bluuebunny/crossref_metadata_2025 huggingface dataset:
659 Four Limb Amputations due to Peripheral Gangrene from Vasopressor Use
Authors: Selva Raj D R , Adjei B , Ken Vin W , Fumakia N
Published: October 2021

Case

Symmetrical peripheral gangrene (SPG) is a relatively rare phenomenon characterized by symmetrical distal ischemic damage that leads to gangrene of 2 or more sites in the absence of large blood vessel obstruction, where vasoconstriction rather than thrombosis is implicated as the underlying pathophysiology. We present 2 cases of symmetrical peripheral gangrene (SPG) associated with the use of vasopressors to elevate blood pressure, resulting in four-limb amputation. Both patients had different backgrounds, and each presented to Accident and Emergency (A&E) with Streptococcal septicemia and subsequently septic shock, warranting ICU admission and the use of vasopressors to optimize blood pressure. Both patients then started to develop symmetrical peripheral gangrene of both the upper and lower limbs leading to staged amputations performed electively. Vasopressors including dopamine and norepinephrine are used frequently in the treatment of septic shock and its effectiveness is firmly established. However, it can result in peripheral gangrene due to the prolonged vasoconstrictive effect on peripheral blood vessels. Therefore, it is crucial that the astute physician consider the possibility of the development of peripheral gangrene and amputation when using vasopressors to treat septic shock.
750 An Unusual Presentation of a Rare Clinical Entity – A Case Report of Spontaneous Common Bile Duct Perforation in an Adult
Authors: Ahmed F , Subahan N , Menyah E , Koshy R , Khawaja A
Published: October 2021

Spontaneous or non-traumatic perforation of the extrahepatic biliary system is a rare clinical phenomenon, with few cases reported since its first mention in medical literature by Freeland in 1882. Given the rarity, misdiagnosis is common with the diagnosis almost always made during urgent exploratory laparotomy. We describe a case of spontaneous common bile duct (CBD) perforation in an 83-year-old female with no associative underlying disease process identified.

The patient presented with sudden onset abdominal pain with no identifiable trigger, with minimal past medical history. Examination was remarkable for findings of epigastric tenderness and guarding. Haematological investigation was remarkable only for hyperamylasaemia and leucocytosis. Pneumoperitoneum was ruled out and following contrast CT abdomen and pelvis a working diagnosis of mild pancreatitis was made. US Abdomen and MRCP found no evidence of cholelithiasis, with minimal biliary duct dilatation. The patient continued to deteriorate on the ward, with aspiration of new intrabdominal fluid collection raising suspicion of perforated viscus. Exploratory laparotomy revealed a 1-cm defect in the CBD with frank bile leak. A T-tube was placed in the common bile duct defect, with an abdominal robertson drain also inserted. No further bile leak was identified via Tubogram, with the patient successfully discharged following multidisciplinary rehabilitation in intensive care and the ward setting.

Surgeons should seek out this uncommon diagnosis in patients with hyperamylasaemia and suspected cholelithiasis who do not conform to normal biliary/pancreatic disease progression patterns.
779 An Unusual Manifestation of Tophaceous Gout in The Flexor Digitorum Superficialis Tendon of An Immunocompromised Patient: A Case Report and Literature Review
Authors: Glynn N , Martin S , Lewis H
Published: October 2021

Aim

This case report showcases an unusual presentation of tophaceous gout, in an immunocompromised patient. Furthermore, through a literature review, we highlight challenges posed by immunocompromised patients, the clinical manifestations of gout in the hand and principles of management.

Method

We report the case of a 62-year-old lady with previous liver transplant on immunosuppressants. She was admitted with a left palmar abscess, pyogenic tenosynovitis of the index finger and was taken to theatre for debridement and washout. Superimposed infection was apparent. This originated from an exophytic mass extending from the palm to FDS tendon insertion. This was debulked and histologically confirmed as gout. A review of the literature was performed using key search terms on PubMed relating to manifestations of gout in the tendons of the hand, and in patients on immunosuppression.

Results

Reports in the literature describe cases of gouty tendinopathy in both flexor and extensor tendons. Reported symptoms include triggering, tendon rupture and tenosynovitis. Gout occurs in a higher frequency in transplant patients. This can be attributed to medications such as cyclosporine which predispose to hyperuricaemia. Management of this condition involves medical optimisation. Despite concurrent problems with wound healing in the immunocompromised with gout, surgical intervention may be required. Indications include superimposed infection, attenuated tendon glide, joint movement, and neuropathy. Perioperative antibiotics are recommended in all immunocompromised patients.

Conclusions

This case highlights an unusual presentation of gout and the challenges of managing patients on immunosuppressant therapy. A greater awareness of this condition will allow for appropriate management in this high-risk patient cohort.
787 The Hidden and The Lost: A Case of a Rare Complication from A Long-Lost Surgical Technique
Authors: Oo M K , Kamarul Bahrin M H , Win S Y , Perry M J
Published: October 2021

Background

Various operative techniques have been developed for liver transplant since the 1960's. Waddell-Calne technique for biliary reconstruction in orthotopic liver transplant (OLT) was one of the rare and now relatively obsolete techniques. The aim of our presentation is to describe a long-term complication of this lost technique and how it posed multiple diagnosis and management challenges after 35 years post-liver transplant.

