Gastric Outlet Obstruction Secondary to Severe Thoracolumbar Scoliosis.

A 78-year-old woman with a history of idiopathic thoracolumbar scoliosis presented with signs, symptoms, and imaging findings consistent with a gastric outlet obstruction secondary to the rib cage impinging on the pylorus of the stomach. She underwent an operative intervention and intra-operative findings were consistent with severe scoliosis with the right rib cage impinging on the pylorus, causing gastric outlet obstruction. A laparoscopic procedure was performed to pexy the greater curvature of the stomach to the left upper quadrant and a percutaneous endoscopic trans-gastric jejunostomy was inserted at the end. Thoracolumbar idiopathic scoliosis is a relatively benign common condition. However, with the increasing aging population and resultant higher incidence of progression to degenerative scoliosis, more patients are presenting with severe spinal and rib cage deformities that can cause rare intra-abdominal sequelae. We report the first case of a gastric outlet obstruction caused by the rib cage impinging on the pylorus in a patient with severe thoracolumbar scoliosis.

Severe ischaemic colitis secondary to microvenular thrombosis in a hypercoagulable patient.

A young patient with multifactorial prothrombotic risk factors presented with signs and symptoms of ischaemic colitis, without evidence of bowel hypoperfusion on imaging. She deteriorated with trial of conservative management and required operative management. Intraoperative findings demonstrated severe, confluent large bowel necrosis, sparing the rectum. A total colectomy was performed, with return to intensive care unit due to intraoperative hemodynamic instability. A return to theatre the following day allowed for formation of ileostomy and definitive closure. Histopathological findings of microvenular thrombosis were confirmed. Venous causes of ischaemic colitis present diagnostic challenges due to variable presentation and imaging findings. Microvascular venous thrombosis is likely secondary to multifactorial prothrombotic risk factors including positive autoantibodies and variable compliance with warfarin therapy for aortic value replacement. We present this case of ischemic colitis secondary to an unusual aetiology to emphasize the need to remain clinically suspicious of severe abdominal pain despite relatively benign imaging findings.

Emergency laparotomy in older adults with geriatric medicine input implications of demographics, frailty and comorbidities on outcomes.

BACKGROUND: We (1) describe West Australian (WA) older adults undergoing emergency laparotomy (EL) in a tertiary-centre Acute Surgical Unit (ASU) with proactive geriatrician input and (2) explore the impact of Clinical Frailty Scale (CFS) and Charlson's Comorbidity Index (CCI) on patient outcomes. METHODS: We performed a prospective cohort-study of older adults undergoing EL, between April 2021 and April 2022, in a tertiary ASU, with dedicated geriatrician-led perioperative care via the Older Adult Surgical Inpatient Service (OASIS). RESULTS: Of 114 patients, average age was 76.7 ± 7.61 years-old (range 65-96), with 35.1% (n = 40) frail (CFS 5-7), 18.4% (n = 21) vulnerable (CFS 4) and 46.5% (n = 74) not frail (CFS 1-3). 61.4% (n = 70) were severely comorbid (CCI ≥5), 34.2% (n = 39) moderately comorbid (CCI 3-4), and 4.4% (n = 5) mildly comorbid (CCI 1-2). 95.9% (n = 109) EL patients were reviewed by OASIS. Inpatient mortality was 7.9% (n = 9) and 1-year mortality 16.7% (n = 19). Majority, 64.9% (n = 74), were discharged directly home with 17.5% (n = 20) discharged with in-home rehabilitation. Each increment in CCI was associated with increased in-hospital (HR 1.38, p = 0.034) and 1-year (HR 1.39, p = 0.006) mortality, and each increment in CFS with 1-year mortality (HR 1.62, p = 0.016). Higher CFS but not CCI was associated with increased level of care at discharge. Age was not statistically significant with any outcomes. CONCLUSION: We describe demographics, frailty and comorbidity of 114 older adults undergoing EL in ASU. We suggest CFS and CCI as independent risk-stratification tools, and proactive management of both comorbidity, and frailty, should be incorporated into preoperative optimisation.

Implementation of a geriatric in-reach service improves acute surgical unit outcomes; a retrospective before-and-after study.

