Tracheal Stent Buckling and In-stent Stenosis: A Proposed Airway Management Algorithm for Airway Obstruction for Patients With Tracheal Stents.

EMERGENCY AIRWAY management strategies for patients with complications due to tracheobronchial stents are of growing interest to anesthesiologists. Although tracheal stenting increasingly is used to manage tracheobronchial stenosis of both benign and malignant conditions,1-3 official guidelines for the perioperative airway management of patients with tracheobronchial stents in situ are lacking.3 Here, the authors discuss the management of airway obstruction from a tracheal stent strut protrusion and in-stent stenosis in a patient with a self-expanding nitinol tracheal stent in situ. They discuss the airway management strategy employed and outline a pragmatic airway management algorithm for patients with tracheal stents presenting with airway obstruction.

A spontaneous retroperitoneal haemorrhage resulting in abdominal compartment syndrome requiring laparotomy: A case report and proposed management algorithm.

INTRODUCTION AND IMPORTANCE: Spontaneous Retroperitoneal Haemorrhage (SRH) is a rare condition, which in its extreme state can result in Abdominal Compartment Syndrome (ACS). The aim of this case report is to provide an overview of the diagnosis and management of SRH and to present an algorithm to inform and guide clinical decision-making in the context of ACS. CASE PRESENTATION: A 74-year-old woman with multiple risk factors for SRH developed a tense abdomen in ICU post-cardiac graft study. Radiological imaging confirmed multiple bleeding points to the contralateral side of the graft access site. She underwent endovascular treatment for her condition, however, developed ACS necessitating surgical evacuation of the haematoma. CLINICAL DISCUSSION: SRH is a rare condition that may be difficult to diagnose on physical exam. Medical, endovascular and surgical approaches are recognised treatments. ACS is an extreme variant of SRH and although endovascular management can specifically address the acute bleed, surgical evacuation of the haematoma is the only treatment that can effectively reduce abdominal compartment pressures. CONCLUSION: SRH can cause abdominal compartment syndrome with subsequent multiorgan failure. Ultimately, as outlined in this case, surgical evacuation of the haematoma was the only treatment able to reduce abdominal compartment pressures.

Prognostic role of alpha-fetoprotein in patients with hepatocellular carcinoma treated with repeat transarterial chemoembolisation.

BACKGROUND: Repeat transarterial chemoembolisation (rTACE) is often required for hepatocellular carcinoma (HCC) to achieve disease control, however, current practice guidelines regarding treatment allocation vary significantly. This study aims to identify key factors associated with patient survival following rTACE to facilitate treatment allocation and prognostic discussion. METHOD: Patients with HCC undergoing rTACE at six Australian tertiary centers from 2009 to 2014 were included. Variables encompassing clinical, tumour, treatment type and response factors were analysed against the primary outcome of overall survival. Univariate analysis and multivariate Cox regression modelling were used to identify factors pre- and post-TACE therapy significantly associated with survival. RESULTS: Total of 292 consecutive patients underwent rTACE with mainly Child Pugh A cirrhosis (61%) and BCLC stage A (57%) disease. Median overall survival (OS) was 30 months (IQR 15.2-50.2) from initial TACE. On multivariate analysis greater tumour number (p = 0.02), higher serum bilirubin (p = 0.007) post initial TACE, and hepatic decompensation (p = 0.001) post second TACE were associated with reduced survival. Patients with serum AFP ≥ 200 ng/ml following initial TACE had lower survival (p = 0.001), compared to patients with serum AFP level that remained < 200 ng/ml post-initial TACE, with an overall survival of 19.4 months versus 34.7 months (p = 0.0001) respectively. CONCLUSION: Serum AFP level following initial treatment in patients undergoing repeat TACE for HCC is a simple and useful clinical prognostic marker. Moreover, it has the potential to facilitate appropriate patient selection for rTACE particularly when used in conjunction with baseline tumour burden and severity of hepatic dysfunction post-initial TACE.

Popliteal pseudoaneurysm after FOLFOX chemotherapy for metastatic colorectal cancer.