Case presentation

Our case is on a 50-year-old lady with a history of OLT for end-stage liver failure secondary to type-1 autoimmune hepatitis. Peri and postoperative period were completely unremarkable. 35 years later, she presented with symptoms of recurrent cholangitis. Magnetic resonance cholangio-pancreaticography demonstrated biliary tree dilatation with choledocholithiasis and possible cholecystitis. Removal of the distal stones together with pig-tail stent insertion was achieved via endoscopic retrograde cholangio-pancreaticography, however, her biliary colic persisted. The background of OLT and grossly distorted anatomy on imaging posed a challenge for further surgery. Extensive tracing of the history back from 1985 and multicentre multidisciplinary discussion revealed that the Waddell-Calne technique was carried out for her OLT where a gallbladder conduit was used for the hepaticojejunal-anastomosis. Finally, excision of the gallbladder conduit and hepaticojejunostomy with long Roux-en-Y was able to perform successfully.

Conclusions

Waddle-Calne technique is rarely seen globally nowadays but should be considered as a possible cause of recurrent cholangitis in patients with a history of OLT a long time ago. We demonstrated that the knowledge of such a rare procedure, together with the multidisciplinary approach could enormously benefit the management of the case.
798 A Rare Complication and Unexpected Pathology Following an Anterior Exenteration – A Case Report
Authors: Robertson S , Lazaraviciute G , Kerr L , Hendry D
Published: October 2021

We present a case report of an unexpected pathology in addition to a rare complication in a 62-year-old female following an anterior exenteration and an abdominal wall reconstruction. Initial biopsies characterised the malignancy as a potential urachal adenocarcinoma, but the final pathology revealed a solitary endometrial adenocarcinoma metastasis from endometrial cancer 6 years previously.

Due to the nature of the tumour, an abdominal wall resection was required, and reconstruction involved a pedicled thigh flap. Post-operatively the small bowel herniated under the flap and this resulted in true mechanical small bowel obstruction. The loop of herniated bowel is visible on CT imaging in the area of the proximal thigh. The patient returned to theatre for an emergency laparotomy and the abdominal wall defect was closed instead with a surgical implant derived from animal tissue. The patient made an excellent recovery, was discharged home, and continues to do well. This patient is an example of excelling in adversity.
817 Loss of Libido in A Man with An Incidental Leydig Cell Tumour Of the Testis: A Rare Tumour Discovered Following an Isolated Common Complaint
Authors: Brown D , Tsampoukas G
Published: October 2021

Introduction

Leydig cell tumours (LCTs) are rare testicular stromal neoplasms classically presenting with a painless testicular mass or swelling in adults. Symptoms secondary to hypogonadism may occur resulting from the hormonal activity of these tumours. Loss of libido is described in LCTs in conjunction with other symptoms; however, no case has reported this as the sole presenting feature.

Case report

We describe the case of a 42-year-old man presenting to his General Practitioner with loss of libido and no other features suspicious of testicular cancer. Ultrasound performed due to an unrelated epididymal cyst detected an incidental mass confirmed as a benign LCT following radical orchidectomy. Biochemical markers remained normal throughout and following treatment his libido returned to normal.

Conclusions

This case may serve as a reminder for clinicians to maintain a high index of suspicion for testicular neoplasms in patients with features of hypogonadism in the absence of classical features for testicular cancer.
831 Bouveret’s Syndrome (A Gallstone Disease Causing Gastric Outlet Obstruction): A Case Series and Review of Literature
Authors: Adnan A , Ahmed M , Sultana A , Vitone L
Published: October 2021

Bouveret’s syndrome refers to a gastric outlet obstruction due to the impaction of a large gallstone following retrograde migration via a bilio-duodenal fistula. Although no clear management guideline has been formulated, different treatment modalities have been described, including endoscopic stone removal using classical endoscopic devices, like snares and forceps; or fragmentation of stones with new devices, such as laser and extracorporeal shockwave lithotripsy (EWSL).

We report a case series of Bouveret’s syndrome with interesting radiological and endoscopic findings which have been successfully managed either via endoscopic measures such as stone extraction and/or duodenal stenting, or surgical intervention. The report is followed by a literature review including diagnostic and management options of this rare condition. All our patients were elderly with multiple comorbidities. Two patients presented with upper gastro-intestinal bleeding, while the other two presented with abdominal pain and bilious vomiting. The diagnosis was confirmed by computerised tomography (CT) scan and upper gastro-intestinal endoscopy. Endoscopic stone removal was successful in one case. In one patient, stone was fragmented but could not be removed completely, so he was managed via duodenal stent insertion. The other two patients required surgical intervention. One case was complicated by gallstone ileus which required laparotomy and extraction of stones from two sites, while the other required subtotal cholecystectomy, stone extraction and repair of duodenal fistula. The patients recovered well. The diagnosis of Bouveret’s Syndrome is made after performing appropriate imaging studies. The first line management option is endoscopic treatment. If this fails, surgical intervention is recommended.
844 A Case of Pulmonary Artery Banding for Future Anatomical Repair in Congenitally Corrected Transposition of the Great Arteries (ccTGA)
Authors: Banjoko A , Kumar A
Published: October 2021

This is a case of a patient prenatally diagnosed with ccTGA. Immediately after birth, postnatal transthoracic echocardiography diagnosed ccTGA with concomitant Ebstein’s anomaly of the tricuspid valve, without a ventricular septal defect (VSD). Initially, this dysplastic tricuspid valve had mild tricuspid regurgitation. However, by 12 months follow up, the patient was becoming symptomatic, and their tricuspid regurgitation had become severe.

