Diagnostic markers in acute appendicitis.

BACKGROUND: An adequate medical history combined with clinical examination is usually enough to make the diagnosis of acute appendicitis. The aim of this study was to determine the value of elevated white cell count (WCC), C-reactive protein (CRP), and bilirubin as diagnostic markers of acute appendicitis. METHODS: A retrospective analysis was carried out on consecutive patients who underwent appendicectomy over a 3-year period. All data including patients' age, sex, blood test results, and appendix histology were summarized. Sensitivities, specificities, positive, and negative predictive values of WCC, CRP, and bilirubin were calculated separately or in combination for all patients. RESULTS: A total of 447 patients were included. There is a significant difference in the results between patients with negative and positive appendicitis with regards to CRP (32 vs. 73; P < .001), mean total WCC (10.9 vs. 14.0; P < .001), and the mean levels of bilirubin (10.9 vs. 17.2; P < .001). CONCLUSIONS: The diagnosis of appendicitis remains multifactorial and blood tests may help to guide the surgeon in the decision making.

Simultaneous xanthogranulomatous cholecystitis and gallbladder cancer in a patient with a large abdominal aortic aneurysm.

There have been reports of the coexistence of abdominal aortic aneurysm (AAA) with intra-abdominal malignancy including gastric, colonic, pancreatic, and renal. We herein report a case of a previously undiagnosed AAA and a presenting complaint consistent with acute cholecystitis. Following cholecystectomy, this was noted to be a rare form of chronic cholecystitis: xanthogranulomatous cholecystitis. There is a known possible association of this uncommon condition with gallbladder cancer. The management of concomitant pathologies can present a real challenge to the multidisciplinary team, especially with large aneurysms.

Evaluation of patient's understanding and recall of the consent process after open inguinal hernia repairs.

INTRODUCTION: Open inguinal Hernia repair is one of the most commonly performed operative procedure. Despite this, hernia repair can cause considerable morbidity and rarely mortality. Some of these complications such as chronic pain and testicular complications can be easily disregarded, thereby leading to medico-legal claims being made. As a result, the quality of consent process is crucial in increasing patient satisfaction after inguinal hernia repair. This is a prospective study exploring patient's recall of the consenting practice after elective open inguinal hernia repairs at our institute. METHODS: Patients who had an elective, Lichtenstein inguinal hernia repair between January to October 2009 were identified. Patients were contacted by telephone after 3 days and a questionnaire was completed. RESULTS: There were 86 patients included in our study. The male:female ratio was 70:16 whilst the average age was 63.2+/-19.2 years. 42 patients stated pain relief as the main indication for having the operation whilst 30 patients feared incarceration or strangulation as the main indication. Infection was the complication recalled most by patients in our study (31 patients), followed by bleeding (30 patients). Only 2 patients were aware of developing potential chronic pain and 10 patients realised the potential for testicular problems. 57 patients were aware of having a mesh inside their groin. There were 61 patients who were aware of laparoscopic approach as an alternative to open inguinal hernia repair. CONCLUSIONS: Recall of consent is very poor. As a result, repeating the information stated and providing additional resource may reinforce the consent process.

Isolated endarterectomy of femoral bifurcation in critical limb ischemia: is restoration of inline flow essential?

This retrospective study reviews clinical outcomes of isolated common femoral endarterectomy (CFE) for critical limb ischemia (CLI), in particular whether poor runoff and inability to restore inline flow has negative impact. In 30 patients, runoff was assessed on preoperative angiograms and categorized into groups based on Society of Vascular Surgery criteria. Data were evaluated using Cox Regression survival analysis. Freedom from secondary revascularization was not affected by runoff score (hazard ratio for compromised and poor groups being 1.8 (95% CI 0.16 to 20.8) and 1.47 (95% CI 0.09 to 24.3), respectively; P = .894). Distal inline flow was not achieved in 25 (83%) patients, but this was not associated with significantly worse outcome (P = .295, log-rank test). In conclusion, CFE can be performed in CLI with high technical success and there is no significant effect of runoff score on recurrence of symptoms. Limb salvage can be achieved even if options to restore inline flow are limited.

An unusual complication encountered incidentally at laparoscopic cholecystectomy: a case series.

