New Horizons in Clinical Case Reports最新文献

Introduction

A material-associated true aneurysm after previous use of a vascular prosthesis for arterial reconstruction mostly in peripheral arterial occlusion disease (PAOD) is considered a rare but serious complication.

Case description

A 49 year old male patient underwent several sequential steps of arterial recanalization/reconstruction because of PAOD, stage IIb (walking distance, <100m) according to local findings with endovascular measures and vascularsurgical bypass implantation by means of a femoropoliteal P1-prosthetic bypass at the right and left leg (the right distal prosthetic segment was extended with a venous bypass to the P3-segment because of a distal suture aneurysm and arterial thrombosis of the right calf. After 10 years, a true prosthetic aneurysm was diagnosed at the right thigh using Duplex-ultrasonography and complementary MR-angiography. It was successfully treated with a femoro(prosthetico)-infragenual 6-mm-Gore^®-Propaten^® bypass (W.L. Gore, Putzbrunn, Germany) down to the P3-segment of the right popliteal artery. Nineteen articles were found in the literature search, which had been published since 1995. Most frequently, pseudoaneurysms of knitted polyester prostheses at the femoro-popliteal segment occurred after approximately 12.91 years in average. In one third of cases, 2 ore more aneurysms of dacron prostheses were described. Histological and electromicroscopic investigations revealed mainly breakings of filaments and foreign body reactions. In more than half of the patients, the aneurysm was resected and for reconstruction, an interponate was implanted. Complete removal of the prosthesis and endovascular therapy were only 2nd choice.

Results and Conclusions

Development of true prosthetic aneurysms has not been satisfyingly clarified yet. It belongs to the late complication profile - even it occurs rarely - and should be controlled after a postoperative interval of one decade if the arterial recanalization/reconstruction was performed using prosthetic material after previously - in the sequential approach - endovascular intervention and venous bypass could not be used.

Introduction

Sepsis is the presence (probable or documented) of infection. With its systemic manifestations of severe sepsis and septic shock posing a major healthcare burden in the UK and globally, there is clearly a potential for physician and patient awareness. Current evidence suggests that administration of appropriate antibiotic therapy within 1 hour on recognition of sepsis and its sequelae improves mortality rates among patients. In the UK, the National Institute of Clinical Excellence (NICE) and The Surviving Sepsis Campaign (SSC) recommends the use of intravenous antibiotics within the first hour of recognition of sepsis.

Case description

To determine the number of patients receiving their antibiotics within 1 hour from recognition of sepsis and to assess compliance of Queen’s Hospital Burton Trust (QHBT) with the NICE and Surviving Sepsis Campaign’s recommendation for early antibiotic therapy. A 2-month retrospective chart analysis was conducted to determine the interval from documented onset of sepsis to initial administration of antibiotic for patients at QHBT. Inclusion criteria included patients presenting to Accident and Emergency aged 16 and over scoring 4 or more on their NEWS (National Early Warning Chart Scoring) chart. Patients presenting to a paediatric and gynaecological/obstetric setting were excluded. Patients started on antibiotics at the GP were also excluded.

Results and Conclusions

Charts of 82 patients with documented sepsis were reviewed. 51 patients received their antibiotics within 1 hour representing 62% of all patients presenting to Accident and Emergency at QHBT over the 2 months period. At QHBT, over the 2-month period, very few patients receiving their antibiotics within 1 hour. Therefore, the administration of antibiotics in 38% of all patients exceeded the 1 hour period recommended by NICE and Surviving Sepsis Campaign guidelines. These results have been used as a baseline for future quality assurance and improvement initiatives aimed at minimizing the time to antibiotic administration for this group of patients, who are at high risk of death. Data have been shared with physicians, allied health professionals and patient groups at board meetings. A re-audit is in process with initial results looking promising.

Splenic aneurysms are rare but life-threatening complications of acute pancreatitis. The main risk is aneurysmal rupture and subsequent death from haemorrhage if not treated promptly.

For a long time, surgery has been the mainstay of definite treatment of splenic aneurysms. In this report, we highlight a partially ruptured splenic aneurysm which was successfully treated via endovascular trans-catheter embolisation using N-butyl cyanoacrylate glue and metallic coils.

Introduction

Inflammatory fibroid polyps (IFPs) are rare, benign tumours originating from the submucosa of stomach or small bowel. They account for only 0.1-3.0% of all gastric polyps. Histogenesis remains unknown. In adults, benign tumours such as IFPs are an uncommon cause of small bowel obstruction.

