bluuebunny/crossref_metadata_2025 huggingface dataset:
143 Massive Intra-Hepatic Subcapsular Liver Haematoma Post-Laparoscopic Cholecystectomy- A Rare Complication of a Common Procedure'
Authors: Saad E , O'Connell L , Khan I , Barry K
Published: October 2021

Laparoscopic Cholecystectomy (LC) is currently considered the gold standard for the management of symptomatic gallbladder stones disease. Specific complications remain challenging, particularly postoperative bleeding, bile leak, and bile duct injury. We report a rare case of a giant intrahepatic subcapsular haematoma (ISH) complicating LC.

Case Presentation

A 59-year-old female presented with symptomatic biliary colic. Her past medical history was noted for obesity (BMI>50). She underwent an elective LC with an uncomplicated intraoperative course; however, post-operatively she developed hypovolaemic shock with an acute haemoglobin drop requiring fluid resuscitation and blood transfusion. Emergency CT revealed a massive subcapsular haematoma measuring 21cm×3.1cm× 17cm at the right liver margin without evidence of ongoing bleeding. She was managed conservatively- as per a tertiary hepatobiliary surgery centre’s advice- with meticulous clinical observations, serial monitoring of haemoglobin, and repeat CT to assess for interval progressions. She progressed well with conservative management and did not require surgical or radiological intervention. A follow-up liver sonography performed eight weeks post-discharge confirmed a complete resolution.

Conclusion

Giant ISH is an exceedingly rare but life-threatening complication following LC which merits special attention. Our case demonstrates the necessity of close postoperative monitoring of patients undergoing LC and considering the possibility of ISH in those who experience refractory postoperative hypotension. It also highlights the decisive role of diagnostic imaging in securing a timely and accurate diagnosis of post-LC ISH.
153 Carotid-Cavernous Fistula Causing Bradycardia Following Maxillofacial Trauma: A Case Report
Authors: Wege J , Anabtawi M
Published: October 2021

A 53-year-old male presented to the local A&E department with a fractured mandible following a single punch to the lower face, and was admitted under Oral & Maxillofacial Surgery. A subsequent finding was chemosis, relative afferent pupillary defect, minimal soft exophthalmos, reduced visual acuity and colour vision in one eye, but with no associated trauma to the orbits. A CT scan showed no sign of other injury, no blood collection, and the small amount of orbital emphysema didn’t appear to be the cause of symptoms. A heart rate of 40bpm was observed, with ECG and telemetry ruling out cardiac causes of bradycardia. With this clinical picture and no orbital space occupying lesion or collection identified on the CT scan, an MRI of the head was requested, which showed superior ophthalmic vein occlusion, resulting in a diagnosis of a direct carotid-cavernous fistula (CCF). The proptosis increased slowly over 24 hours and became pulsatile. The patient was subsequently referred to the tertiary centre for treatment with endovascular embolisation using coils, which resulted in full resolution of the signs and symptoms. This case presents a rare acute presentation of CCF after indirect trauma. It is assumed that bradycardia was caused via the oculo-cardiac reflex. This presentation could have led to a clinical diagnosis of retrobulbar haemorrhage or tension pneumo-orbit, triggering surgical or needle decompression of the orbit. Such treatment would have had catastrophic consequences. This is a reminder to consider this rare diagnosis and cause of bradycardia after facial trauma.
236 Omental Fat Torsion Masquerading Clinically as Acute Appendicitis in a Young Male Patient: A Rare Aetiology of Acute Abdomen and The Value of Diagnostic Laparoscopy
Authors: Abuelgasim M , Baggaley A , Saad E
Published: October 2021

Acute abdominal pain is a common surgical presentation and acute appendicitis remains the top differential for most young adults. Omental fat torsion has emerged as a rare aetiology of an acute surgical abdomen in the younger population that closely mimics acute appendicitis in its clinical presentation. Preoperative diagnosis is extremely challenging in this age group due to the rarity of the condition and the non-specific nature of its clinical and laboratory findings, and hence most reported diagnoses were made intra-operatively.

We report a case of omental fat torsion in a 22-year-old male who presented with clinical features that were highly suggestive of acute appendicitis. However, the diagnostic laparoscopy revealed a normally looking appendix and terminal ileum, with the presence of a twisted segment of the greater omentum in the right lumbar region. A laparoscopic omentectomy and a prophylactic appendectomy to prevent furture acute appendicitis were performed with an uneventful postoperative recovery. Histology confirmed omental fat infarction and a normal appendix.

This reported case highlights a rare cause of right iliac fossa pain and demonstrates the value of diagnostic laparoscopy in the context of clinically suspected acute appendicitis in younger male patients. Diagnostic imaging was not deemed necessary in our patient given the strong clinical suspicion of acute appendicitis. Prompt laparoscopy led to definitive diagnosis as well as treatment and avoided the radiation exposure necessitated during a diagnostic computed tomography scan.
282 Cholecystoappendicular Fistula- 1st Ever Reported Case
Authors: Prakash Narayan P , Oyewole B , Mandal A , Belgaumkar A , Campbell-Smith T
Published: October 2021

A 30-year-old male presented with a history of recurrent episodes of acute cholecystitis; first acute attack associated with fever and nausea was 18 months prior to this presentation, for which he was managed conservatively for acute cholecystitis with antibiotics and analgesia following an ultrasound that showed features of acute cholecystitis with no obvious gallstones.

