bluuebunny/crossref_metadata_2025 huggingface dataset:
779 Endoscopic Repair of a Chronic Duodenal Perforation Complicated by a Contained Collection: A Case Report
Authors: Shah S , Mohammed E , Saleem M
Published: August 2023

Duodenal perforations are a surgical emergency with high mortality. Most perforations require open or laparoscopic surgical repair, whereby the ulcer is oversewn, sometimes using a Graham patch. However, surgery is not without complications.

We report the case of a 70-year-old man with a chronic, perforated duodenal ulcer that was repaired endoscopically. The patient presented with a 1-month history of epigastric abdominal pain, exacerbated by eating, and associated with a weight loss of 3.5 stones. Examination revealed a hard, irregular mass in the epigastrium. CT imaging showed a 6.8cm x 5.2cm x 4.1cm collection with an air-fluid level communicating with the D2 duodenum and extravasation of contrast into the collection.

The collection was unable to be drained under radiological guidance due to difficulty in visualising and accessing it. Surgical intervention was deemed difficult to due to the site and chronicity of the perforation.

The patient underwent endoscopic repair. Two interrupted sutures were placed using an Apollo overstitch system. APC was applied to the edges of the perforation and an OVESCO clip was placed ontop. Repeat CT imaging did not show any evidence of recurrent perforation.

Endoscopic repairs have mainly been performed as an adjunct to surgical repair or during ERCP procedures, primarily using endoclips. We present a case where endoscopic repair alone was successful in sealing a duodenal perforation whilst leaving the collection intact.

We believe this case is interesting and with advances in endoscopy, endoscopic repair could provide a minimal invasive option for managing duodenal perforations, especially complicated, chronic ones.
845 A Case of Testicular Salvage Following Complete Capsular Rupture Due to Direct Trauma During Ju-Jistu
Authors: Fardanesh A , Omogbehin T , Lindsay J , Sharif M , Green J
Published: August 2023

Background

Testicular rupture refers to injury of the tunica albuginea and subsequent extrusion of seminiferous tubules. It occurs usually in young men following high impact or sporting injuries. Prompt diagnosis is required, and treatment is time-critical to avoid testicular loss.

Clinical scenario

A 32-year-old man presented to the emergency department with scrotal pain five hours after a direct blow to the right scrotum whilst doing Ju-Jutisu. Examination revealed a tense, swollen and extremely tender right hemi-scrotum. An urgent testicular ultrasound confirmed a right complete capsular rupture with almost circumferential superior-pole tunical defect. The patient was promptly consented for scrotal exploration +/- right sided orchidectomy. Intra-operatively finding was a complete rupture of the right testes and considerable haematoma. A partial orchidectomy was performed, resecting all devitalised seminiferous tubules while the viable testicle was re-constructed with combined primary apposition of albuginea and a tunica vaginalis flap. The resulting cosmetic appearance was adequate. The patient was discharged home the following day, with antibiotics and his recovery was uncomplicated. At four weeks, the patient reported no further pain and post operative imaging was reassuring. He was pleased to avoid complete orchidectomy.

Discussion

Clinicians should have a high index of suspicion for testicular rupture following blunt trauma to scrotum. Patients are frequently anxious about loss of testes and the impact on self-image, fertility, and hormonal function. This case demonstrates that prompt urological review and early scrotal exploration can prevent testicular loss.
855 Mirror-Image Large Complex Odontomes
Authors: Budhdeo R , Graham A , Harrison M
Published: August 2023

Background

This report outlines a nine-year follow-up of two 10-year-old patients who attended the paediatric dental department reporting an absent mandibular first permanent molar (FPM). Both reported no pain, no familial history of hypodontia and no altered sensation in the inferior dental (ID) nerve distribution. Clinical examination revealed mandibular expansion in the unerupted tooth area.

Special Investigations

Panoramic jaw radiographs revealed extensive radio-opaque masses in the mandibular FPM area in both children, in mirror-image sites. Subsequent cone beam CT identified extensive displacement of the FPM with an associated large mixed radiopaque/radiolucent lesion in the body of mandible. Interestingly, the mandibular second permanent molar (SPM) was present in one case and absent in the other.

Diagnosis/Management

The provisional diagnosis for both cases was a complex odontome however, heavily calcified ameloblastic fibro-odontoma could not be excluded. Management involved surgical removal of the odontogenic tumour with FPM maintenance. Histopathology confirmed the diagnosis of a complex odontoma in both cases. On long-term review in both cases the FPM failed to erupt. Cystic follicular enlargement of the FPM in one case prevented eruption, and a coronectomy was performed in the other on the FPM apices were too close to the ID nerve to be extracted.

Discussion

These cases highlight the importance of monitoring dental eruption patterns in childhood. Despite the mirror image diagnosis, multiple factors were considered when identifying treatment options for each individual patient. Aetiological questions regarding this particular odontogenic tumour type are raised by the presence or absence of the SPM.
857 Congenital Pulmonary Airway Malformation: A Case Report of Concealed Malignancy
Authors: Ahmed R , Staunton L , Ryan R
Published: August 2023

Introduction

Congenital pulmonary airway malformation (CPAM) is a developmental disorder in which hamartomatous lesions arise in the lower respiratory tract. Large population data suggests the incidence to be between 0.87 and 1.92/10,000 live births. Adults most often present with persistent cough or recurrent LRTIs. Their rarity can lead to misdiagnosis as a cystic lesion.

