The Role of Magnetic Resonance Imaging in a Difficult Case of Gallstone Ileus.

Gallstone ileus is an uncommon condition that is difficult to diagnose clinically. Although several cases have been reported in the literature, radiolucent gallstones in the setting of gallstone ileus are an exceedingly rare occurrence, and we have not identified any authors who used magnetic resonance imaging (MRI) for the acute diagnosis of this condition. While an MRI is the gold standard for visualizing gallstones, inpatient MRIs are difficult to obtain, even in resource-rich settings. However, if given a high index of suspicion for gallstone ileus, it is pertinent to advocate for an inpatient MRI despite a resolution of patients' symptoms due to the nature of the disease symptomology.

Pre-operative Bariatric Clinic Attendance Is a Predictor of Post-operative Clinic Attendance and Weight Loss Outcomes.

AIM: Our primary aim was to determine whether non-attendance at pre-operative clinics were associated with non-attendance at post-operative clinics and its influence on weight loss. We also sought to examine the relationship between gender, ethnicity and post-operative clinic attendance with respect to weight loss post-bariatric surgery. METHODS: A retrospective audit was performed for patients undertaking the bariatric surgery program at the Auckland City Hospital between 2013 and 2016. RESULTS: One hundred and eighty-four patients completed our program, with a mean age of 46.1 years. Mean weight at commencement was 133.3 kg, with a BMI of 47.4. At 2 years follow-up (n = 143), excess weight loss was 70.8% following RYGB and 68.0% following LSG (p = 0.5743). More patients attended all pre-operative than post-operative clinics (67.4% vs 37.5% p = < 0.001). One pre-operative clinic non-attendance was associated with less weight loss at 2 years and it increases the risk of missing at least 50% of post-operative clinics with a risk ratio of 2.73, p = 0.005. Non-attendance of at least 50% of post-operative clinics was also associated with less weight loss at 2 years (33.4 kg vs 44.3 kg, p = 0.040). Although Maori and Pacific Islanders more frequently missed > 50% of post-operative clinics, weight loss was similar between European, Maori and Pacific Islander populations (2-year weight loss 44.2 kg vs 40.74 kg vs 44.1 kg, respectively, p = 0.8192). CONCLUSION: Pre-operative clinic non-attendance helps predict post-operative clinic non-attendance. Missing any pre-operative clinics and at least 50% of scheduled post-operative clinics is associated with poorer weight loss outcomes.

Comparison of endoscopic and percutaneous drainage of symptomatic necrotic collections in acute necrotizing pancreatitis.

INTRODUCTION: Primary endoscopic and percutaneous drainage for pancreatic necrotic collections is increasingly used. We aim to compare the relative effectiveness of both modalities in reducing the duration and severity of illness by measuring their effects on systemic inflammatory response syndrome (SIRS). METHODS: We retrospectively reviewed all cases of endoscopic and percutaneous drainage for pancreatic necrotic collections performed in 2011-2016 at two hospitals. We assessed the post-procedure length of hospital stay, reduction in C-reactive protein levels, resolution of SIRS, the complication rates, and the number of procedures required for resolution. RESULTS: Thirty-two patients were identified and 57 cases (36 endoscopic, 21 percutaneous) were included. There was no significant difference in C-reactive protein reduction between endoscopic and percutaneous drainage (69.5% vs 68.8%, P = 0.224). Resolution of SIRS was defined as the post-procedure normalization of white cell count (endoscopic vs percutaneous: 70.4% vs 64.3%, P = 0.477), temperature (endoscopic vs percutaneous: 93.3% vs 60.0%, P = 0.064), heart rate (endoscopic vs percutaneous: 56.0% vs 11.1%, P = 0.0234), and respiratory rate (endoscopic vs percutaneous: 83.3% vs 0.0%, P = 0.00339). Post-procedure length of hospital stay was 27 days with endoscopic drainage and 46 days with percutaneous drainage (P = 0.0183). CONCLUSION: Endoscopic drainage was associated with a shorter post-procedure length of hospital stay and a greater rate of normalization of SIRS parameters than percutaneous drainage, although only the effects on heart rate and respiratory rate reached statistical significance. Further studies are needed to establish which primary drainage modality is superior for pancreatic necrotic collections.

Multiple interventions with prolonged length of stay are required for treatment of necrotizing pancreatitis.