The patient had further episodes of acute cholecystitis with no signs of obstructive jaundice and subsequent ultrasound showed multiple small gallstones. Due to the severity of his symptoms, he was scheduled for a planned cholecystectomy.

During surgery (right subcostal incision)- findings were that of a contracted gall bladder with dense adhesions, after careful dissection a fistulous tract between the appendix and gallbladder was identified along with a cholecystoduodenal fistula.

An en-bloc cholecystectomy plus appendicectomy was performed with the duodenotomy repaired. On the first day post op there was approximately 300 ml of bilious effluent in drain, a white cell count-8.1 x 109 and hemoglobin -12.1 g/dL, Serum bilirubin-1.4mg/dL, ALP-104mg/dL. The second and third post-operative days were uneventful with minimal bile mixed serous fluid in drain respectively with no other complains, following which the drains were removed and patient discharged home.

Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is a cholecystoduodenal (70%), followed by cholecystocolic (10–20%), and the least common is the cholecystogastric fistula accounting for the remainder of cases.

No case of cholecystoappendicular fistula has been reported so far.
284 Wunderlich Syndrome - Case Report of a Surgical Emergency Due to Spontaneous Non-Traumatic Retroperitoneal Haemorrhage
Authors: Patil S , Prakash Narayan P , Henderson J
Published: October 2021

A 42-year-old female with no other significant co-morbidities presented with complaints of sudden onset abdominal pain, she was in state of shock- her haemoglobin dropped drastically to 6.8g/dl from 11.8g/dl. She was resuscitated and was given blood transfusion.

CT Scan was suggestive of retroperitoneal haemorrhage due to rupture of Renal angiomyolipoma (RAML). Patient underwent selective embolization of renal artery the next day and was discharged after 3 days of post-operative stay.

Wunderlich Syndrome-is a rare condition in which spontaneous nontraumatic renal haemorrhage occurs into the subcapsular and perirenal spaces is most commonly caused due to spontaneous rupture of RAML.It is characterized by Lenk’s triad – Acute flank pain, flank mass, hypovolemic shock. Size of AML (>4 cm), prothrombotic states such as pregnancy are main causes of AML rupture. Patients are managed conservatively or with help of selective arterial embolization. Nephrectomy is last resort in a hemodynamically unstable patient or in cases of embolization failure.

When dealing with acute abdomen with haemodynamic instability in non-traumatic cases it is essential to consider possibility of Wunderlich Syndrome. Early diagnosis, availability of Interventional radiology is key to successful management and potentially avoiding a Nephrectomy.
304 First Reported Case of Metachronous Tumours With Delayed Recurrence from The Neuroendocrine Tumour Arising in A Tailgut Cyst
Authors: Basit R H , Khan R.BN
Published: October 2021

Background

Malignant transformation of tailgut cysts (benign retrorectal cysts) into Neurodendocrine tumours (NETS) is extremely rare with less than 30 reported cases in the literature. A tiny proportion of these cases report early recurrence (within 2 years) and to our knowledge none have reported delayed recurrence 6 years after primary resection.

Case history

We report a 55-year-old male who underwent laparoscopic excision of a 5 cm presacral tumour found incidentally and confirmed histologically to be a G1 NET (WHO Classification) arising from a pre-existing tail gut cyst, with no evidence of metastasis.16 months later the patient presented with bowel obstruction secondary to adenocarcinoma of the colon at the splenic flexure. The patient underwent laparoscopic left hemicolectomy; histology confirming a moderately differentiated adenocarcinoma (TNM stage pT3pN0). The patient underwent adjuvant chemotherapy post-operatively based upon immunohistochemistry. The patient was followed up for both tumours with CEA, serum chromogranin A, colonoscopies, and CT scans. At 5th year post hemicolectomy, CT scan revealed a new asymptomatic 18 mm left internal iliac lymph node which was avid on octreotide scan consistent with metastasis secondary to NET resected previously. He, therefore, underwent 30Gy sabre radiotherapy.

Conclusions

There is no consensus regarding follow up duration post early NET resection. The recurrent NET was picked up incidentally as part of the 5-year colorectal adenocarcinoma follow up at our unit. The recurrent NET would not have been identified had this not been a metachronous case. Thus, consideration must be given to both radiological and biochemical follow up post NET resections.
344 Managing Clinical Rarities: A Unique Case of Non-Inflamed Appendix in A Port Site Hernia
Authors: Tribedi T , Kulkarni N
Published: October 2021

Introduction

Port site hernias containing the appendix are sporadically described in the literature, with most cases presenting with acute appendicitis. Cases of a normal appendix being found in such hernias are extremely rare and rarely published. Here we describe a patient with a port site hernia containing a non-inflamed appendix. The lack of similar recorded cases makes this a unique case to highlight and discuss.

