New Horizons in Clinical Case Reports最新文献

Introduction

Appendicitis has been known to cause acute small bowel obstruction through mechanical and physiological interactions with the ileum. Here a 52 year old male, who, following 3 days of lower abdominal pain, bowels not having opened and vomiting was found on computed tomography (CT) scan to have a mechanical small bowel obstruction. This was operated on via lower midline laparotomy and adhesiolysis. An inflamed appendix was found to have wrapped itself around the terminal ileum causing a focal stricture. After appendectomy the patient was discharged 6 days later and made a full recovery.

Case description

A 52 year old man with a past history of GORD, hypertension and peripheral vascular disease (with aorto-bifemoral bypass) was admitted onto our Surgical Triage Unit (STU) at 22:10 on a Thursday evening. He complained of a 3 day history of illness consisting of cramping lower abdominal pain, bowels not having opened and recurrent bilious vomiting.

Results and Conclusions

An urgent CT scan reported “High grade small bowel obstruction, with change of calibre in the distal ileum. This may be secondary to adhesions (previous bilateral femoral bypass) or internal hernia. Incidentally, the appendix also looks inflamed. No perforation or intra-abdominal collections.” At laparotomy, the appendix was inflamed with free pus in the peritoneal cavity and dilated small bowel loops in the vicinity. On closer inspection it could be seen that the inflamed appendix had wrapped itself around the terminal ileum stenosing its lumen and causing the small bowel obstruction.

Take home message

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  Always consider a concurrent appendicitis in cases of small bowel obstruction

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  Do not exclude an appendicitis in cases of left sided abdominal pain as was the case here

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  If suspected consider performing computed tomography before proceeding to surgery

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  The co-existence of these two pathologies may alter operative approach

Introduction

The commonly reported risks of a cholecystectomy include bile leak, bile duct injury, infection, bleeding, and retained gallstones. Approximately 1-2% of all patients who undergo cholecystectomy have stones left in the common bile duct (CBD) that require further intervention. The use of surgical clips to ligate the cystic duct has been routine since the advent of the laparoscopic cholecystectomy as the standard of care in the 1990s. One rare risk associated with the use of surgical clips is a migrated clip that can result in an obstructed CBD.

Case description

The patient is a 72 year old male who presented with sudden onset, severe, right upper quadrant (RUQ) pain with associated nausea and vomiting after eating fried food. His past surgical history was significant for an uncomplicated laparoscopic cholecystectomy 7 years prior for acute cholecystitis. The patient had been having intermittent RUQ pain for 2 years prior to his presentation and had undergone an esophagogastroduodenoscopy that demonstrated mild gastritis. The patient had no other surgical or procedural history.

On examination, the patient had mild tenderness to palpation in the RUQ. Of note, his labs were significant for a white blood cell count of 11000, aspartate aminotransferase of 760, alanine aminotransferase of 427 and total bilirubin of 3.0. A computed tomography scan demonstrated a hypodense lesion in the intrapancreatic common bile duct with the morphology of a surgical clip measuring 7mm. Magnetic resonance cholangio-pancreatography confirmed the CT findings. The decision was made to proceed with an endoscopic retrograde cholangio-pancreatography (ERCP) from which a clip inside a sludge ball was extracted. The patient tolerated the procedure well and underwent a routine post-procedure course.

Results and Conclusions

Post cholecystectomy clip migration is a rare condition that can lead to choledocholithiasis and cholangitis. Predisposing factors that have been suggested include cholecystitis, postoperative complications and the use of an excessive amount of clips. It has been theorized that the mechanism for clip migration is secondary to inadvertent placement of clips in the biliary tree, clip slippage or subclinical bile duct injuries. The appropriate treatment strategy for choledocholithiasis secondary to post cholecystectomy clip migration is ERCP.

