bluuebunny/crossref_metadata_2025 huggingface dataset:
470 Redo Mitral Valve Surgery via Median Sternotomy Versus Mini-Thoracotomy: A Systematic Review and Meta-Analysis of Clinical Outcomes
Authors: Shirke M , Ravikumar N , Tan S , Mutsonziwa N , Soh V , Harky A
Published: November 2022

Aim

Redo mitral valve surgery is a high-risk cardiac procedure. Median re-sternotomy (MS) remains a common approach in many centres. However, there is a significant risk of morbidity and mortality associated with this approach. Alternative procedures such as the right anterolateral minithoracotomy (MT) have been explored. This review compares the clinical outcomes of re-sternotomy versus right mini thoracotomy in mitral valve surgery.

Method

A systematic, electronic search was performed according to PRISMA guidelines to identify relevant articles that compared outcomes of the MS versus MT procedures in redo mitral valve surgery. Data regarding mortality, length of hospital stay, stroke, infection were extracted and analysed

Results

Thirteen studies were identified, enrolling 4,549 patients. Length of hospital stay (MD= -3.70, 95% CI[-4.89, -2.51]), 30-day mortality (OR=0.58, 95% CI[0.39, 0.87]), new-onset renal failure (OR=0.38, 95% CI [0.22, 0.65], and length of ICU stay (MD=-0.62, 95% CI[-1.21, 0.02]) were statistically significant in favour of the MT approach. Infection rates (OR=0.52, 95% CI[0.24, 1.12]) were lower in the MT group; however, the difference was not significant. No significant differences were observed in the CPB time (MD=-2.68, 95% CI[-8.53, 3.17]), aortic cross-clamp time (MD=-2.40, 95% CI[-17.07, 12.27]), and rates of stroke (OR=1.03, 95% CI[0.55, 1.92]).

Conclusions

Right mini thoracotomy is a safe alternative to the traditional re-sternotomy for patients who have had previous cardiac surgery. The approach offers a reduced length of hospital stay, ICU stay, and a lower risk of new onset renal failure requiring dialysis. This review calls for robust trials in the field to further strengthen the evidence.
471 Assessing the Accuracy and Bias of Digital Symptom Checkers with Myocardial Infarction Patients
Authors: Wallace W , Chan C , Chidambaram S , Hanna L , Iqbal F , Acharya A , Normahani P , Ashrafian H , Markar S , Sounderajah V , Darzi A
Published: November 2022

Aim

The accuracy and safety of symptom checkers in diagnosing and triaging patients is of concern; especially those with life-threatening conditions. The study's aims were to: 1. assess the accuracy of symptom checkers in diagnosing and triaging myocardial infarctions (MI) and, 2. determine whether differences in gender or presentation type exist.

Method

This prospective diagnostic accuracy study assessed 8 symptom checkers using 100 MI patients of various presentations: typical or atypical. The ability of a symptom checker in providing MI as the first diagnosis (D1) and the first 3 (D3) diagnoses were diagnostic accuracy measures. Triage advice was deemed correct if the symptom checker recommended seeking emergency treatment.

Results

Symptom checkers correctly diagnosed 48.0±31.4% of cases with MI first. D3 accuracy was 72.6±20.2%. Mean triage accuracy was 82.6±12.6%.

24.0±16.2% of atypical cases had a correct primary diagnosis. D3 accuracy for atypical MI was 43.8±20.6%, significantly lower than that of typical MI (p<0.01). Atypical case triage accuracy was 52.7±20.0%, significantly lower than typical cases (84.2±14.7%, p<0.01).

10.0% of the atypical female cases were diagnosed correctly with MI as the first diagnosis. Female atypical cases had significantly lower accuracy than typical female cases for all accuracy measures (p<0.01).

Conclusions

Symptom checkers generally provide low accuracy for diagnosing MI. Approximately 20% of cases were under-triaged. Results varied between symptom checkers: patients who presented with atypical symptoms tended to be under-diagnosed and under-triaged, especially those who were female. This demonstrated potential gender bias and therefore raises questions regarding symptom checker regulation and safety.
524 Infective Endocarditis Timings and Indications for Intervention in Neurological Complications
Authors: Nwakwu C , Badran A
Published: November 2022

Background

Infective endocarditis (IE) is the inflammation of the endocardium. Cardiac surgery is reserved for patients that deteriorate despite best medical therapy. Neurological complications are a serious IE complication. There is still not a clear consensus on how and when IE should be treated when neurological complications occur. Identifying in which patients to intervene and when can help improve patient management.

Aim

To evaluate the management and outcomes of patients that presented with IE in the Wessex region of England with a particular focus on treatment of patients with neurological complications.

Method

Patient records were accessed to collect data on patient demographics, infection status and clinical management of patients between 2019–2020.

Results

147 patients with IE were included, 19 patients with neurological complications underwent early surgery (n=15) or late surgery (n=4). The mean ages were 54 (30–76) and 55 (22–82) respectively. There was no statistical association between timing of surgery, early (within 14 days of CT) or late, and mortality (p=0.53). The median stay in hospital for early and late surgery was 28 days and 47 days respectively. The only significant indicator for having early surgery was the presence of staph aureus (p=0.008). The 6-month survival for early and late surgery was 73.3% and 100% (p=0.212).

