The ampulla of Vater: A potential target for metastatic melanoma?

Malignant melanomas are aggressive cancers that can prove to be fatal, with Australia harbouring the highest incidence of skin cancers worldwide. Surprisingly, as little as 13.4% of patients undergoing surgical resection of high-risk melanomas remain disease-free after 2 years, with 31.6% showing evidence of distant spread. Although rare, secondary tumours of the ampulla of Vater have been documented, with the most common primaries involving breast, renal and melanoma cancers. We report the case of a malignant melanoma of the ampulla of Vater occurring in a patient 4-year post-surgical resection of a Stage II melanoma manifesting as acute pancreatitis with obstructive jaundice. Given the rarity of secondary ampullary tumours, metastatic melanoma should always be considered in patients with obstructive jaundice and a history of melanoma resection. In the absence of distant disease, surgery may be considered after consensus at multidisciplinary team meetings and after consideration of the patient preference.

A Case of Perforated Cholecystitis into a Parastomal Hernia.

Introduction: Parastomal hernia is a common complication following an enterostomy. Gallbladder herniation into parastomal hernia is rare and may become symptomatic and inflamed and very rarely can lead to gallbladder perforation. We present the first case of gallbladder perforation inside a parastomal hernia with a unique skin change. Case Description. In this report, an 87-year-old female with a history of previous open cystectomy and ileal conduit formation, presented with right upper quadrant pain and worsening parastomal swelling. A computed tomography scan showed a parastomal herniation of the gallbladder, cholelithiasis, and possible early acute cholecystitis. Within 12 hours of admission, bile staining skin changes developed around her urostomy site which raised our suspicion of a perforated gallbladder. Biliary peritonitis was confirmed on laparoscopy the same day. We proceeded with an open midline cholecystectomy without hernia repair. The patient was well at her last follow-up. Discussion. A literature review found 14 published cases of incarcerated gallbladder hernia. This uncommon condition mainly affects elderly females. Ten cases were managed operatively, and four cases were managed nonoperatively, with good outcomes. Currently, no consensus on treatment guidelines exists. In a frail elderly patient, a nonoperative approach may be suitable. Operative management was indicated in this case due to clinical concerns of perforation due to developing skin changes. This cutaneous sign has not been previously documented in the literature. Conclusion: While rare, the gallbladder can herniate and become incarcerated inside a parastomal hernia. Bile staining of the skin should raise clinical suspicion of perforation. Management options depend on patient and pathology factors and can be nonoperative or operative, with or without hernia repair.

A new variation of duplicated extrahepatic bile duct encountered intraoperatively on cholangiogram.

A potentially devastating complication of laparoscopic cholecystectomy (LC) includes iatrogenic bile duct injury, the incidence of which has remained stable at 0.3% over the past three decades. Although there are several relative risks such as surgeon experience and patient factors (male sex, obesity, older age), misinterpretation of biliary tree anatomy contributes towards 80% of iatrogenic common bile duct (CBD) injuries. Although extremely rare, an isolated duplicated common hepatic duct anomaly with a normal CBD remains a potential variation to encounter during biliary surgery. With only one similar variation published worldwide, we report the second case encountered during LC and confirmed on cholangiogram. Given these anomalies are asymptomatic and perpetuate iatrogenic CBD injuries, awareness of this variation is crucial. Preoperative diagnosis is possible with the use of magnetic resonance cholangiopancreatography; however, such imaging is not routinely used prior to LC in Australia due to factors including expense and availability.

Ultrasound evaluation of pouch of Douglas obliteration and rectal deep endometriosis in women who have had previous combined colorectal and gynaecological laparoscopic surgery for rectal endometriosis: A pilot study.

