bluuebunny/crossref_metadata_2025_split huggingface dataset:
1547 An Alternative Approach to High-Risk Resternotomy
Authors: Kho J , Khalil A , Petrou M 
Published: October 2021

Abstract

Introduction
Resternotomies are associated with substantial perioperative morbidity and mortality. Strategies described in literature mostly involve peripheral cannulation pre-sternotomy. Disadvantages of this technique relate to prolonged systemic heparinisation and cardiopulmonary bypass (CPB) time and the sequelae of hypothermic circulatory arrest. We describe a two-stage approach that potentially reduces the complications associated with high-risk resternotomy.

Method
3 high-risk patients (from pre-operative CT images) were referred for redo complex aortic surgery. A right mini-thoracotomy incision was first made in the 4th or 5th intercostal space. The right lung was isolated and careful blunt dissection was carried out to mobilise the heart and great vessels attached to the sternum. Once these structures were free, thoracotomy incision was closed. A standard median sternotomy was then performed and central cannulation carried out after systemic heparinisation. Rest of the surgery was performed routinely. In one patient, aortic aneurysm was heavily adherent and attempts to mobilise it fully proved impossible. Resultantly, systemic heparinisation was administered and the patient was cannulated in the right superficial femoral artery and right atrium (via mini-thoracotomy). CPB was instituted and the patient cooled to 28 °C. Right superior pulmonary vein vent was introduced to prevent left ventricular distension from hypothermic ventricular fibrillation. Once the heart and aneurysm were decompressed on full CPB, complete mobilisation was performed safely. All 3 patients survived surgery without major complications.

Conclusions
Meticulous preoperative planning is key to management of high-risk resternotomy. We describe a novel technique which we believe minimises risk of morbidity and mortality in these complex cases.
1638 Decade-Long Trends in Surgery for Acute Type A Aortic Dissection
Authors: Benedetto U , Sinha S , Dimagli A , Cooper G , Mariscalco G , Uppal R , Moorjani N , Krasopoulos G , Trivedi U , Angelini G , Akowuah E , Tsang G 
Published: October 2021

Abstract

Background
Little is known about unwarranted variations in care and outcomes of patients who undergo surgical repair for type A acute aortic dissection(TAAD). We aim to investigate decade-long trends in TAAD surgical repair in England.

Method
Retrospective review of the National Institute for Cardiovascular Outcomes Research (NICOR) National Adult Cardiac Surgery Audit (NACSA) registry from January 2009 to December 2018 , which prospectively collects demographic and peri-operative clinical information for all adult cardiac surgery procedures in the UK.

Results
Over the 10-year period,3,686 TAAD patients underwent surgical repair in England. A steady doubling in the overall number of operations conducted in England was observed from 237 cases recorded in 2009 to 510 in 2018. Number of procedures per hospital per year also doubled, from 10 in 2009 to 21 in 2018. The risk profile of the operated patients remained unchanged. Overall, in-hospital mortality was 17.4% with a trend toward lower mortality in the most recent years (from 22.8% in 2009 to 14.7% in 2018). There was a significant variation in operative mortality across regions with a trend towards lower mortality in regions with a high-volume hospital.

Conclusions
Surgery is the only treatment for acute TAAD but is associated with high mortality. Prompt diagnosis and referral to a specialist center is paramount. The number of operations conducted in England has doubled in 10 years and the associated survival following surgery has improved. Regional variations exist in service provision with a trend towards better survival in high volume centers.
1655 Thoracic Aortic Aneurysmal Disease: Timing and Outcome of Surgery
Authors: Elghazouli Y , Badran A , Naseer M , Ohri S 
Published: October 2021

Abstract

Aim
A thoracic aortic aneurysm (TAA) is a pathological dilatation of the thoracic aorta. There is significant morbidity associated with a dilated aorta including mortality. Open thoracic surgery is the mainstay of management for proximal lesions, offering definitive treatment. We aim to evaluate the outcomes of patients operated on for TAA and consider high risk associations for mortality.

Method
Data was retrospectively collected from 234 patients that underwent elective open thoracic surgery at UHS for TAA disease, between 2015 and 2019. Demographics, clinical factors, surgical details, as well as outcome measures were gathered.