Conclusions

Early surgery was not shown to be significantly associated with 6-month mortality but did lead to earlier discharge from hospital. Neurological complications in endocarditis significantly affects survival. Due to the limited number of patients considered further data is needed to draw more conclusive results.
787 Surgical Outcomes and Optimal Approach to Treatment of Aortic Valve Endocarditis with Aortic Root Abscess: Single-Centre Experience and Meta-Analysis
Authors: Harris W , Sinha S , Caputo M , Angelini G , Rajakaruna C , Benedetto U , Ahmed E , Vohra H
Published: November 2022

Aim

To evaluate the impact of aortic root abscess (ARA) on the postoperative outcomes of surgically managed infective endocarditis (IE) and to inform optimal surgical approach.

Method

Between 2009 and 2020, 143 consecutive patients who underwent surgical management for aortic-valve IE were included in a retrospective cohort study. Multivariate and propensity-weighted analyses were used to adjust for demographic imbalances between those without (n=93; Group NARA) and with ARA (n=50; Group ARA). These results were then included in a meta-analysis of existing data, performed following a literature search of Medline, Embase and the Cochrane library. Additionally, empirical subgroup analysis appraised the two most used surgical techniques; Patch Reconstruction (PR) and aortic root replacement (ARR).

Results

In-hospital mortality was 8% and 12% in Group NARA and ARA, respectively (p=0.38).

Six clinical studies were included in the meta-analysis. Group ARA was associated with an increased risk of in-hospital mortality (OR=1.74 96% CI: 1.18–2.56) and late mortality (HR=1.27 95% CI: 1.03–1.58). Our reoperation meta-analysis had high levels of heterogeneity (I2=59%) and found no significant differences in reoperation between group ARA and NARA (HR=1.48; 95% CI: 0.92–2.40). However, inconsistent reoperation figures could be explained by varying institutional preferences for surgical approach as our propensity-weighted analysis suggested that ARR is associated with an advantageous preoperative profile compared with PR.

Conclusions

The presence of an ARA in aortic valve endocarditis is associated with elevated early and late mortality despite modern standards of care. Additionally, we contend that ARR should be considered as best practice for IE cases complicated by ARA.
1035 Gender Equality in Heart Transplantation: A Single Centre Study
Authors: Surendran A , Mascaro J , Dumitriu I
Published: November 2022

Background

International Society for Heart and Lung Transplantation catergoirises female gender in donor/recipient, as a significant risk factor for mortality after heart transplantation. Further, donor-recipient gender mismatch is also reported to be a determinant of post-transplant morbidity/mortality. To examine the effect of gender in survival outcomes, we conducted a retrospective study.

Method

Population comprised of 298 patients undergoing heart transplantation from 2001 to 2021, divided into four groups on the basis of donor and recipient matching. Group A consisted of men who received male donor-hearts, group B of women who received female donor-hearts, group C of women who received male donor-hearts, and group D of men who received female donor-hearts. Standard heart transplantation protocols were applied to all patient groups for graft preservation, surgical technique, donor-recipient size matching, induction & immunosuppressive therapy.

Results

The study groups were found to be homogeneous to the major preoperative- risk- factors (aetiology, transplantation status, donor-recipient-age, total ischemic time). Donor gender, recipient gender and donor-recipient gender mismatching did not significantly modify the short and mid-term survivals, functional recovery, and primary graft dysfunction post-surgery.

Conclusions

Even though previous reports suggest that gender negatively affects survival, this proved to have no influence on the outcomes in our study. These results can be explained by a correct donor-recipient size matching. The well-documented female recipients’ tendency to more frequent and fatal rejection was not confirmed in our experience. The patient's age at transplantation, the routine use of induction therapy and an aggressive immunosuppressive regimen may be the substrate of these findings.
19 A Rare Case of Parapharyngeal Schwannoma Mimicking Peritonsillar Abscess in a Young Female Patient
Authors: Khan A , Rehman A , Omakobia E , Sood S , Khan S
Published: November 2022

Introduction

Parapharyngeal Space (PPS) tumours are responsible for 0.5% of head and neck cancers. Presenting features can mimic peritonsillar abscess. A differential diagnosis of PPS tumour should therefore be considered in young, systemically well patients with resistant peritonsillar masses.

Aim

To report a rare case of parapharyngeal schwannoma in a fit and well adult female with a focus on investigations and optimal management.

Method

A 29-year-old, Caucasian female presented with a three-week history of a right sided oropharyngeal mass, odynophagia, and dysphonia. A stagnant clinical picture prompted further investigation with Magnetic Resonance Imaging (MRI). This demonstrated a 7cm right sided PPS mass arising from the deep lobe of the right parotid gland. Mass excision and partial, ipsilateral parotidectomy confirmed Schwannoma (neurilemoma).

Results & Discussion

Schwannomas account for a third of PPS tumours. Arising from neurological Schwann cells, they are often encapsulated, benign tumours which are characterised by slow and asymptomatic growth. Presentation often follows mass effects leading to dysphagia, odynophagia, and dysphonia. MRI and FNAC remain the gold standard in confirmation of diagnosis. Insensitivity to radiotherapy ensures that surgical resection is the mainstay of treatment and may utilise the transcervical, transparotid or transmandibular approach.

