Pancreatic duct filling during cholecystectomy intraoperative cholangiogram and incidence of postoperative pancreatitis.

Background and Aim: Laparoscopic cholecystectomy (LC) with intraoperative cholangiography (IOC) is a commonly performed surgical procedure in most hospitals. Anecdotal evidence suggests that when the pancreatic duct (PD) inadvertently fills during IOC, there may be an increased risk of postoperative pancreatitis (POP). However, there is a paucity of information in the literature about both the incidence of pancreatitis post LC and the incidence of PD filling on IOC and any potential relationship between the two. Methods: A retrospective review was performed of all LC performed in our institution over a 10-year period. IOC images were reviewed and clinical data collated. Results: Of the 1243 procedures identified, 952 had IOC images available for review and were included in the study. The incidence of POP was 0.7%. The incidence of PD filling was 13.4%. Patient's age, sex, urgency of surgery, preoperative liver function tests (LFTs), history of pancreatitis, contrast leakage, and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were not statistically related to the incidence of POP. Of those with PD filling, 2% had POP versus 0.5% who had no PD filling. This trended toward significance on univariate analysis (P = 0.05). However, on logistic regression, POP was the only significant independent risk factor (P = 0.02). Conclusion: The incidence of pancreatitis post LC and IOC is low. PD filling is associated with increased incidence of pancreatitis in this scenario and it is crucial for clinicians to be aware of this potential risk. This retrospective study was based on the review of saved images, and therefore PD filling might have been underestimated. Prospective studies would be useful to ascertain any definitive clinical association.

The enigma of asymptomatic idiopathic pneumoperitoneum: A dangerous trap for general surgeons.

INTRODUCTION: Idiopathic pneumoperitoneum is an extremely rare condition that can easily be misdiagnosed as an acute abdomen. Awareness of this phenomenon can help avoid unnecessary surgical intervention and the potential associated morbidities. PRESENTATION OF CASE: A 76 year old man presented to hospital with dyspnoea and productive cough and was diagnosed with an infective exacerbation of COPD. He subsequently had a CTPA which showed a significant amount of free intraperitoneal gas in the upper abdomen. He was completely asymptomatic from this with no abdominal pain, distension, or significant rise in inflammatory markers. Of note, he had never had previous abdominal surgery or endoscopic procedures. He showed no signs of peritonism and was closely observed with serial abdominal examinations for 24 h. He subsequently tolerated oral intake and was discharged 8 days after admission. DISCUSSION: Spontaneous pneumoperitoneum can be due to a variety of intrathoracic, gynaecologic, intra-abdominal and iatrogenic causes. This is a rare case of asymptomatic idiopathic pneumoperitoneum where no clear aetiology or risk factors were found for his free intraperitoneal gas. To the best of our knowledge there have only been two published case reports in the English literature describing idiopathic pneumoperitoneum in a patient that was completely asymptomatic from it. CONCLUSION: As a general surgeon it is important to be aware of the non-surgical causes of pneumoperitoneum. Knowledge of this uncommon condition may help reduce the risk of unnecessary laparotomy.

Isolated spontaneous biceps abscess causing septic shock in a diabetic patient: A rare case report.

INTRODUCTION: Intramuscular abscesses, particularly in the biceps brachii, are an extremely rare phenomenon. When present they are usually secondary to trauma, intramuscular injections, or systemic disease. PRESENTATION OF CASE: A 56 year old diabetic woman presented to our emergency department with a 3 day history of fever, cough, and a painful left shoulder. Although she had a mechanical fall 2 weeks prior, she denied any pain in her shoulder immediately after the fall. She also denied any history of drug abuse or recent intramuscular injection. On examination she looked acutely unwell and was in acute septic shock requiring inotropic support. Computed tomography of her shoulder showed a large intramuscular abscess in her left biceps brachii muscle. She was immediately taken to the operating theatre for open exploration and washout of the abscess. The multiloculated abscess was tracking into the glenohumeral joint. Post operatively she showed significant clinical improvement and after a 2 week course of intravenous antibiotics recovered well and was discharged from hospital. DISCUSSION: Intramuscular abscesses are usually seen in patients who are immunocompromised. Intramuscular needle injections and haematomas secondary to trauma are also risk factors. To the best of our knowledge, there have only been 4 published reports in the English literature of intramuscular abscess formation in the biceps brachii. CONCLUSION: We report a case of a seemingly spontaneous intramuscular biceps abscess in a diabetic patient presenting with septic shock.

