bluuebunny/crossref_metadata_2025 huggingface dataset:
458 Blood Loss Following First Time Coronary-Artery-Bypass-Graft (CABG)
Authors: Ishak L , Morcos K , Curry P
Published: October 2021

Introduction

Blood loss following cardiac surgery is a recognised complication associated with post-operative mortality and morbidity.

Aim

To identify parameters associated with blood loss and need for blood transfusion following first time coronary-artery-bypass-graft (CABG).

Method

Data was collected retrospectively on 50 patients who underwent a first time CABG between 12/02/2020 – 21/09/2020 at the Golden Jubilee National Hospital (GJNH). Parameters included pre-operative and post-operative haemoglobin, platelets, INR, calcium levels, patient age, body-mass-index (BMI), creatinine clearance (CrCl), presence of co-morbidities, anti-coagulant drug use, cross-clamp time, bypass time, re-exploration rates and number of grafts. Patients who required a blood transfusion post-operatively were compared with those who did not require transfusion.

Results

Seventeen of the 50 patients required a blood transfusion. This group had a lower mean post-operative haemoglobin levels (90.82 vs 107.82, p = <0.001), lower mean post-operative platelet levels (138.47 vs 187.09, p = 0.02), higher post-operative INR (1.25 vs 1.15, p = 0.15), higher mean BMI (27.93 vs 30.433, p = 0.063), higher mean renal dysfunction severity grades (0.7 vs 0.3, p = 0.044) and lower mean CrCl (78 vs 97, p = 0.025). The transfused patient group had older mean age (68.29 vs 64.84, p = 0.065) and a longer mean post-operative hospital stay (9.38 vs 6.67 days, p = 0.043). More patients had pre-operative haemoglobin <120 (p = 0.26), post-operative haemoglobin <90 (p = <0.0001) and post-operative platelets <100 (p = 0.0029). One patient in the transfused group died post-operatively.

Conclusions

Sub-optimal peri-operative blood levels, renal dysfunction, patient age and patient BMI can influence blood loss and requirement for transfusion following first time CABG.
462 Factors Associated with Longer Post-Operative Hospital Stay Following First Time Coronary-Artery-Bypass-Graft (CABG)
Authors: Ishak L , Morcos K , Curry P
Published: October 2021

Prolonged post-operative hospital stay is associated with worse patient healthcare outcomes.

Aim

To identify parameters which correlate with longer post-operative hospital stay (POHS) following first time Coronary-Artery-Bypass-Graft (CABG)

Method

Data was collected retrospectively on 50 patients who underwent a first time CABG between 12/02/2020 – 21/09/2020 at the Golden Jubilee National Hospital (GJNH). Data included patient demographics, body-mass-index (BMI), presence of co-morbidities, peri-operative blood results, pre-operative renal dysfunction, left ventricular systolic dysfunction (LVSD), severity of left main stem disease, New York Heart Association (NYHA) Functional Classification score, number of grafts, cross-clamp time and bypass time.

Results

The mean POHS was 7.5 days. Patients with a POHS>7.5 days had a total mean POHS twice as long (12.07 vs 5.7 days, p < 0.001). They spent more time in intensive care unit (2.6 vs 0.97 days, P = 0.05), high dependency unit (2.5 vs 1.2 days, p = 0.005) and ward (7 vs 3.5 days, p = 0.001) compared to the shorter POHS group. They had a higher mean age (69 vs 65, p = 0.036), lower mean CrCl (80.32 vs 95.14, p = 0.141), higher mean renal dysfunction severity grades (0.8 vs 0.28, p = 0.014), higher mean LVSD severity grades (0.33 vs 0.17, p = 0.35) and higher mean NYHA scores (2.2 vs 1.88, p = 0.17). More of the patients had renal dysfunction (p = 0.01), were on ≥ 2 anticoagulants (p = 0.028), had sub-optimal pre-operative bloods (p = 0.075) and required blood transfusion post-operatively (p = 0.02). One patient in the longer POHS group died.

Conclusions

Longer POHS was associated with older age, worse renal function, presence of co-morbidities, sub-optimal peri-operative blood levels and requirement for post-operative blood transfusions.
772 Surgery for Bullous Lung Disease
Authors: Mohamed B , Awad Ahmed S , Hussein H , Ahmed M E A
Published: October 2021

Aim

The aim of this study to assess the surgical presentation and outcome for bullous lung disease in Sudanese patients.

Method

A cross sectional hospital based descriptive retrospective study. Procedures were conducted at Al-Shaab Teaching Hospital Sudan during the period from November 2009 to September 2012.

Results

11 patients had lung bullae in the given period. Smoking does not play an important role in the development of bullae in healthy young adults in our patients. Vanishing Lung syndrome (VLS) was seen in 18% of patients without history of smoking. The patients presenting in the fifth decade of life constituted (36.3%) of total number. symptoms of presentation were chest pain and SOB and half of them (45.5%) had exertional dyspnoea. The duration of symptoms before presentation was more than 2 months. Asthma was the only respiratory disease associated seen in 45%. HBV and HTN were the most associated diseases seen in 27% and 18% respectively without significant findings in the history. The diagnosis was made by highresolution CT. Chest in all patients. Bullectomy was done to majority of patients. Muscle sparing thoracotomy is the standard approach (Posterolateral Thoracotomy). improved regarding symptoms and signs (90.9%) and) and no death reported.