Conclusion

There is a significant degree of overlap in the epidemiology and presenting features of peritonsillar abscess and PPS tumours. In cases of treatment resistant, chronic peritonsillar masses a differential diagnosis of PPS tumour must therefore be excluded.
20 A Novel Case of Metastatic Hypopharyngeal Carcinoma Without Nodal Involvement
Authors: Khan A , Taylor R , Omakobia E , Glore RJ
Published: November 2022

Introduction

In the UK, patients with hypopharyngeal carcinoma are managed via a multidisciplinary team approach based on UK National MDT Guidelines. Hypopharyngeal cancer often presents late, 80% of patients presenting with Stage III or IV disease, with PET-CT recommended for these patients to assess for metastases.

Aim

To report a novel case of an elderly ex-smoker with hypopharyngeal carcinoma without nodal involvement.

Method

An 86-year-old ex-smoker presented to the otolaryngology department with a T2N0 hypopharyngeal carcinoma, which was later upstaged to T3N0M1 following a PET-CT scan.

Results & Conclusions

This case highlights discrepancies between the MDT Guidelines and NICE guidance over when to perform staging scans. NICE recommends PET-CT for T4 or N3 disease compared to Stage III or IV disease in the National MDT guidelines. Our patient would not have qualified for PET-CT under NICE guidance and his metastatic disease would have been undiagnosed. This case highlights that lack of nodal involvement does not exclude metastases and there should be a low index of suspicion for distant metastases in patients with significant systemic symptoms.
25 The Trapped Twin Within: A Rare Case Report of Fetus in Fetu
Authors: Jadhav P , Vaze D , Shimpi A , Hegde A , Anne D , Viswambharan V
Published: November 2022

Introduction

Fetus in fetu is an uncommon congenital anomaly in which the malformed monochorionic diamniotic twin is entrapped within the body of the host twin, due to embryogenic defects or arrest of blood supply. Differentiation from teratomas is done by the evidence of budding vertebral column and limbs in radiological investigations.

Fetus in fetu has an incidence of 1 in 500,000 births with less than 200 cases reported. Herein,we present a case of 1 year old male infant brought with a growing abdominal mass.

Case report

A 12-month-old male child was brought by the mother with a growing abdominal mass in right lower quadrant and failure to thrive. Tumor markers were negative and radiological investigations confirmed a huge retroperitoneal 12 *10 cm fetus in fetu compressing the inferior vena cava. Transverse laparotomy and in-toto excision following meticulous dissection was done. Histopathology confirmed the diagnosis of fetus in fetu.

Conclusion

Though a rare entity, fetus in fetu warrants a suspicion in a pediatric abdominal lump and special focus to differentiate from teratoma is recommended. Surgical excision is curative.
26 Case Report of a Pseudoaneurysm from Distal Anastomosis of Open AAA 32 Years Previously, Contained Within Original Aortic Sac
Authors: Clelland A , Sravanam S , Chatha S , Metcalfe M
Published: November 2022

An 86-year-old gentleman attended hospital with confusion following collapse at home. On examination the abdomen was soft, non-tender and distended with an expansile mass. He underwent elective open repair of a 7cm AAA 32 years prior to current presentation. His past medical history included severe aortic stenosis and atrial fibrillation for which he was anticoagulated with warfarin.

CT imaging of head for intracranial pathology. Triple phase contrast CT studies to assess possible aortic pathology.

CT brain excluded intracranial pathology as cause of collapse. CT triple phase aortogram demonstrated an 8.4cm infrarenal abdominal aortic aneurysm. Arterial phased images show contrast in the previous aortic repair, however delayed images showed extravasation of contrast from a potential leak at the distal suture line, with blood filling the original aortic sac, outside the aortic surgical graft. No retroperitoneal leak was identified.

This presentation was amenable to relining of the aorta with an EVAR however given the patient was asymptomatic and had significant comorbidities, no further intervention was undertaken. The patient and family agreed with this plan of action, and the patient died 3 weeks later. The duration of this contained leak was unknown.
101 A Case Report on Persistent Mullerian Duct Syndrome Presenting as Obstructed Inguinalhernia in an Adult Male
Authors: Somasekhar K , Bangalore Mahalinga D
Published: November 2022

Persistent Mullerian Duct Syndrome (PMDS) is defined as the presence of müllerian derivatives, uterus, and Fallopian tubes in otherwise normally masculinized 46, XY subjects. It's more common in children with cryptorchidism and is a rare finding during hernia surgery among adults with a risk of malignant degeneration. Here we present the case of a 34-year-old adult male with a history of irreducible swelling in the right groin for 1 day and with a past surgical history of left sided hernia repair 10 years back. On examination a tender, irreducible swelling was noted in the right inguinoscrotal region, opposite side and groin area appeared normal with normal male pattern virilisation. A clinical diagnosis of irreducible right inguinal hernia was made, and the patient was taken up for surgery under spinal anaesthesia. Intraoperatively, right sided sliding hernia with an indirect hernia sac was noted with the contents being degenerated uterus, right fallopian tube connecting to the cornua of uterus along with right gonadal tissue at the fimbrial end within the broad ligament. Consent was taken and hernioplasty was performed after excision of the gonadal tissue along with the fallopian tube. On histopathological examination the gonadal tissue was found to be of testicular origin with fibrosis and degeneration. The diagnosis of persistent Müllerian duct syndrome was confirmed. This case report adds on to the current literature on incidence and presentation of PMDS amongst adults and highlights the importance of knowing the pattern of occurrence of this rare condition.
107 A Rare Presentation of a Giant, Multi-Compartmental Lipoma of the Hand Causing Median Nerve Compression
Authors: Shah R , Rahman S , Pywell M , Ibanez J
Published: November 2022

Lipomas are the commonest benign tumour, made up exclusively of adipose tissue, and can arise anywhere in the body. However, giant lipomas of the hand, defined as greater than 5cm in diameter, are rare. They have the potential to invade and cause a multitude of symptoms due to the compression and proximity of underlying structures.