INTRODUCTION: Popliteal artery aneurysms are a rare occurrence in the general population. We present the case of a male who developed a popliteal artery pseudoaneurysm following chemotherapy for metastatic colorectal cancer. CASE PRESENTATION: A 49-year old male presented with a popliteal artery pseudoaneurysm after completing four two-weekly cycles of FOLFOX chemotherapy. There was no history of infection, knee trauma, inflammatory diseases, or any family history of cardiovascular disease or aneurysms. Examination revealed a tender pulsatile mass in the right popliteal fossa with calf oedema. Computed tomography angiography demonstrated a right popliteal pseudoaneurysm, that was treated with endovascular stent grafting. DISCUSSION: Anecdotal evidence suggests a link between chemotherapy and the rapid development of abdominal aortic aneurysms exists. Aneurysms have been reported following cisplatin and 5-fluorouracil treatment and trans-arterial administration of irinotecan, a key component of chemotherapy. Chemotherapeutic agents have also been shown to compromise the integrity of the vascular wall through apoptosis of endothelial and smooth muscle cells. In our case, the pseudoaneurysm developed acutely after treatment with FOLFOX, therefore a mechanistic association is plausible. CONCLUSION: Differentiating aneurysms as false (pseudo) or true is important to help determine the underlying aetiology. Common causes of pseudoaneurysms include arterial blunt or penetrating trauma. True aneurysms commonly develop from inflammatory atherosclerosis, however mycotic infection, inflammatory arteritis, and entrapment syndrome should be excluded. There may be some evidence to suggest a genetic predisposition to popliteal artery aneurysms. Anecdotal evidence suggests a weak association between chemotherapy and aneurysm progression, warranting further investigation into a causative link.

Low accuracy and confidence in chest radiograph interpretation amongst junior doctors and medical students.

Accurate chest X-ray (CXR) interpretation is an essential skill in clinical practice. Previous studies have shown poor accuracy and confidence rates (CR) of CXR interpretation by junior doctors and medical students. We presented 10 chest radiographs via an online questionnaire to Australian medical students and junior doctors, who were asked to identify the radiographic abnormality from a list of 15 options and to rate their confidence for each answer. Of 67 complete responses, junior doctors achieved a mean score of 57.6% and medical students 56.1%, with CR of 67 versus 58% respectively. There was a significant positive relationship between accuracy and CR among junior doctors (Pearson's coefficient + 0.798, P = 0.006) and students (Pearson's coefficient + 0.716, P = 0.020). This study identified similarities in strength and weakness in CXR interpretation between medical students and junior doctors. There was a positive association between test scores and self-rated confidence scores.

Case report: Iatrogenic brachial artery dissection with complete anterograde occlusion during elective arterial line placement.

INTRODUCTION: Brachial arterial catheters provide a more accurate reflection of central aortic arterial pressure compared to their radial counterparts. Although brachial arterial line complications are uncommon, we report a case of a rare iatrogenic brachial artery dissection with complete anterograde occlusion from elective arterial line placement. PRESENTATION OF CASE: A 41-year-old female presented for a right upper and middle lobe resection of a large neuroendocrine lung cancer. A brachial arterial line was inserted for continuous blood pressure monitoring using clinical landmarks. Six hours postoperatively the left hand was noted to be pale, cool and pulseless with complete paraesthesia. Thrombus was initially suspected on computed tomography angiography. Upon return to theatre, extensive dissection of the posterior brachial arterial wall was identified. CONCLUSION: We review our diagnostic pathway and treatment of this rare complication. Recommendations to minimise the risks of complications from brachial arterial line insertion are also overviewed. We recommend the routine utilization of ultrasound-guided technique and regular post-insertion neurovascular monitoring for the prevention and early recognition of complications from brachial artery catheter insertion.

Transjugular biopsy case report of inferior vena cava hepatocellular carcinoma with intracardiac extension.