Conclusions

Bullous lung disease with bilateral lung involvement is common in our patients. However, there was no association between lung bullae and smoking in our population. lt's associated with other respiratory disease. The outcome was excellent, and no death was reported. To prevent the miss diagnosis we need sensitive and noninvasive investigation tools.
870 Surgical Outcomes of Primary and Two-Stage Atrioventricular Septal Defect (AVSD) Repair: A Single Institution Experience
Authors: Kwong J J , Hew C C , Haranal M
Published: October 2021

Objective

To examine the surgical outcomes of primary and two-stage repair of complete atrioventricular septal defect(AVSD).

Method

This retrospective study included 74 patients who underwent operation for balanced complete AVSD between January 2015 and December 2018 in National Heart Centre Kuala Lumpur. Patient demographics, types of procedure, post-op complications and follow-up atrioventricular (AV) valve function were analysed.

Results

Twenty-one patients (median age: 3 months(2.28-4.32months)), weight: 3.10kg( 2.7-3.82kg)) had Pulmonary Artery Banding (PAB) prior to complete AVSD repair. The post-banding weight of patients rose from 3.1kg to 6.4kg prior to complete repair. The rate of ventilator dependence decreased from 19.8 to 4.8%. There was no worsening of post-banding left AV valve insufficiency (5%) before the complete repair. There was no statistically significant difference in the outcomes after complete AVSD repair in both groups (mortality p = 0.133, morbidities p = 0.471). There was a trend towards higher left AV valve insufficiency in the PAB group over time (at discharge, 10 vs 12%; at 3-months, 12 vs 6%; at 1-year, 14 vs 11%). Similarly, the PAB group also demonstrated a trend towards higher rates of major post- operative complications (33 vs 21%) and in-hospital mortality (9.5 vs 1.9%).

Conclusions

PAB remained as an effective palliative procedure for patients who are not suitable for primary AVSD repair at the time of presentation. However, it is associated with a higher incidence of left AV valve insufficiency at follow up.
1097 17 Years of Treating Deep Sternal Wound Infections at A Single Institution: Outcomes and Lessons Learned
Authors: Argyriou A , Hasan R , Abunasra H , McLaughlin K , Bilal H , Sogliani F , Datta S
Published: October 2021

Introduction

Deep sternal wound infections (DSWI) are a serious complication following cardiac surgery that comprise of any infection penetrating the subcutaneous tissue of the sternum. DSWI have been found to increase mortality and worsen prognostic outcomes following surgery.

Method

We conducted a retrospective cohort study using hospital e-records from 2000 to 2017 of all adult patients operated on with a median sternotomy at our institution. Univariate and multivariate analysis along with mortality and Kaplan-Meier survival curves compared the DSWI population against the remaining study population, using SPSS-25 software.

Results

Of 15521 total patients in the study, 145 (0.9%) suffered a DSWI. Variables that were associated with DSWI included age at operation (p = 0.019), gender (p = 0.007), BMI (p = 0.001), diabetes (p < 0.0001), renal disease (p = 0.008), operative urgency (p = 0.007), type of operation (p = 0.02), Euroscore (p = <0.0001), bypass-time (p = 0.038) and crossclamp-time (p = 0.008). A logistic regression encompassing significant variables revealed that gender (p = 0.031 CI 1.45-1.96), BMI (p < 0.0001 CI 1.03-1.10), diabetes (p = 0.007 CI 1.20-3.67) and type of operation (p = 0.018 CI 1.23-1.87) remained significant when covariate contribution was eliminated. DSWI subgroup mortality was insignificant at 30 days (3.4%vs2.9%, p = 0.68) but significantly worse at 90 days (8.3%vs3.7%, p = 0.004) and at 1 year (17.2%vs5.4%, p < 0.0001). Kaplan-Meier analysis depicted a significantly worse survival distribution for the DSWI population compared to rest of study (Log-Rank<0.05).

Conclusions

At our centre, DSWI are attributable to certain modifiable and set demographics and contribute heavily to medium-term mortality. A better understanding of DSWI risk factors may pinpoint those at risk and benefit the multidisciplinary team to ultimately reduce the rate of DSWI.
1258 Computational Modelling Of 3D Printed Scaffolds for Heart Valve Regeneration
Authors: Georgi M , Wu L , Ma H , Hamilton G , Song W
Published: October 2021

Aim

Prosthetic heart valve replacement remains the gold standard treatment for valvular heart disease. However, its durability is limited and there is thus a need to develop an understanding of the feasibility of alternative replacement therapies. 3-dimensional printing of heart valves has been explored due to its patient-specific design and control of desired biomechanical properties. Computational studies of the synthetic valves will contribute to optimisation of designs, as well as improved understanding of the biomechanical behaviour of the complex structures.

Method

Aortic valve dimensions at an average of 100mmHg were used for the computerised design of the valves. Fine Element Analysis modelling generated computational experiments alongside predicted results. Simulated radial pressures tests were conducted at pressures from 0mmHg to 140mmHg and compression tests were conducted at displacement levels between 0-10mm. A Young’s modulus of 0.5 MPa was used. All simulations were conducted in a quasi-static manner.