We describe a case of a 64-year-old woman who presents with a swelling of the left thenar eminence, associated with numbness and tingling in all fingers.

MRI and nerve conduction studies confirmed the diagnosis of a lipoma causing median nerve compression. The patient underwent elective surgical excision using a volar approach, with good postoperative recovery. The excised lesion, measuring 12x7x2.4cm, is the largest giant lipoma of the hand reported in literature, and the first to demonstrate invasion from the mid palmar space into both the dorsal sub-aponeurotic space and carpal tunnel.

Space occupying lesions, such as giant lipomas of the hand, are a rare but important secondary cause of compression neuropathies of the upper extremity and must be suspected when these neuropathies present with atypical symptomatology. Any patient presenting with a soft-tissue lesion of the hand demonstrating rapid growth, pain or large size must be thoroughly investigated to rule out malignancy. MRI forms an essential part of the workup in such cases due to its high diagnostic accuracy. Malignant transformation of giant lipomas of the hand is extremely rare, and such lesions can be removed by en bloc marginal resection with excellent postoperative results.
115 Management of Femoral Non-Union with Post-Traumatic Bone Defect Using Second-Generation PRECICE® Nail - a Case Report
Authors: Lu V , Zhang J , Krkovic M
Published: November 2022

Introduction

The management of post-traumatic bone defects with non-union remains a surgical challenge. Common limb length discrepancy (LLD) procedures involve Masquelet technique, vascularised bone grafts, distraction osteogenesis using external fixators, yet they pose a functional and economical challenge for patients, given high complication rates and need for revision surgery. Magnetically driven PRECICE nails are self-lengthening internal devices activated via an external controller. We present one patient with post-traumatic femoral non-union with concomitant bone defect, using second-generation PRECICE nail.

Case Study

One 57-year-old gentlemen suffered open femoral fracture after a motorcycle accident. Having previously undergone open reduction internal fixation, he presented to us with atrophic non-union and bone defect, which were simultaneously treated with a second-generation PRECICE nail. Our treatment protocol was based on the strain theory and involved initial distraction by ∼5mm at non-union site, at a rate of 1mm per day, to decrease strain on bone graft cells and promote callus formation. One week later, the non-union site was compressed to close the gap completely. After another four weeks, distraction using the PRECICE nail started, in increments of 0.25mm, four times a day, until the desired length was achieved. The patient achieved union and the initially planned limb lengthening regime was achieved with minimal complications.

Conclusions

By initially distracting the bone defect by ∼5mm, then compressing the gap, before distraction started, strain on bone graft cells was minimised, allowing robust callus and regenerate growth. Self-lengthening, magnetically driven PRECICE nails can successfully restore union and manage limb length discrepancies with reasonable patient satisfaction and minimal complications.
118 A Case Report on Mucinous Adenocarcinoma Colon in a 14-Year-Old
Authors: Diwakar G , Govindraja E , Bangalore Mahalinga D
Published: November 2022

Pediatric colorectal cancers are rare tumours that carry poor prognosis but none the less the incidence of these tumours is on the rise. Here we present a case of a 14-year-old boy who complained of vague abdominal pain, altered bowel habits and unintentional weight loss for 1 month. On examination a fixed hard mass was palpable on the left side of abdomen and had elevated CEA levels. Open biopsy and immunochemistry confirmed the tumour to be adenocarcinoma of colorectal origin. Patient and guardians denied surgery initially and one month later presented with obstructive symptoms for which left hemicolectomy was done and on histopathological examination mucinous adenocarcinoma stage- T3d N1 M0 was confirmed, the patient was later referred for chemotherapy. The patient showed transient improvement but succumbed to the disease 10 months after the diagnosis. This case highlights the importance of early detection of colorectal malignancy in children by raising awareness of its occurrence and by considering malignancy as a part of the differential diagnosis in pediatric cases with vague GI complaints. Currently colorectal carcinomas in children are being managed in line with the adults due to lack of sufficient evidence and data despite its aggressive nature in the younger age group.
134 Case Report and Review of Literature: Advanced Sino-Nasal Adenoid Cystic Carcinoma with Intracranial and Intradural Extension
Authors: Rassam J , Sood T
Published: November 2022

Introduction

Adenoid cystic carcinoma (ACC) is a rare cancer of the head and neck that primarily occurs in the salivary glands. Sino-nasal ACC (SNACC) is a much rarer entity; this paper presents an exceedingly rare case of SNACC with both intracranial and intradural extension. In addition to this, a review of the literature has been performed.

Case Study

Our case describes the diagnosis of SNACC with both intracranial and intradural extension in a 55yr old female which was subsequently managed with palliative radiotherapy.

Review of literature and Conclusions

Currently, there are only few larger studies that have been conducted on SNACC and only isolated case reports of SNACC with intracranial extension. Aggregated data suggests that SNACC tends to present late at T3-T4 stage, has a 5-year survival of 60% and holds the best prognosis when surgical resection is feasible.