Introduction

Metabolic syndrome (MetS) is associated with inactivation of coronary endothelial small/intermediate (SK_Ca/IK_Ca) conductance calcium-activated potassium channels and dysregulation of coronary arteriolar endothelial function in animals and humans. We investigated the effects of cardioplegia-ischemia/reperfusion (I/R) and NS309 pretreatment on the in-vitro coronary arteriolar responses to endothelium-dependent vasodilators substance P and ADP in pigs with or without MetS.

Case description

The MetS pigs were developed by feeding with a hyper-caloric, fat/cholesterol diet and the control animals fed with a regular diet for 12 weeks (n=8/group). Coronary arterioles (90-180 micrometers in diameter) were dissected from the harvested left ventricle tissue sample of pigs with and without MetS. The changes in diameter were measured with video microscopy. Microvessel was perfused in the presence or absence of selective SK_Ca/IK_Ca activator NS309 (10^-5M). The in-vitro coronary arterioles were then subjected to 60 minutes of cardioplegia-hypoxia (15°C) and 60 minutes of re-oxygenation.

Results and Conclusions

At the end of reperfusion, the microvessel was treated with the endothelium-dependent vasodilators substance P and ADP. The relaxation responses to the substance P and ADP after cardioplegia-I/R were significantly decreased in MetS vessels versus control (Lean), respectively (P<0.05), indicating MetS causes more impairment of endothelium-dependent-relaxation as compared with controls (Lean). Furthermore, pre-treating the MetS or control (lean) pig-microvessels with the SK_Ca/IK_Ca activator NS309 (10^-5M) significantly improved the recovery of coronary endothelial function showing increased response to substance P and ADP as compared with no pretreatment alone (P<0.05), but this protective effect is more pronounced in lean-pigs than that of MetS pigs (P<0.05).

Take home message

This study demonstrates that cardioplegic-ischemia/reperfusion impairs endothelial function and inactivation of endothelial SK_Ca/IK_Ca channels of the coronary microcirculation in the setting of metabolic syndrome.

Introduction

Giant cell tumor of the tendon sheath usually occurs in the tendon sheath of the hand, fibrous tissue surrounding the joints, mucosal bursa, but rarely in those of the knee. Tenosynovial GCT are rarely intraarticular. We describe a case of an intra-articular localized Tenosynovial giant cell tumor arising from the anterior cruciate ligament (ACL) in a 30 year female who presented with pain and recurrent swelling of her left knee without prior history of a trauma.

Materials and methods

The case involves a 30-year-old female patient. She presented with sudden onset of recurrent left knee swelling for 18 months without any history of preceding trauma. Tests for internal derangement of the left knee yielded negative finding. MRI however was reported as localized extra articular PVNS of left knee joint. Arthrotomy surgery of the left knee was decided and it revealed a purple colour mass attached to the distal 2/3 of the lateral and posterior lateral of the ACL.

Results

Histopathology revealed hyper cellular areas, composed of sheets of rounded or polygonal cells with a variable admixture of giant cells containing fat and rimmed hemosiderin pigments. It revealed a benign giant cell tumor of tendon sheath.

Discussions

MRI had been reported as the best to diagnose this tumor, however correlation with histopathology is also a must. On MRI, GCTTS appears as a heterogeneous mass in soft parts, with a low T1 and T2 signal which corresponds to the hemosiderin deposit. Left knee arthrotomy via lateral approach was performed in our case. Another method that can be used is arthroscopic excision, however there is no standard treatment protocol but excision with or without radiotherapy is the treatment option.

Conclusion

GCTTS is a rare tumor involving large joints especially in the knee. Diagnosis can be confirmed with MRI and excision of the tumor can be done via arthrotomy or via arthroscopy.

Introduction

Combined limb-sparing surgery and radiation therapy are considered the standard of care for soft tissue sarcomas (STS) of the extremities. The correlation between radiation therapy and the risk of post radiation fracture is known but underestimated and can end up in serious long-term complications.