BACKGROUND: Diagnosis of hepatocellular carcinoma (HCC) can be established with near certainty by correlating radiological imaging with clinical presentation. However, in the absence of diagnostic certainty, biopsy of liver tissue is mandatory for optimal management. We present our management of a patient with advanced liver disease who presented with an IVC mass extending into the right atrium, with co-existing liver lesions not meeting criteria for an imaging diagnosis of HCC. CASE PRESENTATION: A 62-year-old male with Child-Pugh C liver cirrhosis presented with decompensated liver failure. Multiple imaging modalities demonstrated an inferior vena cava (IVC) mass extending into the right atrium with co-existing liver lesions not meeting radiological criteria for an imaging diagnosis of HCC. There was no contiguous evidence of HCC in the liver, yet there was extensive tumour burden in the IVC representing a separate metastatic lesion without any indication of direct tumour spread. Under fluoroscopic and angiographic guidance, a biopsy catheter was advanced through the right atrium into the IVC. Histology from the biopsy demonstrated fragments of malignant tumour with features consistent with moderately differentiated HCC without thrombus. Given the poor prognosis associated with metastatic HCC with IVC and intracardiac involvement, a multidisciplinary decision was made with the patient's family for palliation care. CONCLUSION: Transjugular biopsy of IVC masses can be performed effectively, in an awake patient, without the need for sedation or anaesthesia. Where multiple imaging modalities fail to confirm a diagnosis for liver or IVC pathology, transluminal biopsy can assist with definitive diagnosis and treatment planning.

Preoperative left hepatic lobe devascularisation to minimize perioperative bleeding in a Jehovah's Witness undergoing left hepatectomy.

INTRODUCTION: Major liver resection in a Jehovah's Witness presents unique clinical challenges requiring multimodal blood minimization strategies to reduce perioperative complications. We report a case where complete left hepatic lobe devascularisation was undertaken to minimize bleeding in a Jehovah's Witness undergoing left hepatectomy. PRESENTATION OF CASE: A 65-year-old male Jehovah's Witness presented for open left hepatectomy for a large left-sided hepatocellular carcinoma involving segment IV of the liver. Three weeks prior to surgery, the patient underwent left portal vein embolization. To isolate and devascularise the left lobe, the gastroduodenal artery and left hepatic artery were then occluded with coils. The bed of the left hepatic artery was then embolised to stasis with particles. Finally, the anastomosis back to the right hepatic artery was also occluded by coils. The patient underwent uneventful surgery with an estimated blood loss of 450mls. DISCUSSION: Left hepatectomy in a Jehovah's Witness patient is feasible but requires careful planning and a multidisciplinary approach. Major liver resection represents a well defined but complex haemostatic challenge from tissue and vascular injury, further complicated by hepatic dysfunction, and activation of inflammatory, haemostatic and fibrinolytic pathways. In addition to the haemoglobin optimization strategies utilized preoperatively, the use of interventional radiology techniques to further reduce perioperative bleeding should be considered in all complex cases. CONCLUSION: Combination of portal vein embolization and hepatic lobe devascularisation to produce total vascular occlusion of inflow to the left lobe radiologically allowed a near bloodless surgical field during major liver resection in a Jehovah's Witness patient.

Postoperative wristwatch-induced compressive neuropathy of the hand: a case report.

INTRODUCTION: Postoperative peripheral nerve injuries are well-recognised complications of both surgery and anaesthesia and a leading cause of litigation claims. We present a rare cause of compressive sensory and motor neuropraxia of the median, ulnar and radial nerves of the right hand resulting from a wristwatch that was worn on the first postoperative night following minor surgery. Mechanisms of this compressive neuropathy are discussed, with specific recommendations made regarding the wearing of wristwatches, jewellery and constrictive clothing in the immediate postoperative period. CASE PRESENTATION: A 12-year-old white boy presented with a complete glove and stocking sensory and motor neuropathy involving his right hand from a wristwatch that was worn on the first postoperative night following uneventful surgery for a minor procedure. Over the following 12 hours the oedema and erythema resolved with complete return of motor function. After 18 hours, the sensory deficit completely resolved. CONCLUSIONS: Postoperative neuropraxia is often preventable. Paediatric patients, especially if thin, may be particularly susceptible to a compression neuropathy from constrictive clothing or jewellery, in particular circumferential varieties such as wristwatches. These items should not be worn in the immediate postoperative period as pressure on peripheral nerves can result in severe and debilitating nerve injury. Education should be given to all medical staff, carers or parents of children undergoing surgery on the avoidance of wearing wristwatches, jewellery or constrictive clothing in the immediate postoperative period. Early medical evaluation of any postoperative nerve injury is of paramount importance.