Surgery is the intervention of choice for symptomatic patients. The role of expectant management in asymptomatic patients remains controversial. In adults, resection may be favoured as these lesions are prone to infection and malignancy develops in approximately 1%.

Method

We present the case of a 44-year-old woman, with shortness of breath and pleuritic chest pain. CT revealed a 9.7 x 5.4cm lucent lesion in the left lower lobe, initially identified as a large bulla or parenchymal cyst. Decision to resect was made post discussion with the patient, who was keen to proceed to surgery, due to ongoing symptoms.

Results

A left lower lobectomy was performed via VATS. She was discharged on post-operative day 6, made an excellent recovery on 6-week follow-up and has entered surveillance. Histopathology revealed that the cyst was partially lined with respiratory epithelium and palisading histiocytes; favouring a CPAM type 1 diagnosis. Microscopically, there were foci of mucinous lepidic adenocarcinoma.

Conclusions

It is important to consider CPAM in the differential for cystic lung diseases. Surgical resection should be considered for CPAM regardless of symptoms, due to the uncertainty in diagnosis from imaging alone and the potential for malignant change.
862 Successful Surgical Management of Chylothorax Secondary to Gorham-Stout Disease
Authors: Hyland L
Published: August 2023

Introduction

Gorham-Scout Disease (GSD) is a rare skeletal disorder of unknown aetiology characterised by progressive osteolysis and excessive lymphovascular proliferation. Chylothorax is a severe and life-threatening complication of GSD that confers a poor prognosis. Literature review reveals only one previous case of successful surgical management for chylothorax secondary to GSD.

Case presentation

A teenage asylum seeker presented with a large left pleural effusion on a background of chronic left flank collection secondary to lymphovascular malformation. Cytological analysis of the fluid drained from chest drain insertion confirmed a chylothorax. A posterior rib excision biopsy helped to confirm the diagnosis of GSD. She had VATS ligation of the thoracic duct and talc pleurodesis, however, due to recollection and ongoing symptomatic discomfort, she subsequently underwent left thoracotomy, decortication of lung and pleurectomy. These surgical interventions helped to stabilise the chylothorax with ongoing management for GSD related to radiotherapy and pain control via the administration of bisphosphonates.

Conclusions

GSD is a rare disease that can develop a number of severe complications including a chylothorax. Management via surgical and radiotherapeutic techniques can provide long term remission, however, other modalities may be needed in order to optimise analgesic requirements.
870 Benign Cystic Mesothelioma- a Rare Intra-Abdominal Tumour
Authors: Karagiannidis G , Powell A , Toquero L
Published: August 2023

Introduction

Benign cystic mesothelioma is a rare intra-abdominal tumour affects primarily women who are in reproductive. Since this pathology has a rare occurrence, a similar presentation, and similar imaging features, the diagnosis is based on histologic findings and there is no current standard treatment for this condition.

Presentation of case

In this case report, a 40-year-old female patient presented in the Emergency Department with a five-day history of right-sided, migratory, abdominal pain. She was systemically well, and her inflammatory markers were unremarkable. The patient was investigated for appendicitis, with a CT scan showing a multi-loculated cystic structure below the liver. Her case was discussed with the Basingstoke Peritoneal Malignancy Institute who felt this may demonstrate benign cystic peritoneal mesothelioma. As per their advice, and the thoughts of the local MDT team, the patient underwent a diagnostic laparoscopy, and the cystic mass was removed. The diagnosis of benign cystic peritoneal mesothelioma was then confirmed by histology.

Discussion

Based on literature, this is a rare and asymptomatic form of mesothelioma.Imaging is able to provide suspicion of this type of benign mesothelium, but only histological examination can provide a definitive diagnosis. Additionally, on review there are no guidelines regarding management and no standard treatment for this condition. The only effective treatment for a benign cystic mesothelioma is surgery, but no evidence-based strategies exist.

Conclusions

It is critical to publish more case reports on this condition once it is diagnosed in order to formulate guidelines and to advance towards a possible effective treatment solution.
915 Obturator Hernia: A Case Report of Intestinal Obstruction in a 79yo Male with Challenging Diagnosis and Non-Standardised Treatment
Authors: Finch B , Chishti I
Published: August 2023

Introduction

Obturator Hernia (OH) is a rare condition that accounts for <1% of all abdominal wall hernias but is associated with the highest mortality and morbidity. OH in men are especially rare, with a male:female ratio of 1:14. Early surgical intervention is often delayed due to clinical and radiological diagnostic difficulties. At present, there are no international guidelines for treatment or best surgical approach to manage this condition.