Case description

We reviewed the records of 3 patients with pathological femur fracture years after wide local excision of a STS of the proximal lower extremity with postoperative radiation therapy. All patients received more than 50 Gray to the entire femur circumference. No one received perioperative chemotherapy. During surgery, all patients had bone exposure, whereas only one patient had the periosteum stripped.

Results and Conclusions

Two patients were female and one male. The median time from surgery/radiation to fracture was 116 months (range, 84 to 156 months). The median age at the time of diagnosis was 66 years (range, 54 to 79 years). All fractures occurred within the radiation treatment field. Two fractures occurred after minimal or no trauma, one fracture occurred after a mountain bike fall. All three fractures 3/3 (100%) developed a non-union. One patient died due to uncontrolled pulmonary metastasis and local recurrent disease. In the second case we had to perform an exarticulation at hip level due to an uncontrolled infected non-union with soft tissue defect despite several surgical revisions. The third patient is still under treatment of his non-union.

Take home message

Local control rates after combined therapy for the treatment of soft-tissue sarcomas are high. However, pathologic fractures after radiation therapy pose an extreme challenge in their treatment and may be associated with long-term complications that can cause physical disability and impairment of the quality of life.

Introduction

Bariatric surgery is the most effective treatment for morbid obesity and its co-morbidities. Women are advised against becoming pregnant in the first 12-18 months after surgery due to the potential nutritional compromise induced by weight loss. An increasingly recognised complication following bariatric surgery are Petersen-type internal hernias. We present a case of life-threatening Petersen’s hernia at 31 weeks of pregnancy in a patient who had previously undergone laparoscopic Roux-en-Y gastric bypass for morbid obesity.

Case description

A 31-week pregnant 28-year-old (G2P1) presented as an emergency with abdominal pain, vomiting and absolute constipation. Two years previously she had undergone a laparoscopic Roux-en-Y gastric bypass and had lost 31kg. She was tachycardic, tachypnoeic and pyrexial. Blood tests performed showed a raised white cell count 14.4x10⁹/L, haemoglobin 114g/L, C-reactive protein 36mg/L, urea 4.1mmol/L, creatinine 64μmol/L and lactate 1.94mmol/L.

An abdominal ultrasound scan showed free fluid in the abdomen and confirmed a viable intra-uterine foetus. A targeted abdominal computer tomographic (CT) scan showed a closed loop obstruction of the jejunum and proximal ileum around the Roux-en-Y reconstruction, most likely an internal hernia of Petersen. The herniated small bowel was non-enhancing, distended and fluid-filled, therefore thought to be non-viable radiologically.

Results and Conclusions

The patient underwent emergency Caesarean section followed by laparotomy, small bowel resection and formation of laparotomy. She was returned to theatre 24 hours later for a second-look laparotomy. The intra-operative findings demonstrated healthy common channel measuring 270cm, bilio-pancreatic limb measuring 80cm and a long narrow gastric pouch and a small alimentary limb remnant. The gastric bypass was reversed by excising the remnant alimentary limb and fashioning gastro-gastrostomy and anastomosing the bilio-pancreatic limb to the common channel. The patient made an uneventful recovery. Clinicians involved in the management of patients with previous gastric bypass should be aware of the potential complications. We suggest that obstetric care of post-operative bariatric patients requires early liaison with the bariatric surgical team.

Take home message

Obstetric care of post-operative bariatric patients requires early liaison with the bariatric team. Clinical presentations of Petersen’s hernia are non-specific and clinicians should have a high index of suspicion of this diagnosis when assessing patients with previous surgery involving Roux-en-Y reconstruction.

Introduction

Flail chest is a severe life threatening injury with mortality rates reaching up to 33%, traditionally treated with mechanical ventilation (“internal fixation”). Recently, some authors recommend a surgical approach for highly unstable flail chest. Several rib fixation techniques have been described although none are considered gold standard. Despite growing evidence of benefits for both the patient as well as the hospital, there is a general reluctance to perform rib fixation. In smaller hospitals such as the one referred to in this text, general surgeons are called to manage these patients and as such, it is a prerequisite of their training to be aware of all available treatment options, including standard and novel surgical solutions for flail chest injury.