From our case and the four other cases published on SNACC with intracranial extension it can be seen there is a clear distinction with management of patients with or without intradural extension. Intradural extension is a contraindication to surgical resection and once found deems the disease stage as primarily palliative.

The focus for treatment of SNACC particularly with intracranial extension should catch disease early and prevent intradural spread. This maximises the number of patients who can undergo surgical resection and improves prognosis.
148 Migrated Esophageal Stent Causing Imminent Ischemia. a Case Report
Authors: Atif QAA , Raza M , Essiet E , Ahmed K
Published: November 2022

Introduction

Esophageal stents are being used more frequently for maintaining esophageal lumen patency in benign as well as malignant conditions. But the stents do not come without complications. The most common complication is stent migration. It can go unnoticed in asymptomatic individuals whereas timely exclusion of more urgent complications associated with migration is necessary to avoid morbidity and mortality.

Case presentation

We present the case of a 58-year-old patient with inoperable esophageal cancer. He underwent esophageal stenting twice, for palliation, and on both occasions, the stents did not maintain its position. He presented with abdominal pain, abdomen was peritonitic on examination and computerised tomography (CT) scan showed that the esophageal stent had migrated into his ileum. Upon laparoscopy, stent was found lodged in distal ileum causing ischemia and imminent perforation. We found the radiology and per-operative images interesting and are sharing herewith.

Conclusion

With the growing use of esophageal stents, it is important to recognize the possible immediate and delayed complications to manage them effectively. Surgeons need to be aware of the possible complications and have a high index of suspicion to diagnose and treat these.
166 Management Dilemma in an Unusual Presentation of Acalculous Acute Cholecystitis
Authors: Bose S , Alasmar M , Doran H
Published: November 2022

Acute acalculous cholecystitis is a recognised but seldom encountered entity except in immunocompromised and critically ill patients. Epstein-Barr virus infection, on the other hand, is a common viral illness throughout the world, mostly in the younger age groups. However acute cholecystitis due to EBV infection is very rare to occur and can be difficult to diagnose. Here we present a case of a middle-aged adult who presented with upper abdominal pain and non-specific viral illness-like symptoms. LFTs were of a mixed picture, and she had marginally raised inflammatory markers. Standard imaging studies excluded gallstones, but she had thickened gallbladder wall with pericholecystic oedema and some fat stranding, but normal intra hepatic biliary tree and CBD. Strikingly there were sizable lymph nodes in abdomen and thorax. Suspecting viral aetiology, a viral screen was performed which gave a positive EBV result. However, on daily clinical examination she kept on worsening symptomatically and a decision to operate was made following discussion with gastroenterologists and the patient. To note, EBV result was delayed and arrived after she had the operation. This case gives an example of a rare surgical case which may create a diagnostic dilemma amongst clinicians. Whilst understanding that management of acalculous cholecystitis is usually conservative, but in a clinically deteriorating young patient like this there may be a case for cholecystectomy or cholecystostomy. Here the learning point should be to think of other possible diagnoses and consider viral aetiologies earlier which may avoid a procedure on a patient.
222 Bilateral Patellar Tendon Rupture Following Low-Energy Trauma in a Young Patient Without Predisposing Risk Factors
Authors: Murphy S , McAleese T , Elghobashy O , Walsh J
Published: November 2022

We describe the case of a 25-year-old male who presented with a bilateral patellar tendon rupture without any of the identified risk factors for tendon injuries. Our patient is the youngest adult reported to date with confirmed bilateral, unprovoked, patellar tendon ruptures. We accompany our case with an up-to-date literature review on this topic. A degree of clinical suspicion is required for emergency room physicians as well as orthopaedic surgeons assessing such patients to avoid missing bilateral injuries. Point of care ultrasound may be utilised when there is doubt regarding the diagnosis. Prompt surgical management and a specific rehabilitation programme are both required to ensure maximum recovery of these patients.
230 A Rare Case of Catamenial Pneumothorax (CP) in a Middle-Aged Patient with Liver Herniation
Authors: Bushra R
Published: November 2022

Catamenial pneumothorax (CP) is the recurrent accumulation of air in the pleural cavity in reproductive-age women without concomitant respiratory disease.

We report a forty-year-old lady with no past medical history first presented to her local hospital with haemoptysis, severe chest pain, recurrent spontaneous pneumothorax, and dyspnoea, coinciding with menstruation. In addition to a right-sided pneumothorax, in this admission, the chest radiograph showed a right-sided nodule overlying the right hemithorax, and CT showed multiple right-sided ‘pleural’ nodules on the diaphragmatic side.

She underwent a single-port VATS procedure which revealed herniation of the liver through a centrally located diaphragmatic defect, together with the adhesion of the superior lobe to the parietal pleura. The diaphragm was repaired using multiple stitches, followed by buttressing and plication to cover further and reinforce the fixed portion, and a pleurectomy was undertaken to prevent recurrent pneumothorax.

The aetiology of CP remains obscure. However, physiologic hypotheses, the migration theory, the metastatic or lymphovascular microembolisation theory, and the transgenital-transdiaphragmatic passage of air theory are mentioned in other literature. Radiological investigations such as CXR and CT scans showed pneumothorax or pleural nodule evidence, and Investigative inspection of the pleural diaphragmatic surface at thoracoscopy often reveals defects (termed fenestrations) as well as small endometrial deposits. These deposits have also been seen on the visceral pleural surface among women undergoing routine surgical treatment for recurrent pneumothorax.