Case Presentation

We present the case of an emaciated 79-year-old male with a 12-day history of right iliac fossa pain radiating to the right thigh, with a 2-day history of absolute constipation, vomiting and significant weight loss. This patient had a surgical history of elective right open inguinal hernia, on background of moderate-COPD. CT imaging revealed small bowel obstruction secondary to a small right obturator hernia containing a loop of small bowel. The patient underwent an exploratory laparotomy with intra-operative findings of 1cm defect in the right obturator foramen containing viable small bowel with incidental finding of right-sided femoral hernia; both defects corrected with PDS interrupted sutures. Iatrogenic perforation of the small bowel during hernia-reduction resulted in small bowel resection with primary anastomosis. The patient developed ileus requiring TPN post-operatively. During follow-up, there was no evidence of recurrence or further complications.

Conclusion

OH diagnosis is challenging owing to its rarity and non-specific presentation. Surgical intervention is the only definitive management for OH, thus awareness of this condition is crucial to allow an earlier approach and attempt to mitigate the associated high morbidity and mortality rates.
921 Cutaneo-Gastric Conduit Fistula Formation Following Oesophagectomy: A Rare Presentation of Anastomotic Leak
Authors: Campbell M , Gregorios C , Konstantinos P , Lamb G , Moorthy K , Bansi D , Ibrahim M A H
Published: August 2023

Anastomotic leak is a significant contributor towards postoperative morbidity and mortality following oesophagectomy occurring between 5-30%. Clinical presentation as cutaneo-gastric conduit fistula is extremely rare as reported in the present study.

A 60-year-old woman with previous right thoracotomy and lobectomy due to pneumonia underwent an Ivor Lewis oesophagectomy for a gastro-oesophageal junction adenocarcinoma. The operation was complicated by extensive adhesiolysis and 2.5L of blood loss requiring intra-operative transfusion. Postoperatively the patient developed acute respiratory distress syndrome (ARDS) from which she subsequently recovered. The integrity of the anastomosis was confirmed by oral contrast swallow and CT, after which the patient was discharged. Two weeks later, the patient was readmitted with right-sided chest pain and a swelling at the distal end of the thoracotomy scar. A purulent collection was identified and drained under interventional radiology. A repeat CT revealed the presence of a cutaneo-gastric conduit fistula originating from the anastomosis site. This was managed with endoscopic gluing of the gastric conduit wall defect and the application of a self-expanding metallic stent (SEMS) that was secured with an Apollo overstitch system to prevent migration. The patient was discharged with follow-up endoscopy confirming closure of defect.

This report highlights the rare complication of cutaneo-gastric conduit fistula after oesophagectomy, associated risk factors and the successful management with SEMS application secured with Apollo overstitch.
933 Inguinal Bladder Hernia: Case Report and Literature Review
Authors: Ravi V , Wilkins A
Published: August 2023

Background

Partial bladder herniation into the inguinal canal has an incidence of 1-3%. Most patients are asymptomatic, and diagnosis is made incidentally upon imaging or during surgical repairs. Complete herniation of the bladder and distal ureters is rare, and few cases of resultant acute kidney injury or hyperkalaemia have been reported. This case presentation includes preoperative and intra-operative images, and literature review.

Case presentation

A 73-year-old gentleman with longstanding bilateral inguinal hernia, benign prostatic hyperplasia, type 2 diabetes mellitus, and obesity presented with new-onset lower urinary tract symptoms and intermittent pain over his right inguinal hernia. His PSA (Prostate-Specific Antigen) was raised, and imaging identified bilateral hydronephrosis, and right inguinal hernia containing distal ureters and bladder. He was added to the waiting list for elective hernia repair.

Whilst awaiting repair, he was admitted with acute kidney injury and hyperkalaemia, which was managed with cardiac protection, urethral catheterisation, hydration, and serial blood tests. After stabilization, he underwent an open right inguinal hernia repair with mesh. His acute kidney injury resolved; however he failed trial without catheter (TWOC), and was discharged with a catheter pending TWOC clinic review. General Surgical Follow up is planned to discuss left inguinal hernia repair.

Conclusion

Awareness of bladder herniation into the inguinal canal is essential to avoid iatrogenic injury. Careful pre-operative planning and correction of physiological abnormalities is vital to ensure good surgical outcome. More unusual sequelae of untreated hernias are likely to become more frequent, if fewer elective hernias are performed.
982 Abdominal Wall Reconstruction Following Full Thickness Bilateral Rupture of the Rectus Abdominis
Authors: Suhail D , Smith O , Lim P , Chintapatla S
Published: August 2023

Introduction

Rupture of the rectus abdominis is a rarely seen condition and there is no consensus its management.

Case Description

A 20-year-old male presented with severe lower abdominal pain that occurred during exercise (i.e., ‘burpees’). MRI revealed full-thickness bilateral rupture of the rectus abdominis. Abdominal wall reconstruction involved bilateral rectus muscle repair using plastic surgical techniques and placement of a biosynthetic mesh (Phasix ST from BD) in the retrorectus plane. Postoperatively, our patient could walk pain-free at 3 weeks, jog pain-free at 10 weeks, and run up to 2 miles at 25 weeks. 

Literature Review

There is no consensus on how to manage this rare injury or whether surgical or conservative treatment yields better results. Pubmed, Medline and Embase databases were searched to identify relevant studies using the following MeSH terms, “rectus abdominis” and “rupture”, as well as their free text counterparts. The search resulted in 391 articles. Manual cross-referencing was performed, limiting the included articles to 8 for review. 6 out of the 8 selected articles discussed management using conservative means, while only 2 cases were managed surgically. Interestingly, no other exercise-related cases in the literature were managed surgically. Instead, all exercise related cases were managed conservatively, while traumatic cases were managed surgically. Among both surgically and conservatively treated patients, all patients returned to normal levels of activity.