BACKGROUND: A proportion of patients with acute pancreatitis (AP) develop necrosis. Around a third will become infected, and this is associated with a significant requirement for intervention and support. We evaluated the burden of necrotizing pancreatitis (NP) in an Australian tertiary hospital with regards to morbidity, mortality and resource consumption. METHODS: This is a retrospective case series of patients with AP admitted for at least 5 days to identify those with NP between 2009 and 2014. Data were analysed in groups according to the determinant-based classification of AP severity. RESULTS: Of 1339 patients with AP, 546 stayed 5 days or longer, and 38 had necrosis. Overall mortality for those with necrosis was 10.5% (4/38). Infection complicated necrosis in 45% (17/38). Organ failure also occurred in 45% (17/38) of patients with necrosis. All patients in the critical category and severe category required admission to the intensive care unit for a median of 21 and 12 days, respectively. A total of 90% of patients with critical category disease developed multi-organ failure, whereas most with severe category disease developed single organ failure only. Overall length of stay increased with increasing severity of disease. Intervention was required in 82% of infected necrosis (median 4 procedures). Those without infection also required multiple radiological investigations (median 7). CONCLUSION: Necrosis is uncommon in our cohort but is associated with a significant health-care burden. Almost half the patients with necrosis develop organ failure requiring prolonged hospital and intensive care unit stay. Patients require multiple investigations and interventions for infected necrosis. NP remains a costly, morbid disease in our society.

Mesothelial inclusion cyst: a rare occurrence.

Mesothelial inclusion cyst is a rare benign tumour that has only 130 cases reported in the literature. Accurate diagnosis and optimal management of this condition remains uncertain. We report a 51-year-old African gentleman, whom presents with abdominal pain and constipation. A computed tomography scan was performed and revealed a large cystic lesion in the right paracolic gutter. The differential diagnosis included appendiceal mucinous neoplasm, cystic tuberculosis and duplication cyst. A laparotomy was performed due to his symptoms and size of the cyst. Macroscopically, the tumour had a size of 25 × 10 × 10 cm and revealed a necrotic lymph node. It was resected en bloc with the appendix and an ileocolic anastomosis performed. Histology revealed a diagnosis of mesothelial inclusion cyst and acute appendicitis. The patient recovered well and had no recurrence at 2-year follow-up.

Is the acute surgical unit model feasible for Australian regional centres?

BACKGROUND: A significant proportion of general surgery emergency procedures are conducted after-hours in regional centres. The acute surgical unit (ASU) model reduces the number of after-hours operations performed. We review the burden of emergency surgery in a regional centre and assess what components of the ASU model would benefit regional hospitals. METHODS: Retrospective analysis was performed on data for all emergency cases performed at Latrobe Regional Hospital (LRH) over a 1-year period. Time into and out of theatre was used to determine total theatre usage and if the operation occurred after-hours. ED triage time to theatre and start time for appendicectomy was compared to data from our metropolitan referral hospital, Monash Medical Centre (MMC), which has employed an ASU. RESULTS: General surgery emergency cases in regional areas are regular and predictable with a median of two emergency cases performed, and a mean theatre time of 156 min per day at LRH. On weekdays, 43.1% (n = 503) of emergency cases were done in the evening (18.00-24.00 hours), compared to 20.3% (n = 217) on weekends when an emergency theatre is available during the day. LRH performed more appendicectomies after-hours than MMC over a 1-year period. CONCLUSION: Regional centres have a significant burden of general surgery emergency procedures; of which the number performed after-hours is comparable to metropolitan centres. The number of procedures and theatre time required by these cases justify a dedicated emergency theatre in-hours similar to metropolitan ASU models and this would reduce emergency operating after-hours.

Delayed post-traumatic capillary haemangioma of the spine.

Capillary haemangiomas are well-circumscribed aggregates of closely packed, thin-walled capillaries separated by connective tissue stroma. In subcutaneous tissue they are termed pyogenic granuloma and commonly follow trauma. They rarely occur in the spine. We present a 43-year-old woman with a 6-week history of thoracic myelopathy and back pain on a background of T7 and T8 vertebral compression fractures from a motor vehicle accident 10 years previously. MRI demonstrated a posteriorly based extradural homogeneously enhancing mass at this level. The lesion was resected and diagnosed histopathologically as a capillary haemangioma. The patient's symptoms resolved and she made an uneventful recovery. The literature is reviewed and the possible pathogenesis is discussed.