Results
There were 166 males (71%) and 68 females (29%), with a mean age of 66 years. We found that 105 operations involved the aortic root, 171 the ascending aorta, 20 the aortic arch and 12 the descending aorta. 30 day mortality was 5.13%. Female patients that underwent aortic root surgery (P = 0.05), as well as those with prosthetic aortic valves (P = 0.01)and post-operative complications were associated with a significantly higher mortality.

Conclusions
A number of factors are associated with morbidity and mortality in this high-risk Surgery. These should be considered when discussing risks of intervention with patients.
32 Congenital Arteriovenous Malformation of The Breast Associated with Giant Hairy Naevus: A Case Report
Authors: O'Beirn E , Elliott J , Neary C , McLaughlin R 
Published: October 2021

Abstract

Introduction
An arteriovenous malformation (AVM) is defined as an abnormal connection between arteries and veins, bypassing the capillary system. AVM of the breast is a rare clinical entity, with limited evidence to guide management. We present the case of a congenital AVM of the breast in an otherwise healthy woman, with an interesting presenting complaint.

Case Description
A 38-year-old female presented with a ‘buzzing’ sensation and mastalgia in her left breast. Examination revealed a visible pulsatile linear abnormality with a bruit on auscultation. Duplex ultrasonography demonstrated mixing of the arterial and venous flow, consistent with an AVM. Operative management entailed ultrasound guided identification, ligation and excision of all aneurysmal segments. Histopathologic evaluation demonstrated an AVM with no malignant features. At one year postoperatively, the patient reported complete symptom resolution. Literature review identified nine case reports, including two cases of congenital breast AVM, both treated surgically. Seven cases of iatrogenic AVM were identified, with diagnosis based on duplex ultrasonography and management by surgical ligation in all except one, which resolved spontaneously.

Conclusions
ongenital AVM of the breast is a rare clinical entity. Diagnosis can be established using duplex ultrasonography, while CT and MRI may be useful for preoperative planning. Endovascular management alone is associated with high recurrence rates and surgical excision is the favoured approach where technically feasible without major aesthetic or functional compromise.
53 A Rare Malignant Lesion of the Jaws
Authors: Patel V 
Published: October 2021

Abstract

Introduction
Primary intraosseous carcinoma (PIOC) of the jaw is an incredibly rare lesion with approximately 200 cases reported in the literature. PIOC are mostly asymptomatic incidental radiographic findings and present as poorly-defined, non-corticated radiolucencies often with root resorption and cortical perforation. Prognosis is considered poor and best predicted by histological grade.

Case report
A gentleman in his 50s presented to his dentist with a draining sinus from his LR6 tooth. A radiograph revealed a non-corticated radiolucency localised to the distal root of the LR6. 7 months later, he returned with pain and mobility of the LR7. Another radiograph revealed a non-corticated radiolucency from around the distal root of the LR6 extending to the LR8. Urgent biopsy of the mandibular bone was arranged by the oral and maxillofacial surgery team. Histopathology revealed the lesion was likely a benign squamous odontogenic tumour. However, it was not possible to exclude a well-differentiated squamous cell carcinoma. Correlation of clinical findings, imaging and multidisciplinary team discussion was recommended. Following the MDT meeting, excision of the bony lesion was undertaken. Histopathology this time returned as primary intraosseous carcinoma NOS T4N0M0, thought to have arisen from a radicular cyst associated with the LR6/7. The treatment was right segmental mandibulectomy, fibular free flap, selective neck dissection (I-III) and adjuvant radiotherapy.

Conclusions
This case highlights how subtle radiographic features can represent malignancy in lesions appearing cystic at first. Although rare, clinicians should be aware of PIOC as a differential diagnosis when presented with radiographic features which could represent malignancy.
96 A Rare Case of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?
Authors: Chew P R , Hogg F 
Published: October 2021

Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare subtype of T-cell lymphoma that develops around breast implants and was first described in 1997. To date, the estimated risk of BIA-ALCL in UK is reported to be 1 in 24000, but as yet appears to have a substantial variation of incidence around the world. The aetiology of this recognised clinical entity remained widely unknown.
A 72-year-old woman in remission for systemic anaplastic lymphoma kinase (ALK)-positive ALCL of right axilla, presented with a discoloured lump at the medial mastectomy scar following a progressive enlargement of right breast, 20 years after silicone breast implant reconstruction. Imaging studies showed fluid collection and herniation of the affected breast implant. Subsequently, the discoloured lump burst and patient then had tissue biopsy and removal of her right breast implant in together with intravenous antibiotic. Histocytopathological examination confirmed the presence of BIA-ALCL without capsular invasion and the growth of Gram-negative bacteria were noted in fluid culture. Total capsulectomy was performed and patient continues to be in remission with no local or systemic therapy.
We reported a rare yet interesting case of the coexistence of BIA-ALCL and systemic ALK-positive ALCL in an elderly patient. This case has further strengthened the causal relationship of composition and/or textured implant, and the presence of a theoretical association of a select group of pathogens maybe a trigger and contributes to the pathogenesis of BIA-ALCL. Due to the rarity of this disease, diagnosis can be challenging and requires a multidisciplinary approach.
97 A Case Report: Necrotising Leukocytoclastic Vasculitis (NLV) Of the Breast Mimicking Necrotising Fasciitis (NF)
Authors: Chew P R , Munro K 
Published: October 2021

Abstract
Leukocytoclastic vasculitis (LV) is an inflammation of the small vessels in the dermis characterised by the deposition of immunocomplexes in the involved vessel walls. It commonly manifests as palpable purpura, limited to the skin and predominantly of the lower limb. We report a rare case of necrotising LV (NLV) affecting bilateral breast, manifesting clinical features of necrotising fasciitis (NF), and emphasizes the potential diagnostic challenges that markedly influence the treatment and survival of patients.
A 48-year-old female presented with an acute onset left breast skin necrosis and discolouration that rapidly progressed to the contralateral breast with surrounding erythema and oedema of the chest wall yet spared the intermammary cleft. Some non-blanching purpuric rash were also noted on upper abdomen and left lower limb. COVID-19 test was negative. CT scan showed extensive bilateral breast fat stranding and oedema. Patient became clinically septic with a moderately raised CRP and mild acute kidney injury. Radical mastectomies and chest wall excision were performed with intra-operative findings of cloudy fluid and easily peeled away subcutaneous tissue from fascia. Urgent gram stain and culture showed no organisms. Tissue biopsies subsequently showed the diagnosis of NLV. Chest wall defect was then reconstructed with split skin grafts, NLV treated with corticosteroids and patient made an uneventful recovery.
This case highlights the incidence of a rare and aggressive manifestation of NLV on the breast that mimics NF, emphasizing the clinical differentiation that may lead to catastrophic results and significant cosmetic defect, if a differential diagnosis cannot be determined at the time.
106 Stentolith As an Uncommon Complication of Loss to Follow Up After Endoscopic Biliary Stenting
Authors: Ng S , Lam M , Gil N , Shamali A 
Published: October 2021

Abstract

Introduction
Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration.

Case Presentation
A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, and the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex.

Discussion
Complications of stenting include cholangitis, stent occlusion and migration [2]. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months (1). However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith” [4]. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation [6]. Variation in formation has been described, with plastic stents developing circumferential stones [12-25], due to potential space between the wall and stent.

Conclusions
This highlights the importance of robust inter-disciplinary working; careful patient follows up and implementation of a mandatory registry at all hospitals for stented patients.
128 Rapidly Proliferative Pilomatrixoma On the Eyebrow of A 7-Year-Old Boy – A Case Report
Authors: Patel M , Sinha M 
Published: October 2021

