P-BN16 Gallbladder agenesis in a gentleman presenting with biliary sepsis: a case report and review of literature

Background Gallbladder agenesis (GBA) is a well-recognised, yet rare embryological malformation, that is thought to stem from a failure of the gallbladder and cystic duct to bud from the common bile duct in the 5th week of gestation. The anomaly has an estimated incidence of 10-65 per 100 000 and is often an incidental finding. A quarter of those affected are symptomatic, often presenting in a similar manner to cholecystitis or choledocholithiasis. There is a lack of awareness and guidance on its investigation and management, making GBA a diagnostic challenge, which often leads to unnecessary high-risk surgical exploration. Methods A 64-year-old man presented with right upper quadrant abdominal pain, fevers, jaundice and persistent vomiting. On examination he was confused, visibly jaundiced and septic with deranged liver function tests. An initial ultrasound scan of the abdomen revealed dilated common bile ducts, with no evidence of choledocholithiasis, however, a gallbladder could not be identified. Magnetic resonance cholangiopancreatography confirmed a ‘post-cholecystectomy’ picture, despite no history of abdominal surgery. This led us to the diagnosis of gallbladder agenesis. Results There are no dedicated guidelines regarding the investigation and management of GBA. Efforts have been made to stratify the diagnostic imaging of GBA. Malde et al suggest that if the gallbladder is not visualised on USS, the next most appropriate investigations in order of accuracy are MRCP, CT and ERCP, respectively. Interestingly, they further suggest that if results of imaging remain inconclusive, they should be repeated again once the acute phase of the illness or symptoms have resolved. Inadvertently, this suggestion was applied in our case, as the patient underwent a repeat MRCP following the resolution of his acute symptoms. In our case, MRCP allowed an effective final diagnosis, avoiding unnecessary investigations and exploratory surgery. It also provided a detailed anatomical picture, excluding the possibility of an ectopic gallbladder. Conclusions The present case accentuates the importance of non-invasive imaging such as MRCP in appropriately diagnosing this phenomenon and avoiding unnecessary operative exploration.

Enamel Caries Detection and Diagnosis: An Analysis of Systematic Reviews

Detection and diagnosis of caries—typically undertaken through a visual-tactile examination, often with supporting radiographic investigations—is commonly regarded as being broadly effective at detecting caries that has progressed into dentine and reached a threshold where restoration is necessary. With earlier detection comes an opportunity to stabilize disease or even remineralize the tooth surface, maximizing retention of tooth tissue and preventing a lifelong cycle of restoration. We undertook a formal comparative analysis of the diagnostic accuracy of different technologies to detect and inform the diagnosis of early caries using published Cochrane systematic reviews. Forming the basis of our comparative analysis were 5 Cochrane diagnostic test accuracy systematic reviews evaluating fluorescence, visual or visual-tactile classification systems, imaging, transillumination and optical coherence tomography, and electrical conductance or impedance technologies. Acceptable reference standards included histology, operative exploration, or enhanced visual assessment (with or without tooth separation) as appropriate. We conducted 2 analyses based on study design: a fully within-study, within-person analysis and a network meta-analysis based on direct and indirect comparisons. Nineteen studies provided data for the fully within-person analysis and 64 studies for the network meta-analysis. Of the 5 technologies evaluated, the greatest pairwise differences were observed in summary sensitivity points for imaging and all other technologies, but summary specificity points were broadly similar. For both analyses, the wide 95% prediction intervals indicated the uncertainty of future diagnostic accuracy across all technologies. The certainty of evidence was low, downgraded for study limitations, inconsistency, and indirectness. Summary estimates of diagnostic accuracy for most technologies indicate that the degree of certitude with which a decision is made regarding the presence or absence of disease may be enhanced with the use of such devices. However, given the broad prediction intervals, it is challenging to predict their accuracy in any future “real world” context.

Single institutional experience of management of penetrating trauma chest

Chest trauma is now the second most common non-intentional traumatic injury. Chest trauma is associated with high mortality. Control of blood loss and stabilization of vital organs is of vital importance over diagnostic and therapeutic measures. Bleeding may arise from chest wall, intercostal or internal mammary arteries, great vessels, mediastinum, myocardium, lung parenchyma, diaphragm or abdomen. Modified early warning signs (MEWS) score of >9 on presentation have shown higher rate of mortality. Diagnostic modalities such as extended-focused assessment with sonography in trauma (eFAST) have been effective. The type of surgical approach alters according to the site of injury. We here presented our experience with six such patients. All the six patients involved in this study had penetrating trauma chest with various sharp weapons including dagger, ice pick, flag post. Time of presentation of all these patients were delayed due to ours being a tertiary centre. The patients were explored on the basis of eFAST findings, intercostal drainage, hemodynamics. Out of the six patients two patients succumbed and the patients who died also had high MEWS score. All the patients were approached surgically with respect to the type of injury sustained. Penetrating chest trauma present a challenging clinical situation which warrants early evaluation and intervention. The cases of chest trauma then be it blunt or penetrating should always be treated within the advanced trauma life support (ATLS) guidelines followed by the definitive management. Regardless of any penetrating object, the foreign body should be left in situ and only to be removed under vision. If in case the penetrating object has already been removed the operative intervention is decided on the amount of drainage. With blunt chest trauma, approximately 15% of the deaths result directly from intrathoracic injury, but with penetrating chest trauma, nearly 100% of the deaths result from intrathoracic injury. Hence, the operative exploration of the chest in penetrating chest trauma and should be done on emergent basis as the mechanism of injury, vital organ damage and hemodynamic status all equate to higher rate of mortality.

