Perioperative Presentations of Kounis Syndrome: A Systematic Literature Review.

Kounis syndrome commonly is described as a complex multisystem phenomenon mainly affecting coronary arteries, resulting in coronary vasospasm in the context of an allergic manifestation. This article reviews the literature regarding perioperative presentations of the syndrome. A systematic search in MEDLINE and Embase databases was performed for case reports through June 16, 2021, on Kounis syndrome triggered by medications administered in the perioperative setting. The authors' search resulted in 35 perioperative reports of Kounis syndrome, with the majority of the cases occurring in men between 40 and 80 years of age, manifesting within 20 minutes following the administration of the suspected trigger. Chest pain and ischemic changes on the electrocardiograph were the most frequent presentations, while intravenous antibiotics and neuromuscular blocking agents were the most common triggers. In most instances, the patients had a good recovery following the event. Coronary vasospasm is often less frequently recognized as a form of allergic manifestation in the perioperative setting. Many potential triggers, such as antibiotics and neuromuscular blocking agents, are routinely administered during surgery. Awareness of this condition, early diagnosis, and effective management of this condition can lead to good outcomes.

Management of bile duct stones at cholecystectomy: an Australian single-centre experience over 2 years.

BACKGROUND: Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series. METHODS: A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population. RESULTS: Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126 min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8 mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23). CONCLUSION: This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.

Gallbladder volvulus with preoperative and intraoperative imaging.

Volvulus of the gallbladder is one of the rarest conditions to affect the gallbladder, however, it should remain an important differential. Typically, it is diagnosed in elderly women, but it has also been reported in children and men. The lack of unique distinguishing features make diagnosis difficult to distinguish between other gallbladder pathology such as acute cholecystitis; however, delayed recognition or non-operative management is associated with higher mortality. We present the case of a 92-year-old woman who presented with this pathology, had diagnosis established preoperatively and was successfully treated with a cholecystectomy.

Should we resect colorectal cancer in patients over the age of 85?

BACKGROUND: The prevalence of colorectal cancer in the elderly is rising, with increasing numbers of older patients undergoing surgery. However, there is a paucity of information on the surgical outcomes and operative techniques used in this population. AIM: To evaluate the post-operative outcomes for patients ≥ 85 years old following colorectal cancer resection as well as evaluating the outcomes of laparoscopic resection of colorectal cancer in patients over 85. METHODS: Patients who underwent colorectal cancer resection at our institution between January 2010 and December 2018 were included. The study was divided into two parts. For part one, patients were divided into two groups based on age: Those age ≥ 85 years old (n = 48) and those aged 75-84 years old (n = 136). Short term surgical outcomes and clinicopathological features were compared using appropriate parametric and non-parametric testing. For part two, patient's over 85 years old were divided into two groups based upon operative technique: Laparoscopic (n = 37) vs open (n = 11) colorectal resection. Short-term post-operative outcomes of each approach were assessed. RESULTS: The median length of stay between patients over 85 and those aged 75-85 was eight days, with no statistically significant difference between the groups (P = 0.29). No significant difference was identified between the older and younger groups with regards to severity of complications (P = 0.93), American Society of Anaesthesiologists grading (P = 0.43) or 30-d mortality (2% vs 2%, P = 0.96). Patients over 85 who underwent laparoscopic colorectal resection were compared to those who underwent an open resection. The median length of stay between the groups was similar (8 vs 9 d respectively) with no significant difference in length of stay (P = 0.18). There was no significant difference in 30-d mortality rates (0% vs 9%, P = 0.063) or severity of complication grades (P = 0.46) between the laparoscopic and open surgical groups. CONCLUSION: No significant short term surgical differences were identified in patients ≥ 85 years old when compared to those 75-85 years old. There is no difference in short term surgical outcomes between laparoscopic or open colorectal resections in patients over 85.

The impact of comorbidities on post-operative complications following colorectal cancer surgery.

