of units of blood transfusion prior to their diagnosis of anastomotic leak were more likely to develop an anastomotic leak (p = 0.001). CONCLUSION: Perioperative blood transfusions are associated with a significantly increased risk of an anastomotic leak following bowel resection with primary anastomosis for colorectal cancer.

An Unusual Case of Large Cell Neuroendocrine Cancer of the Gallbladder With Mixed Adenocarcinoma Component in a Patient With Pancreatobiliary Maljunction.

Gallbladder neuroendocrine tumors (GB-NETs) and gallbladder neuroendocrine carcinomas (GB-NECs) are rare forms of neuroendocrine neoplasms (NENs). Most GB-NENs present as incidental findings or as gallbladder polyps in the course of investigation of nonspecific symptoms such as upper abdominal pain and nausea. Given the rarity of GB-NENs, only a few small case series are currently available describing this entity, and even fewer guiding consensus on standard treatment and the role of adjuvant therapy.  We present the case of a 65-year-old South American female referred for a chronic history of intermittent post-prandial epigastric pain, bloating, nausea, and occasional diarrhea. Pancreaticobiliary maljunction with dilation was present and she was diagnosed with primary gallbladder large cell neuroendocrine carcinoma (GB-LCNEC) mixed with a minor component of gallbladder adenocarcinoma.

Gallbladder volvulus with preoperative and intraoperative imaging.

Volvulus of the gallbladder is one of the rarest conditions to affect the gallbladder, however, it should remain an important differential. Typically, it is diagnosed in elderly women, but it has also been reported in children and men. The lack of unique distinguishing features make diagnosis difficult to distinguish between other gallbladder pathology such as acute cholecystitis; however, delayed recognition or non-operative management is associated with higher mortality. We present the case of a 92-year-old woman who presented with this pathology, had diagnosis established preoperatively and was successfully treated with a cholecystectomy.

Massive pulmonary embolism and intra-cardiac thrombus requiring systemic thrombolysis 9-hours post emergency laparotomy.

The link between abdominal surgery and venous thromboembolism (VTE) has been well established with recent evidence exploring the optimal VTE risk reducing strategy. However, despite these strategies pulmonary embolisms (PEs) do occur, which in the immediate post-operative setting creates a dilemma; to treat the VTE with anticoagulation but balance against the risk of hemorrhage. Treatment guidelines often do not include post-operative patients leaving the decision up to the treating physician to weigh the relative risks on an individual basis. We present a 59-year-old lady who developed a life-threatening submassive PE within 9 h of an emergency laparotomy for a perforated rectal cancer. She was treated with systemic thrombolysis after alternative interventions had been excluded. She responded well to therapy with no major bleeding. She was successfully discharged home after a short period of inpatient rehabilitation.

Open splenic artery aneurysm repair in a patient with previous laparoscopic sleeve gastrectomy.

We present the case of a female patient in her 40s who underwent a splenic artery aneurysm (SAA) repair following a previous laparoscopic sleeve gastrectomy (SG). We aim to discuss the management approach to SAAs and considerations in the setting of previous bariatric surgery.The patient consented to this case report. We include preoperative and postoperative radiological images and intraoperative images.While pseudoaneurysms following bariatric surgery have been reported, we present a case of a likely true SAA following SG. Our experience may assist others who come across similar cases in the future.

Effect of obesity on post-operative outcomes following colorectal cancer surgery.