Results

As the radial pressure on the valves increased, the Mises stresses increased. The maxium Mises stress of the heart valve was 0.09MPa and 0.13MPa under the pressures of 90mmHg and 140mmHg respectively. As valve displacement increased, the Mises stress of the heart valves proportionally rose. In simulated radial pressures tests, the compressive force was 0.19N at 1mm compressive displacment and 1.8N at 10mm compressive displacment.

Conclusions

The simulations demonstrated that 3D-printed heart valve scaffolds can withstand simulated radial pressure and compression tests. A further mechanical tests of the printed scaffold and understanding of its response to hemodynamic dynamic flow is required for the continuity of further study.
1292 Aortic Valve Neocuspidization Using Glutaraldehyde-Treated Autologous Pericardium: A Literature Review
Authors: Chan J. , Basu A. , Di Scenza G. , Bartlett J. , Fan K. S. , Oo S.
Published: October 2021

Background

Aortic Valve Neocuspidization using glutaraldehyde-treated autologous pericardium was first performed by Ozaki et al. in 2007. This technique has become an alternative to tissue and mechanical valve as long-term anticoagulation is not required and shows promising midterm results and durability.

Method

A comprehensive search was performed on the major database using search terms “Ozaki technique” AND “Aortic Valve Neocuspidization” AND “AV Neocuspidization” AND “Autologous pericardium” AND “glutaraldehyde-treated autologous pericardium”. Articles up to 1st of August 2020 were included in this study.

Results

A total of 9 studies with a total of 1342 patients were included. The mean age was 67.36 and 54.23% were male. 66.32% and 23.92% of patients had aortic stenosis and aortic regurgitation, respectively. 66% of patients had a native tricuspid aortic valve and 31.37 % patients’ native aortic valve was bicuspid. Three studies reported their experience performing Aortic Valve Neocuspidization via mini sternotomy.

Conclusions

Aortic Valve Neocuspidization is an alternative to biological and mechanical prostheses for surgical aortic valve replacement. The short and mid-term outcome are comparable without the need for long term oral anticoagulation. Long term follow-up data is required for this novel approach to be widely adopted.
1355 Clinical Profile of Congenital Heart Diseases in Children in Khartoum, Sudan
Authors: Elhassan A B E , Salman M. Suliman T , Elkhidir I. Hassan E , Mohamed S. Omer O , Ibrahim A , Mohammed F , Abuzied A , Elhassan M
Published: October 2021

Aim

Congenital heart diseases (CHDs) are heart abnormalities that present at birth and are one of the most common birth defects in children. Few studies assessed the clinical profile of CHDs in Sudan, and they are almost outdated. The aim of this study was to provide a recent overview of the clinical profile of CHDs in Khartoum, Sudan.

Method

a descriptive cross-sectional hospital-based study was done in 2016 in 3 main pediatric tertiary care hospitals in Khartoum. Firstly, the authors included all patients presented with suspicion of cardiac diseases. From which only those diagnosed with CHDs were included. The total sample size was 112 patients, from which CHDs comprised 60 patients.

Results

among the 112 patients, 53.6% had CHDs, 25% had acquired diseases, and 21.4% were normal. Of those with CHD, 60% were having acyanotic CHD, and 21.7% were having cyanotic CHD, the remaining patients had other cardiac defects. VSD was the most predominant individual CHD (33%), followed by ASD (19%), PDA (16.8%) and TOF (16.8%). VSD was the most common acyanotic lesion, while TOF was the most common cyanotic lesion followed by TGA and pulmonary atresia (PA).

Conclusions

We have an updated overview of the clinical profile of CHDs in Khartoum, Sudan. CHDs were the most common form within all pediatric patients with cardiac disease. From these CHDs, acyanotic lesions were the most common ones. VSD was the most common acyanotic lesion followed by PDA. TOF was the most common cyanotic lesion. These findings are consistent with studies done regionally and internationally.
1608 Mitral Valve Disease Timing and Outcomes of Surgery
Authors: Mabon M A , Badran A , Ramadan T , Abuseedou R , Ohri S
Published: October 2021

Aim

Mitral valve disease (MVD) is a heart valvular defect associated with significant morbidity and mortality. Individual patient management depends on symptomatic disease, fitness and type of pathology. Surgical intervention remains the standard for definitive management. The optimal time to operate is debated and considerations for earlier surgical intervention include reduced risk of surgery and co-morbidity prevention. We aim to evaluate when patients with MVD receive treatment and if this is associated with patient outcome

Method

Patients who received surgery for MVD between 2018 and 2020 were included. Electronic records were examined, and a database was created of patient demographics, symptoms, surgery and outcomes.

Results

Our patient cohort consisted of n = 355, with n = 198 receiving elective intervention. There was a higher male to female ratio (58% vs 42% respectively). Mean intervention time was 157.6 days and mean age was 71 years (24-93). Cohort mortality rate was 6.5% (n = 23). The cohort was split into two groups; early surgical intervention (within 90 days from diagnosis) consisting of n = 59 and late surgical intervention (after 90 days) n = 139; demographics and comorbidities were similar in both groups. No significant associations were found between intervention time and our variables. There was no significant association between intervention time and 60-day mortality or with any complication.