BACKGROUND: Colorectal cancer surgery is complex and can result in severe post-operative complications. Optimisation of surgical outcomes requires a thorough understanding of the background complexity and comorbid status of patients. AIM: The aim of this study is to determine whether certain pre-existing comorbidities are associated with high grade post-operative complications following colorectal cancer surgery. The study also aims to define the prevalence of demographic, comorbid and surgical features in a population undergoing colorectal cancer resection. METHOD: A colorectal cancer database at The Prince Charles Hospital was established to capture detailed information on patient background, comorbidities and clinicopathological features. A single-centre retrospective study was undertaken to assess the effect of comorbidities on post-operative outcomes following colorectal cancer resection. Five hundred and thirty-three patients were reviewed between 2010-2018 to assess if specific comorbidities were associated with higher grade post-operative complications. A Clavien-Dindo grade of three or higher was defined as a high grade complication. RESULTS: Fifty-eight percent of all patients had an ASA grade of ASA III or above. The average BMI of patients undergoing resection was 28 ± 6.0. Sixteen percent of all patients experienced a high grade complications. Patients with high grade complications had a higher mean average age compared to patients with low grade or no post-operative complications (74 years vs 70 years, p = 0.01). Univariate analysis revealed patients with atrial fibrillation, COPD, ischaemic heart disease and heart failure had an increased risk of high grade complications. Multivariate analysis revealed pre-existing atrial fibrillation (OR 2.70, 95% CI 1.53-4.89, p <0.01) and COPD (OR 2.02 1.07-3.80, p = 0.029) were independently associated with an increased risk of high grade complications. CONCLUSION: Pre-existing atrial fibrillation and COPD are independent risk factors for high grade complications. Targeted perioperative management is necessary to optimise outcomes.

Unusual Presentation of a Sigmoid Mass with Chicken Bone Impaction in the Setting of Metastatic Lung Cancer.

BACKGROUND: Ingestion of foreign bodies can cause various gastrointestinal tract complications including abscess formation, bowel obstruction, fistulae, haemorrhage, and perforation. While these foreign body-related complications can occur in normal bowel, diseased bowel from inflammation, strictures, or malignancy can cause diagnostic difficulties. Endoscopy is useful in visualising the bowel from within, providing views of the mucosa and malignancies arising from here, but its ability in diagnosing extramural malignancies arising beyond or external to the mucosa of the bowel as in the case of metastatic extramural disease can be limited. CASE SUMMARY: We present the case of a 60-year-old female with an impacted chicken bone in the sigmoid colon with formation of a sigmoid mass, on a background of metastatic lung cancer. On initial diagnosis of her lung cancer, there was mild Positron Emission Tomography (PET) avidity in the sigmoid colon which had been evaluated earlier in the year with a colonoscopy with findings of diverticular disease. Subsequent computed tomography (CT) scans demonstrated thickening of the sigmoid colon with a structure consistent with a foreign body distal to this colonic thickening. A repeat PET scan revealed an intensely fluorodeoxyglucose (FDG) avid mass in the sigmoid colon which was thought to be inflammatory. She was admitted for a flexible sigmoidoscopy and removal of the foreign body which was an impacted chicken bone. She had a fall and suffered a fractured hip. During her admission for her hip fracture, she had an exacerbation of her abdominal pain. She developed a large bowel obstruction, requiring laparotomy and Hartmann's procedure to resect the sigmoid mass. Histopathology confirmed metastatic lung cancer to the sigmoid colon. CONCLUSION: This unusual presentation highlights the challenges of diagnosing ingested foreign bodies in patients with metastatic disease.

Stump appendicitis 5†years after laparoscopic appendicectomy.