Conclusions

Full-thickness, bilateral rupture of the rectus abdominis can occur during exercise. Intervention depends on the size and severity of the injury, but surgical and conservative treatment yield similar results.
1001 A Case Report on Popliteal Artery Occlusion After a Low-Energy Trauma Years After Total Knee Arthroplasty
Authors: Kocyigit G Z , Yilmaz S , Usmanov N , Bertan T , Colkusu M , Guler İ , Singa D
Published: August 2023

Aim

To highlight the significance of dislocated total knee arthroplasty, which is more likely to happen after a low-energy trauma and can result in limb-threatening neurovascular complications and compartment syndrome, we present a case of mild trauma that resulted in the co-occurrence of the occlusion of the left popliteal artery and vein 10 years after the implantation.

Method

Three weeks after a low-energy fall on her knee at home, a 69-year-old woman presented to our orthopedics clinic with swelling, paresthesia, and paralysis in her left leg. She had edema and significant ecchymosis, and the tibial pulses in her left knee had vanished. She had uneventful bilateral knee arthroplasty surgery on her right and left knees six and ten years ago, respectively. Her medical history is significant for type 2 diabetes mellitus and hypertension. Doppler ultrasound and CT angiography showed occluded popliteal artery and vein. Following thromboembolectomy by cardiovascular surgeons, orthopedic surgeons underwent lower leg preventative fasciotomy under general anesthesia by creating two longitudinal incisions on either side of the tibia.

Results

Doppler ultrasonography on the fifth follow-up day revealed biphasic flow in the posterior tibial artery and monophasic flow in the dorsal tibial artery, however, the paralysis and paresthesia were still present. Ultimately, unilateral above-knee amputation was performed.

Conclusions

Due to the high level of concern for vascular injury and compartment syndrome, we advise physicians to consider popliteal artery injury while treating patients who underwent total knee arthroplasty years ago and present with minimal trauma.
1043 Giant Spindle Cell Lipoma of the Perianal Region: A Rare Cause of a Perianal Mass
Authors: Julius B , Schmidt K
Published: August 2023

Background

The anal and perianal region is an anatomically complex region. The differential diagnosis for perianal masses is broad and can represent both benign and malignant lesions.

Case Presentation

We present the case of a 63-year-old gentleman who presented to the outpatient clinic with a large perianal mass which had been present for one year. The mass was increasing in size and becoming painful. He did not report any alterations in bowel habit, per rectal bleeding or discharge. His past medical history was significant for type 2 diabetes mellitus and hypertension. He reported a 40-pack year smoking history.

On examination, there was a pedunculated soft tissue mass arising from the left side of the anal area measuring approximately 12cm in diameter. MRI scan demonstrated a malignant appearing polypoid lesion originating from the left buttock region close to but separate from the internal anal sphincter.

He underwent an elective examination under anaesthesia (EUA) and excision of the perianal lesion. The lesion was multilobulate and involving the external anal sphincter, it was excised en bloc via an elliptical incision. Histological assessment revealed a spindle cell lipoma. The patient had an uneventful post-operative recovery and given the histology findings no further adjuvant treatment was considered necessary.

Discussion

Spindle cell lipomas are rare, benign lesions characterized by a classic triad of mature adipocytes, ropey collagen, and uniform spindled cells. Surgical excision represents the first line treatment.

Conclusion

Perianal mass lesions can often pose diagnostic challenges and this case highlights the importance of pathological assessment.
1046 A Multi-Specialty Approach to the Management of CBD Stones: Utilising a High-Power Holmium Laser to Perform Laser Lithotripsy of a Complex Common Bile Duct Stone
Authors: Grainger C , Ali H , Cynk M , Shaw A
Published: August 2023

Laser Lithotripsy is a therapeutic technique commonly used for the treatment of urological stones. This report presents the case of a patient with a common bile duct (CBD) stone refractory to traditional management approaches including ERCP, internal and external drains. A plan was made for the patient to undergo laser lithotripsy of their CBD stone in a multi-disciplinary procedure. A high-power Holmium laser, operated by a Urology Consultant, was used to perform percutaneous fragmentation of the CBD stone. An Interventional Radiologist was also scrubbed to assist with access. The Upper GI Surgeon had also been involved in the planning of the case and was on standby should there be a need to proceed to further surgical intervention at this time. Intra-operatively, good progress was made in reducing the size of the stone, however due to the stone’s composition complete fragmentation could not be achieved. There is a current plan to bring the patient back for a further attempt and complete fragmentation.