BACKGROUND: Australia's ageing population is challenging for surgical units and there is a paucity of evidence for geriatric co-management in acute general surgery. We aimed to assess if initiating a Geriatric Medicine in-reach service improved outcomes for older adults in our Acute Surgical Unit (ASU). METHODS: The Older Adult Surgical Inpatient Service (OASIS) was integrated into ASU in 2021. We retrospectively reviewed all patients over age 65 admitted to ASU over a 12-month period before and after service integration with a length of stay (LOS) greater than 24 h. There was no subsequent truncation or selection. Primary outcomes were 30-day mortality, LOS, and 28-day readmissions. Secondary outcomes were discharge disposition, in-hospital mortality, and hospital-acquired complications (HACs). RESULTS: 1339 consecutive patients were included in each group, with no differences in baseline characteristics. There was a significant decrease in 28-day readmissions from 20.2% to 16.0% (P < 0.05), greatest in patients undergoing non-EL operative procedures (21.9% pre-OASIS vs. 12.6% post-OASIS; P < 0.05). Trends towards reduced 30-day mortality (7.17% vs. 5.90%; P = 0.211), in-hospital mortality (3.88% vs. 2.91%; P = 0.201), permanent care placement (7.77% vs. 7.09%; P = 0.843) and HACs (8.14% vs. 7.62%; P = 0.667) were seen, although statistical significance was not demonstrated. LOS remained unchanged at 4 days (P = 0.653). CONCLUSION: The addition of a geriatric in-reach service to a tertiary ASU led to a significant reduction in 28-day readmissions. Downtrends were seen in mortality, permanent care placement, and HAC rates, while LOS remained unchanged.

Secondary extramedullary plasmacytoma in the absence of active multiple myeloma: a rare cause of small bowel obstruction.

A 75-year-old woman with a history of multiple myeloma in remission presented with signs, symptoms and imaging findings consistent with a small bowel obstruction secondary to an intussusception. She underwent operative management, and intraoperative findings were consistent with an intussusception of mid small bowel as the cause of the small bowel obstruction. The offending portion of small bowel was resected, and histopathology confirmed a plasmacytoma deposit in the small bowel at the lead point of the intussusception. Secondary extramedullary plasmacytomas in the gastrointestinal system are rare but can have significant consequences like small bowel obstruction requiring operative management. We present a rare case that emphasizes the need to be highly suspicious for uncommon sequelae of multiple myeloma like secondary extramedullary plasmacytomas when managing patients with history of multiple myeloma in remission with concerning abdominal symptoms.

Extensive subcutaneous emphysema and intra-abdominal sepsis following haemorrhoid operation: a rare complication of a novel procedure.

Doppler-guided haemorrhoidal artery ligation and recto anal repair (HAL-RAR) procedure is a relatively new, minimally invasive procedure for the treatment of Grades III and IV haemorrhoids. A 71-year-old female presented with sepsis, abdominal distension and extensive subcutaneous emphysema and was found to have intra- and extraperitoneal rectal perforation requiring repair, laparoscopy and sigmoid colostomy. Suture ligation of the haemorrhoidal artery can inadvertently be above the peritoneal reflection and result in full thickness rectal perforation secondary to ischaemic necrosis. Previous vaginal prolapse mesh repair should be considered as a relative contraindication to HAL-RAR as it can significantly distort the anatomy.

Surgical management of isolated caecal varices presenting with massive lower gastrointestinal haemorrhage: a case report and review of the literature.

Caecal varices are extremely rare with poorly defined management due to paucity of data. A 52-year-old man was diagnosed with a 3-day history of melena with a background of chronic liver disease and non-steroidal anti-inflammatory use. Investigations revealed anaemia with haemoglobin of 62 g/L, liver function derangement (Gamma-glutamyl transferase 251 U/L, alanine transaminase 40 U/L, bilirubin 84 umol/L, alkaline phosphatase 85 U/L), coagulopathy (International Normalized Ratio 1.6) and acute kidney injury (Creatinine 285 umol/L). Gastroscopy demonstrated no signs of upper gastrointestinal bleeding or portal hypertension. A large volume haematochezia occurred necessitating resuscitation with massive transfusion protocol, and colonoscopy was abandoned in favour of computerized tomography (CT) angiography, which revealed a large varix feeding the caecum. Urgent laparotomy and a right hemicolectomy was performed with application of abdominal vacuum dressing. The hemicolectomy sample was opened on back table demonstrating large caecal varix causing intraluminal bleeding. The patient was stabilized in intensive care, and a further laparotomy was performed 2 days later where an end ileostomy was formed. Caecal varices have been reported in literature with management via trans-jugular intrahepatic portosystemic shunt, endoscopically or conservatively with beta-blockade. Here we present, to the best of the author's knowledge, the first reported case of successful surgical management of caecal varices.

Diagnosis and surgical repair of delayed tracheal perforation post thyroidectomy in context of previous cranio-spinal radiotherapy - A case report.