Due to the patients worsening symptoms and regurgitation, clinical intervention was pursued. The patient had Cardiovascular Magnetic Resonance performed to assess for myocardial fibrosis and to measure the size of each ventricle. After imaging and MDT discussion, the patient was deemed suitable for a double switch operation, a form of anatomical repair. However, since this patient did not have pulmonary stenosis (PS), they required a pulmonary artery (PA) band before anatomical repair. This procedure has dual benefits: to retrain the morphological left ventricle (mLV) to cope with systemic pressures, and to induce a septal shift, which can reduce the severity tricuspid regurgitation. At 18 months of age, this patient had their PA band placed. The patient immediately had a reduction in the severity of their tricuspid regurgitation. In the future, this patient will have cardiac catheterisation performed to measure mLV pressures and assess when the patient is ready for anatomical repair.

The morphology of this patient is rare, as most patients with ccTGA have an associated VSD. This case describes a potential management pathway for a ccTGA patient without VSD and an Ebstenoid tricuspid valve. It also demonstrates the benefits of PA banding in a ccTGA patient with this morphology. This is a unique contribution, due to the rarity of this specific morphology and the limited evidence and guidance for its successful management.
868 The management of acute lower gastrointestinal bleeding using a Sengstaken-Blakemore tube
Authors: Iskandarani M , Fadel M , Boshier P , Howell A M , Tekkis P , Kontovounisios C
Published: October 2021

Introduction

Acute lower gastrointestinal haemorrhage can potentially be life-threatening. We present a case of a massive rectal bleed which was managed successfully with a balloon tamponade device designed for upper gastrointestinal haemorrhage.

Presentation of case

A 75-year-old gentleman, with a history of human immunodeficiency virus and cirrhosis with portal hypertension, presented with bright red rectal bleeding. Investigations showed a low haemoglobin level (74 g/L) and deranged clotting. Oesophago-gastro-duodenoscopy demonstrated no fresh or altered blood. Flexible sigmoidoscopy revealed active bleeding from a varix within the anterior rectal wall 4 cm from the anal verge. Efforts to stop the bleeding, including endoscopic clips, adrenaline injection and rectal packing, were unsuccessful and the patient became haemodynamically unstable. A Sengstaken-Blakemore tube was inserted per rectum and the gastric balloon was inflated to tamponade the lower rectum. The oesophageal balloon was then inflated to hold the gastric balloon firmly in place. A computed tomography angiogram demonstrated no evidence of haemorrhage with balloon tamponade. After 36 h, the balloon was removed with no further episodes of bleeding.

Discussion

The application of a balloon tamponade device should be considered in the management algorithm for acute lower gastrointestinal bleed. Advantages include its rapid insertion, immediate results and ability to measure further bleeding after the catheter has been placed.

Conclusions

Sengstaken-Blakemore tube per rectum may effectively control massive low rectal bleeding when alternative methods have been unsuccessful.
890 Bilateral Acetabular Fractures Induced by An Epilepticseizure In a Paediatric Patient: A Unique Case Andits Management
Authors: Mohamed N , Makaranka S , Cheema K , Harnett P
Published: October 2021

Bilateral acetabular fractures following epileptic seizures are a rare but known occurrence in adults, with an 18.5% mortality rate. These fractures occurring post epileptic seizures have not been previously documented in children. We report a case of a 13-year-old boy who presented to hospital via ambulance following two violent generalised tonic–clonic seizures in a postictal state, metabolically acidotic and a low haemoglobin. Acute abdomen was suspected, and the patient underwent a CT scan which showed bilateral acetabular fractures with central dislocations of both femoral heads and free fluid in the abdomen. The patient underwent initial damage control intervention with insertion of bilateral distal femur skeletal traction. Definitive fixation of the acetabular fractures occurred 1 week later with an open reduction internal fixation with novel supra- pectineal plates using a Pfannenstiel incision. We use this report to increase awareness of significant pelvic injuries in paediatric patients post epileptic seizures.
904 ‘Excuse me, Sir?’ - A Case for Compassion and Non-discrimination in Surgery
Authors: Murray J , Mitchell P
Published: October 2021

Background

The delivery of compassionate and non-discriminatory care to all patients in the hospital environment is vital. Yet, this striking surgical case report demonstrates that ignorance and prejudice against transgender patients still exists, resulting in poorer health outcomes.

Case presentation

A 64-year-old transgender woman presented with severe epigastric pain and left arm weakness. She became haemodynamically unstable as a result of Type A aortic dissection during thrombolysis for a presumed ischaemic stroke. The patient was addressed as ‘Sir’ on multiple occasions causing her visible distress; she confided in the team that she felt judged and that her concerns were not taken seriously. When the thoracic surgery registrar was informed that the patient was transgender and used female pronouns, their reply was that this information was ‘irrelevant’ and ‘unimportant’.