The most effective treatment strategy is early surgical repair and resection of the diaphragm and the affected lung with pleurodesis and hormonal therapy to achieve amenorrhoea.
231 Tillaux Fracture in a 40-Year-Old Man: A Rare Case Report
Authors: Kwan TY , Khalik M
Published: November 2022

Tillaux fracture is an intra-articular Salter-Harris III fracture affecting the anterolateral aspect of the distal tibia. It is commonly seen in children and adolescents but rare for adults. As Tillaux fracture can be unstable, misdiagnosis may result in delayed surgical treatment and development of complications such as post-traumatic arthritis and persistent syndesmotic instability.

A case of adult Tillaux fracture is reported, involving a 40-year-old gentleman who sustained a low energy injury. He presented to local hospital after being assaulted by a stranger. He tripped over a low fence and sprained his left ankle in external rotation. On examination, he was not able to weight bear. There were swelling and focal tenderness at the triangular concavity of distal fibula. Ankle X-Ray was reported as normal. It required CT scan for diagnosis after reviewed by orthopaedics team at fracture clinic. The patient was subsequently treated with lag screw fixation and recovered after 6 weeks post-operatively.

This case highlights the importance of a systematic method to interpret ankle X-Ray. It is essential to observe the tibio-fibular overlap and any change in the outline of bony cortex of the fibular notch. CT scan has a high sensitivity in delineating fracture pattern hence it should be performed when there is difficulty to confirm the diagnosis solely based on X-Ray.

In conclusion, Tillaux fracture should be suspected when patients present with external rotation injury. There should be low threshold to perform CT scan when there is any uncertainty with the ankle X-Ray interpretation.
296 Knowing When to Put the Knife Down - a Case Report on Osteoradionecrosis of the Chest Wall
Authors: Randall C , Sankar T
Published: November 2022

Radiation therapy is a common treatment for carcinoma of the breast. It has shown to reduce the incidence of local reoccurrence and improve life expectancy, but it is not without complications. Osteoradionecrosis (ORN) of the chest wall is a recognised but rare complication, which can lead to full thickness necrosis, localised infection, and pathological rib fractures.

This case report discusses a 78-year-old female with a history of adjuvant radiotherapy for a left breast malignancy, who developed three distinct wounds on her left anterior chest wall. Over five years, these wounds ulcerated and formed sinus tracks exposing the rib cage. The patient also developed various local infections requiring antibiotics.

Management options were explored, ranging from conservative dressings, anti-inflammatories and steroids to medical options traditionally used to treat ORN of the mandible, such as the combination of Pentoxifylline and vitamin E, and Hyperbaric Oxygen Therapy (HBO2). However, the most beneficial definitive treatment proposed was surgical intervention using either a latissimus dorsi or an upper limb fillet flap. Despite this, the patient's social, cosmetic, and surgical concerns focussed the current management towards the conservative highlighting the importance of “putting down the knife” and the role of monitoring the disease with biannual clinic follow ups. While surgery is likely a necessity in the future, this case study highlights the importance of considering medical input and keeping the patient's interests at the forefront of surgical practice.
333 A Rare Case of Skeletal Muscle Metastasis of Colorectal Cancer
Authors: Bodapati S , Kulkarni N
Published: November 2022

Introduction

Colorectal carcinoma is one of the most commonly diagnosed cancers. Metastasis is seen in the liver, lung, peritonium and bone. Though skeletal muscles make up a majority of our body mass, they are an extremely rare site for metastasis

A 74 y/male known to have total ulcerative colitis was put on the 2WW due to change in bowel habits, weight loss and anemia. Investigations revealed a large cavitating lesion in the right colon with no evidence of metastasis. He underwent an open total pan procto-colectomy, small bowel resection and end ileostomy

Histopathology showed the tumour was a completely excised adenocarcinoma

During surveillance it was noted his CEA levels were high, for which he had a host of investigations including a CT scan and a PET scan, all of which had no interval changes.

He mentioned that he noticed a lump in his left thigh. Orthopedicians advised an MRI scan which showed a tissue lump covering the front of the thigh, within the vastus medialis.

A biopsy revealed metastatic adenocarcinoma.

He also had left wrist pain. A thorough examination revealed a hard mass within the swelling. Ultrasound confirmed a solid well circumscribed mass with vascularity.

Given the above information the patient felt he would be like to complete the remaining of his life with dignity and comfort at home and was fast-track discharged.

Discussion

Skeletal muscle metastasis of colorectal cancers is always associated with a prognosis that is somber and terminal. A high degree of suspicion is needed for diagnosis.
344 A Rare Case of Meckel's Diverticulitis With a 3 Cm Enterolith
Authors: Abunaser M , Sabri S , O'connor A , Arora P , Andrews C
Published: November 2022

Meckel's diverticulum (MD) is a rare condition that affects only 2% of general population. Only 4 to 6% of those Meckel's diverticulea are symptomatic. Furthermore, having a MD containing enterolith is extremely rare, and herein we present a case of 55-year-old lady with Meckle's diverticulitis containing a 3 cm enterolith. The patient presented with symptoms mimic appendicitis; however, upon further evaluation with an enhanced abdomino-pelvic CT an MD containing enterolith was confirmed. An interval laparoscopically assisted diverticulectomy was performed and the patient recovery was un-eventful.
362 The Scarlet Pimpernel: A Case of Polyarteritis Nodosa Presenting as a Left Hepatic Artery Aneurysm
Authors: Kuganesan T , Sayers A , Brown S , Hutton L
Published: November 2022