Whilst this approach has been described in the literature and is likely to become more common in practice, it is a newly emerging approach for the trust and presents some important considerations for future practice. This case demonstrates the value of transferable skills and multi-specialty approaches to the management of surgical pathologies which fail standard treatment strategies. It also highlights the power of innovation in surgery to continue to find new ways to treat common and important pathologies.
1057 Fournier’s Gangrene Caused by Porphyromonas Asaccharolytica; a New Bug in the Block?
Authors: Ali Muhammad-Kabir , Bolton E , Gibbons N , El-Husseiny T
Published: August 2023

Introduction

Fournier’s gangrene (FG) is a urological emergency characterised by a destructive inflammation of the genital and perineal area typically forming necrotising fasciitis that affects the external genitalia and the perineum resulting in the gangrene of infected tissues as well as generalised systemic deterioration in its severest form. Although FG is typically polymicrobial, we found it can very rarely be mono-microbial and caused by Porphyromonas asaccharolytica, an obligate anaerobic gram-negative rod.

Case presentation

We present a case of a 44-year-old man seen in the emergency department with bilateral scrotal swelling, redness, and pain. A diagnosis of acute epididymo-orchitis (on a background of chronic severe phimosis) was made. Ultrasound imaging of the testes was consistent with features suggestive of epididymo-orchitis and reactive hydrocoele. The patient also tested positive for the SARS-Cov-2 virus but had no respiratory symptoms.

Empirical treatment, as per Trust antimicrobial policy, was initiated with intravenous Flucloxacillin which was changed, following the results of blood culture growth of Porphyromonas asaccharolytica, to Meropenem, Vancomycin and Clindamycin.

On day 3 of admission, an ulcer was noticed at the base of the scrotum which progressed rapidly into a fulminant Fournier's gangrene. He was treated radically with urgent debridement and direct closure of the wounds and was discharged after 2 weeks on admission.

Conclusions

We report a case of Fournier’s gangrene caused by a rare gram-negative organism in an asymptomatic unvaccinated COVID-19 patient. Clinicians need to have a high index of suspicion that this organism can also be a cause of Fournier’s gangrene.
1065 Radical Nephrectomy and Inferior Vena Cava (IVC) Thrombectomy: Management of Level IV Thrombus
Authors: Larney M , O'Connor C , Collins P , McGuinness J , Conneely J , Connolly S
Published: August 2023

Introduction

IVC invasion with tumour thrombus occurs in 10-25% of renal cell carcinoma (RCC) patients (1). IVC thrombi are classified according to anatomical levels. Cardiopulmonary bypass is indicated for level IV thrombi which extend above the diaphragm, including atrial thrombi or when the reduction in cardiac output with IVC cross-clamping cannot be tolerated. This technique maintains haemodynamic stability and allows better vision during thrombectomy.

Case report

A 46-year-old male presented with a three-week history of vague abdominal pain and night sweats. Subsequent CT thorax, abdomen & pelvis, and MR venogram found a 10cm right renal tumour extending into the right renal vein, inferior vena cava and tumour thrombus extending 50% into the right atrium.

Management

Following MDT discussion, this gentleman underwent right radical nephrectomy, IVC thrombectomy, sternotomy and retrieval of tumour thrombus from his right atrium. This was performed under approximately one hour of deep hypothermic circulatory arrest. The patient made an excellent recovery with 10 days spent in hospital post-operatively. His histology subsequently showed a clear cell renal carcinoma, ISUP grade 3, with positive vein margin. Its final staging was pT3cN0R1. Follow up was with three monthly surveillance CT scans.

Discussion

The median survival of untreated RCC patients with venous thrombi is just 5 months, thus, this is lifesaving and very urgent surgery (2). Procedures for Level 4 IVC thrombi should take place in high volume centres with access to both cardiothoracics for cardiopulmonary bypass or veno-venous bypass and surgeons with expertise in vascular reconstruction and liver mobilization.
1072 Diaphragm Disease: NSAID-Induced Small Bowel Strictures. the Challenges of Surgical management
Authors: George H , Abbud N , Davis G , Skinner P
Published: August 2023

Non-steroidal anti-inflammatory drugs (NSAIDs) are used commonly, yet there is little literature surrounding NSAID-induced small bowel strictures, particularly those requiring surgery. We present the case of a 42-year-old female treated surgically over six years.

This patient had used NSAIDs for several years; she was referred due to weight loss, anaemia and abdominal pain. Computerised topography (CT) scan showed small bowel obstruction. Initial treatment was laparotomy with small bowel resection. Histology revealed six strictures in the jejunum with incomplete obstruction – attributed to NSAIDs.

Despite counselling her NSAID usage persisted and over the next two years she was treated for jejunitis and had a perforated duodenal ulcer repaired. At this point the patient ceased NSAID use, however the next twelve months saw three presentations with small bowel obstruction, all managed conservatively. This case is concordant with literature suggesting strictures can continue to develop despite NSAID cessation. She was placed on the surgical waiting list but symptoms worsened – anaemia requiring transfusions; hypokalaemia requiring IV replacement and 38-kilogram weight loss. She received total parenteral nutrition before surgery.

She underwent another bowel resection with anastomosis. Initially she regained weight and biochemistry stabilised, however further obstruction developed the next year at the anastomosis site.