Conclusions

There is no significant association found between timing of intervention and patient outcome. Early surgical intervention is no worse than later surgical intervention although the data supports patients were intervened at the most appropriate time according to clinical evaluation.
1623 Atrial Fibrillation Post Aortic Valve Replacement: Prevalence and Causative Factors
Authors: Baker S , Badran A , Naseer M , Ohri S
Published: October 2021

Aim

Atrial fibrillation (AF) is the most prevalent arrhythmia. Post-Operative AF (POAF) occurs in a third of patients post cardiac surgery. We aim to explore the incidence of AF post aortic valve replacement (AVR) and whether clinical and echocardiographic parameters can predict the likelihood of AF and therefore influence the management of patients.

Method

Our study consisted of 985 patients who underwent AVR between 2018 – 2019 from a single major cardiothoracic surgery centre in the UK. Data was collected from the electronic patient records retrospectively.

Results

Mean age of the cohort was 71.8 years (27-92). There were more males (68.2%, n = 672) than females (31.8%, n = 313). A majority of patients (51.8%, n = 510) developed an episode of AF in the post-operative period, of which 65.1% was new onset (n = 330). Incidence of post-operative AF was associated with more HTN (p = 0.007), poor left ventricular function as well as increased left atrial diameter (P = <0.001).

Conclusions

There is a high incidence of AF following AVR surgery. Comorbidities as well as left atrial diameter have a statistically significant relationship with this incidence and could be used as predictors of postoperative atrial fibrillation.
1657 Systematic Review and Meta-Analysis of Mortality Risk Prediction Models in Adult Cardiac Surgery
Authors: Sinha S , Dimagli A , Dixon L , Gaudino M , Caputo M , Vohra H , Angelini G , Benedetto U
Published: October 2021

Background

The most used mortality risk prediction models in cardiac surgery are the European System for Cardiac Operative Risk Evaluation(EuroSCORE)(ES) and Society of Thoracic Surgeons(STS) score. There is no agreement on which score should be considered more accurate nor which score should be utilised in each population sub-group. We sought to provide a thorough quantitative assessment of these 2 models.

Method

We performed a systematic literature review and captured information on discrimination, as quantified by the area under the receiver operator curve(AUC), and calibration, as quantified by the ratio of observed-to-expected mortality(O:E). We performed random effects meta-analysis of the performance of the individual models as well as pairwise comparisons and sub-group analysis by procedure type, time and continent.

Results

The ES2(AUC 0.783[95%CI 0.765-0.800];O:E 1.102[95%CI 0.943-1.289]) and STS(AUC 0.757[95%CI 0.727-0.785];O:E 1.111[95%CI 0.853-1.447]) both showed good overall discrimination and calibration. There was no significant difference in the discrimination of the two models(Difference in AUC -0.016; 95%CI -0.034 to -0.002;p0.09). However, the calibration of ES2 showed significant geographical variations(p < 0.001) and a trend towards miscalibration with time(p0.0057). This was not seen with STS.

Conclusions

ES2 and STS are both reliable predictors of short-term mortality following adult cardiac surgery in the populations from which they were derived. STS may have broader applications when comparing outcomes across continents and time periods as compared to ES2.
41 Low Flow Priapism as A Complication of Covid-19 Infection
Authors: Ahmed S , Alabai M , Datta S
Published: October 2021

On 12 March 2020 the World Health Organisation (WHO) declared a pandemic of SARS-COV-2(Covid 19). We report a case of a 58-year-old man who presented with dyspnoea, pyrexia and a dry cough. Upon admission he was noted to be in a severe Type 1 Respiratory Failure with Bi-lateral pulmonary infiltrates suggestive of Covid 19 infection. Rapid transfer to ITU ensued with Intubation, Ventilation and Inotropic support. Priapism was noted a day into admission which was subsequently aspirated by the Urology team, achieving detumescence. Priapism is a state of persistent penile erection that continues for 4 hours beyond sexual stimulation. We describe the role of thrombosis, dysregulation of the clotting cascade and acute disseminated intravascular coagulation (DIC) as shared pathologies in priapism and Covid 19 infection. We highlight the importance of vigilance for extra-pulmonary manifestations of Covid-19 and feel that the pro-thrombotic phenomena exhibited by Covid-19 infection affects distal vasculature in the same manner as Low Flow Priapism and hence explains why our patient suffered from this particular urological complication
154 Complete Inguinal Bladder Hernia Causing Acute Obstruction of Right Upper Urinary Tract
Authors: Madden-McKee C , Getty M , Thompson T
Published: October 2021

Case Summary

An 86-year-old male nursing home resident presented with increasing confusion and was initially treated for catheter-associated urinary tract infection. CT scan demonstrated acute acalculous cholecystitis and complete inguinal bladder hernia with compression of right vesico-ureteric junction leading to acute obstructive renal failure. Percutaneous cholecystostomy and percutaneous nephrostomy were attempted but were not possible due to patient non-compliance. Patient improved with conservative management.

Discussion

Bladder involvement in inguinal herniae is rare with most cases being identified at the time of hernia repair and there is a 17% risk of intra-operative bladder injury. Key risk factors include increasing age, male gender, lower urinary tract symptoms and previous hernia repair. Percutaneous nephrostomy followed by inguinal hernia repair is the treatment of choice for most patients. Clinicians should aim to make the diagnosis of inguinal bladder hernia pre-operatively to reduce risk of intra-operative bladder injury during hernia repair. Acute acalculous cholecystitis tends to occur in critically ill patients and is a marker of poor prognosis.
237 Massive Subcapsular Intra-hepatic Haematoma Post-laparoscopic Cholecystectomy: A Rare Complication of a Common Procedure
Authors: Saad E , O'Connell L
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 US performed eight weeks post-discharge confirmed a complete resolution.

