Case report: Endovascular embolization of the thoracoacromial branch of axillary artery after gunshot trauma at a regional trauma center.

INTRODUCTION AND IMPORTANCE: Penetrating subclavian-axillary artery injury is a rare vascular injury associated with high morbidity and mortality rates traditionally treated with open surgical repair, however endovascular treatments have been utilized in selected cases. CASE PRESENTATION: We report a case of a 31-year-old male with a traumatic gunshot injury to the thoracoacromial branch of the left axillary artery successfully managed with endovascular embolization at a regional trauma center. CLINICAL DISCUSSION: The availability of a hybrid operating suite in severely injured patients is associated with reduced time to intervention, reduced operative duration and improved clinical outcomes. Our experience demonstrates the utility and benefit of a hybrid operating theatre in a regional trauma center. The availability of a hybrid suite allowed rapid diagnostic and therapeutic angiography with a minimally invasive approach and eliminated the need for urgent open surgical management. However, the high costs associated with a hybrid operating theatre remain the major barrier for most regional centers. CONCLUSION: The availability of hybrid operating theatre at a regional trauma center allowed early diagnosis and successful management of the injury with a minimally invasive endovascular approach.

Case report: Haemoperitoneum secondary to acute rupture of primary hepatic angiosarcoma.

INTRODUCTION AND IMPORTANCE: Primary hepatic angiosarcoma (PHA) is a rare and aggressive liver malignancy of endothelial cell origin and is associated with poor outcome. Pre-operative confirmation of the diagnosis is challenging, as clinical and radiological findings are generally non-specific. Very rarely, spontaneous haemoperitoneum may occur due to the spontaneous rupture of previously undiagnosed PHA. CASE PRESENTATION: We describe a case of a 28-year-old male with haemoperitoneum due to the rupture of previously undiagnosed PHA. After failing to respond to the non-operative measures, the patient underwent emergency partial liver resection and recovered without any post-operative complications. Histopathological examination of the specimen confirmed the diagnosis of PHA. Two months after the operation, the patient represented with advanced metastatic disease and disseminated intravascular coagulation (DIC). The patient died one month after discharge. CLINICAL DISCUSSION: A patient with PHA presents a diagnostic challenge due to its rare incidence and non-specific clinical findings. Spontaneous intra-abdominal haemorrhage can occur due to PHA rupture and carries a dismal prognosis. In addition to emergency haemorrhage control, complete surgical resection with clear margins is the definitive treatment to date, however, most cases of PHA are unresectable at diagnosis and recurrence is common even after complete resection. CONCLUSION: PHA is associated with very poor outcomes, due to its rapid progression, early recurrence, and metastatic nature. The median survival is approximately 5 months. Haemoperitoneum secondary to rupture of previously undiagnosed PHA is uncommon and is a poor prognostic indicator. Complete surgical resection of the disease is challenging and there is no established treatment.

Increasing rate of para-oesophageal hiatus hernia surgical repair within Australia.

BACKGROUND: Symptomatic para-oesophageal hiatus (PEH) hernias are treated by surgical intervention, and are associated with older age (>50 years) and higher body mass index (>25 kg/m2 ). Both risk factors are increasing within the Australian population. Given these trends, this study aimed to determine if the rate of PEH repair is increasing within Australia. METHODS: The study used publically available Medicare Benefits Scheme service data for operations claimed under the item number 31468 (PEH hernia, repair of, with complete reduction of hernia, resection of sac and repair of hiatus, with or without fundoplication) between 1 January 2001 and 31 December 2016. Directly age-standardized rates per 100 000 population were calculated using the 2001 Australian standard population and compared using Poisson regression models. RESULTS: Repair of PEH significantly increased (P < 0.0001) in Australia during this period, with the average number of services increasing by 14.6% per annum. Average rates of repair increased significantly (P < 0.001) with increasing age up to 75 years after which they significantly reduced (P < 0.001) in each successive age group. Western Australia had the greatest increase in annual claims and Northern Territory had the least, but the state-specific average claim rate over the whole period was highest in Queensland and lowest in Northern Territory. CONCLUSION: Operations claimed under Medicare Benefits Scheme item number 31468 have significantly increased in Australia since January 2001. Reasons for this rise are likely multifactorial, and may indicate increasing PEH incidence, increased diagnosis and investigation or increased surgical capability to manage the issue laparoscopically with reduced peri-operative morbidity.

International publication trends in hepato-pancreato-biliary surgery: emergency compared to oncology.