INTRODUCTION: This is a case series of erosion of the common bile duct by an in situ stent found incidentally during laparoscopic cholecystectomy (LC). To the best of our knowledge, this is one of the first reported incidences of this nature. METHOD: Four individual case reports. RESULTS: Thirty nine patients with an in situ CBD stent underwent LC for symptomatic gallstones in our institution over a 4-year time period (2005 to 2009). Four patients were found to have the stent eroding through the wall of the CBD. In these four patients, endoscopic retrograde cholangiopancreatography (ERCP) had previously been performed - extracting stone(s) - followed by sphincterotomy and insertion of a 7 Fr pigtail stent (measuring 4 cm). The operation was converted to open in two patients, and the procedure was abandoned in one of these cases. In the other two patients, the anatomy of Calots triangle was delineated well, and the operator was able to complete LC. The duration between initial pigtail stent insertion and LC ranged from 32 to 400 days. None of our patients required a definitive surgical repair of the CBD or T-tube placement. The stent was removed during surgery in one case, removed endoscopically at a later date in two patients, and passed spontaneously in one patient. All four patients made a good postoperative recovery. CONCLUSION: CBD erosion is a complication of plastic biliary stent insertion. CBD stent erosion will make surgery more hazardous especially if it remains in situ for a significant period of time. CBD erosion can generally be managed conservatively without the need for surgical repair. Awareness of this complication should prompt earlier surgery or earlier removal of plastic pigtail stents.

A life-threatening complication of Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome predisposes to the development of vascular malformations, which may present as life-threatening haemorrhage. This article presents a patient with Ehlers-Danlos syndrome in whom spontaneous rupture of an unusual arteriovenous fistula occurred. This rare diagnosis can be reached through close attention to the history and examination.

Faecal peritonitis secondary to perforated recto sigmoid colon by a large gallstone: a case report.

Large bowel obstruction is an important surgical emergency. The cause of obstruction may be benign or malignant, and include large bowel volvulus, polyps, intraperitoneal adhesions, strictures and neoplastic growths. Large bowel obstruction caused by gallstone(s) is a very rare phenomenon and not many cases are reported in the English literature. The present report describes a case of large bowel obstruction and faecal peritonitis caused by a gallstone perforating sigmoid colon. A database search (PubMed) did not locate any cases of large bowel perforation by a gallstone in the English literature, and hence this case report may be the first on this subject.

Migration of superior vena cava stent.

There has been a recent increase in the use of endovascular prostheses resulting in complex surgical and interventional complications not previously recognised. We report a case of Superior vena cava stenosis treated with a wallstent which migrated to the right atrium, necessitating a combined radiological and surgical approach to retrieve it.

Aneurysm of antecubital vein: an unusual complication of peripheral intravenous cannulation.

BACKGROUND: Intravenous cannulation is a very common procedure. Venous aneurysm secondary to peripheral intravenous cannulation is extremely rare. Moreover, venous aneurysm can mimic other conditions and may confuse the issue. CASE PRESENTATION: We describe a case of a 45-year-old woman who was referred with the diagnosis of varicose vein of right arm. A history of intravenous cannulation at the same site was noted that raised suspicion. The swelling was compressible and turned out to be a venous aneurysm. The lesion was completely excised. Postoperative recovery was uneventful. Histology findings were in conformity with the preoperative diagnosis. CONCLUSION: Caution should be exercised in diagnosing varicose vein at a site that bears a history of intravenous cannulation. The case also raises an important issue regarding consent. Should patients undergoing peripheral intravenous cannulation be warned of this rare complication?

Recognition and management of abdominal compartment syndrome in the United Kingdom.