Validation of a clinical decision rule: chest X-ray in patients with chest pain and possible acute coronary syndrome.

Current literature suggests that a large proportion of chest X-rays (CXRs) performed in emergency department (ED) patients with chest pain and suspected acute coronary syndrome (ACS) are unnecessary. The Canadian ACS Guidelines aim to guide clinicians in the appropriate use of CXR within this patient population. This study determined the prevalence of clinically significant CXR abnormalities and assessed the utility of the guidelines in a population of ED patients with chest pain and suspected ACS. Included in the study were participants over the age of 18 who presented to an Australian metropolitan ED, over a 1-year period, with a primary complaint of chest pain and who had a CXR and troponin level ordered in the ED (N = 760). We retrospectively compared their radiographic findings with their recommendations for CXR according to the ACS Guidelines. We found that 12 % of the participants had a clinically significant chest X-ray. The guidelines had a sensitivity of 80 % (95 % CI 0.70-0.87) and specificity of 50 % (95 % CI 0.47-0.54). The positive predictive value was 18 % (95 % CI 0.15-0.22) with a 95 % negative predictive value (95 % CI 0.92-0.97). Had the ACS guidelines been applied to our patient population, the number of CXR performed would have been reduced by 47 %. This study suggests that the ACS Guidelines has the potential to reduce the numbers of unnecessary CXR performed in ED patients. However, this would come at the expense of missing a minority of significant CXR abnormalities.

Gallbladder perforation following transarterial chemoembolisation; a rare but serious complication.

Transarterial chemoembolisation (TACE) is the mainstay of treatment for large or multifocal hepatocellular carcinoma (HCC). However, this procedure is not without potential complications. We report the case of a 72-year-old man with cirrhosis with HCC treated by TACE using drug-eluting beads. He developed persistent fever and severe right upper quadrant pain post-procedure. CT abdomen revealed a large fluid collection closely abutting the gallbladder and tracking inferiorly along the right flank. This fluid collection originated from the gallbladder and contained locules of gas with a contrast-enhancing wall, consistent with an infected biloma. These imaging findings confirmed gallbladder perforation complicating TACE. The development of gallbladder perforation post-TACE from acute ischaemic cholecystitis producing gallbladder wall necrosis is exceedingly rare. The presence of gallbladder perforation must be recognised in patients with persisting symptoms and imaging evidence of a perihepatic fluid collection because specific treatment with intravenous antibiotics and percutaneous drainage of the biloma is necessary.

Incidental maxillary sinus findings in patients referred for head and neck CT angiography.

BACKGROUND: Maxillary sinus pathology is a common finding on routine CT scans of the head and neck. The purpose of this study was to assess the incidental findings in the maxillary sinus on CT scans in patients who presented for head and neck CT angiography. STUDY DESIGN: Images of patients referred for head and neck CT angiography were reviewed over a 5-month period. All maxillary sinus incidental findings were recorded and categorised into mucosal thickening, polypoid mucosal thickening, partial and total opacification. The age and gender of the patients and the side of mucosal pathology was also recorded. RESULTS: A total of 262 CT scans were reviewed (524 maxillary sinuses). Seventy-two patients had pathological changes (27.5%), 44 (16.8%) had mucosal thickening, 20 (8.0%) had polypoid thickening, 6 (2.3%) had partial and another 7 (2.7%) had complete opacification. CONCLUSIONS: There is a high rate of undiagnosed maxillary sinus pathology incidentally found on CT scans. Clinicians reviewing head and neck CT scans such as dentists, general medical practitioners, maxillofacial and ENT surgeons should be vigilant and aware of maxillary sinus disease when interpreting CT scans of the maxilla and patients should be followed up appropriately.