Hypermagnesaemia causing mesenteric ischaemia and small bowel infarction

We present a case of mesenteric ischaemia caused by hypermagnesaemia after ingestion of a large oral dose of magnesium citrate, which resulted in smooth muscle relaxation, hypotension and bowel infarction. The patient had a history of chronic bowel dysmotility and renal impairment. On operative exploration, the bowel was noted to have a distinct pattern of ischaemia along its antimesenteric border. Small bowel resection was performed, and the patient was left in discontinuity, with definitive repair and anastomosis performed 24 hours later. The patient’s magnesium level was 8.39 mg/dL, which was treated with intermittent haemodialysis and eventually normalised over several sessions. Our patient recovered and was discharged after a month-long hospitalisation. She returned shortly after with respiratory failure and died. On review of the literature, we identified similar cases and present a pathophysiological mechanism of hypermagnesaemia causing mesenteric ischaemia, consistent between our cases and those already reported.

Zollinger ellison syndrome due to primary nodal gastrinoma located outside the limits of the conventional gastrinoma triangle: report of a case

Primary nodal gastrinoma is a rare entity and the diagnosis is often contemplative when no other non - nodal primary site can be identified despite thorough investigations and operative exploration. Here we report one such case wherein a primary nodal gastrinoma was diagnosed as an entity of exclusion. Additionally, the location of the disease outside the confines of the conventional gastrinoma triangle further contributes to the rarity of the presentation. A young male patient had presented to us with history of multiple operations in the past for recurrent upper abdominal pain presumably consequential to peptic ulcer disease viz a trucal vagotomy and gastrojejunostomy, duodenal ulcer perforation surgery and a cholecystectomy. CT scan and endoscopic USG showed a preaortic calcified node located outside the limits of the gastrinoma triangle. A raised serum gastrin level and an endoscopic guided FNAC confirmed the diagnosis of a gastrinoma. A 68 Ga-DOTANOC PET CT revealed an exclusive nodal uptake with no discenable primary lesion. Normalization of gastrin levels after removal of the involved pre-aortic node further pointed to the diagnosis of primary nodal gastrinoma. A high index of clinical suspicion is warranted especially in a history of multiple surgeries for recurrent upper abdominal pain and location of the lesion outside the confines of the ‘Gastrinoma Triangle’ should not be deterrent for the diagnosis.

A Diagnostic Algorithm to Guide Operative Intervention of Zone 5 Flexor Injuries

Background: Given the importance of the neurovascular structures in the volar forearm, accurate diagnosis of zone 5 flexor injuries is critical. Purpose: We sought to test the hypothesis that tendinous injury would be more likely in the distal 50% of the forearm and muscle belly injury would be more likely in the proximal 50% of the forearm. Methods: From December 2015 to December 2016, we conducted a prospective clinical study of patients 18 years and older with zone 5 flexor lacerations. We excluded those with concomitant ipsilateral injuries in flexor zones 1 to 4, multiple lacerations in flexor zone 5, prior neurovascular injuries, crush injuries, patients who underwent operative exploration prior to transfer to our facility, and patients who were unable or unwilling to provide consent. Neurovascular and musculotendinous injuries on physical examination were recorded. All patients underwent operative exploration. Physical examination accuracy and the incidence of musculotendinous and neurovascular injury in the distal 50% of the forearm were compared with the proximal 50% of the forearm. Results: The distal 50% of the forearm (group 1, n = 14) had higher probability of tendon injury (64%), whereas lacerations of the proximal 50% of the forearm (group 2, n = 5) did not result in any tendinous injuries. Rather, all patients in group 2 had muscle belly injuries. There was no difference in the rate of neurovascular injury between groups. Physical examination alone was highly accurate in diagnosing nerve injuries (93%–100%) but less accurate in diagnosing arterial injuries (79%–80%) regardless of the location of injury. Conclusions: Due to the lack of tendinous injuries in proximal zone 5 lacerations, along with the accuracy of physical examination in determining the presence of neurovascular injuries, patients with lacerations in the proximal half of the forearm, without evidence of nerve or arterial injury, can likely be observed in lieu of immediate operative exploration.

