Immediate Impact of Centralization on Abdominal Aortic Aneurysm Repair Outcomes for a Vascular Network in the South West of England: A Retrospective Cohort Study.

OBJECTIVE: Our aim was to assess the short-term impact of centralization on the outcomes of patients undergoing abdominal aortic aneurysm repair in a vascular network in the South West of England. BACKGROUND: The centralization of vascular services has been implemented nationally across the National Health Service to improve patient outcomes. The full impact of these major changes has not yet been fully analyzed. METHODS: A retrospective cohort study examining outcomes of patients undergoing abdominal aortic aneurysm repair, based on prospectively entered National Vascular Registry data, pre and post centralization in the South West of England. The primary outcome was mortality at 30 days. Secondary measures included 30-day morbidity, length of hospital stay, and length of intensive care unit stay. RESULTS: The 30-day mortality was unchanged pre and post-centralization (11% vs 12%, P = 0.84). The 30-day morbidity rate was also unchanged (24% vs 25%, P = 0.83), as was length of intensive care unit stay (3 vs 3 days, P = 0.74). Overall length of stay was not significantly different (8 vs 6 days, P = 0.76). Subgroup analysis of patients with elective, ruptured, and symptomatic aneurysm repair demonstrated no differences in 30-day mortality. There was a significantly shorter stay post-centralization for patients with symptomatic aneurysms (6 vs 12 days pre-centralization, P = 0.012). CONCLUSIONS: The process of centralization of abdominal aortic aneurysm repair in a vascular network was safe for patients and had no immediate impact on outcomes. Longer-term outcome measures and financial data will be required to further assess the benefit of centralization.

Gallbladder-associated symptomatic hepatic choristoma: Should you resect?

INTRODUCTION: Hepatic choristomas or ectopic livers are uncommon, and occur due to a failure of embryological liver development. They pose a risk of carcinogenesis, with transformation to hepatocellular carcinoma (HCC) being described in the literature (Arakawa et al., 1999). It is often a silent clinical finding that can occur anywhere in the body and is usually diagnosed incidentally during abdominal surgical procedures or autopsies (Eiserth et al., 1940). We present the case of a patient with a symptomatic ectopic liver that was detected preoperatively, and removed laparoscopically with the gallbladder. PRESENTATION OF CASE: A 73-year-old lady was referred to our unit for a gallbladder tumor on ultrasound which was done for biliary colic. Tumor markers were normal. Computed tomography (CT) scan showed an enhanced soft tissue lesion measuring about 3×1.5cm interposed between the gallbladder and liver. Laparoscopic exploration revealed a bean-shaped hepatic choristoma attached to the liver on the medial wall of the gallbladder. The lesion was removed by en-bloc resection during laparoscopic cholecystectomy and extracted carefully in an endobag. Histopathological examination confirmed the absence of carcinogenesis. DISCUSSION AND CONCLUSION: Hepatic choristomas (HC) are a rare entity, usually identified during abdominal surgeries. It had been reported in several studies with different presentations. Awareness of this unexpected finding and familiarity of its potential complications and carcinogenesis will improve care delivery when encountered. Surgical treatment should be considered when the choristoma is not attached to the liver, in light of its potential transformation into HCC.

Giant gastric lipoma presenting as GI bleed: Enucleation or Resection?

INTRODUCTION: Gastric lipomas are unusual benign lesions and account for less than 1% of all tumours of the stomach and 5% of all gastrointestinal lipomas (Thompson et al.2003; Fernandez et al. 1983 [1,2]). Although predominantly asymptomatic and indolent; they may present with gastric outlet obstruction and upper gastrointestinal (GI) bleeding owing to size and ulceration. Only a few cases have been reported, presenting large in size with massive GI bleeding (Alcalde Escribano et al. 1989; Johnson et al. 1981 [3,4]). PRESENTATION OF CASE: We report the case of a 62-year-old gentleman who presented to the emergency department with massive upper GI hemorrhage. He was initially resuscitated and stabilized. Later gastroscopy showed a large submucosal tumour (Fig. 1). Biopsy revealed adipose tissue. Computed tomography (CT) scan of the abdomen and pelvis showed a huge well defined oval soft tissue lesion measuring about 16×8×8cm. The mass noted a homogenous fat density arising from the posterior wall of stomach with no extramural infiltration (Fig. 2). The tumour was completely enucleated through an explorative gastrotomy incision (Fig. 4). DISCUSSION AND CONCLUSION: Massive bleeding secondary to a giant gastric lipoma is a rare finding of a rare disease. The majority of cases in the literature result in major gastric resection. Familiarity with its radiological findings and a high index of suspicion can lead to proper diagnosis in the acute setting. If malignancy is carefully ruled out, stomach preserving surgery is an optimal treatment option.

Gallbladder Mucus Plug Mimicking Ascaris Worm: An Ambiguous Cause of Biliary Colic.

Biliary colic is a visceral pain caused by attempts of the gallbladder or bile duct to overcome the obstruction in the cystic duct or ampulla of Vater. Obstruction can be due to different etiologies such as stone, mass, worm, and rarely by mucus plug. We report the case of a 31-year-old gentleman who presented with recurrent biliary colic and weight loss. Work-up showed linear calcifications in the gallbladder extending to the common bile duct suggesting hepatobiliary ascariasis. Further investigations including stool analysis, upper endoscopy, endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) did not support our provisional diagnosis. Laparoscopic cholecystectomy was performed. Histopathological finding was grossly ambiguous; a rope-like mucus plug resembling ascaris worm was noted. The patient's condition improved instantly after the procedure. To our knowledge, we are reporting the first case in the English literature describing this unique entity of symptomatic gallbladder disease to increase awareness and improve its management.