OBJECTIVE: Abdominal compartment syndrome(ACS) is a condition associated with high mortality if undiagnosed and untreated. ACS is seen in patients managed in intensive care units. Very little is known on the causes, diagnosis and treatment of this condition in the United Kingdom. DESIGN: Questionnaire study. SETTINGS: 222 intensive care units in the UK dealing with acute abdominal condition. RESULTS: 127 (57.2%) questionnaires were returned (32 from teaching hospitals and 95 from district general hospitals. Among these, 96.9% of teaching hospitals and 72.6% of district general hospitals had seen cases of ACS. The conditions most frequently associated with ACS were small and large bowel surgery (67%), vascular surgery (62%) and trauma (60%). ACS was suspected mainly when there was a distended abdomen (98.6%), oliguria (94.5%) and increased ventilatory support (72.2%). The diagnosis was confirmed either clinically (68.4%) or by measuring intra-abdominal pressure (83.7%). The commonest method for measuring intra-abdominal pressure was the intra-vesical route. The pressure threshold for diagnosing the condition was variable, with a range of 11-50 mmHg. There was a large variation in the number of patients who were decompressed. CONCLUSION: Fewer patients are diagnosed with ACS in district general hospitals compared with teaching hospitals. The threshold for the diagnosis of ACS is variable in the UK, as were the numbers of patients who were decompressed, suggesting that many doctors are still reluctant to accept this condition. This study would suggest that there is a need for standardisation of diagnostic threshold and protocols regarding decompression in ACS.

Measurement of critical lower limb tissue hypoxia by coupling chemical and optical techniques.

It has been a long-term goal to develop non-invasive methods that can detect critical levels of tissue hypoxia to help in the management of chronic lower limb ischaemia. In the present study, skeletal muscle oxygenation was measured using a new Clark-type TCPO2 [transcutaneous PO2 (partial pressure of O2)]/PCO2 (partial pressure of CO2) monitoring system and optical NIRS (near-infrared spectroscopy) at graded levels of hypoxaemia using a rabbit model (n=6). The TCPO2/PCO2 probe was placed on the shaved hindlimb to record SPO2 (skin PO2) and SPCO2 (skin PCO2) continuously. A pair of NIRS probes were placed on the limb to monitor HbO2 (oxyhaemoglobin) and Hb (deoxyhaemoglobin). Graded hypoxaemia was achieved by stepwise reductions of FiO2 (fraction of inspired O2) from 30% to 6%. Animals were allowed to recover after each episode of hypoxia at an FiO2 of 30% as indicated by normalized arterial blood PO2. There was a significant (P<0.05) decrease in SPO2 with all grades of hypoxaemia and no significant changes in SPCO2. There was a significant (P<0.05) increase in muscle Hb with all grades of hypoxaemia and a significant (P<0.05) decrease in HbO2 when FiO2 was below 15%. A significant correlation was found between the SPO2 and HbO2 (r=0.92, P<0.001) and both were significantly correlated with arterial blood PO2 (P<0.001). The new TCPO2/PCO2 system, in addition to its application for the assessment of conditions such as chronic venous insufficiency where alteration in skin oxygenation occurs solely, also has potential in conditions such as peripheral vascular disease where both skin and muscle oxygenation may be affected.

Prevention of contrast-induced nephropathy in vascular patients undergoing angiography: a randomized controlled trial of intravenous N-acetylcysteine.

OBJECTIVE(S): Apart from proper hydration, only oral N-acetylcysteine (NAC) has shown efficacy in reducing radiographic contrast media (RCM)-induced acute renal failure, though its benefit has been challenged. We investigated the effect of intravenous (i.v.) NAC on renal function in patients with vascular disease receiving RCM for angiography. METHODS: Single-center, randomized, double-blind, placebo-controlled trial. Based on a previous study, a trial with 44 patients each in placebo and treatment arms would give at least 80% power to show a statistically significant difference at the 5% level. Vascular patients undergoing angiography were consented and segregated into those whose serum creatinine (SC) level was normal or raised (men >1.32 mg/dl; women >1.07 mg/dL). All patients received 500 mL i.v. normal saline 6 to 12 hours prior to and then after angiography. Groups with normal SC and raised SC were randomly assigned to either 1 g of NAC with normal saline before and after angiography or nothing (placebo). Main outcome measures were change in SC and creatinine clearance (CrCl) as measured 1, 2, and 7 days postangiography (with comparison between active and placebo groups using unpaired t test) and incidence of acute renal decline (>25% or 0.5 mg/dL rise in SC) at 48 hours (with comparison between active and placebo using the Fisher exact test). RESULTS: Forty-six patients received NAC (29 normal SC, 17 raised SC), and 48 received placebo (27 normal SC, 21 raised SC). There was no significant difference in postangiography SC or CrCl at any of the time points measured between NAC and placebo in patients with either normal or raised SC. In the raised SC group, 3 patients from both the NAC and placebo groups suffered acute renal declines. Importantly, at 48 hours, the impaired SC group had a significant reduction in CrCl (-14% +/- 41% vs +18% +/- 58%: P = .0142) and a significant rise in SC (+7.0 +/- 25% vs -1.6% +/- 10%; P = .0246) when compared with the normal SC group. CONCLUSIONS: NAC (i.v. at 1 g) precontrast and postcontrast does not confer any benefit in preventing RCM-induced nephropathy in vascular patients. Patients with pre-existing raised SC have an increased risk of renal impairment as defined by a fall in CrCl and a rise in SC post-RCM when compared with patients with normal SC who appear to benefit from hydration.