Case Description

81-year-old lady, with adenocarcinoma of the upper rectum, underwent a laparoscopic high anterior resection in late 2018. With 12 mm ports placed in Umbilicus and RIF. 5mm ports placed in RUQ and LUQ. The 12 mm ports were closed with deep suture closure and the skin was closed using clips. Computerised tomography (CT) imaging at one year showed local cancer recurrence and a small abdominal wall hernia in the right iliac fossa. During subsequent resection surgery, a RIF port site hernia was identified intraoperatively. The hernia sac consisted of an uninflamed appendix. The hernia was reduced and an appendicectomy was performed with the hernia being closed with interrupted suture closure. Histology of the appendix confirmed no evidence of inflammation.

Discussion

When a clinical rarity is encountered there is often minimal literature to guide management and decisions must be made based on surgical principles and clinical reasoning. Although here an appendicectomy was performed, resection of a normal appendix remains a contentious point in the surgical field. This case demonstrates a potential management option to guide surgeons who encounter this clinical rarity in their future practice.
351 Anterior Ethmoid Artery Septal Flap for Endoscopic Reconstruction of Frontal Sinus CSF Leak
Authors: Adegboyega G , Elhassan H A , Zocchi J , Lambertoni A , Bozkurt G , Karligkiotis A , Turri-Zanoni M , Battaglia P , Bignami M , Castenuovo P
Published: October 2021

Introduction

Anterior skull base cerebrospinal fluid (CSF) leaks are managed successfully with endonasal surgery. Endoscopic closure of CSF leaks from posterior table of the frontal sinus remains challenging. Vascularized Hadad-Bassagasteguy flap (HBF) reconstruction of the skull base has increased CSF closure rates but does not extend to frontal sinus. We describe our technique using septal flap pedicled by anterior ethmoid artery (AEA) for repairing frontal defects.

Method

Retrospective review of cases of frontal CSF leak repair using the AEA flap reconstruction. Flap design: an anterior vertical septal mucosa incision at posterior border of the frontal sinusotomy is made and extended to nasal floor. Posterior vertical incision is made 1 cm posterior to the projection of the axilla of the middle turbinate on the septum and extended to nasal floor. A horizontal incision along the nasal floor joins the two incisions. The flap is raised and rotated into the frontal sinus over the posterior table reconstructed defect.

Results

Three patients identified. Two males, one female, aged 11, 33 and 56. Patient histories included recurrent bacterial meningitis following head trauma, recurrent sinusitis and fronto-ethmoidal osteoma, with intraoperative CSF leak and CSF rhinorrhea due to meningoencephalocele. The three posterior wall defects were successfully repaired endoscopically with multilayer reconstruction and the AEA septal flap.

Conclusions

The anterior ethmoid artery septal flap can be successfully utilised for frontal CSF leak repair. Flap is conveniently located for frontal sinus defects. When the septum is intact it provides an excellent final layer as part of multilayer reconstruction.
477 Surgical Solutions and Problems in An Adult Patient with VACTERL Association
Authors: Smith H , Hargest R
Published: October 2021

Background

We report an adult patient with features of VACTERL - oesophageal and anal atresia, with cardiac malformation. In infancy he underwent colonic interposition for oesophageal atresia using the transverse colon as a conduit. As a teenager he underwent formation of a Koch continent ileostomy after previous stoma formation for anal atresia. Eventual failure of the Koch pouch nipple valve necessitated a laparotomy for attempted refashioning. Unfortunately, this operation was beset by life-threatening complications and a protracted post-operative course. He presented to our hospital with a laparostomy, high output enterocutaneous fistulae (ECF) necessitating home total parenteral nutrition (TPN), severe cachexia and deconditioning.

Method

Conservative therapy was utilised to improve the nutritional and physiological status of the patient. Simultaneously, attempts were made to define the anatomy of his abdomen in relation to previous surgery. However, operation notes for the original procedures (oesophageal reconstruction and Koch pouch formation) were lost due to closure of the hospital which he attended at the time.

A laparotomy was subsequently performed to manage the ECFs. Most of the small intestine was unsalvageable due to multiple fistulae and adhesions, leaving 35cm of small bowel terminating in an end ileostomy. A cholecystectomy was performed to mitigate gallstone formation.

Conclusions

Efficient communication is imperative in the management of complex patients. The loss of original operation notes made interpretation of subsequent imaging and planning of surgery troublesome. In contrast, efficient communication between teams involved in his peri-operative care, particularly the respiratory and intensive care teams facilitated a smooth post-operative course and successful discharge from hospital.
549 Use of 3D Printing Technology in Surgical Planning and Decision Making in ENT Skull Base Surgery- An Axial 3D First in Northern Ireland
Authors: Mallon A , Farnan T
Published: October 2021

39-year-old male seen at ENT clinic with inverted papilloma polyp of nasal sinus. CT showed multi-sinus mucosal thickening. The surgical options discussed were modified Lothrops endoscopic sinus surgery or an open approach of frontal sinuses with osteoplastic flap and septorhinoplasty.

A model 3D skull was created by Axial 3D using stereolithography 3D printing technology with photopolymer resin. The skull was made in 1:1 scale with tolerance of 0.2mm. The tumour was printed in a contrasting colour, which allowed clear visualisation and appreciation of tumour boarders and relations to surrounding structures.

