Iatrogenic diaphragmatic herniation of the liver into the pericardium-a case report.

Iatrogenic diaphragmatic herniation is rare. This case is an example of herniation of the liver into the pericardial space post-transdiaphragmatic pericardial window formation for recurrent pericarditis. This case highlights that transdiaphragmatic herniation of intra-abdominal organs should be considered in patients presenting with gastrointestinal or cardiorespiratory symptoms with history of iatrogenic diaphragmatic defect.

Replacing plastic bread clips with cardboard will prevent bowel perforation.

Plastic bread clips cause significant morbidity and mortality if accidentally ingested. A review of all existing case reports published in medical literature was conducted in PubMed, MedLine and Google Scholar. Key words included but was not limited to; clip, tag, tab, closure, kwik lok, bread, bag, ingestion, bowel, obstruction, perforation, plastic and foreign body. References of all the articles were sought out to ensure completeness. Fifty-six cases between 1975 and 2020 were analysed to understand the complications and the characteristics of the bread clip that caused these. About 28% of case reports described bowel perforation, with 61% of these occurring in the small bowel. Plastic bread clips are firm in nature, long lasting, and are shaped to grasp onto bowel, thus leading to these complications. Commercially available alternatives are introduced in order to encourage replacing plastic bread clips worldwide.

Comparative Analysis of Models of Care and Its Impact on Emergency Cholecystectomy Outcomes.

Background: The implementation of the acute surgical unit (ASU) model has been demonstrated to improve care outcomes for the emergency general surgery patient in comparison to the traditional "on call" model. Currently, only few studies have evaluated surgical outcomes of the ASU model in patients with acute biliary pathologies. This is the first comparative study of two different emergency surgery structures in the acute management of patients with acute cholecystitis and biliary colic. Methods: A retrospective review of patients who underwent emergency cholecystectomy for acute cholecystitis and biliary colic at two tertiary hospitals between April 2018 and March 2019 was conducted. Primary outcomes included length of hospital stay, time from admission to definitive surgery, and postoperative complications. Secondary outcomes include proportion of cases performed during daylight hours, length of operating time, rate of conversion to open cholecystectomy, and consultant surgeon involvement. Results: A total of 339 patients presented with acute biliary symptoms and were managed operatively. Univariate analysis identified a shorter mean time to surgery in the traditional group compared to the ASU group (29.2 hours versus 43.1 hours; P < .001). There was no difference in mean length of stay, operation duration between models, and postoperative complication rates between groups, with the majority of surgeries performed during daylight hours. The ASU group had a greater proportion of consultant-led cases (48.2% versus 2.5%, P < .001) compared to the traditional group. Conclusion: Patients with acute biliary pathology requiring laparoscopic cholecystectomy achieve equivalent surgical outcomes irrespective of the model of acute surgical care.

Impingement by a polymyomatous uterus: a rare cause of large bowel obstruction.

A primiparous female developed acute large bowel obstruction Day 1 post lower segment Caesarean section. Initially presumed to be post-operative ileus, increasing abdominal pain and distension over the next 24 h prompted a surgical consult. Computed tomography imaging demonstrated an abrupt transition point of the large bowel behind a polymyomatous uterus. Although this case resolved with vigorous patient mobilization, literature review reveals previous cases resolving only after intraoperative mobilization of the uterus. It is distinct from ileus as bowel sounds are present, onset is abrupt, progression is rapid and mobilization of the uterus causes immediate resolution. This condition is likely to be more common than the literature would suggest, its scarcity partially due to the reluctance to image young females especially during pregnancy.

Jejunal perforation secondary to migrated biliary stent.

An 80-year-old female presented with acute left-sided abdominal pain. Cross-sectional imaging demonstrated a contained perforation around a migrated biliary stent within a large incisional hernia. Significant surgical background included an open cholecystectomy complicated by bile leak and insertion of a biliary stent 2.5 years prior. The stent had migrated at the time of attempted retrieval 10 weeks post-insertion. A decision was made to pursue conservative management after which time she remained asymptomatic until her acute presentation. Emergency laparotomy, adhesiolysis, stent removal, small bowel resection and abdominal wall closure were successfully performed in this case. In the setting of the biliary stent migration, it is important to consider individual patient's risk factors for acute perforation, such as intra-abdominal adhesions or diverticular disease, when deliberating conservative management versus elective surgical intervention for stent retrieval.

Comparative analysis of emergency general surgery on-call structure and its impact on emergency appendicectomy outcomes.