BACKGROUND: There is growing interest in publishing trends given the increasing amount of research publication across various specialities. Studies relating to hepato-pancreato-biliary (HPB) surgery show an oncological focus compared to benign, emergency and trauma. METHODS: Analysis of ISI JCR impact factors in the Web of Knowledge and the Scimago Journal Rank through Scopus was performed to select four readily available, relevant and frequently read journals from the surgery category. A total of 5265 articles between 2012 and 2016 were categorized relating to emergency or oncology topics. A secondary analysis of PubMed MeSH term was performed to scrutinize trends of publishing over the period 1960-2016. RESULTS: Of the 5265 articles screened, 2062 related to HPB surgery. Of these, 49% (1007 of 2062) were oncology related. This trend towards oncology-related topics is continued in HPB subspecialty journals where 51% (679 of 1320) of articles are oncology related. Emergency- and trauma-related topics accounted 10% (198 of 2062) overall, whereas in subspecialty journals, they account for 8% (111 of 1320). Secondary analysis of MeSH term trends demonstrated a now stable trend over the last 20 years of liver and pancreatic trauma to oncology ratio of 1:10 publications, and biliary trauma to oncology publishing ratio of 1:5. CONCLUSIONS: Quantitatively oncology topics are published favourably, whereas emergency- and trauma-related HPB articles appear static. This is in keeping with baseline trends over the last five decades. Further analysis could delineate whether publishing in trauma subspecialty journals compensate for this trend.

Loop and drain technique for subcutaneous abscess: a safe minimally invasive procedure in an adult population.

BACKGROUND: This study evaluated the safety, efficacy and compliance of an emerging technique for managing complex subcutaneous abscesses in an adult population (≥16 years). METHODS: A retrospective review of prospectively collected data between April and October 2015 at a rural hospital comparing conventional incision drainage (CID) and repetitive packing to the minimal incision, irrigation, loop and drain technique (LDT). LDT method was consistent with previous publications, being ≤5 mm incisions at abscess edges, irrigation and passage of a VessiLoop through the cavity and then secured above the skin. The loop remained in situ until resolution. Both groups had empirical oral antibiotics. RESULTS: Sixty-three patients required intervention for complex subcutaneous abscess: CID group had 27 patients and LDT had 36 patients. The mean age of CID group was 43.9 years (range: 16-86 years), all required intervention in theatre with 10 patients lost to follow-up (37%) and the remaining 17 required a mean of 11.8 (range: 1-17) care visits. The mean age of LDT group was 34.9 years (range: 16-62 years), 11 completed intervention in ED under local anaesthetic (30%) and 27 required general anaesthesia. Compliance to follow-up clinic was 100%: 27 seen once at 10-14 days with loop removal and nine were seen a second time to complete care. There were no re-operations. CONCLUSION: This is the first LDT data in adults and proves it is safe and effective. It saves operating theatre time with 30% of LDT treated in the Emergency Department and ensures excellent follow-up compliance as patients return for VessiLoop removal. Healthcare burden is greatly reduced using LDT; most patients require only one review at 10-14 days.

What proof is in your Christmas pudding? Is caring under the influence possible?

OBJECTIVES: To determine the ethanol concentration of commonly available Christmas puddings, and to extrapolate the blood alcohol content (BAC) of typical health care professionals after Christmas lunch at the hospital. DESIGN AND SETTING: We conducted fractional distillation of Christmas puddings and analysed the distillate for ethanol content. We then applied standard pharmacological and physiological assumptions to assess predicted BAC in typical male and female health care professionals at our hospital. MAIN OUTCOME MEASURES: Ethanol concentration of each pudding; estimated BAC of health care professionals after ingestion and at the end of a 30-minute lunch break. RESULTS: The concentration of ethanol in common Christmas puddings ranged from 0.260 to 1.685 g per 125 mg slice. The concentration of ethanol per pudding was not greater than the stipulated specifications on the packaging, where shown. After pudding ingestion, the theoretical BAC of a typical 70 kg male and 60 kg female health care professional ranged from 0.001 to 0.004 g/dL and from 0.001 to 0.006 g/dL, respectively. Neither male nor female staff had a predicted BAC > 0.000 g/dL by the end of the lunch break. CONCLUSION: Christmas puddings contain ethanol that does not all evaporate during the cooking process. However, the rise in BAC after ingestion of a typical slice of Christmas pudding was negligible and unlikely to affect work performance or safety or impair a health care worker's ability to make complex decisions.