The patient underwent FESS with modified Lothrops approach, achieving good clearance of polyp. The operation resulted in relief the patient’s symptoms.

Discussion

The use of a 3D model allowed for visualisation of tumour size and relation to surrounding anatomy, particularly the absence of dural involvement within the fontal sinus. It assisted in surgical planning. The use of the 3D skull was beneficial for patient as it allowed less invasive surgery and therefore shorter recovery time. It was also beneficial for the hospital organisation as it lowered resource requirements of theatre time, hospital bed days and staff resources. One limitation of the 3D printed skull was that the fine lamellae ethmoid air cells were not shown due to the manufacturing process.

Conclusions

The use of 3D printing is becoming increasingly popular as a surgical aid. We found the use of the 3D skull to be useful in individualised surgical planning for endoscopic sinus surgery.
554 An Unusual Case of a “Hernia Within a Hernia” Resulting in Small Bowel Obstruction and Strangulation
Authors: Mallon A , Skelly R , Beirne C
Published: October 2021

59-year-old female presented with symptoms of small bowel obstruction. She had a history of previous open right hemi-colectomy. She also had a previous complex strangulated ventral hernia which had required laparotomy and repair. Following this the patient had recurrence of the ventral hernia.

Examination demonstrated a non-tender irreducible recurrent ventral hernia in a patient with a high BMI (> 40). CT reported a midline hernia containing dilated small bowel loops. Additionally, there was a separate narrower hernia arising from the original larger hernia containing a strangulated loop of small bowel.

Emergency laparotomy was performed. At operation there was a large hernia containing a smaller secondary hernial defect. Within this secondary defect, there was a loop of jejunum with a constriction band. which was released. There was no vascular compromise to the bowel and no need for resection. The hernial sac was excised and the abdominal wall repaired. Post-operative recovery was uneventful.

Discussion

The patient had a known, recurrent wide necked ventral hernia. However, this was the first presentation of the new, smaller hernia. This case is unusual in that it demonstrates a multi-locular “hernia within a hernia”. Although multi-locular hernias have been previously described, there is a paucity of literature on these.

Conclusions

This “hernia within a hernia” is an uncommon surgical finding for which there is limited literature. Clearly without urgent surgical intervention there would be an increase in morbidity and mortality.
559 One Mesenteric Defect, Two Segments of Colon, A Number of Surgical Strategies! A Rare Case of An Internal Hernia Causing Bowel Ischemia
Authors: Devani P , Al-Saadi N , Bowrey D
Published: October 2021

Internal hernias due to mesenteric defects are a rare cause of bowel obstruction, but once present their complications are associated with a high morbidity and mortality. We present the case of a 24-year-old patient who presented to the emergency department with signs and symptoms of an acute abdomen. Following surgical review, taking into consideration the patient’s clinical, biochemical, and radiological findings, the patient was taken for immediate emergency surgical exploration. A laparoscopic approach was initially taken, which revealed dilated and ischemic colon, and therefore an open approach was then adopted. Operative findings included a very mobile caecum and proximal ascending colon which had herniated through a defect in the small bowel mesentery, the sigmoid colon had subsequently become incarcerated by the caecum and small bowel too. Both the ascending and sigmoid colon had become ischemic. A number of surgical strategies were considered, and given the patients age it was decided to preserve as much normal bowel as possible. Thus, a right hemi- and sigmoid colectomy were performed with an ileo-transverse anastomosis and formation of an end colostomy. In this case, radiological diagnosis pointed to a suspicion of an internal hernia, and operative diagnosis highlighted a rare mesenteric defect causing herniation and subsequent ischemia. Relying on the patient’s clinical condition and an early decision for surgical intervention resulted in a positive outcome for outpatient. The patient made a good recovery following the bowel preserving surgery.
560 Case Report: A Very Rare Case of Incidentaloma of a Large Adrenal Cavernous Haemangioma
Authors: Chua Y , Quake S , Prasad K , El-Saify W
Published: October 2021

Introduction

Incidentaloma are asymptomatic and unanticipated adrenal tumours found on radiological imaging for unrelated diagnostic inquiries. Adrenal cavernous haemangioma is a rare, differentiated and benign tumour arising from the endothelial layer of blood vessels. This is a rare phenomenon with only 66 cases reported in the literature between 1955 and 2018.

Case Details

This is a case of a 79-year-old Caucasian gentleman who presented in March 2020 with vague abdominal discomfort and anaemia on a background of multiple co-morbidities including in particular, an asymptomatic left 5.6cm adrenal incidentaloma found in 2014. A computed tomography scan of abdomen-pelvis in June 2020 revealed progression in size of the incidentaloma to 20.8cm. Biochemical tests confirmed non-functioning adrenal tumour. The patient underwent open left adrenalectomy, left nephrectomy, splenectomy and distal pancreatectomy. The diagnosis of adrenal cavernous haemangioma was subsequently made on histopathological examination. Post-operatively, our patient made a good physiological recovery.

Discussion

There are no established diagnostic and treatment guidelines for adrenal cavernous haemangioma. Larger tumours are often treated surgically to exclude malignancies and to prevent potential complications as well as symptom relief. Literature reviews showed that most cases were surgically managed, and diagnoses were made through histology post-operatively.

