Segmental arterial mediolysis: a rare cause of an acute abdomen.

Segmental arterial mediolysis (SAM) is a nonatherosclerotic, noninflammatory and nonimmune arteriopathy of unknown aetiology. We present the case of a 43-year-old male who presented to the emergency department with abdominal pain. A computed tomography of abdomen and pelvis showed a narrow, hypodense superior mesenteric artery after the origin, raising the possibility of thrombus or vasculitis. He was commenced on rivaroxaban and steroids. He subsequently presented with an acute abdomen in a collapsed state. Repeat imaging of his abdomen and pelvis revealed an ischaemic ileal segment and caecum. He required an emergency laparotomy with resection of the ischaemic segment and formation of a double-barrelled stoma. SAM is an important diagnosis for clinicians and radiologists to be aware of, given the risks of life-threatening haemorrhage and acute organ ischaemia. This is a commonly overlooked cause of abdominal pain, where an early diagnosis with lifestyle modifications may prevent disease progression and subsequent development of life-threatening complications.

The surgical admission proforma: the impact on quality and completeness of surgical admission documentation.

BACKGROUND: Inadequate medical documentation has been associated with a higher rate of adverse events and may have medicolegal consequences. An accurate admission note is critical as it is frequently referred to during inpatient stay, particularly when the patient is acutely unwell and during handover of care. AIM: We set out to implement a surgical admission proforma and evaluate its impact on the quality of acute surgical admission notes. METHODS: A standardised, structured admission proforma for use with all emergency general surgery patients in a busy model 3 hospital was designed and implemented. Previously, all admission notes were performed freehand. The quality and completeness of admission notes was evaluated both before and after implementation of the proforma over two separate 4-week periods by assessing documentation across 19 criteria. RESULTS: Two hundred and fifty-one admission notes before proforma implementation and 273 admission notes after implementation were assessed. Proforma uptake was 97%. Documentation improved in all 19 criteria, with statistical significance achieved in 17 of these. These include past medical history, medication lists, allergy status, physical examination findings, blood results, vital signs and management plan. The proforma showed evidence of improved communication with both nursing staff and senior colleagues. CONCLUSIONS: The surgical admission proforma has significantly improved the quality and completeness of admission documentation, ensuring improved patient safety and efficiency of care. Structured admission proformas have a positive impact on patient outcomes, doctors' performance, hospital efficiency, communication and audit quality control, thus providing multiple clear benefits in comparison to freehand admission notes.

Technical challenges and potential solutions for rectal and sigmoid tumours following previous radiation for prostate malignancy: A case series.

INTRODUCTION: The aftermath of pelvic radiotherapy for prostate cancer (PC) can pose a significant challenge for surgeons in the management of rectal and sigmoid tumours, resulting in extensive fibrosis and difficult anatomy. Higher rates of ureteric injuries and anastomotic leakage following anterior resection (AR) have been reported with no clear consensus for an optimal approach. We present three cases, each employing a different surgical approach tailored to the individual patient-specific and disease-specific factors. PRESENTATION OF CASE: In each case, the patient had active radiation proctitis. Case 1 was a T3 rectal cancer 9 cm from the anal verge. A non-restorative procedure was performed with a permanent end colostomy, due to the extensive pelvic fibrosis encountered in a comorbid patient. In case 2, a large rectal polyp at 12 cm from the anal verge was managed using transanal minimally invasive surgery (TAMIS) with a covering loop ileostomy. In case 3, an elderly patient with dementia with a malignant sigmoid polyp underwent a segmental resection rather than standard oncological resection, thus avoiding either a stoma or rectal anastomosis in the context of active radiation proctitis. All three patients remain well at follow-up with no evidence of recurrence. DISCUSSION: All three cases demonstrate an individualised approach, taking into account specific factors relating to both patient and disease. In all cases, the presence of active chronic radiation proctitis meant that primary colorectal anastomosis was not safe, thus, alternative approaches were taken. CONCLUSION: It is essential to tailor treatment according to patient-specific and disease-specific factors.

The clinical dilemma of the persistent idiopathic pneumoperitoneum: A case report.

INTRODUCTION: Idiopathic pneumoperitoneum (IP) is a rare phenomenon which merits special attention. It is defined as free intraperitoneal air which is not caused by viscus perforation and does not require surgical intervention. It is generally considered a diagnosis of exclusion and often poses a genuine diagnostic dilemma. PRESENTATION OF CASE: We present an unusual case of persistent pneumoperitoneum with no identifiable cause which was found incidentally on a computed tomography (CT) scan in a patient with chronic cough and no prior surgical history. Serial consults revealed no abdominal symptoms or signs. He was managed conservatively and remains asymptomatic despite having a persistent IP on serial radiology. DISCUSSION: To our knowledge, our case is the first in the literature of an idiopathic pneumoperitoneum that persisted on subsequent radiology and was managed successfully without surgical intervention. This is a highly important case for all practicing general surgeons to learn from as knowledge of this phenomenom may help avoid unnecessary surgical intervention and potential morbidities associated with this. CONCLUSION: IP is a diagnosis of exclusion which should only be made after surgical and non-surgical causes have been outruled. In the absence of signs of peritonitis and evidence of gastrointestinal perforation on CT, a conservative approach is warranted, allowing patients to avoid unnecessary surgical intervention.