A 54-year-old female presented to a secondary care hospital with right upper quadrant pain, headache, and persistent dysuria after empirical antibiotic treatment for a urinary tract infection (UTI). Her brother had died under the age of 50 from aneurysmal disease associated with Polyarteritis nodosa (PAN). Urinalysis demonstrated erythrocytes, leucocytes, and nitrites. Her CRP was 428mg/L and ESR 102 mm/hr. CT of the abdomen and pelvis showed reduced attenuation within both kidneys, and she was treated as acute bilateral pyelonephritis with IV antibiotics. Her abdominal pain changed, she described a “pop” in her right hypochondrium, and she developed a new visual disturbance, despite normalisation of her inflammatory markers. This warranted a repeat CT scan which showed an occlusion of the left hepatic artery with surrounding inflammation and an 8mm aneurysm proximally. MRI and CT venogram of the head was unremarkable. PAN was diagnosed on remote consultation with a tertiary care hospital. It is a necrosing vasculitis affecting small to medium sized arteries with aneurysmal dilatation. There is no genetic cause known, though familial cases have been described. The patient was started on treatment dose Dalteparin and transferred to a tertiary hospital. Selective embolisation of the hepatic artery aneurysm was not undertaken, but she was treated with glucocorticoids and cyclophosphamide. This case highlights a rare condition presenting similarly to a treatment refractory UTI requiring multidisciplinary patient care and the need for repeat imaging following clinical deterioration/change.
440 Gallbladder Volvulus: A Rare Cause of Acute Abdominal Pain in Paediatrics
Authors: Jaly Y , Clarke M , Driver C
Published: November 2022

Gallbladder volvulus or torsion is an extremely rare but recognised entity, which can cause acute abdominal pain. We describe an unusual case of a previously well 8-year-old male who presented with a short history of right-sided abdominal pain and vomiting and was found to have a gallbladder volvulus at laparoscopy. The patient was admitted with a history of sudden onset, severe, right-sided abdominal pain associated with non-bilious vomiting. On examination, he had localised right-sided abdominal tenderness. Laboratory investigations showed mildly raised inflammatory markers. The working diagnosis was acute appendicitis, and he was taken to theatre for a diagnostic laparoscopy. At laparoscopy, a necrotic, torted gallbladder was identified with its long axis horizontal. The gallbladder was de-torted and a laparoscopic cholecystectomy was performed. The postoperative course was uncomplicated, and the patient was discharged home on the third postoperative day. Gallbladder volvulus is an unusual diagnosis in children and is characteristically described in elderly women. The presentation can mimic that of acute appendicitis or cholecystitis. The diagnosis is challenging and is usually made incidentally, either radiologically or at the time of surgery.
476 Case Report: A Fishy Case of Flexor Tendon Injury
Authors: Mactier M , Davies K , Gilmour A
Published: November 2022

Introduction

We describe the first documented case of a flexor pollicis longus (FPL) tendon injury occurring secondary to a fish bite.

Case Report

A 52-year-old right hand dominant male was referred with inability to flex his right thumb following a pike bite whilst fishing in a nearby Loch. Clinical examination revealed superficial abrasions to his right thumb with two deeper puncture wounds over the volar pulp. He had no active flexion of the interphalangeal joint. Radiographs showed no fracture/foreign body. Given deep animal bite, intravenous antibiotics and operative exploration were indicated. Intraoperative findings revealed 100% division of the FPL tendon (zone II); this was repaired using a modified Strickland method. The patient completed 48 hours intravenous antibiotics and was discharged with physiotherapy-led follow up.

Discussion

Animal bites are a common presentation to the Emergency Department however non-domesticated animals account for <5% cases. We are not familiar with managing marine animal bites and the literature is lacking. Only 2 cases of sting-ray injuries have been described, both of which were associated with delayed presentation and poor functional outcome. Aquatic injuries also contain unique bacterial flora including Vibrio, Aeromonas and Pseudomonas which merits consideration.

Conclusion

This case highlights the importance of managing innocuous wounds with caution in case of underlying structural damage. Unusual animal bites should be closely monitored with low index for surgical exploration to avoid delayed complications. Discussion with microbiology specialists should also be considered.
509 Splenosis, an Important Differential for Peritoneal Metastases
Authors: Tanwar A , Gurung C , Pangeni A , Shrestha A , Basnyat P
Published: November 2022

Splenosis is defined as the auto-transplantation of splenic tissues in other sites of the body. It is a rare benign condition and can be an incidental finding. However, early diagnosis is essential as the differential diagnosis of splenosis includes peritoneal metastases.

Early identification relies on recognising relevant past medical history including splenic injury and or splenectomy. Splenosis can be confirmed through the usage of a technetium-99m colloid scan. By using nuclear medicine scans, repeated invasive investigations such as biopsy and diagnostic laparoscopies can be avoided.

We present here a case of a 51-year-old woman who was extensively investigated by the gynaecology department and general surgery department, even undergoing a diagnostic laparoscopy following repeated presentations to primary and secondary care with chronic abdominal and pelvic pain. She had a splenectomy 28 years earlier for traumatic splenic injury. CT scan of abdomen and pelvis showed features suspicious of multiple peritoneal metastases and hence she was urgently referred to a colorectal cancer multidisciplinary meeting. A subsequent technetium-99m colloid scan confirmed multiple splenic nodules in the peritoneal cavity. The patient was reassured and discharged.