Conclusions

Adrenal cavernous haemangioma typically present as incidentalomas which require further investigations. They are very rare non-functioning benign tumours that can be difficult to be differentiated from other adrenal malignancies.
581 Renal Arteriovenous Fistula Percutaneous Embolization Using the Amplatzer Vascular Plug II
Authors: Soliman H , Abdel-Aal A , Elsabbagh A , Hamed M , Underwood E , Saddekni S
Published: October 2021

Introduction

Renal arteriovenous fistula (AVF) is not considered a common condition; however, it can occasionally complicate with renal impairment and heart failure secondary to high cardiac output. Recently, percutaneous embolization has overcome traditional surgery as the first line of its management, because of better success rates as well as less morbidity and mortality.

Case report

A 68-year-old male who presented with a renal AVF post left partial nephrectomy associated with a large pseudoaneurysm. This was found on a computed tomography angiography (CTA) scan, a routine follows up for his endovascular aortic aneurysm repair. Due to the patient’s co-morbidities and to avoid the potentially fatal pseudoaneurysm rupture, a minimal invasive approach was agreed in the multidisciplinary meeting. He was treated by percutaneous transcatheter embolization using the Amplatzer Vascular Plug II (AVP-II) through a right femoral arterial access. The patient recovery was uneventful, following an overnight stay he was discharged home. CTA done four and ten months later showed the AVP-II device inside the left renal artery branch feeder with no artifacts seen. There was absence of recanalization of the AVF. In the literature, adopting the transarterial route for the renal AVF treatment with AVP-II device as a single embolotherapy device has not been reported before.

Conclusions

Our report display the feasibleness of AVP-II in renal AVF treatment by arterial feeder embolization, specifically in fistulas with high flow and short communication as our case in which it showed offered multiple advantages over coils and is more cost effective.
586 Peri-Pancreatic Migration of Lost Intra Uterine Device: Case Report and Review of Literature
Authors: Bhattacharya P , Amada H , George A
Published: October 2021

Intra uterine devices (IUDs) is one of the most effective form of contraception available today. Uterine perforation and IUD migration is a rare but serious complication and is reported to occur in 0.05 to 13 cases out of 1000 IUCD placements. Migration of IUD to pelvis and lower abdominal organs following uterine perforation has been reported widely in literature. However far migration into the upper abdomen in very rare. Here we report a case asymptomatic peri-pancreatic migration of IUD.

A 65-year-old lady being investigated for pneumonia was picked up to have an asymptomatic IUD lying in front of the pancreas. The patient recalled having a hormonal Mirena coil placed 12 years previously for menopausal symptoms. Routine 3-year general practitioner follow-up failed to detect the IUD on vaginal examination. The patient denied spontaneous IUD discharge. However, three subsequent pelvic ultrasound scans did not detect any retained IUD and she was discharged as unrecognized IUD expulsion. She remained asymptomatic for the next 12 years with no abdominal symptoms though she did report to the General Practitioner, multiple episodes of new onset hot flushes when opening bowels - which was managed conservatively with reassurance.

It was decided to surgically remove the IUD. Intraoperatively, the IUD was found densely adherent to the lesser omentum close to the pancreas and stomach and was removed safely laparoscopically. The patient made a good postoperative overnight recovery and was discharged.

Intra-abdominal migration of IUDs is a very rare complication of IUD insertion and when detected should be promptly treated with Laparoscopic removal.
592 A Large Lipoma: An Unusual Presentation of the Tongue
Authors: Shathur A , Rashid A , Patel V , Ffolkes L , Jayaram R
Published: October 2021

Background

Lipomas are commonly identified tumours of the body however they are rarely found in the oral cavity. Rarer still is it to report a case of a lipoma in the tongue as they are more commonly located in the buccal mucosa.

Objectives

To diagnose and explore the pathogenesis of a soft-tissue swelling of unknown origin

Method

A thorough patient history and clinical examination was undertaken followed by magnetic resonance imaging (MRI) which revealed an alarming report at first glance. An incisional biopsy of the lesion was then carried out to aid in diagnosing the lesion.

Results

The swelling caused the patient no pain however the mere size of the lesion affected the patient’s tongue movement and function which therefore affected the patient’s quality of life. The imaging and the biopsy of the lesion led to a diagnosis of a large lipoma on the lateral border of the tongue.

Conclusions

To the authors’ best knowledge, we present a rare case of a patient whom we diagnosed with a large lipoma on the lateral border of the tongue. This case report discusses the stages of patient management from initial presenting complaint, up to the maintenance of the patient following the diagnosis of this lesion.
597 Counting on You to do The Count: An Unusual Case Report of a Delayed and Missed Gossypiboma Secondary to Swiss Cheese Model Failings
Authors: Amin P , Chan T
Published: October 2021

Introduction

Gossypiboma is a term describing a retained surgical swab which is a serious complication following any surgical intervention. The incidence of these cases is wholly under reported, partly due to medicolegal aspects, but also due to the misnomer of diagnosis. In this case, we discuss the multifactorial deficiencies which led to a significant morbidity in a patient who had remained asymptomatic for nine years since index surgery.

