bluuebunny/crossref_metadata_2025_split huggingface dataset:
1043 Giant Spindle Cell Lipoma of the Perianal Region: A Rare Cause of a Perianal Mass
Authors: Julius B , Schmidt K 
Published: August 2023

Abstract

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

Abstract
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

Abstract

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

Abstract

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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract

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 &lt;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

Abstract

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

Abstract

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

Abstract

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

Abstract

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.