Conclusions

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 a refractory postoperative hypotension. It also highlights the decisive role of diagnostic imaging in securing a timely and accurate diagnosis of post LC-ISH
302 Migratory Foreign Body in The Neck- How A Fishbone Morphed into A Piece of Glass In 18 Months
Authors: Horlick S , Sehgal S , Al-Dulaimy B , Anmolsingh R , Goswamy J
Published: October 2021

Background

Foreign body (FB) ingestion is a common presentation to ear, nose, and throat (ENT) surgeons. Usual culprits include fish or chicken bones, steak, or non-organic items. FBs can be categorised into batteries, hard objects, and soft boluses. Hard objects that have not passed beyond the post-cricoid region require removal to minimise perforation risk. In rare cases FBs are reported to migrate extra-luminally into surrounding tissues of the neck necessitating cross-sectional imaging ahead of neck exploration.

Case Report

A 70-year-old lady presented to A&E with a sensation of FBs in her throat. She was aphagic without dyspnoea. Home-cooked fish ingestion was the precursor. Panendoscopy was clear. The patient was discharged once tolerating fluids and soft diet. She presented 14 months later to the ENT clinic with a persistent FB sensation in her throat. A computed-tomography scan of neck showed a right sided, radio-opaque, 3 cm foreign body sitting just anterior to the carotid sheath, behind the right superior thyroid lobe. An elective external neck exploration revealed a 3 cm shard of glass which was successfully removed without complications.

Conclusions

Extra-luminal migration of FBs is extremely rare. They may present with life-threatening suppurative or vascular complications. A literature review revealed that migratory FBs tend to be sharp and long such as needles, wires, or fishbones. To allow prompt diagnosis and management, we propose a low threshold for CT imaging in instances with a clear history and persistent symptoms even when panendoscopy is negative.
356 An Unfortunate Case of Spinal Injury and Bladder Dysfunction During the Covid-19 Pandemic
Authors: Lane J , Johnston M , Davies M
Published: October 2021

There is no doubt that COVID-19 has had a profound impact on every medical and surgical speciality. In the height of the pandemic many non-emergency services were shut down, including dental services, with unexpected consequences. We present a case which highlights the unexpected and indirect consequences of a national lockdown on a Urology patient and discuss learning points.

A 54-year-old male, previously fit and well suffered with a small dental abscess, media outlets were reporting that dental surgeries were closed, and he therefore attempted to drain the abscess himself. The infection spread to his epidural space, causing compression via a collection at L2 and consequently spinal cord injury. This was managed with urgent lumbar decompression and antibiotics.

A specialist functional urology team were involved after his transfer to the tertiary spinal unit 3 months after his first presentation. He was catheterised but suffered with recurrent catheter blockages. Video urodynamics demonstrated a stable bladder with a low-pressure leak point, managed with urethral catheterisation. A repeat video urodynamics demonstrated a loss of compliance and stress incontinence. Unclear as to whether he would regain function rehabilitation techniques are currently being attempted prior for definitive operative management with an artificial sphincter.

This case highlights the indirect impact of COVID-19 on UK urology services, and this has not been widely reported.
412 Polytetrafluoroethylene(PTFE) Pledgets Masquerading As A Pseudo-Aneurysm Of Left Ventricle Apex. A Case Report
Authors: Moawad N , Asopa S , Lloyd C
Published: October 2021

Background

TransCatheter Aortic Valve Implantation (TAVI) is now established as an alternative for open aortic valve replacement in high-risk patients with severe calcified degenerative aortic stenosis.

Case presentation

Here we report a case of a 78 tears old female patient who presented six months following transapical TAVI with a pulsatile mass over the left anterior mini thoracotomy wound. Transthoracic echocardiography showed suspicion of a left ventricular apical aneurysm with no evidence of free pericardial fluid.Contrast enhanced CT reported a large pseudo-aneurysm arising from the apex of the left ventricle extending through the left anterior thoracic wall. She was scheduled for emergency surgical exploration via median sternotomy. Upon median sternotomy there were dense pericardial adhesions limiting the mobilization of the heart specially the apex, which necessitated establishment of cardiopulmonary bypass. The heart was arrested, and the dissection was completed. The cavity in connection with the ventricular apex had purulent contents and the site of the TAVI ventriculotomy was secure with the PTFE pledgets in place with no evidence of leakage. Samples of the cavity fluids had pus cells, but no organisms were grown. The patient made an uneventful recovery and was discharged home 6 days postoperatively.

Discussion

PTFE pledgets are frequently used in cardiac surgery to support surgical closure. These pledgets on a contrast enhanced CT scan can make it difficult to correctly diagnose and may mimic anastomotic leaks as both give similar hyper-dense appearance on contrast enhanced CT scan
455 A Case of An Unusual Penetrating Brain Injury
Authors: Augustin A , Joseph M , Abraham A , Nair R , Sudharsan P V , Yenukoti R
Published: October 2021

Introduction

Penetrating brain injuries (PBI) are less common than closed head traumas. Interest in frontal lobe injuries dates back to 1848’s famous Phineas Gage incident. Here, we report a case of a construction worker, who showed a remarkable neuropsychiatric outcome following a workplace accident.