Case description

A 54 year old male patient with known hypertension presented to the emergency department with a 24 hour history of sudden onset and severe right iliac fossa pain, which progressively worsened. He was pyrexial on admission, had decreased appetite and had significant weight loss over the previous few months. There were no other gastrointestinal symptoms. The clinical examination and laboratory findings were consistent with a diagnosis of appendicitis. However, a CT scan of the abdomen and pelvis was suggestive of small bowel obstruction. This scan was reported by two radiologists due to the inconclusive aetiology of the small bowel obstruction. Though the first impression was acute-on-chronic crohn’s disease, on further analysis of the images a well defined oval shaped homogenous mass was noted in the distal ileum. An MRI scan confirmed terminal ileal inflammatory changes with intraluminal cystic changes. The patient underwent a laparoscopic right hemicolectomy. Intraoperatively, a cystic mass in the terminal ileum was found to be causing small bowel obstruction. Histology revealed that the mass was composed of fusiform and stellate shaped stromal cells with marked oedema and eosinophilia consistent with the diagnosis of IFP. The patient had an uneventful postoperative recovery.

Results and Conclusions

Despite the fact that inflammatory fibroid polyps are very rare lesions, they should be taken into consideration as a differential diagnosis in patients presenting with small bowel obstruction, as prompt surgical resection is the only known effective treatment.

Introduction

During the first years of combined allogenic kidney-pancreas-transplantation bladder diversion of the exocrine pancreas secretion was used. After reporting urological and systemic complications it was switched to an enteric diversion with excellent results of pancreas function. Today enteric diversion of the pancreatic ductal secretion is the standard procedure. Nevertheless there are still patients alive with bladder diversion from the early years of transplantation with a good pancreatic function but loss of kidney function. This case describes such a patient and how we dealt with the problem.

Case description

A 53-year old male patient presented with a progressive renal failure twenty years after combined allogenic kidney-pancreas-transplantation with bladder diversion of the exocrine pancreas secretions. Urine excretion was declining with a pre-dialysis renal failure. Still the pancreas transplant was working properly without the need of insulin therapy. We therefore carried out a separation of the graft duodeno-cystostomy and re-established diversion by a side-to-side graft duodenal-recipient ileal anastomosis. This was done by a 2-layer hand sewn technique. Bladder catheter, drainage near the bladder and drainage near the anastomosis were removed after 5, 8 and 10 days respectively. The pancreas showed proper function without the need of insulin therapy. The patient was released from hospital 14 days after the operation.

Results and Conclusions

Transposition of a pancreas transplant from the bladder to the terminal ileum twenty years after primary transplantation is technically possible. In this case it was also reasonable in order to protect the bladder from the aggressive pancreatic ductal secretion. Because of the declining urine excretion due to progressive failure of the kidney transplant the exocrine secretion was not properly diluted anymore with the risk of hematuria, lower urinary tract infections, reflux-associated pancreatitis and transitional cell dysplasia. These conditions could limit the opportunity for the patient for a second kidney donation.

Take home message

Transposition of a pancreas transplant from the bladder to the terminal ileum twenty years after primary transplantation is technically possible and reasonable to offer the patient a chance for a second kidney donation.

Introduction

Malignant ulcer at the duodenal bulb is extremely rare. The commonest cause of ulcers here is peptic ulcer disease. Therefore the routine biopsy of ulcer at D1 is not routinely recommended, to avoid complications.

Case description

An 83-year-old lady presented to the surgical outpatient clinic with upper abdominal pain radiating to left side of her chest. She had recent history of significant weight loss, approximately 22kg. Abdominal examination was unremarkable.

Results and Conclusions

Haemoglobin and Liver Function Tests were normal. Gastroscopy showed one large 3cm ulcer with a shaggy base and rolled over margin in the first part of the duodenum (D1) which appeared malignant. Initial histology confirmed adenocarcinoma of uncertain origin. CT scan showed a 2.9x3.7cm partially cystic mass lesion in the head of the pancreas that was locally invading into the first part of the duodenum, with no evidence of metastases. Immunohistochemistry showed strong Ca19.9 positive, favouring primary pancreatic origin.

Take home message

Pancreatic cancer presenting as an ulcer in D1 is very rare. If a suspicious looking ulcer is found endoscopically at D1, it should be biopsied. A CT scan of the abdomen is also important in the work-up of such cases.

Introduction

Non traumatic osteonecrosis is the ischaemic death of cellular elements within bone. Etiological factors implicated include long term corticiosteroid use, alcoholism, sickle cell disease, systemic lupus erythematosus, amongst others. Common sites of involvement include the proximal femur, knee, shoulder, ankle. Metaphyseal-diaphyseal lesions have been well described radiolographically, however are commonly considered asymptomatic. There is thus a paucity of literature describing techniques used for symptomatic diaphyseal or metaphyseal lesions not involving the epiphyseal region.