BACKGROUND: In Australia, there has been a shift from the traditional 'on-call' surgical model to the 'acute surgical unit' (ASU) model to improve outcomes in acute general surgery. Using emergency appendicectomy as a standardized procedure, we aimed to identify the different patterns of care between these on-call structures by comparing two metropolitan district hospitals; one that employs a traditional on-call model and the other, which employ the ASU model. METHODS: Data on consecutive patients undergoing emergency appendectomies at the two hospitals (traditional and ASU model) between July 2018 and December 2018 were retrieved for retrospective review. Patient factors, preoperative factors, operative factors and post-operative outcomes were collected and tabulated for comparative analysis between the traditional versus ASU model of care. RESULTS: Univariate analysis demonstrated that there were a greater proportion of consultant-led cases (P < 0.001), a shorter time to theatre (P = 0.047) and a greater number of out-of-hours operations (P < 0.001) in the ASU model compared to the traditional model. A larger proportion of patients from the traditional model underwent a computed tomography scan as part of their diagnostic workup compared to the ASU model (P < 0.001). There was no difference in negative appendicectomy rates, intraoperative conversion rates, post-operative complication rates or mean lengths of hospital stay between the two on-call models. CONCLUSION: The ASU and traditional on-call model appears to achieve equivalent care outcomes for patients with acute appendicitis.

Cohort study of 1241 patients to identify predictors of negative appendicectomy.

BACKGROUND: Acute Appendicitis is the most common surgical presentation within Australia. Despite the increasing use of radiological investigations to aid clinical diagnosis, many appendectomies result in a histologically normal appendix. This study examines the histological negative appendicectomy rate (NAR) in a metropolitan hospital and determine factors associated with a negative appendicectomy (NA). METHODS: Patients who underwent emergency appendicectomy for suspected acute appendicitis at Logan Hospital, Australia, between February 2016 and March 2019 inclusive were included. Clinicopathologic and imaging variables were analysed for associations with NA. RESULTS: A total of 1241 patients underwent emergency appendicectomy of which 121 patients (9.8%) had a NA. The NAR for clinical diagnosis alone (no imaging) was 9.9%, 14.5% for ultrasonography alone and computed tomography scan alone was 4.9%. Univariate analysis revealed age <27 years (P < 0.001), absence of hypertension (P = 0.008), symptoms >48 hours (P < 0.001), absence of leucocytosis (P < 0.001), undergoing ultrasonography only (P < 0.001), undergoing computed tomography scan only (P < 0.001), macroscopically normal appendix (P < 0.001) and time to operation >24 hours (P < 0.001) were associated with NA. Multivariate analysis identified symptoms >48 h at presentation (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.20-3.24; P = 0.007), absence of leucocytosis (OR 2.41, 95% CI 1.52-3.81; P < 0.001) and macroscopically normal appendix (OR 5.70, 95% CI 3.49-9.33; P < 0.001) to be associated with a NA. CONCLUSION: The NAR reported is lowest in an Australian institution. The identified predictors of NA will be useful in identifying patients who would truly benefit from an appendicectomy versus those would have a higher rate of NA who may be suitable to be treated non-operatively to be spared the unnecessary morbidity of surgery.

Early outcomes of emergency ventral hernia repair in a cohort of poorly optimized patients.

BACKGROUND: Strangulated and obstructed ventral hernias require emergent repair to mitigate the risk of life-threatening complications. Emergency ventral hernia repairs are associated with a higher rate of surgical complications and recurrence compared to elective repairs. The purpose of this study was to explore the impact of patient factors, hernia and operative characteristics on post-operative outcomes in patients requiring emergency ventral hernia repairs. METHODS: Data were collected from a prospectively held database on 86 consecutive patients undergoing emergency ventral hernia repairs between January 2016 and January 2019 at Logan Hospital. Patient, hernia and operative characteristics were collected for reporting and analysis. RESULTS: Of the 86 patients, 29 (34%) developed a surgical complication, of which 17 patients (59%) had surgical site infections. We identified obesity (P = 0.017), history of smoking (P = 0.008), American Society of Anesthesiologists class of III-IV (P = 0.008), hernia defect size ≥3 cm (P = 0.048) and concomitant small bowel resection (P = 0.028) to be associated with post-operative surgical complication. Multivariate analysis identified smoking (P = 0.005) and concomitant small bowel resection (P = 0.026) as independent predictors for developing surgical complications. Seven patients (8%) recurred at a median of 221 days. Incisional hernias (P = 0.001), recurrent hernias (P < 0.001), greater than one defect (P < 0.001) and bowel involvement (P = 0.049) were associated with higher rates of hernia recurrence. CONCLUSION: Patient factors significantly influence outcomes in the emergency setting. Given that this is not modifiable at the time of surgery, greater emphasis needs to be placed on optimizing the physical and behavioural factors of patients with early symptomatic hernias for an elective repair.

Operative Surgery Is Rarely Required in the Acute Management of Diverticulitis in the Modern Era.