Endoscopic management of gastric perforation secondary to chicken bone: A report of 2 cases.

INTRODUCTION: Ingested foreign bodies (IFB) can uncommonly cause perforation of the gastrointestinal tract. The traditional management is surgical exploration via laparotomy or laparoscopy, although endoscopic options are now gaining prominence. PRESENTATION OF CASE: We present two patients with almost identical clinical presentations of post-prandial abdominal pain and anorexia. On examination they were haemodynamically stable with localised epigastric tenderness. Both patients underwent CT scan of the abdomen, with one scan revealing a foreign body in the stomach penetrating the full thickness of the gastric wall with the tip lying extraluminally. They subsequently underwent endoscopy where a chicken bone was found perforating the wall of the stomach. This was removed via snare and endoscopic clips were used to close the site of perforation. DISCUSSION: The majority of ingested foreign bodies pass through the gastrointestinal tract harmlessly. However some IFBs can cause significant complications like bowel obstruction, bleeding, abscess formation, migration to other organs, and in our case perforation. The diagnosis may be delayed due to an insidious clinical presentation especially if the patient does not recall ingesting anything untoward. Our patients managed to avoid surgery by undergoing successful endoscopic therapy. CONCLUSION: In selected cases, endoscopic management is more cost-effective, minimally invasive, has less post-operative complications, and leads to a more expeditious recovery. Therefore, the role of therapeutic endoscopy for gastric perforations secondary to foreign bodies should always be considered.

Acute pancreatitis as a complication of routine colonoscopy-A rare case report.

INTRODUCTION: Abdominal pain after colonoscopy is a relatively common symptom and usually benign. Colonoscopy-induced pancreatitis is an extremely rare phenomenon that can sometimes be missed leading to delayed diagnosis and treatment. PRESENTATION OF CASE: A 53 year old woman presented to the Emergency Department with abdominal pain, a significantly raised lipase and a CT scan revealing pancreatitis. She had no previous history of pancreatitis or any aetiological risk factors. Her pain started 2 h after having a routine outpatient colonoscopy for polyp surveillance. The endoscopist had no difficulty during the procedure and the findings were unremarkable. She developed a Systemic Inflammatory Response Syndrome (SIRS) and an ileus requiring a prolonged hospital admission. However with conservative management she improved and was discharged on day 11 post-admission in stable condition. DISCUSSION: The mechanism of colonoscopy-induced pancreatitis is not well understood. Hypotheses include mechanical trauma to the pancreas caused by the endoscope particularly at the splenic flexure, over-insufflation of the colon, external abdominal pressure, and transmural colonic burns via electrocautery causing irritation to the pancreas. CONCLUSION: Pancreatitis should be considered in the differential diagnosis of abdominal pain post-colonoscopy after the more common explanations are excluded.

Asymptomatic herniation of ureter in the routine inguinal hernia: A dangerous trap for general surgeons.

INTRODUCTION: Inguinoscrotal hernias of the ureter are an extremely rare phenomenon. They can pose a threat to the unprepared general surgeon performing routine herniorrhaphy. PRESENTATION OF CASE: A 72 year old man presented with a one year history of a lump in the left groin causing occasional discomfort. On examination a partially reducible left sided inguinal hernia was found. He had no urinary symptoms and was otherwise fit and healthy. He had a right inguinal hernia similar to this repaired 20 years ago. DISCUSSION: Intraoperatively the patient had a large sliding inguinoscrotal hernia with a bulky amount of retroperitoneal fat. A white tubular structure was found amongst the hernia contents but demonstrated peristalsis on stimulation with forceps. It was initially thought to be a duplicated vas deferens. The hernia contents were pushed back in and a Lichtenstein repair was performed. Postoperatively the patient was found to have normal renal function and a CT IVP showed mild dilatation of the left ureter amidst irregular retroperitoneal fat (reduced hernia contents). There was no evidence of a stricture or ureteral damage. The urologists managed the patient conservatively with bi-annual imaging of the renal tract. CONCLUSION: Many ureteral inguinal hernias reported in the literature have been on renal transplant patients, while rarely on native kidneys. This case suggests no inguinal hernia repair is routine. Awareness of this anomaly is important, to avoid ureteral injury during herniorrhaphy.