A 31-year-old healthy man presented with right lower quadrant pain and tenderness, mild neutrophilia and clinical presentation consistent with appendicitis, despite undergoing a laparoscopic appendicectomy 5 years prior. CT scan demonstrated a caecal phlegmon, in the expected region of the appendiceal stump. The patient was taken for laparoscopy and a 2 cm inflamed appendiceal stump was encountered. A distal caecectomy was performed and the patient made an unremarkable recovery. Histological examination was consistent with acute inflammation of the appendiceal stump. Only a small number of case reports of stump appendicitis have been published so far. Correct identification and ligation of the appendiceal stump is crucial to prevent this complication. Although normally it is treated with completion appendicectomy, the optimal treatment approach for this condition has not been well established.

Randomized prospective controlled trial of lateral internal sphincterotomy versus injection of botulinum toxin for the treatment of idiopathic fissure in ano.

BACKGROUND: Chronic anal fissure is a significant cause of morbidity. Internal sphincterotomy has long been the operative treatment of choice. Concerns remain, however, on its effects on continence. Botulinum toxin has been used as an agent for chemical sphincterotomy, causing temporary alleviation of sphincter spasm and allowing the fissure to heal. The aim of the present study was to compare the results of sphincterotomy to botulinum toxin. METHODS: The study was designed as a randomized controlled trial. All adult patients over the age of 18 with chronic idiopathic fissure in ano who had failed conservative treatment were included in the trial. Patients were randomized to receive either Botox or sphincterotomy. Pain, healing of fissure and continence scores were the outcomes assessed. RESULTS: A total of 38 patients were studied. Seventeen patients were randomized to receive Botox and 21, sphincterotomy. Patients in the Botox group were found to have significantly higher 2-week pain scores and reoperation rates, and poor healing. Continence scores were not significantly different in the two groups. CONCLUSION: Sphincterotomy gives better results than Botox in the treatment of fissure. Botox, however, is safe with no complications and no detriment to continence and could be used in certain situations.

The value of laparoscopic staging for patients with colorectal metastases.

BACKGROUND: Resection offers the only chance of cure for hepatic colorectal metastases. However, preoperative staging does not always reliably detect unresectable disease. The aim of this study was to investigate the role that laparoscopy with ultrasound may have in detecting unresectable disease, thus sparing patients from unnecessary laparotomy with the associated morbidity and cost. METHODS: A retrospective review of all patients considered for liver resection of colorectal metastases during a 3-year period was performed, analyzing factors likely to predict resectable disease, rates of resectability, and success of laparoscopic staging at detecting unresectable disease. RESULTS: Of 73 patients with resectable disease on computed tomography, 24 were deemed to need laparoscopy, and 49 proceeded directly to laparotomy. Those first undergoing laparoscopy had shorter disease-free intervals between diagnosis of colorectal cancer and detection of hepatic recurrence and greater numbers of hepatic metastases. Twelve of the 24 patients who underwent laparoscopy had unresectable disease, and 8 of these were detected at laparoscopy. Forty-six of the 49 patients proceeding to laparotomy directly had resectable disease. CONCLUSIONS: Laparoscopic staging of hepatic colorectal metastatic disease detects most unresectable disease, preventing unnecessary laparotomy. The likelihood of disease being unresectable is in part predicted by the disease-free interval and the number of hepatic metastases.

Is laparoscopic intraoperative cholangiogram a matter of routine?

BACKGROUND: Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits. METHODS: Relevant articles in English were identified from the Medline database, and reviewed. RESULTS: The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01). CONCLUSIONS: Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.

Mucinous cystadenoma of the appendix.

Mucinous neoplasms of the Appendix are rare conditions, usually diagnosed intraoperatively or postoperatively on the pathology report. They have an association with colonic and ovarian neoplasms, and spillage can result in pseudomyxoma peritonei. While appendicectomy is adequate treatment for cystadenomas, cystadenocarcinomas require a right hemicolectomy. Open approach is recommended for the surgical treatment of these lesions.

Postpartum pneumomediastinum and subcutaneous emphysema: two case reports.

Spontaneous pneumomediastinum associated with subcutaneous emphysema is a rare condition also known as Hamman's syndrome. It can also be seen postpartum. We present two cases of subcutaneous emphysema associated with childbirth in nulliparous women, both of which resolved spontaneously.