Conclusions

Barriers to health care for transgender individuals and a focus on compassion when treating the surgical patient are discussed. A lack of education, individual ignorance and the serious nature of this case led to psychological distress and may have contributed to a delay in diagnosis. There is an urgent need to raise awareness of transgender health disparities in medical and surgical training, to ensure that all patients are treated equally, and their dignity is maintained, even in challenging and stressful situations. Appropriate engagement and leadership from senior members of the surgical team will foster non-discriminatory practices and the creation of an inclusive environment, focusing on the use of correct pronouns and addressing patient concerns.
905 Inferior Mesenteric Artery Branch Aneurysm Causing Ischemic Colitis – A Sequela of Anabolic Steroid Use
Authors: Joshi S , Sebastian M , Koshy A
Published: October 2021

An inferior mesenteric artery (IMA) aneurysm comprises less than 1% of all reported visceral artery aneurysms. A 34-year-old bodybuilder with a history of anabolic steroid (AS) use of unknown duration, dose and frequency initially presented to the hospital with recurrent bouts of acute onset abdominal pain and alternating episodes of watery-mucous diarrhoea and constipation. Patient’s medical history was otherwise unremarkable with no stigmata of any connective tissue disorders.

A diagnosis of ischemic colitis secondary to a distal IMA branch aneurysm measuring 6mm x 5mm x 10mm on CT was made three years after first presentation. Flexible sigmoidoscopy confirmed mucosal changes consistent with sigmoid ischemic colitis.

A robotic anterior resection was performed due to two failed attempts at coiling the aneurysm. The histology was consistent with a secondary fibromuscular dysplasia in the IMA and its branches. There was a resolution of symptoms and return to normal stool and bowel function post-operatively.

The commonest cause of an IMA aneurysm is the “jet disorder” phenomenon caused by incomplete atherosclerotic occlusion of the superior mesenteric (SMA) and celiac arteries (CA). While the link between AS use and dyslipidaemia is established, the patient’s lipid profile was normal. We believe this case lends valuable insight into atypical causes of ischemic colitis and adds to the literature on AS use and vascular pathology.
911 Delayed Presentation of a Re-Bleed from A Traumatic Splenic Artery Rupture Following Endovascular Management in A Patient with Median Arcuate Ligament Syndrome
Authors: Howitt A , Cuthbert G , Parry D , Elgebali H
Published: October 2021

Endovascular management of splenic blunt trauma is widely accepted as a safe and effective alternative to open surgery in carefully selected patients. Following a radiologically successful intervention, patients are normally discharged with no follow up after 48-72 hours of haemodynamic stability and satisfactory serial haemoglobin levels.

We present a case of a fit and well 24-year-old male patient who presented with abdominal pain, syncope and haemodynamic instability 14 days post successful splenic artery coil-embolization for splenic artery aneurysm rupture secondary to blunt trauma. After initial resuscitation, computed tomography angiography was performed and demonstrated active bleeding from the splenic artery aneurysm which was deemed likely to be a consequence of retrograde filling. The patient underwent successful emergency re-embolization using a combination of embolization coils and Onyx via a trans-splenic approach to eliminate retrograde flow. On further review of the imaging, it was incidentally noted there was evidence suggesting a diagnosis of median arcuate ligament syndrome, which may have predisposed the patient to splanchnic artery aneurysm formation.

This case report highlights a potential limitation of endovascular management compared to open surgery and summarises the literature surrounding splenic artery anatomical variations and the implications of median arcuate ligament syndrome. A re-bleed following embolization is a hostile prospect with potentially catastrophic outcomes for patients if not recognised quickly. The authors propose that interval re-imaging should be considered following endovascular management of blunt splenic trauma.
958 Encapsulating Peritoneal Sclerosis with Pericardial Tamponade: A Case Report
Authors: Spiers H V M , Augustine T
Published: October 2021

Aim

Encapsulating peritoneal sclerosis (EPS) is a rare morbidity associated primarily with peritoneal dialysis. Definitive diagnosis and management can often be prolonged and complicated. The pathogenesis is a two-hit hypothesis of inflammation and myofibroblast differentiation. This report aims to demonstrate the pathogenesis of EPS and provide insight into management.

Method

We present a unique case of a patient with EPS who follows a ‘classical’ disease course before developing a concomitant pericardial sclerosis, presenting with cardiac tamponade. We explore the proposed pathophysiology and provide a hypothesis for both uncommon pathologies presenting in the same patient.

Results

A 45-year-old male was treated for EPS and went on to develop a concomitant pericardial sclerosis. Following referral to our centre, the patient underwent a semi-elective surgical enterolysis and peritonectomy for EPS, with excision of all sclerotic and obstructing peritoneal membrane. Two weeks following the surgery, he developed a pericardial tamponade with cardiovascular compromise, unresolved by two separate episodes of pericardiocentesis, leading to surgical intervention. A pericardial pleural window was created via open thoracotomy and 800ml of thick clotted blood was removed from the pericardial cavity. Histology demonstrated pericardial sclerosis.