BACKGROUND: Colorectal cancer (CRC) resection is currently being undertaken in an increasing number of obese patients. Existing studies have yet to reach a consensus as to whether obesity affects post-operative outcomes following CRC surgery. AIM: To evaluate the post-operative outcomes of obese patients following CRC resection, as well as to determine the post-operative outcomes of obese patients in the subgroup undergoing laparoscopic surgery. METHODS: Six-hundred and fifteen CRC patients who underwent surgery at the Prince Charles Hospital between January 2010 and December 2020 were categorized into two groups based on body mass index (BMI): Obese [BMI ≥ 30, n = 182 (29.6%)] and non-obese [BMI < 30, n = 433 (70.4%)]. Demographics, comorbidities, surgical features, and post-operative outcomes were compared between both groups. Post-operative outcomes were also compared between both groups in the subgroup of patients undergoing laparoscopic surgery [n = 472: BMI ≥ 30, n = 136 (28.8%); BMI < 30, n = 336 (71.2%)]. RESULTS: Obese patients had a higher burden of cardiac (73.1% vs 56.8%; P < 0.001) and respiratory comorbidities (37.4% vs 26.8%; P = 0.01). Obese patients were also more likely to undergo conversion to an open procedure (12.8% vs 5.1%; P = 0.002), but did not experience more post-operative complications (51.6% vs 44.1%; P = 0.06) or high-grade complications (19.2% vs 14.1%; P = 0.11). In the laparoscopic subgroup, however, obesity was associated with a higher prevalence of post-operative complications (47.8% vs 39.3%; P = 0.05) but not high-grade complications (17.6% vs 11.0%; P = 0.07). CONCLUSION: Surgical resection of CRC in obese individuals is safe. A higher prevalence of post-operative complications in obese patients appears to only be in the context of laparoscopic surgery.

Double trouble: synchronous extrahepatic cholangiocarcinoma and gallbladder cancer in a Caucasian woman with no pancreaticobiliary maljunction.

Synchronous malignancies of the bile duct and the gallbladder are rare. These cases are often associated with pancreaticobiliary maljunction which is characterized by a long common shared pancreatobiliary channel leading to the Sphincter of Oddi. This predisposes the biliary epithelium to pancreatic enzyme reflux and makes the development of neoplasia more likely. We describe the case of a 64-year-old Caucasian female who presented with new jaundice and severe cholecystitis secondary to an impacted gallstone which was seen on ultrasound. Magnetic resonance cholangiopancreatography was organized with suspicion of a possible Mirizzi syndrome. This revealed a mid-distal bile duct cancer in addition to cholecystitis from an impacted gallstone. She was treated with intravenous antibiotics for her cholecystitis and underwent an urgent endoscopic retrograde cholangiopancreatography procedure for biliary decompression and stenting for her obstructive jaundice. The patient proceeded to pancreaticoduodenectomy with final histopathology revealing a synchronous primary gallbladder malignancy in addition to the known bile duct cancer.

Pre-operative predictive factors for gangrenous cholecystitis at an Australian quaternary cardiothoracic centre.

INTRODUCTION: The aim of this study was to determine associations between pre-operative factors and gangrenous cholecystitis. Gangrenous cholecystitis represents a severe spectrum of cholecystitis and is associated with an increased risk of complications. Early recognition and diagnosis of gangrenous cholecystitis can optimize prioritization for surgery and improve outcomes. METHODS: A retrospective case-control study was undertaken. Patient demographics, medical comorbidities, pre-operative biochemical and ultrasound findings as well as post-operative outcomes were assessed. Four hundred and fourteen patients who underwent an emergency cholecystectomy between 2018 and 2020 were reviewed. RESULTS: One hundred and nine (26%) patients who underwent emergency cholecystectomy during this 3-year period had gangrenous cholecystitis. These patients were older (median age 65 versus 45, P < 0.001) and more likely to be male (58.7% versus 32.5%, P < 0.001). Patients with coronary disease (OR 2.55, P < 0.001), hypertension (OR 2.25, P = 0.001), or arrhythmias (OR 3.64, P = 0.001) were two-to-three times more likely to have gangrenous cholecystitis. Patients with renal disease (OR 1.92, P = 0.004) or using antiplatelet medication (OR 2.27, P = 0.003) were twice as likely to have gangrenous cholecystitis. Patients who had gangrenous cholecystitis presented with a higher white cell count (median 13 x 109 /L versus 8 x 109 /L, P < 0.001) and a higher C-reactive protein (median 196 versus 18 mg/L, P < 0.001). Patients with gangrenous cholecystitis had poorer post-operative outcomes. CONCLUSION: We verified predictive factors from existing literature and identified a number of novel pre-operative predictive factors for gangrenous cholecystitis which could help with development of a scoring system for clinical use.