This case highlights the difficulties managing this disease – nutrition, haematology and strictures developing years after NSAID cessation. It raises questions over surgery, choice of anastomosis and how to manage this ongoing dilated small bowel segment.
1082 Toying With a Viper: A Case of Paediatric Envenoming Following a Snakebite in the UK
Authors: Chinweze R , Patel D , Rohouma M , Hassan A A
Published: August 2023

Worldwide 5.4 million people suffer from snakebites each year with a further 2.7 million suffering from envenoming and up to 138 000 people are said to have died annually due to snake bites with three times as many people suffering from permanent disability. The British Isles appear lucky in that regard, snake bites in the United Kingdom are rare with the Vipera Berus (Adder) being Britain’s only indigenous venomous snake. There are just over 100 human bites each year with only 14 recorded deaths since 1876 with the last death occurring in 1975.

We present the following case of a 2 year old who was bitten by the Vipera Berus in the fields of Lincolnshire after mistaking the live snake for his favourite toy at home. He presented with local symptoms of envenoming and was given two doses of antivenom during his admission. Despite diagnostic and operative challenges presented by the infrequency of such cases. The combined care from our emergency, paediatric and orthopaedic teams resulted in an optimal outcome and learning experience.
1099 Tonsillar Carcinoma Metastasis to the Central Nervous System: Case Report and Literature Review
Authors: Mian A , Khan S
Published: August 2023

We present a case report of a 51-year-old left-handed male with a background of human papillomovairus 16-positive tonsil squamous cell carcinoma presenting with tonic-clonic seizures and a radiological diagnosis of secondary CNS metastatic deposits. These were initially treated with stereotactic radiosurgery and subsequently with surgery. Surgical resection was performed under general anesthesia with right-sided temporal and parietal approaches. Both the parietal and temporal deposits were removed, while the intraventricular mass was intentionally left to avoid postoperative deficits. Adjuvant radiotherapy and chemotherapy were administered postoperatively. The patient experienced a satisfactory post operative recovery. However, he was reoperated for recurrence 4 months later. He maintained a good quality of life and an excellent performance status throughout, but unfortunately, he passed away in November 2018 due to septic complications. This case history stresses the difficulty in managing oropharyngeal squamous cell carcinomas (SCC) with brain metastatic deposits. There are no current guidelines regarding the management of patients presenting with such a rare condition. Additionally, we performed a literature review and describe the limited previous cases within the literature. More data is thus desirable to better define treatment guidelines and protocols when tonsillar SCC brain metastases are present.
1102 A Rare Case of Parenchymal Liver Injury Presenting Initially as an Obstructive Jaundice
Authors: Gill M , Nair K , Lordan J
Published: August 2023

Parenchymal liver damage is secondary to a sudden insult on hepatocytes, most commonly due to hepatitis or secondary to drug injury.

A 43-year-old gentleman with a pre-existing diagnosis of fatty liver disease, presented with obstructive jaundice. He had a bilirubin of 159 and ultrasound imaging showed gallstones in his gallbladder with a dilated common bile duct (CBD) of 6.7mm. An MRCP showed a dilated CBD with an intraluminal filling defect. He was discharged home when clinically well and referred for an outpatient ERCP. This did not happen for three weeks and at this point, no cause of obstruction was identified, but a plastic biliary stent was inserted. Despite this, his liver function worsened, and he was readmitted with a bilirubin of 421. Following discussion within a multidisciplinary team he underwent a further CT scan and ERCP with stent replacement, these showed no evidence of obstruction. All acute hepatic and virology screens were negative. His bilirubin continued to uptrend hitting 644 and he became coagulopathic with an elevated INR of 2.7. The patient admitted to taking weight loss supplements including a “fat burner” powder regularly for the last two months, in keeping with the duration of his worsening liver dysfunction. He underwent a liver biopsy; the results of which are pending and is currently being treated supportively.

This case presented an interesting diagnostic challenge and there remains ongoing uncertainty. The current working diagnosis is that of an obstructive jaundice which has exacerbated an underlying parenchymal liver injury secondary to supplement use.
1126 Incidental Finding of Thyroid Papillary Carcinoma in a Thyroglossal Duct Cyst
Authors: Dhannoon A , Aziz M , Uzomefuna V , Wickham M
Published: August 2023

Introduction

Thyroglossal cyst is one of the most common benign congenital neck lumps, however, incidental malignancy in these cysts is a rare entity with incidence rate of <1%.

Method

We present a case of a 35-year-old female, who presented with an asymptomatic midline neck mass. ultrasound neck confirmed 3.5 cm thyroglossal duct cyst (TDC). She underwent a Sistrunk procedure to excise the cyst. On histological examination, there was an incidental finding of a papillary cell carcinoma. After multidisciplinary discussion, the patient opted for a total thyroidectomy. On histology the left lobe of thyroid had a 2.2 mm microcarcinoma.

Discussion

Dilemma arises during managing incidental papillary cell carcinoma. Various management options have been described in the literature. This includes total thyroidectomy with or without regional lymph node dissection, radioactive iodine, suppressive thyroxine or wait and watch.

Conclusions

This case highlights the importance of sending excised TDC for histology as it can lead to an early diagnosis of thyroid malignancy and allows adequate management.
1148 A Rare Case of Loose Right Medial Umbilical Ligament Found During Laparoscopic Appendectomy
Authors: Megally M , Prenderville R , Hamour A , Aremu M
Published: August 2023

Aim

We report this extremely rare variation of loose medial umbilical ligament discovered incidentally during laparoscopic appendectomy. This can be a potential cause of bowel obstruction and internal herniation or cause technical difficulty during laparoscopic surgery.