Recurrent laryngeal nerve injury: a complication of central venous catheterization-a case report.

This case report highlights the emergence of new complications associated with old procedures as the frequency of their use increases. A 29-year-old man with aplastic anemia was admitted for a bone marrow transplant. Before this procedure, a Hickman line was inserted. This was followed by hoarseness of voice. An examination revealed an immobile left vocal cord. Further investigations did not show any cause for this complication. Therefore, the hoarseness and vocal cord paralysis was attributed to trauma associated with the insertion of the Hickman line.

The effect of short-term treatment with simvastatin on renal function in patients with peripheral arterial disease.

The objective of this study was to investigate the effects of lipid-lowering treatment on renal function in patients with peripheral arterial disease (PAD). This was a retrospective study of hyperlipidemic claudicants referred to a vascular surgery and risk modification clinic. Serum creatinine and urate concentrations and the fasting lipid profile were measured pretreatment and after 3-4 months of treatment with 20 mg/day simvastatin. In 103 consecutive patients with PAD (57 men; 46 women), median age 67 years (range: 51 to 83) there was a significant decrease in serum creatinine from a mean (SD) of 87 (12) micromol/L pretreatment to 84 (12) micromol/L post-treatment (p<0.0001). This difference was more marked in the tertile of patients with the highest baseline creatinine levels. There was also a significant reduction in serum urate from 0.37 (0.07) mmol/L to 0.35 (0.07) mmol/L (p<0.0001). Both these effects were independent of the degree of total cholesterol (TC) or low-density lipoprotein (LDL) cholesterol reduction. There was a significant reduction in TC from 6.6 (1.0) to 5.2 (0.8) mmol/L and LDL cholesterol from 4.3 (1.0) to 2.8 (0.7) mmol/L; both p<0.0001. Significant improvement also occurred in the high-density lipoprotein cholesterol and triglyceride levels. Cholesterol lowering with simvastatin 20 mg/day improved indices of renal function after 3-4 months of treatment in hyperlipidemic patients with PAD. Further studies are needed to establish and define the clinical relevance of these findings, especially in patients with different degrees of renal failure.

Differential diagnosis, investigation, and current treatment of lower limb lymphedema.

HYPOTHESIS: The causes and management of lower limb lymphedema in the Western population are different from those in the developing world. OBJECTIVE: To look at the differential diagnosis, methods of investigation, and available treatments for lower limb lymphedema in the West. DATA SOURCE: A PubMed search was conducted for the years 1980-2002 with the keyword "lymphedema." English language and human subject abstracts only were analyzed, and only those articles dealing with lower limb lymphedema were further reviewed. Other articles were extracted from cross-referencing. RESULTS: Four hundred twenty-five review articles pertaining to lymphedema were initially examined. This review summarizes the findings of relevant articles along with our own practice regarding the management of lymphedema. CONCLUSIONS: The common differential diagnosis in Western patients with lower limb swelling is secondary lymphedema, venous disease, lipedema, and adverse reaction to ipsilateral limb surgery. Lymphedema can be confirmed by a lymphoscintigram, computed tomography, magnetic resonance imaging, or ultrasound. The lymphatic anatomy is demonstrated with lymphoscintigraphy, which is particularly indicated if surgical intervention is being considered. The treatment of choice for lymphedema is multidisciplinary. In the first instance, combined physical therapy should be commenced (complete decongestive therapy), with surgery reserved for a small number of cases.