Conclusions

This case of EPS is unique given the concomitant pericardial sclerosis. Uraemia may be a common mediator of inflammation in the peritoneum and pericardium, predisposing to sclerosis of both membranes of identical embryological origin. Pericardial sclerosis may be present in EPS patients but may not manifest itself clinically by and large. It also demonstrates that effective surgical intervention can lead to excellent patient outcomes.
969 Intra-Abdominal Rectal Perforation Post Haemorrhoidal Artery Ligation Operation (HALO) And Converted Ligasure Open Haemorrhoidectomy
Authors: Simon N , Saiyara N , Gercek Y
Published: October 2021

Case Report

Symptomatic prolapsing haemorrhoids are usually treated with either haemorrhoidal artery ligation operation (HALO), stapled haemorrhoidopexy or open haemorrhoidectomy. Complications are rare with serious complications like rectal perforation reported scarcely in literature. We report a case of intraperitoneal rectal perforation following transanal haemorrhoidal artery ligation and converted open Ligasure-assisted haemorrhoidectomy in a 74-year-old lady with background portal hypertension secondary to primary biliary cirrhosis. We present this case to highlight the importance of preoperative medical optimisation of portal hypertension prior to surgical intervention and consideration of primary open techniques in grade 4 haemorrhoid surgery.
991 Managing Recurrent Bleeding from Varicose Veins of The Scrotum: A Case Report
Authors: Gowda A , Saleem H , Fonseka T , Nawaz F , Russell T A , Williams S
Published: October 2021

Introduction

Spontaneous recurrent bleeding scrotal varicosity is a rare clinical presentation. The management is undefined and is usually anecdotal from previous case reports. The anatomy and pathophysiology of these presentations are usually complex hence resulting in atypical and challenging management options. To highlight this, we present a case of a patient with recurrent scrotal bleeding secondary to scrotal varicosities.

Care report

A 39-year-old gentleman with heart failure, 4 previous episodes of transient ischemic attacks and atrial fibrillation who was anticoagulated, presented with recurrent left sided scrotal bleeding from dilated superficial scrotal veins. In total, he had 11 presentations over 4 years requiring blood transfusion on 4 occasions. On one occasion the patient required 7 units of packed red blood cells transfused. He had a background of heart failure with hepatic congestion and ascites which failed medical management. Compression, adrenaline and tranexamic acid-soaked gauze, as well as over-sewing feeder vessels offered only short-term relief. His heart failure was difficult to optimise and stopping anticoagulation was not possible, even for a short period of time, due to the high risk of stroke in this patient. Venography revealed a prominent left testicular vein that extensively fed the scrotal veins with bilateral varicoceles. After discussion with the Vascular team, percutaneous coil embolization of the left testicular vein was performed with good results. He has had no significant scrotal bleeding since.

Conclusions

Managing bleeding scrotal varicose veins can be challenging. A multidisciplinary approach may be the most appropriate in managing these patients.
1000 Basal-Squamous Cell Carcinoma Collision Tumour Of the Preauricular Region
Authors: Hallett G , Holden A , Colbert S
Published: October 2021

Collision tumours are defined as multiple neoplasms adjacent to each other or combined in one area and are particularly rare, with only one other basal-squamous cell carcinoma combination of the head and neck region published in the literature.

Case description

An 87-year-old farmer presented to the Maxillofacial Surgery department following referral by his general practitioner concerned with multiple suspected skin neoplasms. Four lesions were identified, two of which required surgical excision with 4mm margins. Following histological investigation, the lesion in the right preauricular area was identified as a basal-squamous cell carcinoma collision tumour which was completely excised with clear margins.

Discussion

This case highlights the possibility of multiple skin neoplasms in a single site and gives an insight into the surgical management of a basal-squamous cell carcinoma collision tumour while aiming to increase clinician awareness of collision tumours especially in high-risk sites such as the head and neck. This case suggests that a 4-5mm surgical margin may be sufficient in removing similar presentations of basal-squamous cell carcinoma collision tumours however highlights the importance of appropriate histological examination of specimens not only to correctly diagnose the tumour but to ensure surgical margins are clear to mitigate recurrence risk. It must be noted that systemic metastases are more common in squamous cell carcinoma than in basal cell carcinoma cases and therefore it is possible that basal-squamous cell carcinoma collision tumours may have higher rates of metastases than traditional basal cell carcinomas.
1130 An Obstructed Morgagni Hernia in Adulthood, Could Regular Cocaine Use Have Exacerbated Symptoms?
Authors: Izard C , Thorne E , Ghallab M , Agrawal A
Published: October 2021

Introduction

Morgagni hernias are an uncommon form of diaphragmatic hernia, it is rare for them to be diagnosed in adulthood and they are often asymptomatic in this population.

Case Report

We report a case of a 26-year-old female who used cocaine on a weekly basis who presented to the emergency department with an acutely obstructed right-sided Morgagni’s hernia. She underwent laparotomy which demonstrated transverse colon with ischaemic associated omentum inside the hernia. The hernia was reduced, the ischaemic omentum was excised and the 4x4cm diaphragmatic defect closed with 2-0 ethibond without mesh.