Case description

Our patient is a 40-year-old woman diagnosed with Arnold-Chiari malformation in 2005 who was then surgically treated with foramen magnum decompression. In 2010 she was treated with 4 months of Dexamethasone 2mg for chemical meningitis. She presented to the Orthopaedic outpatient clinic in 2012, 16 months after ceasing steroid medication, with a 6 month history of difficulty walking due to pain in bilateral groins and bilaterally along her shins, left worse than right. MRI of both hips demonstrated anterior serpiginous lesions within the femoral heads consisted with AVN (Ficat II). MRI of lower legs showed isolated bone infarct in the metaphyseal-dyaphyseal region of her tibias bilaterally. She had bilateral total hip arthroplasties with immediate relief of hip symptoms. Our patient underwent bilateral tibial intramedullary nailing using a Stryker T2 nail with a medial parapatellar approach. At both the 6 week and 5 month follow-up she had no further pain, was non tender to palpation and was very satisfied with result.

Results and Conclusions

We are unaware of any reports of the development of symptomatic diaphyseal osteonecrosis in patients receiving corticosteroids for the treatment of meningitis. Much of the literature regarding management of osteonecrosis is focused on the treatment of epiphyseal lesions in the femoral head and around the knee. Diaphyseal lesions have been well described radiologically but are often defined as asymptomatic and clinically insignificant. Our use of intramedullary nailing thus illustrates an effective surgical option for the treatment of symptomatic diaphyseal osteonecrosis.

Take home message

Osteonecrosis must be considered in all patients receiving high dose or long term steroids for any indication. Intramedullary nailing can be a successful method of treating symptomatic diaphyseal osteonecrosis of long bones.

Bouveret’s Syndrome is the rarest form of gallstone ileus. It is characterized by the passage of a large gallstone through a cholecystoduodenal fistula resulting in obstruction of the proximal bowel. The rarity, and non-specific presentation of Bouveret’s Syndrome, make it a frequently overlooked diagnosis, with a significant associated mortality. We report the case of an 86 year old male presenting to the Emergency Department with nausea, vomiting, and constipation. Diagnosis of Bouveret’s Syndrome was made by CT scan of the abdomen demonstrating a large stone in the proximal duodenum. After failed attempts at endoscopic removal of the gallstone, the patient was taken for surgical enterotomy and foreign body retrieval. Bouveret’s syndrome is a rare entity with limited evidence to favor one approach to management over another. In this case, we review the diagnostic and therapeutic options for this rare form of small bowel obstruction.

Introduction

Hernias are common surgical diseases. Incidence of incisional hernia depends upon the size and location of the former incision and ranges from 3 to 20 percent. In clinical practice the variability of surgical techniques for hernia repair is great and a wide range of publications are available. Surgery for renal cysts depends on whether they are classified simple or complex. Simple cysts are more common and the majority requires no treatment. Complex renal cysts are associated with an increased risk of malignancy. This is the first report on a giant incisional hernia containing bowl combined with a voluminous renal cyst.

Case description

An 80-year-old female diagnosed with a giant incisional hernia combined with a large left renal cyst was referred to our surgical department from a peripheral hospital for hernia repair. Physical examination showed a ventral incisional hernia (50x50cm) extending to the upper thigh with multiple skin lesions and clinical signs of obstipation. CT scan revealed two hernial orifices measuring 13cm and 4.5cm in diameter. The giant hernial sac contained not only incarcerated small and large bowl but also a large left renal cyst containing 3 litres of fluid.

Results and Conclusions

We performed a second median laparotomy with complete release of all abdominal adhesions. The renal cyst was resected and its base marsupialized. Hernia repair was achieved by both sided compartment separation as described by Ramirez combined with an intraperitoneal onlay mesh sized 40cmx60cm. Intraoperative measurement of creatinine in the cyst fluid revealed no connection to the urinary tract making further renal surgery unnecessary. By resecting the renal cyst, intraabdominal volume was markedly reduced allowing tension free abdominal wall reconstruction. Histological examination of the cyst, the hernial sacs and the resected skin revealed no surprising findings. Postoperative recovery was uneventful and drains were removed before discharge. Bowel movement started on the third postoperative day. Wound dehiscence was treated by negative pressure wound therapy and no recurrence has yet been detected two months postoperatively.

Take home message

Surgical repair of giant incisional hernias is challenging and is associated with significant morbidity and mortality. Individual planning of abdominal wall reconstruction is key for successful treatment and is even the more important in complex hernias with loss of domain or accompanying intraabdominal pathologies.