In conclusion, in a patient with a known history of splenic trauma, splenosis is an important differential diagnosis. A careful past medical history and appropriate investigations will avoid unnecessary referral and invasive investigations.
536 Conservative Management of the Colonic Gallstone
Authors: Hurst K , Peiris B , Booth M
Published: November 2022

A 74-year-old woman presents with a 7-day history of increasing lower abdominal pains and reduced bowel movements; resulting in absolute constipation.Twenty-four hours prior to admission she also had symptoms of nauseous and significant abdominal distention. Her past medical history included; diverticulitis, type 2 diabetes, hypercholesterolemia, an ultrasound scan in 2005 confirming gallstones, but no previous abdominal surgery.She was initially treated for bowel obstruction and a CT arranged. CT showed a 4.5 cm gallstone in mid-sigmoid colon and a cholecystocolonic fistula. She was booked for colonoscopy±laparotomy, but on the morning of her planned procedure she repeatedly opened her bowels. Subsequent colonoscopy was negative and repeat CT confirmed the stone was no longer within the gastrointestinal tract.

Several case reports have clearly documented the presence of a cholocystocholic fistula leading to sigmorectal bowel obstruction from gallstones. These reports, however, have all implied that management should primarily be with a laparotomy. Although colonoscopy has also been trialled, few cases appear to have been successful and conversion to laparotomy has been high. This case report highlights a role for conservative management in colonic gallstones, avoiding the morbidity and mortality associated with laparotomy +/- bowel resection.
539 A Case at Crossroads—Urological Presentation, Cardiac Complication and Haematological Diagnosis: Should Imaging Be Pursued Prior to Orchidectomy at All Costs?
Authors: Yasen Z , Kazzazi F , Ioannides K , Velmurugan S , Zegocki K , Li C
Published: November 2022

This case report explores the interesting case of a 71-year-old gentleman who presented with a testicular lump following trauma. Ultrasound imaging of the testicle demonstrated malignancy and subsequently orchidectomy was listed. Due to a scheduling difficulty, this was prioritized ahead of his whole-body computed tomography scan. Intraoperatively, he developed electrocardiogram changes suggestive of a non-ST elevated myocardial infarction. Post-operative imaging demonstrated a diffuse large B-cell lymphoma encroaching the heart and greater vessels. This case report highlights the importance of preoperative imaging, even where it may prove challenging. We assess the adequacy of current guidelines within the UK on imaging for new testicular malignancies.
542 Laparoscopic Division of a Congenital Splenogonadal Portosystemic Shunt: A Case Report
Authors: Charuvila S , Lloyd A , Bhardwaj N , Lloyd D
Published: November 2022

We describe a rare congenital portosystemic shunt. A 37-year-old woman was found to have a previously unreported congenital shunt following investigations into secondary causes of hypertension. The abnormal venous shunt connected the splenic vein to the left ovarian vein. The patient underwent a laparoscopic procedure to successfully divide the shunt. She made a full recovery without complications. To our knowledge, this is the first presentation of a congenital portosystemic shunt involving the splenic and ovarian veins to be reported. This case demonstrates that such a shunt can be amenable for laparoscopic management. The case report shows preoperative scans and intraoperative images.
551 Bilateral Carpal Tunnel Syndrome Following AstraZeneca (AZD1222) COVID-19 Vaccination: A Case Report
Authors: Tullie S , Michell A , Reid A
Published: November 2022

Covid-19 infections correlate with peripheral neuropathy. Correlations extend to vaccination, with reports of polyradiculoneuropathy. We report a case of a 59-year-old right-hand dominant female presenting with bilateral carpal tunnel syndrome (CTS) nineteen days after AZD1222.

BSSH diploma-qualified hand surgeon assessment identified increasing median nerve (MN) paraesthesia and upper limb pain. Symptoms occurred post-AZD1222 second dose administered 12-weeks after the first. Past medical history was unremarkable, and she had not contracted Covid-19. Examination found severe CTS-signs: thenar weakness, positive provocative tests (Phalen's and Tinel's) and 8mm MN static 2-point discrimination. Electrophysiology confirmed very severe wrist bilateral median neuropathies, with no evidence of widespread peripheral neuropathy. Left carpal tunnel decompression found a swollen MN bulging through the transverse carpal ligament. The patient reported symptom improvement 2 weeks post-operatively.

This was reported using MHRA “yellow card” protocols as symptoms occurred within the period of neuropathic side effects. Proposed neuropathy mechanisms in Covid-19 include vasa nervorum microangiopathy. Post-vaccine effects could be connected to such changes in microcirculation implicated in CTS. Vaccines containing SARS-CoV-2 antigens enhance autoimmunity and may cause antibody-mediated effects on the synovial sheath, worsening symptoms in pre-existing CTS. Though we do not claim causality, emerging post-vaccination effects may include exacerbation. It is not uncommon for clinicians to diagnose CTS in patients with symptoms overlooked until an inciting event. With Covid-19 ‘boosters' the long-term strategy, vaccinations may increase neuropathy contribution. Increasing caseloads may present future challenges to hand surgeons managing CTS. Recording correlations may provide a basis for investigating CTS pathophysiology post AZD1222.