INTRODUCTION AND IMPORTANCE: This is the first case of delayed tracheal perforation post total thyroidectomy in the context of previous radiotherapy to the neck. Such a presentation can be easily misdiagnosed and managed as a seroma at significant risk to the patient, as the latter had no precipitating factors and cardiorespiratory compromise. There are nineteen previously described cases of delayed tracheal injury post thyroidectomy of variable severity and variable intervention. CASE PRESENTATION: A 51-year-old man presented with non-tender anterior neck surgical emphysema initially diagnosed on bedside ultrasound and plain X-ray, 22 days following total thyroidectomy and central neck dissection. His background was significant for childhood acute lymphoblastic leukaemia requiring chemotherapy and cranio-spinal radiotherapy. He underwent total thyroidectomy, for multiple bilateral thyroid nodules found on cranio-spinal MRI surveillance concerning for follicular neoplasm. There were significant amount of adhesions tethering the thyroid secondary to prior radiotherapy but no tracheal injury intra-operatively. CLINICAL DISCUSSION: At presentation, no source of air leak was identified on Computer Tomography. He failed conservative management. During surgical exploration, a 2 mm tracheal perforation at the right cricothyroid joint was closed with the right sternothyroid muscle due to the proximity of the perforation with the recurrent right laryngeal nerve. Tisseel was applied over the repair. He recovered without further complications. CONCLUSION: Sudden onset neck swelling post thyroidectomy in the context of significant scaring from radiotherapy, should raise the suspicion of surgical emphysema in the neck patients and confirmed with plain x-ray. Such patients should have multidisciplinary tertiary care.

Global Variations in Practices Concerning Roux-en-Y Gastric Bypass-an Online Survey of 651 Bariatric and Metabolic Surgeons with Cumulative Experience of 158,335 Procedures.

INTRODUCTION: There is significant variation in practices concerning Roux-en-Y gastric bypass (RYGB) among bariatric surgeons, but there is currently a lack of robust data on the nature and extent of these variations. The purpose of this study was to understand global variations in practices concerning RYGB. METHODS: A questionnaire-based survey on Survey Monkey® was created, and the link was shared freely on various social media platforms. The link was also distributed through a personnel email network of authors. RESULTS: A total of 657 surgeons from 65 countries completed the survey. Crohn's disease and liver cirrhosis were considered absolute contraindications for RYGB by 427 surgeons (64.98%) and 347 surgeons (53.30%), respectively. More than 68.5% of surgeons performed routine upper GI endoscopy while 64.17% performed routine ultrasound of abdomen preoperatively. The majority of surgeons (77.70%) used the perigastric technique for Gastric pouch creation. Approximately, 79.5% used orogastric bougie. More than 70% of the respondents did not use any staple line reinforcement routinely. Only 17.67% of surgeons measured the whole small bowel length, and the majority of surgeons (86.5%) used constant length of BP limb. Approximately, 89% used constant length of alimentary limb. Approximately, 95% of surgeons preferred antecolic bypass, and more than 86% routinely closed the Petersen defect. Marginal ulcer prophylaxis was used by the majority (91.17%). Almost 95% of surgeons recommended lifelong vitamin and mineral supplements. CONCLUSION: This survey identifies global variations in practices concerning RYGB. It identifies several areas for future research and consensus building.

Expression of glypican-3 in undifferentiated embryonal sarcoma and mesenchymal hamartoma of the liver.

Glypican-3 (GPC3) is an oncofetal protein that has been demonstrated to be a useful diagnostic immunomarker for hepatocellular carcinoma and hepatoblastoma. Its expression in mesenchymal tumors of the liver, particularly undifferentiated embryonal sarcoma (UES) and mesenchymal hamartoma (MH), has not been investigated. In this study, a total of 24 UESs and 18 MHs were immunohistochemically stained for GPC3 expression. The results showed cytoplasmic staining for GPC3 in 14 (58%) UESs, of which 6 exhibited diffuse immunoreactivity and the remaining 8 showed focal positivity. The patients with GPC3-positive UES tended to be younger (mean 18 years; median 11 years) than those with GPC3-negative tumors (mean 39.4 years; median 27 years), although the difference did not reach statistical significance (P = .06). Eight MHs also exhibited GPC3 immunoreactivity (44%; 4 diffuse and 4 focal). Positive staining in all 8 cases was primarily seen in entrapped nonlesional hepatocytes with a canalicular and cytoplasmic staining pattern. In only 4 cases (22%) was GPC3 immunoreactivity also observed in the mesenchymal component. The patients with positive staining also tended to be younger (mean 2.6 years; median 1.1 years) compared with those with negative staining (mean 16.3 years; median 4.5 years), but the difference was not statistically significant (P = .15). Our data demonstrate that GPC3 is expressed in a subset of UES and MH of the liver. Caution should thus be exercised when evaluating a GPC3-expressing hepatic neoplasm, particularly on a needle biopsy when the differential diagnosis includes poorly differentiated hepatocellular carcinoma or hepatoblastoma.