Should we resect colorectal cancer in patients over the age of 85?

BACKGROUND: The prevalence of colorectal cancer in the elderly is rising, with increasing numbers of older patients undergoing surgery. However, there is a paucity of information on the surgical outcomes and operative techniques used in this population. AIM: To evaluate the post-operative outcomes for patients ≥ 85 years old following colorectal cancer resection as well as evaluating the outcomes of laparoscopic resection of colorectal cancer in patients over 85. METHODS: Patients who underwent colorectal cancer resection at our institution between January 2010 and December 2018 were included. The study was divided into two parts. For part one, patients were divided into two groups based on age: Those age ≥ 85 years old (n = 48) and those aged 75-84 years old (n = 136). Short term surgical outcomes and clinicopathological features were compared using appropriate parametric and non-parametric testing. For part two, patient's over 85 years old were divided into two groups based upon operative technique: Laparoscopic (n = 37) vs open (n = 11) colorectal resection. Short-term post-operative outcomes of each approach were assessed. RESULTS: The median length of stay between patients over 85 and those aged 75-85 was eight days, with no statistically significant difference between the groups (P = 0.29). No significant difference was identified between the older and younger groups with regards to severity of complications (P = 0.93), American Society of Anaesthesiologists grading (P = 0.43) or 30-d mortality (2% vs 2%, P = 0.96). Patients over 85 who underwent laparoscopic colorectal resection were compared to those who underwent an open resection. The median length of stay between the groups was similar (8 vs 9 d respectively) with no significant difference in length of stay (P = 0.18). There was no significant difference in 30-d mortality rates (0% vs 9%, P = 0.063) or severity of complication grades (P = 0.46) between the laparoscopic and open surgical groups. CONCLUSION: No significant short term surgical differences were identified in patients ≥ 85 years old when compared to those 75-85 years old. There is no difference in short term surgical outcomes between laparoscopic or open colorectal resections in patients over 85.

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome: A case report.

INTRODUCTION: Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome (MS) is a complex surgical problem both diagnostically and in terms of management as it mimics both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma. PRESENTATION OF CASE: A 48-year-old gentleman was referred to us with biliary colic and weight loss with ultrasound findings of gallstones. At subsequent follow-up he became deeply jaundiced with deranged liver function and a CT showing a gallbladder mass and dilated biliary tree. Follow-up MRCP suggested XGC and concomitant MS, but a malignant process could not be excluded. Pre-operative fine needle aspiration cytology (FNAC) at the time of percutaneous biliary drainage for his jaundice demonstrated XGC with no evidence of malignancy. Given the dense inflammation and a tense empyema at laparoscopy, he underwent a subtotal fenestrating cholecystectomy. The final histopathological diagnosis was acute cholecystitis. DISCUSSION: Our patient likely had unrecognised acute cholecystitis which progressed to a complex mass with empyema and type I Mirizzi Syndrome, ultimately resulting in severe obstructive jaundice mimicking gallbladder carcinoma. Given that a laparoscopic total cholecystectomy is dangerous in these cases of severe inflammation, a laparoscopic subtotal cholecystectomy has been shown to be a safe alternative to more invasive strategies and was successfully utilised in our patient. CONCLUSION: Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome is a rare manifestation that requires adequate pre-operative work-up to exclude malignancy. Subtotal fenestrating cholecystectomy is a safe and effective alternative to open surgery in these cases of complex inflammation.

Management of bile duct stones at cholecystectomy: an Australian single-centre experience over 2 years.

BACKGROUND: Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series. METHODS: A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population. RESULTS: Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126 min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8 mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23). CONCLUSION: This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.