Acute diverticulitis is an emergency surgical condition that is commonly managed via an acute surgical unit model. Operative surgery is indicated in selected situations including generalized peritonitis or fistulous disease; however, limited data exist on how borderline patients potentially needing surgery may be salvaged by close clinical management with modern interventional techniques. The aims of the study were to identify the operative surgery rates in acute diverticulitis and predictors for identifying patients with complicated diverticulitis. Retrospective data collection was performed on a prospectively held database at a high-volume acute surgical unit at Logan Hospital, Queensland. Patient demographic data, disease-related factors, and treatment-related factors were collected for reporting and analysis. Over three years (2016-2018), 201 patients (64%) were admitted with uncomplicated diverticulitis and 113 patients (36%) with complicated diverticulitis. An observable downward trend was noted in the number of yearly admissions for uncomplicated diverticulitis. Complicated diverticulitis was associated with male gender (P = 0.039), increased length of hospital stay (P < 0.001), temperature ≥37.5 (P = 0.025), increased white cell count (P < 0.001), and elevated C-reactive protein (P < 0.001). Twelve patients (11%) with complicated diverticulitis initially failed conservative management. Seven patients (6%) underwent a definitive Hartmann's procedure, and 5 patients (4%) underwent percutaneous drainage of abscesses. Acute diverticulitis can be safely managed nonoperatively by medical therapy and percutaneous drainage of abscesses, with surgery reserved for patients with complicated diverticulitis with sepsis or peritonitis.

Anti-lipid therapy and risk factor management for triglyceridaemia-induced acute pancreatitis.

BACKGROUND: Pancreatitis secondary to hypertriglyceridaemia is rare, accounting for less than 5% of pancreatitis presentations. We reviewed our institutional experience with triglyceridaemia induced acute pancreatitis to report the clinical presentation, patient demographics and clinical management. METHODS: The Acute Surgical Unit database at a high-volume general surgical referral centre was queried to identify cases of acute pancreatitis secondary to hypertriglyceridaemia between 2016 and 2019. Patient demographics, clinical manifestations, biochemical derangements and treatment regimens were analysed. Current related literature was reviewed. RESULTS: There were 496 presentations for acute pancreatitis of which 14 presentations (2.8%), amongst 12 patients were due to hypertriglyceridaemia. The mean triglyceride level at presentation was 92.46 (standard deviation 46.9) mmol/L. Ten patients (83%) had poorly controlled type 2 diabetes. All patients were managed using conservative therapy combined with a restricted fat diet and commenced on long-term anti-lipid therapy to manage associated risk factors. In addition, 10 patients received an insulin infusion and one patient received insulin infusion, plasmapheresis and heparin infusion in combination. The median length of hospital stay was 5.5 (range 3-13) days. Two patients (16%) developed a recurrent episode related to non-compliance to medical therapy. CONCLUSION: Hypertriglyceridaemia is a rare cause of acute pancreatitis. Successful management involves the treatment of acute pancreatitis in conjunction with long-term anti-lipid therapy and optimisation of associated risk factors.

How to do a uterine flap as a novel way to repair recurrent obstructed obturator hernia in an elderly female patient.

Here, we present a novel surgical technique to repair an obturator hernia with a uterine flap. The description is both written and in video format.

Conservative management of acute perforated diverticulitis: A systematic review.

OBJECTIVE: Acute perforated diverticulitis is frequently observed and spans a spectrum in the severity of its presentation. Emergency surgery is required in patients with generalized peritonitis; however, a large proportion of patients are clinically stable with localized peritonitis. This article aimed to examine this specific group of patients by reviewing the outcomes of their conservative management. METHODS: A systematic literature search was performed on the MEDLINE and PubMed databases. The management outcomes of patients undergoing non-operative treatment for acute perforated diverticulitis were synthesized and tabulated. RESULTS: Of 479 patients, 407 (85%) were successfully managed non-operatively. In total 70 (14.6%) patients failed non-operative treatment and underwent operative surgical management, and two (0.4%) died. Emergency surgery includes a Hartmann's operation (40%) and resection with anastomosis with or without stoma (24%), laparoscopic lavage (16%) and surgical drainage (20%). The success rate of conservative management was 94.0% and 71.4% for patients with pericolic and distant free air, respectively. Treatment failure was associated with a high volume of free air, distant free air and the presence of abscess. CONCLUSIONS: Conservative management is safe and successful in patients with acute perforated diverticulitis without generalized peritonitis. The early recognition of patients who show clinical signs of persistent perforation is important to ensure the success of this strategy.

Jejuno-jejunal intussusception secondary to diffuse intestinal lipomatosis.

A 25-year-old man presented to the emergency department with severe abdominal pain and vomiting. He had previously presented 10 days prior with similar symptoms. Computed tomography imaging showed a large jejuno-jejunal intussusception. Multiple intestinal masses were identified intraoperatively with the rare diagnosis of intestinal lipomatosis later confirmed via histopathology. Diagnosis and management of rare surgical pathologies is always challenging. Intussusception should always be considered as a differential diagnosis for abdominal pain in adults, as adult intussusception is typically due to a structural abnormality with majority of cases requiring surgical intervention. Exploratory laparotomy with segmental resection and primary anastomosis proved to be a successful approach in our case, with the patient having an uneventful recovery. Follow-up has consisted of gastrointestinal endoscopy and colonoscopy, which have not demonstrated any further lipomas.