Case Presentation

45year old gentleman came with complaint of a foreign body accidentally lodged in his forehead. He had no neurological deficits or CSF leak. X-ray revealed that a 5.5cm metallic screw was penetrating his skull, headfirst; CT revealed that approximately 3cm of the screw was in the frontal sinus. He was given antiepileptics and antibiotics prophylactically. Surgically the screw was removed by raising a bone flap and mobilizing the screw carefully by cutting the dura and adequate irrigation, causing minimal damage to the brain parenchyma. The dural deficits were repaired and the frontal sinus was canalized, then a drain was placed, and the patient was shifted to ICU for postoperative monitoring.

Discussion

It is important to prognosticate PBI as they can have neurological deficits that may be lifelong. Understanding the mechanism of injury, aggressive medical management and immediate surgical intervention may lead to improved outcomes. A foreign object of the size of 5.5cm, completely penetrating the skull would have otherwise resulted in extensive parenchymal damage. Literature suggests that no two people have an identical frontal sinus. In our patient the size the frontal sinus has served the purpose of protection against PBI and has resulted in minimal parenchymal injury (of only about 1cm).
479 Penetrating Chest Trauma Causing A Superior Mesenteric Artery-Inferior Vena Cava Fistula and Pancreatic Injury: A Case Report
Authors: Wagner K , Reimann S , Budge M , Claydon M , Musicki K , Ban E.-Jun
Published: October 2021

Penetrating traumatic injuries can present a challenging scenario due to the potential for multisystem involvement requiring swift collaboration between surgical specialities. We present the case of a 66-year-old female who was stabbed in the right posterior chest. CT revealed a diaphragmatic injury, liver laceration involving segments 6/7 with active bleeding, and a posterior superior mesenteric artery (SMA) to anterior inferior vena cava (IVC) fistula. Due to the proximity of the SMA injury to a replaced right hepatic artery origin, the fistulous connection with the suprarenal IVC, and suspected pancreatic and duodenal injuries, a hybrid rather than a purely endovascular approach was taken. A large compliant occlusion balloon was placed percutaneously in the hepatic IVC. Subsequent trauma laparotomy and right medial visceral rotation identified SMA and SMV injuries, which were repaired with temporary supracoeliac aortic clamping. Further kocherisation of the duodenum revealed a 10 cm longitudinal IVC laceration causing sudden large volume venous haemorrhage. This was repaired after control was gained with supracoeliac aortic clamping, infrarenal IVC vessel loop and balloon inflation. An abdominal VAC dressing was applied. Before transfer to ICU, however, 1L of blood was noted in the VAC cannister and a relook laparotomy demonstrated more than 1L of intrabdominal fresh blood. Bleeding vessels around the uncinate process were ligated. After 48 hours, a relook laparotomy revealed no significant bleeding, and the abdomen was closed. A post-operative MRCP demonstrated pancreatic divisum and likely laceration of the aberrant ventral duct. A subsequent peripancreatic collection was managed conservatively.
497 Delayed Gastropleural Fistula: A Rare Cause of a Persistent Pleural Effusion After Blunt Force Trauma
Authors: Chan K Y , Keogh S , Aucharaz N , Temperley H , O'Driscoll J , Ravi N , Tormey S
Published: October 2021

Background

A gastropleural fistula (GPF) is a rare pathological connection between the stomach and pleural cavity. GPFs have been reported following traumatic diaphragmatic ruptures, perforated hiatal hernias and gastric fundal ulcers, and more recently, after bariatric surgery. Diagnosis and treatment are frequently delayed due to the lack of specific clinical, laboratory and radiological findings.

Method

We describe a case of a 53-year-old gentleman who presented to our institution with acute respiratory distress and clinical findings of a pleural effusion. Uniquely he was discharged a week prior following an admission for a traumatic fall down a flight of stairs that resulted in a Grade-IV splenic injury, requiring an emergency splenectomy. A CT-proven massive haemothorax resulted in haemodynamic instability requiring resuscitation and chest drain insertion in the intensive care unit. On commencement of enteral diet, purulent exudate with evidence of food particulates was seen in his chest drain.

Results

Further diagnostic evaluation of drainage contents demonstrated gut flora and a subsequent positive dye test suggested an aero-digestive connection. Repeat CT revealed a fistula between the fundus of the stomach and the left pleural cavity through a ruptured diaphragm. He underwent an open sleeve gastrectomy and primary repair of the diaphragm.

Conclusions

This is the first case in literature reporting a ‘gastropleural fistula’ presenting in such a fashion. Thorough assessment and decisive action led to a satisfactory outcome. Although rare, a persistent effusion with a history of blunt abdominal and thoracic trauma may herald a GPF, which, if not diagnosed promptly, may result in significant morbidity.
505 Failed Femoral Nail with Significant Operative Technical Difficulty: A Practical Solution to Achieve Metalwork Extraction Using Conical Screw Remover
Authors: Paluch A , Clarke A , Smith S , Adams S
Published: October 2021

Introduction

There is a greater risk of delayed healing and revision surgery in atypical femoral fractures (AFFs). Although non-union in reamed intra-medullary (IM) nailing is relatively uncommon, it can lead to fracture of the nail and present a considerable challenge to the treating surgeon.