Case description

The 3 cases involved polytrauma victims who have undergone emergency laparotomy because of abdominal injuries. Rib osteosyntheses were undertaken once the patients were haemodynamically stable. Perforated metal plates and screws were used in all cases. All patients were readily weaned off from ventilation with no post-surgical complications from the osteosynthesis and were subsequently discharged home well. All patients remain asymptomatic and no complications were registered during a 17 months (average) follow up.

Conclusion

Surgical fixation of fractured ribs is a straightforward procedure which promotes reestablishment of ventilatory dynamics. Despite several studies favouring the surgical approach to flail chest, many surgeons are still reluctant to perform this procedure. The authors present a simple and reproducible technique, with good results.

Introduction

Spontaneous intrahepatic portosystemic shunt (PSS) is uncommon. A few cases have been reported with its disappearance after outflow occlusion. It is unclear why it had disappeared, and the mechanism is closely related to the pathophysiology of PSS. The portal circulation is a ‘flow’ and governed by Ohm’s law (Flow=Pressure/Resistance). This can be explained through simulation using an electric circuit, which is also a flow system.

Case description

A 62-year old woman visited with hepatic encephalopathy. She had no history of chronic liver disease or liver trauma. Imaging studies revealed an intrahepatic aneurysmal PSS in Couinaud’s segment 6, formed between the posterior branch of right portal vein and the right inferior hepatic vein. She was managed by laparoscopic right inferior hepatic vein closure using an autostapling device. Her encephalopathic symptoms improved immediately after the operation, and she was discharged uneventfully. At her 8 month follow-up, she was symptom-free and her PSS disappeared entirely.

Results and Conclusions

The basic configuration of splanchnic circulation is essentially two resistors connected in series; the mesenteric vascular resistance and the portal vascular resistance. It is a pressure divider between the aortic pressure and systemic venous pressure. In turn, the portal vascular resistance can be seen as two resistors connected in parallel; the hepatic vascular resistance and the PSS resistance. A PSS means the shunt flow above zero, and according to Ohm’s law, there are two ways for the PSS to be formed. In one condition, the portal pressure increases sufficiently high and a PSS begins to form at a fixed shunt resistance. Once the shunt channel is established, portal pressure will decrease until equilibrium is reached between the portal pressure and the shunt flow. A clinical example is liver cirrhosis. In this condition, PSS will persist even if the outflow is occluded. In the other condition, the shunt resistance can decrease at a fixed portal pressure, such as an aneurysmal dilatation of PSS. In this case, PSS will disappear after outflow occlusion, because the shunt flow becomes zero. The puzzling phenomenon of the disappearance of PSS in our case can be easily explained by simulation using an electric circuit theory.

Take home message

Blood flow is similar to an electric current and is governed by Ohm’s law. By simulating splanchnic blood flow with an electric circuit, we can easily understand the underlying pathophysiology of many seemingly curious phenomena.

Introduction

Necrotising fasciitis a relatively uncommon but rapidly progressive soft tissue infection. The incidence is 0.24-0.4 per 100,000.¹ This condition requires urgent aggressive surgical debridement and broad-spectrum antibiotics. Mortality from this condition has been quoted to be from 6-76%.² Sepsis can cause pre-term labour, fetal infection, and preterm delivery. The prevention of these complications is through early recognition and targeted therapy. This should include aggressive rehydration and broad-spectrum antibiotics, with an emphasis on stabilisation of the mother as a priority, as in doing so the foetal status will likewise improve.³

Case description

A 24-year-old woman who was 24 weeks pregnant presented to the emergency department with septic shock. She had injured the tip of her right elbow four days previously, causing a 0.5cm laceration which was now discharging pus. Her initial blood pressure was 84/43mmgHg, heart rate 110 beat per minute, serum C-reactive protein (CRP) was 392mg/L, and white cell count (WCC) 32x10⁹/L. She was initially given fluid resuscitation, and broad spectrum IV antibiotics. Through prompt coordinated prioritisation of the multi-disciplinary team, this lady was taken to theatre for prompt debridement. We found dirty dishwater fluid, and pus above the fascial layer up to the wrist. She improved dramatically after this.