The impact of comorbidities on post-operative complications following colorectal cancer surgery.

BACKGROUND: Colorectal cancer surgery is complex and can result in severe post-operative complications. Optimisation of surgical outcomes requires a thorough understanding of the background complexity and comorbid status of patients. AIM: The aim of this study is to determine whether certain pre-existing comorbidities are associated with high grade post-operative complications following colorectal cancer surgery. The study also aims to define the prevalence of demographic, comorbid and surgical features in a population undergoing colorectal cancer resection. METHOD: A colorectal cancer database at The Prince Charles Hospital was established to capture detailed information on patient background, comorbidities and clinicopathological features. A single-centre retrospective study was undertaken to assess the effect of comorbidities on post-operative outcomes following colorectal cancer resection. Five hundred and thirty-three patients were reviewed between 2010-2018 to assess if specific comorbidities were associated with higher grade post-operative complications. A Clavien-Dindo grade of three or higher was defined as a high grade complication. RESULTS: Fifty-eight percent of all patients had an ASA grade of ASA III or above. The average BMI of patients undergoing resection was 28 ± 6.0. Sixteen percent of all patients experienced a high grade complications. Patients with high grade complications had a higher mean average age compared to patients with low grade or no post-operative complications (74 years vs 70 years, p = 0.01). Univariate analysis revealed patients with atrial fibrillation, COPD, ischaemic heart disease and heart failure had an increased risk of high grade complications. Multivariate analysis revealed pre-existing atrial fibrillation (OR 2.70, 95% CI 1.53-4.89, p <0.01) and COPD (OR 2.02 1.07-3.80, p = 0.029) were independently associated with an increased risk of high grade complications. CONCLUSION: Pre-existing atrial fibrillation and COPD are independent risk factors for high grade complications. Targeted perioperative management is necessary to optimise outcomes.

Recurrent pancreatitis in the setting of gallbladder agenesis, ansa pancreatica, Santorinicoele and eventual intraductal papillary mucinous neoplasia (IPMN).

Gallbladder agenesis is a rare condition. Patients with gallbladder agenesis can present with biliary type symptoms and rarely pancreatitis. We present the case of a 35-year-old gentleman who was admitted and treated for recurrent pancreatitis on a background of gallbladder agenesis, ansa pancreatica and Santorinicoele. He has had several admissions with pancreatitis and has had multiple imaging modalities during these admissions which we delineate. We discuss this rare anatomical variant and describe the course and management of his illness leading up to his eventual diagnosis of intraductal papillary neoplasia (IPMN).

Unusual Presentation of a Sigmoid Mass with Chicken Bone Impaction in the Setting of Metastatic Lung Cancer.

BACKGROUND: Ingestion of foreign bodies can cause various gastrointestinal tract complications including abscess formation, bowel obstruction, fistulae, haemorrhage, and perforation. While these foreign body-related complications can occur in normal bowel, diseased bowel from inflammation, strictures, or malignancy can cause diagnostic difficulties. Endoscopy is useful in visualising the bowel from within, providing views of the mucosa and malignancies arising from here, but its ability in diagnosing extramural malignancies arising beyond or external to the mucosa of the bowel as in the case of metastatic extramural disease can be limited. CASE SUMMARY: We present the case of a 60-year-old female with an impacted chicken bone in the sigmoid colon with formation of a sigmoid mass, on a background of metastatic lung cancer. On initial diagnosis of her lung cancer, there was mild Positron Emission Tomography (PET) avidity in the sigmoid colon which had been evaluated earlier in the year with a colonoscopy with findings of diverticular disease. Subsequent computed tomography (CT) scans demonstrated thickening of the sigmoid colon with a structure consistent with a foreign body distal to this colonic thickening. A repeat PET scan revealed an intensely fluorodeoxyglucose (FDG) avid mass in the sigmoid colon which was thought to be inflammatory. She was admitted for a flexible sigmoidoscopy and removal of the foreign body which was an impacted chicken bone. She had a fall and suffered a fractured hip. During her admission for her hip fracture, she had an exacerbation of her abdominal pain. She developed a large bowel obstruction, requiring laparotomy and Hartmann's procedure to resect the sigmoid mass. Histopathology confirmed metastatic lung cancer to the sigmoid colon. CONCLUSION: This unusual presentation highlights the challenges of diagnosing ingested foreign bodies in patients with metastatic disease.