Method

A 29-year-old man presented to the emergency department with one day history of central abdominal pain that shifted to right iliac fossa associated with nausea and vomiting. He has no significant past medical history. His abdominal examination revealed tenderness and guarding in the right iliac fossa and his inflammatory markers were elevated. A clinical diagnosis of acute appendicitis was made.

Results

The patient was brought to the operating theatre for laparoscopic appendectomy. Laparoscopy revealed acutely inflamed appendix and also a completely redundant rounded structure extending from the anterior abdominal wall just to the right side of the umbilicus to the small bowel mesentery consistent with right medial umbilical ligament. The left medial umbilical ligament was entirely normal. Excision of right medial umbilical ligament was done using LigaSure laparoscopic instrument and was sent for histology. Laparoscopic appendectomy was also performed. The patient recovered well with no complications.

Conclusions

The medial umbilical ligament is the obliterated umbilical artery. This anatomical variation of the medial umbilical ligament is extremely rare. Surgeons should be aware of anatomical variations of medial umbilical ligament especially during laparoscopic surgeries at it may affect the surgeon’s preference for trocar locations.
1172 Spontaneous Bladder Perforation: A Differential Never to Forget in the Acute Abdomen
Authors: Yousaf A , Darlington D , Perry M
Published: August 2023

Introduction

Spontaneous bladder perforation is a rare occurrence, and diagnosis is often one that is difficult to make. The morbidity and mortality of such patients can be high if not identified early and the appropriate management undertaken promptly. Here we present the case of a 60-year-old man who presented to hospital with recurrent episodes of spontaneous bladder perforation, how he was diagnosed, and how he was managed.

Case Details

A 60-year-old man presented to accident and emergency with peritonism, haemodynamic instability and fevers. He had a background of previous rectal cancer, managed with anterior resection and radiotherapy. Investigation with CT identified free fluid within the abdomen and pelvis, with no clear cause identifiable. Urine dipstick was positive for haematuria. The diagnosis was only confirmed using urethrogram. Management was conservative with bladder rest and urethral catheter.

The patient represented two years later with similar symptoms, and diagnosis was again only made on urethrogram. Again, he was managed conservatively with bladder rest and catheterisation.

Despite the healing of the bladder perforations, he has suffered from numerous complications including pyelonephritis and fistulation.

Discussion

It is important to learn from these rare cases of spontaneous bladder perforations, as the differential is one that should not be overlooked when assessing patients with an acute abdomen. Furthermore, despite management of the perforation, these patients can suffer from ongoing complications going forward.
1214 Wilkie's Syndrome - a Case Report
Authors: Kirk C , Down B , Theivendrampillai T , Dawani A
Published: August 2023

Aortomesenteric duodenal compression syndrome (Wilkie’s syndrome) describes compression of the third duodenal segment between the superior mesenteric artery and aorta, causing upper gastrointestinal (UGI) obstruction. Wilkie’s syndrome typically presents with significant weight loss and features of UGI obstruction. It can initially be treated conservatively with decompression and appropriate re-feeding, but occasionally requires surgical correction.

In this presentation, we describe a case of Wilkie’s syndrome in a non-English speaking foreign national, disengaged from healthcare.

Case Presentation

A 47-year-old Romanian national presented with two months of severe epigastric pain, vomiting, inability to tolerate food intake and severe weight loss, with a background of five years of similar symptoms. On examination, the patient was tachycardic (130), severely dehydrated with skin tenting, and cachexic with a distended abdomen and palpable mass in the epigastrium. Computed tomography imaging was performed, excluding an obstructing malignancy, instead demonstrating significant stomach distension (∼50% of the peritoneal cavity), from Wilkie's Syndrome. The patient underwent oesophagogastroduodenoscopy which demonstrated oesophagitis, gastritis and a duodenal ulcer. Biopsies were negative for H pylori and malignancy.

Management involved nasogastric tube decompression, intravenous electrolyte collection, fluid resuscitation and high dose PPI. The patient was discharged on day 6 with planned follow-up in one month and assessment for requirement of surgical management for Wilkie’s syndrome.

Discussion

We present a rare case of Wilkie’s syndrome and discuss conservative and surgical management. We also use this case of late presentation to highlight the challenges of management, and the importance of clearly communicated follow-up plans in vulnerable populations.
1227 Laparoscopic Repair of a Grynfeltt-Lesshaft Hernia: Case Report
Authors: Quaunine M , Wilkins A , Mitton D , Myatt A
Published: August 2023

Background

Lumbar hernias are an uncommon presentation, with only 300 cases published to date. The aetiology is variable, and they usually present as palpable masses or swellings in the lumbar region. We present a case of successful laparoscopic transabdominal preperitoneal (TAPP) repair of a lumbar hernia with mesh.

Case report

A 62-year-old male patient, with a history of sarcoidosis and hypertension, was referred to general surgeons with a symptomatic enlarging swelling in the left lumbar region. Preoperative computed tomography (CT) and Ultrasound revealed a superior lumbar hernia. Intraoperatively a 2cm defect was identified. A small lipoma was present within the defect and excised. The defect was repaired with a 10x15cm SymbotexTM mesh secured with ProtackTM. There were no complications operatively or post-operatively and he was discharged the following day.