Case Presentation

A 40-year-old woman presented to the emergency department febrile with a one week history of abdominal pain, on a background of a one year history of chronic pain. The patient’s surgical history demonstrated an ovarian fibroid excision and a subtotal hysterectomy nine and six years ago, respectively. It was later noted the chronic abdominal pain had been previously investigated with positive findings on imaging and biopsy, however, she was lost to follow up. A year later, she presented with an acute abdomen and operative findings of a large abscess cavity, containing a retained swab, with small bowel fistulation were noted.

Conclusions

This reiterates the importance of surgical safety checklists, and often despite this there are many factors that can eventually lead to complete alignment of the holes in the Swiss Cheese leading to unfavourable outcomes. It is imperative to remain hypervigilant during checkpoints, particularly in emergencies where the unpredictability of the operation leads to human error. Gossypiboma remains a serious cause for morbidity and mortality, thus the potential for modified safety checklists or alternative methods for surgical counts.
616 Rare KIT gene mutation in a recurrent GIST: Case Report
Authors: O'Neill N , McManus D , Kennedy A , Eatock M , Napier E
Published: October 2021

Introduction

The diagnosis and treatment of Gastro-intestinal stromal tumours (GISTs) has been revolutionized by molecular pathology and targeted therapy.

Description

This patient was diagnosed with locally advanced gastric GIST in 2009. He was initially treated neoadjuvantly with imatinib from 2009- 2010. He underwent laparoscopic resection in 2010. Pathology showed almost complete response with only 1.5mm focus of viable tumour. He did not receive adjuvant imatinib as this was not established practice in 2010. Recurrent disease was resected in 2011. Mitotic count was 200/50hpf. Adjuvant imatinib was given for 5 years then discontinued in 2016. Imaging showed no recurrence over this time period. Molecular testing showed Kit Exon 11 mutation- this is common in GISTs and associated with response to imatinib. Recurrent disease was diagnosed 2018 with a 10x9cm mass between residual stomach and liver– he recommenced imatinib with partial response (maximal response was reached in 2020, but a new 3cm lesion was noted) He underwent further resection of the residual stomach and liver segmentectomy in 2020. Histology showed acellular areas of myxoid degeneration, indicating treatment response however viable tumour remained. Sequencing was performed. This showed the expected mutation in exon 11 but also a mutation in exon 13 of KIT- this has been shown recently to confer resistance to imatinib.

Discussion

Over 90% of GISTs harbour mutations in c-KIT. Recent work has demonstrated that some tumours acquire secondary mutations conferring resistance, following prolonged TKI therapy. Radiological and histopathological features correlate with such events and assist in deciding surgical management.
629 Small Bowel Entrapment Secondary to An Acetabular Fracture: A Case Report
Authors: East J , Nzekwue C , Karthikeyan R
Published: October 2021

Bowel entrapment within a pelvic fracture is a rare clinical occurrence. The first reported case was documented in 1907, with only 24 further cases reported in the literature since. Entrapment usually involves mobile segments of bowel and various fracture sites within the pelvis have been implicated.

We report a case of a 31-year-old ‘trauma alert’, who sustained pelvic fractures following a pedestrian vs car ‘RTC’. The patient was initially taken to theatre for an examination under anaesthesia, where an immobile acetabular fragment was identified, but the hip joint was felt to be stable. A Denham pin was placed in the distal femur and traction applied. Two days post admission they developed abdominal pain and vomiting. A subsequent CT scan demonstrated small bowel entrapment within the acetabular fracture causing a mechanical obstruction. Emergency laparotomy confirmed an intra-acetabular hernia which was released via an extra-peritoneal route. A section of necrotic bowel was resected, and a primary anastomosis performed.

Bowel entrapment poses a difficult diagnostic challenge and there is often a delay in diagnosis. Despite advances in imaging, initial radiographic features can be subtle, and it can be difficult to distinguish clinically between mechanical bowel obstruction and adynamic ileus. This case highlights that bowel entrapment is an important consideration in patients with pelvic fractures following high energy trauma. Awareness of this rare complication and a high index of suspicion are key to early diagnosis and timely surgical intervention, which has the potential to prevent significant complications including bowel obstruction, acute peritonitis and death.
705 Aortic Graft Infection Managed with Bovine Patch, A Case Report and Literature Review
Authors: El-nakhal T , Eid S , Al-Jundi W
Published: October 2021

Aim

to describe good outcomes in a case with Aortic graft infection (AGI) managed with Bovine patch and outline management of AGI.

Method

Literature review utilising keywords ‘’Aortic graft infection’’AND’’Bovine Patch’’ revealed initially 1350 articles, all studies in English were included, all duplicates were removed, screening was performed using the PRISMA flow. To correlate with the findings, we followed up a 72-year-old patient who presented with aortic graft infection followed by graft explantation and a fashioned Bovine graft insertion and followed up for 1 year for any re-infection in the clinics.