Management of infected pancreatic necrosis in the setting of concomitant rectal cancer: A case report and review of literature.

BACKGROUND: Pancreatitis with infected necrosis is a severe complication of acute pancreatitis and carries with it high rates of morbidity and mortality. The management of infected pancreatic necrosis alongside concomitant colorectal cancer has never been described in literature. CASE SUMMARY: A 77 years old gentleman presented to the Emergency Department of our hospital complaining of ongoing abdominal pain for 8 h. The patient had clinical features of pancreatitis with a raised lipase of 3810 U/L, A computed tomography (CT) abdomen confirmed pancreatitis with extensive peri-pancreatic edema. During the course of his admission, the patient had persistent high fevers and delirium thought secondary to infected necrosis, prompting the commencement of broad-spectrum antibiotic therapy with Piperacillin/Tazobactam. Subsequent CT abdomen confirmed extensive pancreatic necrosis (over 70%). Patient was managed with supportive therapy, nutritional support and gut rest initially and improved over the course of his admission and was discharged 42 d post admission. He represented 24 d following his discharge with fever and chills and a repeat CT abdomen scan noted gas bubbles within the necrotic pancreatic tissue thereby confirming infected necrotic pancreatitis. This CT scan also revealed asymmetric thickening of the rectal wall suspicious for malignancy. A rectal cancer was confirmed on flexible sigmoidoscopy. The patient underwent two endoscopic necrosectomies and was treated with intravenous antibiotics and was discharged after 28 d. Within 1 wk post discharge, the patient commenced a course of neoadjuvant radiotherapy and subsequently underwent concomitant chemotherapy prior to undergoing a successful Hartmann's procedure for treatment of his colorectal cancer. CONCLUSION: This case highlights the efficacy of endoscopic necrosectomy, early enteral feeding and targeted antibiotic therapy for timely management of infected necrotic pancreatitis. The prompt resolution of pancreatitis permitted the patient to undergo neoadjuvant treatment and resection for his concomitant colorectal cancer.

Cholecystoduodenal Stenting: An Option in Complicated Acute Calculous Cholecystitis in the Elderly Comorbid Patient.

We describe the course of an 84-year-old lady with acute calculous cholecystitis. She was unable to have a cholecystectomy due to multiple comorbidities including morbid obesity, type 2 diabetes, Guillain-Barrè syndrome, chronic sacral pressure ulcer, and severe cardiac disease. Conservative treatment with intravenous antibiotics was initially successful; however, she subsequently re-presented with an empyema of the gallbladder. She was readmitted for further intravenous antibiotics and underwent percutaneous gallbladder drainage. The patient did not want a permanent catheter for drainage, nor the prospect of repeat drainage procedures in the future for recurrent cholecystitis. Following a discussion of the rationale and risks involved with other minimally invasive techniques, she underwent cholecystoduodenal stent placement following disimpaction and removal of cystic duct stones. The procedure restored antegrade gallbladder drainage, and at 18 months she remains symptom-free from her gallbladder. Long-term management of recurrent cholecystitis in elderly comorbid patients commonly includes permanent cholecystostomy or repeated percutaneous gallbladder drainage, both of which can be poorly tolerated. Permanent cholecystoduodenal stenting is a reasonable alternative in carefully considered patients in whom the benefits outweigh the risks. We describe our experience with cholecystoduodenal stenting and discuss some of the concerns and considerations with this technique.