Conclusions

Following review of the literature, the medical risks of cocaine use are well documented, however they focus on the risks from a pharmacological perspective. Further thought should be given to the effects of inhalant cocaine use and how this may exacerbate herniation from the drastic changes in intrathoracic pressure during inhalation of the substance, this is a new possible risk of cocaine use that is not previously mentioned in the literature and warrants further investigation.
1242 A Surfacing Staghorn: Spontaneous Expulsion of a Large Renal Calculus from A Nephrocutaneous Fistula
Authors: Chandrasekar B , Smith S , Rauf A , Mukherjee R
Published: October 2021

An 83-year-old lady presented to the urology department with right flank pain in the context of a previously known right renal staghorn calculus. On examination, she was found to have a visible discharging sinus in her right flank, and the renal calculus had become visible at the skin surface. Non-contrast CT imaging confirmed that her staghorn calculus had eroded through the skin via a nephrocutaneous fistula. The stone was manually extracted percutaneously on the ward, and she was treated with intravenous antibiotics. She subsequently passed a further stone through the tract and made a good recovery.

This is a highly unusual presentation of nephrolithiasis in a developed country in the 21st century. Review of the literature suggests that surgical management is almost always indicated in patients with staghorn calculi. However surgical management options are not without risk and conservative management of staghorn disease may be appropriate in select patient groups: those with multiple co-morbidities at high risk for GA, in cases of patient refusal of surgery, or in patients with aberrant anatomical factors

Our case highlights a potential complication of conservatively managed staghorn stone disease. To our knowledge our case is the first of spontaneous expulsion of renal stone of this size to be reported in the developed world.
1305 Ureteral Stenting in Conservative Management of Grade IV Blunt Renal Injury
Authors: Mukhtar A. Mukhtar A , Hijazi M. Gareeballah Yousif , Alshareif B.A. Abdalaziz , Ibrahim M. Yahia
Published: October 2021

Post-traumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. A 16-year-old male sustained a motor vehicle accident. Brought after 30 minutes to emergency department, upon arrival he was fully conscious, complaining of severe right hypochondrial and loin pain, abdomen was tender and guarded over the right side, urinary catheter inserted revealed gross haematuria, the patient was resuscitated accordingly, fast ultrasound scan showed minimal fluid collection in the Morison's pouch, the right kidney was swollen with perinephric fluid collection and poor cortico-medullary differentiation. Urgent CT scan findings were deep avulsion of the right kidney. The Patient was planned for conservative management, admitted to high dependency ward, CT scan repeated, and the size of urinoma increased compared to the initial CT, so he was planned for retrograde pyelography and ureteric stenting. Intra-operatively the right ureter was canulated, contrast injected. The pelvi-ureteric junction was intact, extravasation of contrast in the upper pole of the kidney. The right ureter was stented using a size 6 multiloop stent, with the tip directed into the upper pole calyx. The Patient showed dramatic improvement, haematuria cleared and the patient was discharged well after 12 days and the stent was removed after 6 weeks. Despite the improvements with nonoperative management, complications are described and include delayed hemorrhage, delayed massive hematuria and renal scaring with loss of function. Ureteric stenting is playing a major part in the conservative management of high-grade renal injury particularly grade IV type.
1313 Unusual Supraannular Aortic Root Intimal Tear in a Patient with Severe Aortic Regurgitation
Authors: Sef D , Brown S , Haslam E , Rajakaruna C , McAloon C
Published: October 2021

We present an extremely rare case of occult supraannular aortic root intimal tear in a patient presenting with acute severe aortic regurgitation (AR) and a previously undiagnosed bicuspid aortic valve.

A 41-year-old Africo-Carribean female presented to the emergency department with acute pulmonary oedema and increasing dyspnea on exertion. She had been treated empirically with antibiotics for a chest infection. Initial concerns were either aortic dissection or infective endocarditis. Transthoracic echocardiography (TTE) demonstrated a normal size left ventricle with hyperdynamic systolic function and severe AR. The patient was transferred to a tertiary cardiothoracic surgical centre for urgent surgical treatment in view of haemodynamic instability and acute AR. A gated computed tomography aortogram identified pulmonary oedema with an asymmetrically dilated aortic root (maximal diameter 45 mm).

Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and prompted Bentall procedure with mechanical aortic valve. After median sternotomy and initiation of cardiopulmonary bypass, a supraannular aortic intimal tear starting from the right coronary cusp/noncoronary cusp commissure was found with no extension into the aorta. The aortic valve was bicuspid and severe AR not amenable to repair was found. Bentall procedure was performed using the 23/26mm Carbomedics Carbo Seal Valsalva composite graft (Sulzer Carbomedics Inc, Austin, TX, USA).

The patient was discharged on the 7th postoperative day in sinus rhythm. At 30-day clinical follow-up she was symptom free with a satisfactory TTE.
1324 Open Partial Nephrectomy for Renal Cell Carcinoma
Authors: Mukhtar A. Mukhtar A , Alshareif B.A. Abdalaziz , Ibrahim M. Yahia , Hijazi M. Gareeballah Yousif
Published: October 2021

Open partial nephrectomy, or nephron-sparing surgery (NSS), is now considered as the standard for small renal tumors treatment. The oncologic efficacy and safety of NSS for the treatment of stage-T1a renal tumors have been repeatedly demonstrated to be equivalent to radical nephrectomy.

A 66-year-old gentleman chronic smoker was incidentally found to have a small mid pole lesion in the left kidney on routine ultrasound scan, CT finding was 2x2 cm mid pole tumor, no involvement or metastasis, the patient given the option of partial nephrectomy.