Results

Literature search resulted 73 articles discussing the role of Bovine Patch as a choice in prevention of Aortic graft re-infection. In our case, there was no clinical nor radiological evidence of Bovine patch re-infection for over a year. Literature review showed that AGI is a rare but serious complication with mortality up to 60%.The main management is IV antibiotics, followed by graft explantation and consideration of re-implantation of various types of grafts. The European society of vascular surgery (ESVS) guidelines recommend re-implantation with an aortic antibiotic soaked graft, yet re-infection rate is quoted at 20%. however, in our case Bovine graft was free from re-infection at 1 year follow up.

Conclusions

IV anitbioics and explantation remain the mainstay for treatment of aortic grafts infection, however, there is increasing evidence that Bovine grafts show excellent freedom from re-infection at follow up. Hence, this might be the conduit of choice when performing such surgeries; however, more evidence is needed.
707 Principles of Damage Control Surgery in Trauma and Beyond: Experience at A Tertiary Centre
Authors: Quake S Y L , Strong C , Okpala A , Shaaban M
Published: October 2021

Damage control surgery (DCS) is an abbreviated laparotomy used as a temporising measure in critically unwell patients who have limited physiological reserves to tolerate complex definitive surgeries. The aim of DCS is to address life-threatening haemorrhage and manage abdominal contamination. Following an abbreviated laparotomy, patients are continuously resuscitated in intensive care unit until physiological stability can be maintained for definitive surgeries. The role of DCS in the trauma setting is well-described; however, its principles can also be applied in General Surgery for a variety of indications such as mesenteric ischaemia, uncontrolled haemorrhage, and secondary peritonitis. Judicious selection of the non-trauma patient who will benefit from this strategy is paramount. We present two cases of a polytrauma patient (Patient A), and non-trauma patient with abdominal septic shock (Patient B) who underwent DCS at our tertiary centre. Patient A is a 49-year-old male involved in a road traffic accident who sustained multiple injuries including liver laceration, splenic laceration, and colonic injury. Intra-abdominal packing and repair of serosal tears were performed, with a re-look laparotomy 48 hours later -- no further bleeding or visceral injuries were identified. Patient B is a 51-year-old gentleman who re-presented in septic shock due to infected retroperitoneal collection following a bleeding duodenal ulcer, initially managed radiologically. A T tube was inserted into the duodenum with two abdominal drains at initial DCS. After thorough washout, a feeding jejunostomy was sited at the re-look laparotomy. 30-days mortality is 0% and both patients are under follow-up.
796 Chronic Pneumoperitoneum: Cause or Consequence of Pneumatosis Cystoides Intestinalis
Authors: Baggaley A , Clements C , Gerogiannis I , Bloom I
Published: October 2021

Pneumatosis cystoides intestinalis (PCI), ‘gas cysts’ in the wall of the bowel, is a rare sign that can be found as a result of many different conditions, ranging from benign and asymptomatic, to life threatening. Its pathogenesis is not yet fully understood, and patients found to have PCI are treated in a heterogeneous manner. Pneumoperitoneum, however, is much more commonly seen by the General Surgeons, and most often occurs as a result of a perforated viscus; usually necessitating an emergent surgical intervention. Spontaneous pneumoperitoneum occurs very rarely, although it is seen more frequently with small bowel PCI, compared to large bowel PCI.

We present here an unusual case of a patient with acute-on-chronic pneumoperitoneum and subsequently subacute small bowel obstruction associated with small bowel pneumatosis cystoides intestinalis. The patient also had extensive pan colonic and jejunal diverticulosis, although the area of perforation and PCI was discrete and located in the mid-ileum. It is unclear whether the patient had chronic pneumoperitoneum secondary to perforated PCI, or if the PCI developed secondary to an ileum perforation of unknown origin (fitting with the bacterial or mechanical theory of pathogenesis). The patient went onto to have an emergency laparotomy and small bowel resection 28 months after initial presentation and a trial of conservative management.
802 Preservation of a Reconstructed Breast Whilst Undertaking Total Sternal Resection for Metastatic Breast Cancer with a Pedicled Latissimus Dorsi Flap and a Methyl Methacrylate Mesh Sandwich
Authors: Ibrahim N , Morhij R , Patel N G
Published: October 2021

Background

Sternal resection and reconstruction are a complex and challenging procedure that requires a multidisciplinary approach and input from both thoracic and plastic surgeons. Limited data exist on sternal resection and reconstruction for secondary breast malignancies. The goals of sternal and anterior chest wall reconstruction are to maintain chest wall integrity, rigidity, and the negative pressure necessary for respiratory and cardiac functions, protect intrathoracic contents, and restore the chest wall contour.

Case Presentation

A 40-year-old lady developed a solitary sternal metastatic lesion three years after her initial diagnosis with BRCA2 positive breast cancer. She had previously undergone left mastectomy, axillary clearance and implant reconstruction followed by right prophylactic mastectomy and implant reconstruction. She also had neoadjuvant chemotherapy and adjuvant chest wall radiotherapy. Her solitary sternal metastasis was managed with curative intent by complete sternal resection and a combined alloplastic and autologous sternal reconstruction with methyl methacrylate sandwiched between a polypropylene mesh and covered with a pedicled latissimus dorsi flap. The flap was successfully tunnelled under the previous implant-based breast reconstruction capsule. The surgical margins were clear, there were no post-operative complications and no further disease. The patient achieved good cosmetic outcomes.