Case Report

We present a case of AFF treated with IM nail fixation. Metalwork failure of the nail prompted removal of distal locking screws and plating of the fracture site at 8 months. Failure of the plate-bone interface 3 months later led to further revision surgery to remove the broken metalwork. We focus on the significant operative difficulty encountered during removal of the failed IM metalwork and provide a novel practical solution to overcome this particular challenge - insertion of a conical cannulated screw remover under fluoroscopy guidance to create an interference fit with the distal segment of the broken nail.

Discussion

This case is an example of significant and unexpected intra-operative technical difficulty, requiring improvisation and teamwork to manage. We introduce an accessible and uncomplicated alternative to the existing techniques for removal of a broken femoral nail and in doing so hope to benefit peers and colleagues should they encounter similar difficulties in the future.
508 The Early Use of Intratympanic Steroid Injections in the Treatment of Labyrinthitis Obliterans – A Case Report
Authors: Thind R K , Ho G C , Yap D , Hunt A
Published: October 2021

Introduction

Labyrinthitis Obliterans is an inner ear condition characterised by pathological sclerosis and ossification of the membranous labyrinth as a response to inflammatory insult. It is associated with profound sensorineural hearing loss and occasionally dizziness and/or vertigo.In this case report, we describe the use of intratympanic steroid injections in a patient presenting with sudden sensorineural hearing loss (SSNHL) with a radiological diagnosis of Labyrinthitis Obliterans. Whilst many studies suggest the role of oral steroids in SSNHL, there is no current evidence regarding the role of intratympanic steroid injections specifically for the treatment of this condition.

Case Presentation

A 60-year-old gentleman was referred to ENT with a 3-day history of sudden right sided hearing loss. There was no improvement in his Pure Tone Audiometry (PTA) results after 7 days of oral Prednisolone. Subsequently, an MRI Internal Acoustic Meatus showed evidence of right sided Labyrinthitis Obliterans. The patient was initiated on a course of intratympanic Methylprednisolone injections 10 days after initial onset of symptoms. A significant improvement in his baseline hearing of over 60dB was demonstrated after 4 courses of injections over a 3-month period.

Discussion

Our findings reveal that despite a diagnosis of Labyrinthitis Obliterans, the early use of intratympanic steroid injections can significantly improve hearing threshold and quality of life of the patient. The biggest hurdle in the management of Labyrinthitis Obliterans is establishing the diagnosis early and ensuring timely treatment, therefore we would advocate the early use of MRI and early intervention with intratympanic steroid injections.
563 A Rare Case of Small Bowel Obstruction Secondary to Peritoneal Encapsulation, Congenital Adhesional Band and Gallstone Ileus
Authors: Gungadin P , Taib A , Ahmed M , Sultana A
Published: October 2021

Introduction

Small bowel obstruction can be caused by multiple factors. We describe an unusual case of small bowel obstruction secondary to three rare factors: gallstone ileus, peritoneal encapsulation and congenital adhesional band.

Case Presentation

A seventy-nine-year-old male presented with a four-day history of obstipation and abdominal pain. CT abdomen pelvis revealed small bowel obstruction secondary to gallstone ileus. The patient was managed by laparotomy. The intraoperative findings revealed the presence of a congenital peritoneal encapsulation with an adhesional band and gallstone proximal to the ileo-caecal valve. Although there was some dusky small bowel, this recovered following the release of the band.

Discussion

Peritoneal Encapsulation is a rare congenital pathology resulting in the formation of an accessory peritoneal membrane around the small bowel. This condition is asymptomatic and rarely presents as small bowel obstruction. The diagnosis is often made at laparotomy. There are less than 60 cases reported in literature. Gallstone ileus is another rare entity caused by an inflamed gallbladder adhering to part of the bowel resulting in a fistula.

Conclusions

The rarity of these conditions mean that they are poorly understood. A combination of this triad of gall stone ileus in the presence of peritoneal encapsulation and congenital band has not been reported before. Knowledge of this would raise awareness, facilitate diagnosis and management of patients.
571 Case of A Rare Presentation of Solitary Fibrous Tumour of the Pleura (SFTP)
Authors: Ishak L , Kostoulas N
Published: October 2021

Presentation

A 69-year-old male presented with rapidly worsening symptoms of breathlessness, productive cough, and weight loss. Examination revealed a deviated trachea, and no breath sounds on auscultation of the left side of the chest.

Investigations

Chest X-ray revealed a giant mass associated with a large pleural effusion, subtotal lung collapse and mediastinal shift. FEV1 was 39% predicted and DLCO 62% predicted.

Management

Due to the severity of presentation, urgent pleural inspection, drainage, and biopsy were carried out. Compression of the heart resulting in tamponade with increased heartrate and breathlessness was suspected

Further investigations and management

Pleural biopsies and pleural fluid cytology were negative for malignancy. PET-CT showed mild avidity. Definitive management was tumour mass resection via left double space open thoracotomy.

Macroscopy/Microscopy/Immunohistopathology

Intra-operatively, the tumour was giant, occupying three quarters of the chest cavity. It measured 21 × 14×8 cm. The whole lung was attached to the chest wall with adhesions. Microscopy revealed patternless architecture, high vascularity, hypercellularity, necrosis, elongated nuclei, pale cytoplasms and mitotic activity of 2-3 mitotic figures per 10-highpower-fields. Immunohistochemistry stained positive with CD34, BCL2, CD99, Ki-67 and STAT6. Diagnosis of SFT was suspected; malignant potential could not be predicted.