Discussion

Anatomically, the lumbar region is bound by the 12th rib superiorly, the iliac crest inferiorly, erector spinae muscles medially and external oblique laterally. Two defined areas of weakness are the superior (Grynfeltt-Lesshaft’s) and inferior (Petit’s) triangles, the first being more common for hernias and experienced by our patient. Surgical repair is the only definitive management and is recommended due to the significant risk of complications. A therapeutically aimed classification system, such as Mereno-Ageas, can be utilised to decide between open and laparoscopic approaches.

Conclusions

Lumbar hernias are often misdiagnosed due to their rarity. An in-depth history, clinical examination and use of CT preoperatively will aid diagnosis and guide management. Ultimately management will depend on the individual patient and clinician preferences and experience.
1229 Spontaneous Heterotopic Pregnancy Resulting in Tubal Rupture and Complete Spontaneous Abortion: A Case Report in Tiko, Cameroon
Authors: Takoutsing B D
Published: August 2023

Aim

To present a case report of the management and early outcome of a first-trimester spontaneous heterotopic pregnancy (HP) in a low-resource setting.

Method

This piece of work has been reported according to the Surgical CAse REport guidelines.

Results

A 24years old G2P0010 at 11 weeks of gestation with a history of one induced abortion and a family history of twin pregnancies presented with an acute abdomen, associated with vaginal spotting in an afebrile context. Recurrence of the vaginal spotting and increase in the severity of the abdominal pain prompted an obstetrical ultrasound which showed retained products of conception, as well as the presence of a left adnexal mass suggestive of an extrauterine gestational sac at approximately 6 weeks of gestation. There was spontaneous expulsion of retained products of conception. The deterioration of the haemodynamic stability of the patient prompted an emergency laparotomy to be done after a repeat ultrasound suggestive of a ruptured left ectopic pregnancy (EP), and optimisation of the patient. Evacuation of 700ml of dark red haemoperitoneum and salpingectomy was done. The patient was transfused, post-salpingectomy counselling done and was discharged on oral analgesics, blood tonics and antibiotics on day 6 Post–operation.

Conclusions

HP should be suspected in first trimester bleedings especially if associated with an acute abdomen. An ultrasound should be performed on all patients presenting with clinical manifestations of abortion to help in the early diagnosis and treatment of a concurrent EP. Laparotomy is relatively safe in the context of abortion and shock secondary to haemoperitoneum.
1280 Novel Technique of Assessing Intestinal Mucosa in Acute Mesenteric Ischaemia Using a Paediatric Colonoscope
Authors: Harris Y , Hamilton D , Shalli K
Published: August 2023

Acute Mesenteric Ischaemia (AMI) is a surgical emergency associated with a high morbidity and mortality. Treatment of AMI varies from conservative measures to interventional such as embolectomy or laparotomy and the resection of non-viable bowel. Management is primarily guided by computed tomography findings which, though useful, is limited in the accurate assessment of viable bowel.

This case report describes the novel technique of using a paediatric colonoscope to assess intestinal mucosa in a 56-year-old female with AMI. This technique provided a further investigation that allowed for endoscopic mucosal assessment in a young patient with catastrophic AMI on computed tomography. In this case, this allowed for the accurate visualisation of length of viable bowel, thereby guiding further management as to whether laparotomy and bowel resection would be successful in this cohort of patients.
1300 An Unusual Presentation of Gastric GIST With Double Duct Sign
Authors: Chang L M Y , Wilkins A , Brown A , Mitton D
Published: August 2023

Background

Gastrointestinal Stromal Tumour (GIST) most commonly arises from the stomach or small intestine, and commonly presents with mass effect or gastrointestinal bleeding. In this unusual case, imaging demonstrated a double duct sign prompting pancreatic MDT referral.

Case Presentation

A 65-year-old gentleman with a background of rheumatoid arthritis and COPD reported a 2-month history of anorexia and one stone weight loss during a rheumatology clinic follow-up. He was found to be anaemic but markers for his rheumatoid arthritis showed the disease was well controlled and imaging was performed to exclude malignancy. CT Thorax, Abdomen and Pelvis revealed a double duct sign with lung opacification, suggesting pancreatic cancer with lung metastasis. He was immediately referred to the pancreatic Multi-Disciplinary Team and underwent an Endoscopic Ultrasound which showed a 12cm cyst extending from the pelvis to the gastric body. Biopsy confirmed that this large thick-walled cyst was a Gastrointestinal Tumour (GIST). Staging PET scan was negative for metastatic disease. He underwent a laparotomy and GIST excision with a cuff of normal stomach removed. Post-operatively, his recovery was prolonged due to exacerbation of his COPD however he eventually recovered well and was discharged on day 11. There were no other post operative complications.

Conclusions

GIST are rare tumours, making up less than 1% of all gastrointestinal tumour. Patients with GISTs that are primary and localised can achieve a curative outcome through surgery alone. The prognosis of GIST tumours is favourable, with 5-year survival rates at 83%. This case demonstrates the value of pre-operative endoscopic ultrasound.