In surgery, the left kidney was explored, and the tumor mass was seen to occupy the mid pole. The mid pole branch of the renal artery was clamped after cooling the kidney with ice slush following 300cc of 20% mannitol infusion. In-situ nephron-sparing left nephrectomy was done with a margin of 1cm minor upper calyceal injury repaired.

The patient was discharged five days postoperative. Gross examination of the specimen revealed a wedge biopsy of the mid pole with attached perinephric fat with swelling part at the outer surface, pushing the capsule.

Microscopic sections show a well-defined tumor mass in the renal parenchyma, surrounded by a fibrous capsule, composed of a multilocular cystic area lined by malignant cells.

NSS initially was reserved for patients with solitary kidneys, tumors, and those with significant comorbidities predisposing to future renal failure; indications have expanded recently to allow elective partial nephrectomy in the setting of a normal contralateral kidney.
1354 A Rare Case of Gallstone Ileus Due to Cholecystocolonic Fistula
Authors: Shaladi A , Shrestha A , Basnyat P
Published: October 2021

Introduction

Gallstone Ileus (GI) is an uncommon but potentially lethal complication of cholelithiasis. 50 to 70% of gallstones obstruct in the ileum, the narrowest point of the intestine. More uncommonly the gallstone can travel into the large bowel via an incompetent ileo-caecal valve and impact in the colon at a recto sigmoid junction. GI involving the sigmoid colon is extremely rare cause of large bowel obstruction. The gallstone often enters the large bowel through a fistula formation between the gallbladder and colon, and impacts at a point of narrowing, causing large bowel obstruction.

Case Report

We describe the case of a 72-year-old man who presented with features of bowel obstruction. CT of abdomen pelvis (CTAP) showed a large 5x5cm intraluminal gallstone obstructing at the rectosigmoid area. It showed presence of pneumobilia and incidental finding of abdominal aortic aneurysm (AAA). An emergency laparotomy revealed a cholecystocolonic fistula. The stone was extracted after milking the stone proximally and loop colostomy formed at colotomy site. The patient made an uneventful recovery. Reversal of stoma was postponed pending endovascular repair of enlarging AAA.

Discussion

Presenting symptoms of GI are often non-specific, frequently leading to a delay in diagnosis and treatment. Although no fistula was identified in this patient by imaging, the most common cause of GI in most patients is formation of a cholecystoduodenal fistula.

Conclusions

Compared with biliary enteric fistulae, the occurrence of cholecystocolonic fistulae is remarkably rare. Temporary colostomies can be considered for treating these cases alongside one-stage operations
1411 Amoebic Colitis: Inaccurate Diagnosis; Inappropriate Surgery
Authors: Annamalai S , Zaheer M , McDonald R , Miller A
Published: October 2021

Global prevalence of symptomatic Amoebiasis (pathogen Entamoeba histolytica) is approximately 50 million cases per year, with an annual mortality of up to 100,000. Despite this, a diagnosis of amoebiasis is rarely considered in the UK. Transmission is via the faeco-oral route, person-to-person contact or oral-anal sexual contact. The majority of cases diagnosed in the UK are in international travellers or immigrants.

Symptoms of amoebiasis can closely mirror those of Inflammatory Bowel Disease (IBD) resulting in diagnostic uncertainty. A misdiagnosis could result in treatment with corticosteroids, immunosuppressant or biological agents when standard treatment for amoebiasis is actually Metronidazole. In exceptional circumstances, a misdiagnosis of IBD may lead to a patient requiring colectomy and formation of end ileostomy due to an apparent failure of medical management. Emergency colonic surgery is associated with a risk of complications such as wound infections and collections, together with the psychological consequences of major illness and surgery.

We report on two patients who have undergone emergency subtotal colectomy and end ileostomy in whom a diagnosis of amoebic colitis was made on histology. Both British Asian patients were under 55 years of age, had a travel history to India and presented with diarrhoea.

The diagnosis of amoebiasis must be considered in the differential diagnosis for all returning travellers and immigrants who present with GI symptoms, consistent with IBD. A correct diagnosis allows appropriate, simple, curative treatment and avoids unnecessary surgery with its attendant morbidity. Polymerase chain reaction is the gold standard diagnostic test and is currently significantly under-utilised.
1451 Early Experiences with Covid-19 In Surgical Patients at The Start of The Global Pandemic
Authors: Negreskul Y , Wingfield L , Mandal I , Gilmour J
Published: October 2021

Introduction

Covid-19 is a global threat which had emerged rapidly over the course of last year and is particularly deleterious to those with multiple co-morbidities. While limited data is available on the outcomes of emergency surgical patients infected with SARS-CoV-2, initial reports suggest prolonged post-operative course. Early Covid-19 diagnosis and understanding its impact on outcomes are essential for appropriate management of emergency surgical patients. We aim to report a tertiary hospital’s experiences with the first UK patients infected with Covid-19 at the time of surgery.

Method

A limited consecutive, case series (n = 4) was completed in March-April 2020 in a single tertiary centre with a review of case notes, image, and laboratory results.

Results

All patients presented with acute abdominal pathology (appendicitis, incarcerated umbilical hernia and small bowel obstruction). One patient had a laparoscopy whilst the rest underwent open procedures. All patients suffered from multiple co-morbidities and were on average 71 years-old (57-87). Initial SARS-CoV-2 PCR was negative in 3 patients. However, their clinical features, imaging findings and haematological profiles (raised inflammatory markers with lymphopenia) were in keeping with a diagnosis of Covid-19. All patients had a protracted hospital course with an average hospital stay of 22 days (15-30). 3 patients required unplanned ITU (ITU stay: 4-30 days). The length of ITU stay did not correlate with the procedure complexity.