Follow-up was with repeat CT scans for five years. Recurrence risk was given as 20%.

Learning points
625 Intracranial Gossypiboma Nine Years After Intracranial Pressure Bolt Insertion - A Case Report
Authors: Loh R T S , Matys T , Allinson K , Santarius T
Published: October 2021

Background

Resorbable hemostatic agents are commonly used to control bleeding intra- and post- operatively. Once left behind, these agents can occasionally trigger pathological, granulomatous reactions, resulting in space-occupying lesions known as gossypibomas. Here we report a case of an intracranial gossypiboma. These are notoriously difficult to diagnose as they are exceedingly rare and frequently radiologically indistinguishable from other lesions (tumors, abscess etc).

Case Presentation

A 35-year-old woman presented with a generalized tonic-clonic seizure and subsequent left-sided hemiparesis. MRI demonstrated an enhancing lobulated lesion subjacent to a right frontal burr hole, surrounded by vasogenic edema with mass effect and midline shift. Nine years ago, she had a triple bolt inserted to monitor intracranial pressure after sustaining traumatic brain injury in a road traffic accident. Surgicel was used to control bleeding during insertion. She made a full recovery. Co-location of the lesion with the position of triple bolt nine years ago raised a suspicion for gossypiboma. However, the minor nature of the surgery, and the length of time since surgery to presentation were placing this case well outside range of cases reported in the literature. The lesion was resected en bloc, with no recurrence 18 months later. Histological examination revealed presence of foreign material, confirming the suspicion of Surgicel-elicited gossypiboma.

Conclusions

We show here that gossypibomas can occur following a relatively minor procedure and remain clinically and radiologically silent for much longer than what was previously reported. Thus, they should be included in differential diagnoses despite being remarkably rare.
634 Case Report: Large Perforating Ileal Conduit Stone as A Rare Cause of Abdominal Wall Abscess
Authors: Satherley H , Gowda A , Nawaz F , Caddeo G , Stanford R
Published: October 2021

Introduction

Ileal conduits are common following cystectomy for benign or malignant disease of the bladder. They are associated with late complications such as parastomal hernias, strictures, infections and rarely conduit stone formation. We present a previously unreported case of a significant abdominal wall abscess secondary to a very large perforating conduit stone.

Case Report

A 59-year-old female with an established ileal conduit due to multiple sclerosis presented acutely with abdominal pain, peristomal mass and fever. A CT showed a large (40mm) calcification with a fluid collection adjacent to the conduit in the subcutaneous tissues. Emergency incision and drainage of the abscess revealed a large abscess cavity containing a stone. Conduitoscopy demonstrated a narrow stoma and a perforation between the abscess cavity and the lumen of the conduit suggesting extrusion of the stone through an eroded area in the wall of the conduit. A Foley catheter was inserted to bypass the perforation. The patient recovered well after the procedure with the addition of antibiotics. Subsequent conduitoscopy showed closure of the perforation with these measures.

Conclusions

Conduit stones are rare but have the potential to perforate the urinary conduit. We believe that the subcutaneous location of the perforation allowed it to go unnoticed and the stone to achieve a significant size before acting as a nidus for infection. A more proximal perforation would likely result in an intraperitoneal urine leak and earlier presentation with an acute abdomen.
639 Emergency Surgical Approach to A Bleeding Pseudoaneurysm Of the Posterior Inferior Pancreaticoduodenal Artery After Failed Embolisation
Authors: Manku B , Gupta N , Ahmad J , McLaughlin E
Published: October 2021

Background

Pseudoaneurysms of visceral arteries are uncommon, with a prevalence of 0.01% to 0.2%1. Initial treatment is radiological embolisation (RE)2. If this fails, surgical access to the pseudoaneurysm is extremely difficult. They are associated with major complications such as rupture, ischaemia and shock2, with a 20-70% mortality rate3. We report the case of a patient admitted with a life-threatening bleed from an aberrant inferior pancreaticoduodenal artery (IPDA) with failed RE.

Case Summary

A 44-year-old patient presented with right upper quadrant pain, shock and low haemoglobin. His computerised tomography (CT) scan showed a large retroperitoneal haematoma with active bleeding from a 5x6mm IPDA pseudoaneurysm. After resuscitation, access to the IPDA during RE via the coeliac axis and superior mesenteric artery was unsuccessful and he deteriorated. He underwent an emergency laparotomy, which showed the retro-peritoneal haematoma had ruptured into the peritoneal cavity through the transverse mesocolon. Four-quadrant abdominal packing and supra-coeliac manual compression of the aorta was utilised. The right colon was mobilised with full kocherisation of the duodenum. The gastrocolic omentum was divided to enter the lesser sac. The haematoma was evacuated and bleeding branches from the IPDA were suture ligated. He required 26 units of blood throughout admission and underwent 24-hour damage control laparostomy on intensive care. CT mesenteric angiogram post-surgery and re-look laparotomy showed no further active bleeds. He had an uneventful recovery and discharged safely.

Conclusions

RE of visceral artery pseudoaneurysms is challenging. Surgery remains the last resort and should be performed by appropriately trained specialist surgeons.