Conclusions

We describe the first case of breast implant preservation whilst undertaking total sternal resection for an isolated sternal metastasise and reconstruction with a pedicle latissimus dorsi flap and methyl methacrylate mesh sandwich. We advocate combined approach with thoracic and plastic surgery, which allows a safe single stage procedure.
833 An Interesting Association Between Recurrent Acute Pancreatitis and Myotonic Dystrophy, A Case Report
Authors: Vijayagopal K A , Issa M , Fok M , Javed M S
Published: October 2021

Myotonic Dystrophy(MD) is an autosomal dominant genetic condition affecting the musculoskeletal system. Recurrent acute pancreatitis(RAP) is a frequent presentation in the emergency surgical scenario with two or more episodes of established acute pancreatitis separated by a minimum of 3 month periods. We report here a case of a patient presenting with a background of Myotonic Dystrophy with a third episode of RAP. Diagnostic work up led to the discovery of microlithiasis as a possible cause of pancreatitis in our patient. Literature review reports two other case reports detailing a potential association between MD and pancreatitis at the time of writing. This could be due to disturbances of the pancreatobiliary system, resulting from the sphincter of Oddi dysfunction (SOD) and gallbladder myotonia as MD affects the smooth and striated muscle of the gastrointestinal tract. In our case report, we highlight the importance of understanding how MD is a rare cause for a common surgical emergency presentation clinicians should be aware of.
851 Giant Oncocytoma In A Solitary Kidney: A Case Report on Balancing Surgical Resection Against Surveillance
Authors: Srivastava A , Neves J B , Tran M G B
Published: October 2021

Renal oncocytomas are benign kidney neoplasms that are typically small, unilaterally localised (95%) and challenging to differentiate on cross-sectional imaging, hence requiring surgical intervention. We herein present the extremely rare case of a patient with giant, bilateral oncocytomas and oncocytosis, and chronic kidney disease (CKD) and discuss the associated treatment challenges.

A 61-year-old male with no past medical history presented with CKD (eGFR of 32ml/min). On investigation, cross sectional imaging revealed bilateral, multifocal, solid and vascular renal lesions. The largest lesion measuring 115mm x 102mm was situated in the right kidney, with multiple lesions noted in the left kidney, measuring up to 44mm. He subsequently underwent a right radical nephrectomy and histopathological analysis reported oncocytosis of the background kidney. The largest left sided renal lesion was biopsied, also confirmatory of benign oncocytoma. eGFR after surgery was 26ml/min. Following patient-centric consultations, further surgical intervention for the left sided renal lesions was declined, aiming to avoid renal replacement therapy (RRT). He has remained on active surveillance with biannual scans for 6 years. The lesions in his remaining kidney have since grown and coalesced into a single large lesion, with axial dimensions in the most recent MRI scan of 104mm x 306mm. He has progressed to stage IV CKD (eGFR 16ml/min), but still currently without need of RRT.

This case study underscores both the significance of shared decision making in urology and surgery. Ultimately, the most significant skill lies in knowing when to not operate, especially when presented with the rarest of cases.
876 Paediatric NG Tubes and NG Spigots – A Novel Approach to Treating Urinary Retention Secondary to Phimosis in The Emergency Department
Authors: Newman M , Clement K
Published: October 2021

Introduction

Urinary retention due to phimosis is usually treated with an emergency dorsal slit. We present a novel approach to treating urinary retention secondary to phimosis in the emergency department.

Case report

We present a 53 gentleman who was seen in the emergency department due to absolute urinary retention. On review, the gentleman had a grade 5 phimosis. After several minutes of attempting to separate the edges of the forskin, a small opening was created and a size 4Fr NG paediatric NG tube was passed providing temporary relief for the patient. Once the patient was more comfortable, the narrow end of a NG spigot was used to dilate the phimosis enough for a 14Fr catheter to be passed. The patient was observed for a period of time, discharged with a trial without catheter clinic two weeks later and listed for an outpatient circumcision.

Conclusions

This case demonstrates a novel technique for treating urinary retention secondary to phimosis within the emergency department, avoiding the need for an emergency dorsal slit.
880 Rare Benign Chondromyxoid Fibroma of Rib, A Case Report; Is It Really Benign?
Authors: Basak B , Haragan A , Shackcloth M , Thekkudan J
Published: October 2021

Chondromyxoid Fibroma is a benign chondrogenic lesion accounting for less than one percent of the bone tumor; hence, likely to be misdiagnosed. Its presentation can vary from asymptomatic to pain, swelling, and movement restriction. The typical presentation includes a young male with a lesion commonly around the knee joint. However, we detail here an unusual presentation of this benign tumor in a 61-year male referred with chest pain and swelling. Histopathology can be very helpful in diagnosing this rare condition showing the characteristic patterns. Besides, as the tumor is locally aggressive, it can often be misinterpreted and treated as sarcoma. Moreover, it has a high recurrence rate. These characteristics make this rare tumor standout from the other benign tumors. Therefore, these cases need to be viewed thoroughly with a high index of suspicion pre-diagnosis and ensure adequate treatment and follow-up for successful management.