Results and Conclusions

We have presented a case of necrotising fasciitis in a 24 year old pregnant woman whom had extremely early broad spectrum antibiotics and radical surgical debridement. We feel this lady was prioritised by several teams and her efficient, early, coordinated management led to an excellent outcome for both mother and child. Necrotising fasciitis is an uncommon condition with a high morbidity and mortality. Our patient had no risk factors for necrotising fasciitis aside from pregnancy. This may imply as McHenry⁴ suggests, that pregnancy itself may cause an immunosuppressive state enough for it to be considered a risk factor for the disease.

Take home message

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  Necrotising fasciitis/necrotising soft tissue infection is a clinical diagnosis.

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  Management in pregnancy is the same.

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  Management includes broad spectrum antibiotics and very early aggressive surgical debridement.

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  Senior surgical input should be sought early.

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  This is very rare in pregnancy and there are no reported upper limb cases of necrotising fasciitis.

Introduction

Diverticulitis is a well described inflammatory condition of the wall of the gastrointestinal tract with an overall prevalence of 2-10% in developing countries. Typically, the descending and sigmoid colon are affected more commonly than the ascending colon and small bowel in the Western population. Diverticula of the distal ileum are particularly uncommon, with a reported rate of 0.06-1.3% (Jeong et al. 2014). Due to difficulty in pre-operative diagnosis, there is no consensus on therapeutic strategy for right-sided diverticulitis (Lee et al. 2010). Here, the authors present a case of non-Meckel’s diverticulitis of the distal ileum in a Caucasian U.K. patient.

Case description

A 63 year old man presented to the Emergency Department with a one day history of abdominal distension, periumbilical pain radiating to the right iliac fossa, nausea and sweats. He had not defecated for 2 days but reported passing flatus. Past medical history included gout, rheumatoid arthritis and Ulcerative Colitis, managed with Sulfasalazine. He was not a smoker.

On examination, abdomen was visibly distended. There was maximal tenderness in the lower central abdomen and guarding to palpation. Digital rectal examination was normal. Chest radiograph was unremarkable. Plain abdominal film showed faecal loading of the colon, but no obstructive features. C-Reactive Protein (CRP), amylase and white cell count on admission were normal. On repeat testing, CRP was 208mg/L, white cell count 10x10⁹/L, venous lactate 2.3mmol/L and haemoglobin 13.1g/L.

Intravenous fluids and broad spectrum antibiotics were commenced. CT imaging was arranged in view of the severity of symptoms, biochemical findings, patient’s age, medication and history of colitis. CT abdomen pelvis with oral contrast showed a severely inflamed ileal diverticulum. There was no suggestion of a diverticulum on previous radiological or endoscopic investigations. The patient proceeded to surgery for open resection of perforated diverticulum (39cm of ileum) and small bowel anastomosis.

Results and Conclusions

After 24 hour High Dependency observation, the patient made an uneventful recovery. Histological analysis confirmed a thin-walled, diffusely ulcerated, perforated ileal diverticulum resulting from obstructing food.

Anatomically, diverticula are characterised by herniation of mucosa and submucosa through the muscular bowel wall and a true diverticulum should involve all layers. Diverticula of the small bowel are more commonly proximal (75% jejunal, versus 5% ileal). The position, conversely to a Meckel’s diverticulum, is usually on the mesenteric side of the bowel. The aetiology of jejuneo-ileal diverticula is not fully understood however focal muscular weakness, motility dysfunction, high segmental intraluminal pressure and biogenetic factors are believed to contribute (Nakatani et al. 2016).

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