Family planning and inflammatory bowel disease: the patient and the practitioner.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are commonly in their child-bearing years. Maintainance medication, as recommended by international guidelines, is an emotive topic and an anxiety source. This study measures the awareness of patients and primary practitioners of the issues involved. METHODS: A prospective questionnaire was sent to female patients (18-50 years) with an IBD diagnosis in Kerry General Hospital, Ireland, who were identified from radiology and pathology databases. A seperate questionnaire was sent to General Practitioners (GPs) in the region. RESULTS: About 31 female patients (42%) and 49 GPs (43%) returned completed questionnaires. About 29% had Crohn's disease and 71% ulcerative colitis. A total of 42% of patients would allow having IBD or its treatment to influence decisions about family planning. Most patients were on maintainance medications. Despite this, 68% had not discussed family planning with a doctor. One-third believed all medications should be stopped during pregnancy and 68% reported significant anxiety about future pregnancies. A total of 68% GPs report regular contact with IBD patients, but consultations with pregnant IBD patients are less frequent. About 41% of GPs have not opportunistically raised family planning with this patient group and 67% would refer to a tertiary specialist for advice. About 2% of GP's had need to research the topic in the last 12 months. CONCLUSIONS: There is a significant patient knowledge deficit about pregnancy and IBD resulting in unwarranted fears and anxiety. Further evidence based education for GP's with increased gastroenterologist/IBD nurse specialist support should maximize exploitation of health promotion opportunities to electively address this issue.

Vascular endothelial growth factor and not cyclooxygenase 2 promotes endothelial cell viability in the pancreatic tumor microenvironment.

OBJECTIVES: Cyclooxygenase 2 (COX-2) and vascular endothelial growth factor (VEGF), often coexpressed in cancer, are associated with poor prognosis. However, results from pancreatic cancer trials of their inhibitors were disappointing. This study delineated the role of COX-2 and nonsteroidal anti-inflammatory drugs in angiogenesis and VEGF regulation. METHODS: AsPC-1 and BxPC-3 pancreatic cancer cells were cocultured with human umbilical vein endothelial cells (HUVECs). NS398 or VEGF-neutralizing antibody was added, and HUVEC viability assayed. Prostaglandin E2 and VEGF were quantified. Tumor cells were treated with NS398 or celecoxib, and VEGF quantified. RESULTS: In cocultures, HUVEC viability in AsPC-1 was 60% that of BxPC-3 controls (P < 0.05). Prostaglandin E2 and VEGF from BxPC-3 were double that of AsPC-1 (P < 0.05). NS398 reduced prostaglandin E2 to undetectable levels (P < 0.05) but had no effect on HUVEC viability. Vascular endothelial growth factor-neutralizing antibody reduced HUVEC viability in BxPC-3 wells to that of AsPC-1 (P < 0.05). NS398 had no effect on VEGF. Celecoxib increased VEGF in a concentration-dependent manner in each cell line up to 4-fold (P < 0.05). CONCLUSIONS: Cyclooxygenase 2 does not regulate VEGF in pancreatic cancer, and celecoxib upregulates VEGF in pancreatic cancer. It is VEGF, and not COX-2, inhibitors that reduce tumor-stimulated endothelial cell viability. Future pancreatic cancer trials should consider lower-dose nonsteroidal anti-inflammatory drugs in combination with VEGF inhibitors.

Autoimmune pancreatitis: medical and surgical management.

CONTEXT: Autoimmune pancreatitis is characterised by a lymphoplasmacytic infiltrate consisting in part of plasma cells that produce large amounts of IgG4. It can manifest as focal or diffuse enlargement of the pancreas with associated strictures of the pancreato-bilary tree giving rise to symptoms including abdominal pain, weight loss and obstructive jaundice; thus it can be extremely difficult in both presentation and investigation to distinguish from pancreatic carcinoma. Recent advances now facilitate preoperative diagnosis and effective medical management, including steroid treatment of autoimmune pancreatitis so preventing major surgical intervention. CASE REPORT: Two cases of autoimmune pancreatitis are described, each of which presented with obstructive jaundice and a relatively painless pancreatic mass, one with vascular involvement. They each had elevated serum CA 19-9 and ultimately required surgical exploration to definitely exclude malignancy before embarking on non operative treatment. The first case settled spontaneously while the second rapidly improved with steroid treatment. CONCLUSION: These two cases illustrate the difficulties in diagnosing this condition, the efficacy of steroid therapy and the role of surgical intervention in unresponsive cases or those where a diagnostic dilemma remains.