Abstract
Pilomatrixoma or calcifying epithelioma of Malherbe is a benign tumour originating from pluripotent precursors of hair matrix cells. We present a paediatric patient with a rapidly enlarging eyebrow mass with a differential diagnosis of sebaceous cyst, pyogenic granuloma, or malignancy.
A 7-year-old boy presented in primary care with a 0.5cm non-inflammatory nodule on his medial brow present for 2-3 months. History of previous trauma was not elicited and there were no features of bleeding or ulceration. It was then lanced, following diagnosis of an infected sebaceous cyst. Within weeks, the nodule underwent rapid proliferation, enlarging to 2cm in diameter. He was urgently referred to secondary care pending further investigation for possible trauma-induced pyogenic granuloma or malignancy.
Upon presentation in secondary care, we observed a protruding erythematous and ulcerated mass, indurated in texture and adherent to overlying skin. The patient was submitted to excisional biopsy with a vertical elliptical approach to minimise distortion of the brow. Small, calcified deposits were observed in the tumour substance. Histologically, basaloid basophilic cells were predominant and mixed with ghost cells and foci of giant multinucleate cells, verifying diagnosis of a pilomatrixoma.
Pilomatrixoma exhibits tendency towards mimicry of lesions such as epidermoid, sebaceous, dermoid cyst, pyogenic granuloma or even keratoacanthoma with a pre-operative detection rate as low as 11%. With a bimodal age distribution, arising in the first and sixth decades of life, this case highlights a need for a high degree of suspicion in young patients with careful clinical examination in order to aid diagnosis and prompt appropriate treatment.
143 Massive Intra-Hepatic Subcapsular Liver Haematoma Post-Laparoscopic Cholecystectomy- A Rare Complication of a Common Procedure'
Authors: Saad E , O'Connell L , Khan I , Barry K 
Published: October 2021

Abstract

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

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

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

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

Abstract
Acute abdominal pain is a common surgical presentation and acute appendicitis remains the top differential for most young adults. Omental fat torsion has emerged as a rare aetiology of an acute surgical abdomen in the younger population that closely mimics acute appendicitis in its clinical presentation. Preoperative diagnosis is extremely challenging in this age group due to the rarity of the condition and the non-specific nature of its clinical and laboratory findings, and hence most reported diagnoses were made intra-operatively.
We report a case of omental fat torsion in a 22-year-old male who presented with clinical features that were highly suggestive of acute appendicitis. However, the diagnostic laparoscopy revealed a normally looking appendix and terminal ileum, with the presence of a twisted segment of the greater omentum in the right lumbar region. A laparoscopic omentectomy and a prophylactic appendectomy to prevent furture acute appendicitis were performed with an uneventful postoperative recovery. Histology confirmed omental fat infarction and a normal appendix.
This reported case highlights a rare cause of right iliac fossa pain and demonstrates the value of diagnostic laparoscopy in the context of clinically suspected acute appendicitis in younger male patients. Diagnostic imaging was not deemed necessary in our patient given the strong clinical suspicion of acute appendicitis. Prompt laparoscopy led to definitive diagnosis as well as treatment and avoided the radiation exposure necessitated during a diagnostic computed tomography scan.
282 Cholecystoappendicular Fistula- 1st Ever Reported Case
Authors: Prakash Narayan P , Oyewole B , Mandal A , Belgaumkar A , Campbell-Smith T 
Published: October 2021

Abstract
A 30-year-old male presented with a history of recurrent episodes of acute cholecystitis; first acute attack associated with fever and nausea was 18 months prior to this presentation, for which he was managed conservatively for acute cholecystitis with antibiotics and analgesia following an ultrasound that showed features of acute cholecystitis with no obvious gallstones.
The patient had further episodes of acute cholecystitis with no signs of obstructive jaundice and subsequent ultrasound showed multiple small gallstones. Due to the severity of his symptoms, he was scheduled for a planned cholecystectomy.
During surgery (right subcostal incision)- findings were that of a contracted gall bladder with dense adhesions, after careful dissection a fistulous tract between the appendix and gallbladder was identified along with a cholecystoduodenal fistula.
An en-bloc cholecystectomy plus appendicectomy was performed with the duodenotomy repaired. On the first day post op there was approximately 300 ml of bilious effluent in drain, a white cell count-8.1 x 109 and hemoglobin -12.1 g/dL, Serum bilirubin-1.4mg/dL, ALP-104mg/dL. The second and third post-operative days were uneventful with minimal bile mixed serous fluid in drain respectively with no other complains, following which the drains were removed and patient discharged home.
Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is a cholecystoduodenal (70%), followed by cholecystocolic (10–20%), and the least common is the cholecystogastric fistula accounting for the remainder of cases.
No case of cholecystoappendicular fistula has been reported so far.