BACKGROUND: Ultrasound has been demonstrated to accurately diagnose rectal deep endometriosis (DE) and pouch of Douglas (POD) obliteration. The role of ultrasound in the assessment of patients who have undergone surgery for rectal DE and POD obliteration has not been evaluated. AIM: To describe the transvaginal ultrasound (TVS) findings of patients who have undergone rectal surgery for DE. MATERIALS AND METHODS: An observational cross-sectional study at a tertiary care centre in Sydney, Australia between January and April 2017. Patients previously treated for rectal DE (low anterior resection vs rectal shaving/disc excision) were recruited and asked to complete a questionnaire on their current symptoms. On TVS, POD state and rectal DE were assessed. Correlating recurrence of POD obliteration and/or rectal DE to surgery type and symptoms was done. RESULTS: Fifty-six patients were contacted; 22/56 (39.3%) attended for the study visit. Average interval of surgery to study visit was 52.8 ± 24.6 months. Surgery type breakdown was as follows: low anterior resection (56%) and rectal shaving/disc excision (44%). The prevalence of POD obliteration was 16/22 (72.7%) intraoperatively and 8/22 (36.4%) at study visit, as per the sliding sign. Nine patients (39.1%) had evidence on TVS of recurrent rectal DE. Recurrence of POD obliteration and rectal DE was not associated with surgery type or symptomatology. CONCLUSION: Despite surgery for rectal DE, many patients have a negative sliding sign on TVS, representing POD obliteration, and rectal DE. Our numbers are too small to correlate with the surgery type or their current symptoms.

Rare occurrence of small bowel volvulus following laparoscopic appendicectomy for perforated appendicitis.

Intestinal volvulus is a rare complication following laparoscopic surgery. We present the case of a young boy who had developed a small bowel obstruction following laparoscopic appendicectomy for perforated appendicitis. He had no evidence of any congenital malrotation on initial laparoscopy, yet was subsequently found to have a midgut volvulus requiring emergency laparotomy. No resection was required and subsequent convalescence was uncomplicated. This case highlights the importance of recognition of this uncommon but potential early complication of laparoscopy that warrants urgent surgical intervention.

Incarcerated congenital transmesenteric hernia in an adult: a case report.

Transmesenteric hernia is a rare cause of bowel obstruction and strangulation. It can be due to iatrogenic injury, trauma, inflammatory and less likely congenital. We present a case of true congenital transmesenteric hernia in a 26-year-old male with no previous surgical history or trauma. The patient presented acutely with no prior symptoms. Investigations provided limited information towards the diagnosis of the hernia, but suggestive of mid-gut volvulus. Emergency laparotomy was performed to find >75% of small bowel herniating through a proximal jejunal mesenteric defect leading to incarceration and early strangulation. No resection was required and patient recovered well. This case presents yet another rare pathology and highlights the importance of keeping a low threshold for operative intervention in uncertain cases.

Association of waist circumference with outcomes in an acute general surgical unit.

BACKGROUND: Obesity prevalence is increasing in Australia, particularly in non-metropolitan areas. The effect of obesity on acute surgical outcomes is not known. We aimed to record waist circumference (WC) (surrogate for obesity) amongst acute surgical unit (ASU) patients in a New South Wales regional hospital, and compare outcome measures (length of stay (LOS), unplanned return to theatre, readmission rates, intensive care unit (ICU) admission and mortality). METHODS: Retrospective cohort study of 4 months of consecutive ASU admissions, excluding age <16, pregnancy, out-of-area transfer and incomplete data. Patients were classified according to World Health Organization WC definitions as high-risk or non-high-risk (increased-risk and no-risk). RESULTS: Of 695 admissions, 512 met the inclusion criteria (47.1% female, average age 52.8 years (SD 22.3)), with 85.1% (P < 0.001) of females and 69.4% (P = 0.166) of males having an increased- or high-risk WC. This compares to rates amongst inner regional populations of 71.0% (female) and 66.4% (male). LOS was longer for high-risk patients (5.0 days versus 3.7 days, P = 0.002). However, the mean age of high-risk patients was greater (56.6 years versus 46.9 years, P = 0.001) and LOS was longer for those aged ≥60 (P < 0.001). After controlling for age, high-risk WC was not associated with any outcome measure, except amongst ICU admissions, where high-risk patients stayed longer (15.5 days versus 6.8 days, P < 0.001). CONCLUSION: Increased- and high-risk WC was overrepresented amongst female ASU patients. High-risk WC was associated with a significantly greater LOS in patients admitted to ICU. High-risk WC was not associated with other outcomes independent of age. WC is useful for quantifying obesity in the inpatient setting.