Conclusions

These initial cases suggest that Covid-19 complicates post-operative recovery. Multimodal approach including PCR testing, imaging and haematological profiles is essential to identify patients at risk of post-operative deterioration and thus plan care accordingly.
1456 Back-To-Back Surgeries: A Clinic Case Report Regarding Multiple Complex Spinal Surgeries for Treatment of Multiple Osteochondroma With Histological Conversion to Chondrosarcoma
Authors: O'Halloran A , Gallagher N , Farrell T , Darwish S , Morris S
Published: October 2021

Background

Multiple Hereditary Osteochondromas [MHO], previously known as multiple hereditary exostoses, is a rare disorder of bone growth, whereby osseous transformation of the cartilage caps within the diaphyses of long bones or flat bones within the skeleton occurs. A significant complication of MHO is the conversion of any present osteochondroma into a malignant chondrosarcoma. Chondrosarcomas are mesenchymal, non-meningothelial tumours and most commonly present with insidious pain, associated neurological deficit by means of impingement of underlying nerves.

Case presentation

We present a clinical case of a 29-year-old female medical student with a background history of multiple hereditary osteochondromas. A previously competitive cross-fitter, she developed the conversion of MHO into a malignant chondrosarcoma. Presenting to outpatient clinic in late 2017, this lady had a 2-year history of lower back pain and an associated palpable lump. An MRI of the thoracolumbar spine demonstrated a large mass arising from the posterior elements of T11 to L2. A biopsy at the time was found to be of benign pathology, most likely in keeping with this patient’s diagnosis of MHO. The patient returned for review in early 2018, where a repeat MRI showed extension of the previously described lesion into the spinal canal at the level of L1 vertebra. This was concerning that this previously identified osteochondroma lesion could be undergoing malignant transformation. The patient went on to have a series of complex spinal surgeries which we will discuss below.
1517 Case Report: Concomitant Superior Mesenteric Artery and Nutcracker Syndrome
Authors: Rivera Cartland M G , Camprodon R
Published: October 2021

Background

Superior mesenteric artery (SMA) syndrome is a rare1 upper gastrointestinal emergency and diagnosis is reached by a high clinical suspicion and confirmed on CT scan. It classically occurs from the compression of the third part of the duodenum (D3) due to a reduced aorto-mesenteric angle2.

Case report

A 28-year-old Caucasian female presented with a 4-day history of persistent vomiting, generalised abdominal pain, distension and absolute constipation for 3 days. She has no previous past medical history. On examination, she had a BMI of 17. Her abdomen was distended with generalised tenderness on palpation. Her routine blood results showed stage 2 acute renal failure. CT abdomen and pelvis showed a grossly dilated stomach and part 1& 2 of duodenum. She underwent an emergency Roux-en-Y duodeno-jejunostomy and end-side jejuno-jejunal anastomosis. Operative findings were of a grossly distended stomach and D1/2 with superior mesenteric vessels impinging on D3 and on left renal vein.

Conclusions

SMA syndrome is a rare cause of gastric outlet obstruction and following initial hydration and correction of electrolytes a definitive procedure should be considered. Many surgeons favour a conservative approach with a period of ‘fattening’ to increase the aorto-mesenteric angle prior to surgical management. We believe that this only delays the inevitable and patients are best serviced with early surgical bypass.

References

1. Biswas A. Superior mesenteric artery syndrome: CT findings. BMJ Case Rep. 2016

2. Multidetector CT of vascular compression syndromes in the abdomen and pelvis. RadioGraphics 2014;34:93–115. 10.1148/rg.341125010
1534 A rare operation: resection of a complex malignant peripheral nerve sheath tumour deemed inoperable by a national centre
Authors: Chowdhury M. R , Goel A , Sinha P , Chave-Cox R , Pal D
Published: October 2021

We present this rare case which was led by spinal surgeons at Leeds after being deemed not suitable for operative input by a national centre.

A 54-year-old lady who presented with 2-month history of worsening left flank pain on a background of four years. She was otherwise fit and well. CT confirmed aggressive left-sided paraspinal tumour with epidural encroachment, extending from T8 to T10 vertebral levels. Its deep surface was well-defined and extending superficially through the chest wall with destruction of ribs. The mass grew in size in course of days requiring urgent attention due to risk of cord compression. Biopsy proved high grade MPNST.

Malignant peripheral nerve sheath tumor (MPNST) is a rare type of sarcoma, 5-10% of sarcoma cases. MPNST is most common in young adults and middle-aged adults. About 25% to 50% of people with MPNST have NF1. 8% to 13% of people with NF1 will get MPNST in their lifetime.

An MDT approach involving spinal, thoracic, vascular and plastic surgeons opined it requiring extensive surgery due to its complexity. It was performed in stages – embolisation then aortic stent placement followed by final resection of the tumour with chest well reconstruction using an LD flap.

A multidisciplinary and multispecialty approach has led to a positive prognosis for this patient who is on the road to recovery.