Successful reconstruction of distal peroneus longus tendon dislocation associated with a split lesion – a case report

Background Peroneal tendon injuries are one of the differential diagnoses in lateral ankle and rearfoot pain. While partial tears are not uncommon, peroneal tendon dislocation at the peroneal tubercle is very rare. Until now, only three papers have been published, presenting five cases of peroneus longus tendon dislocation over the peroneal tubercle. This report adds a previously undescribed case of a peroneus longus tendon split tear that was partially dislocated and entrapped over the peroneal tubercle. The respective operative approach and the outcome are described. Case presentation A 25-year-old international top-level speed skater developed a painful mass over the lateral calcaneal wall. There was no specific inducing injury in his medical history. In contrast to previous reports, according to the patient’s history, a snapping phenomenon was not present. Conservative treatment was not effective. By inspection and palpation an enlarged peroneal tubercle was assumed. During operative exploration, we found an incomplete longitudinal split tear of the peroneus longus tendon, which was partially dislocated and entrapped over the peroneal tubercle. This mimicked an enlarged peroneal tubercle. A portion of the split tendon was resected. A deepening procedure of the flat groove of the peroneus longus tendon below the peroneal tubercle and a transosseous reconstruction of the avulsed inferior peroneal retinaculum were performed. After six months, the patient had completely reintegrated into his elite sport and has been free of symptoms since then. Conclusions From the presented case it can be speculated that the inferior peroneal retinaculum was overused, worn out, detached, or ruptured due to overpronation and friction the lateral edge of the low-cut speed skating shoe. Then the peroneus longus tendon experienced substantial friction with the peroneal tubercle with possible dislocation during ankle motion. This frictional contact may have finally led to further degeneration and a longitudinal tear of the tendon. Obviously, dislocations can develop insidiously resulting in lesions of the peroneus longus tendon at the peroneal tubercle, ultimately leading to a tendon entrapment. This mimics an enlarged tubercle. The pathology is very rare and can be successfully addressed surgically.

Das akute idiopathische Skrotalödem – eine relevante Differenzialdiagnose des akuten Skrotums im Kindes- und Jugendalter

Zusammenfassung Hintergrund Das „akute Skrotum“ ist ein häufiger kinderurologischer Notfall, der eine rasche Beurteilung zur Diagnose bzw. zum Ausschluss einer Hodentorsion erfordert. Zu den weniger bekannten Differenzialdiagnosen zählt das idiopathische Skrotalödem (AISE). In dieser Studie beschreiben wir Häufigkeit und klinisches Management des AISE in unserer Klinik. Patienten 319 Patienten im Alter von 0 bis 17 Jahren, die zwischen 01/2013 bis 12/2017 in der kinderurologischen Klinik der KUNO-Kinderklinik St. Hedwig Regensburg mit der Diagnose „akutes Skrotum“ behandelt wurden. Methode Retrospektive Analyse der Patientenakten. Ergebnisse 234/319 Patienten wurden ambulant und 85/319 (27%) stationär behandelt. Bei 23/319 (7,2%) wurde ein AISE diagnostiziert. Alle Patienten mit AISE wurden ambulant behandelt, bei keinem dieser Patienten musste eine operative Exploration erfolgen. Weitere Diagnosen der ambulanten Patienten: Epididymitis (87/234; 37%), Hydatidentorsion (42/234; 18%), Hodentorsion (5/234; 2%) Hodentrauma (10/234; 4%), Hydrozele (9/234; 4%), unspezifische Hodenschmerzen (58/234; 25%). Diagnosen der stationären Patienten: Hodentorsion (58/85; 68%), Hydatidentorsion (17/85; 20%), Epididymitis (8/85; 9%), Hodentrauma (1/85; 1%), Tumor (1/85; 1%). Diskussion Das AISE ist eine Ausschlussdiagnose mit typischem klinischem Bild. Zusammen mit dem charakteristischen Befund in der (Doppler-) Sonografie ist eine sichere Abgrenzung zu anderen Differenzialdiagnosen des akuten Skrotums möglich. Durch die korrekte Diagnosestellung können unnötige Klinikaufenthalte, Operationen und medikamentöse Behandlungen vermieden werden. Schlussfolgerung Das AISE ist eine relevante Differentialdiagnose des akuten Skrotums, das Kinder- und Jugendärzten bekannt sein sollte.

Telemedicine-guided forearm emergency decompressive fasciotomy for compartment syndrome

Introduction We highlight the utility of telemedicine and telementoring for the management of orthopaedic emergencies using a case of forearm compartment syndrome following a penetrating trauma in a northern Inuit community in Nunavik, Quebec, Canada. Methods & Results As in many cases of compartment syndrome in rural settings, the patient was at a high risk of developing irreversible complications. A prompt diagnosis followed by an emergency decompressive fasciotomy was warranted. Using telemedicine and telementoring guidance, the diagnosis of compartment syndrome was made, and the patient’s volar compartment was successfully decompressed by a local emergency physician in a timely manner. Subsequently, the patient was able to be safely transferred to a level 1 trauma centre for further surgical management. This included a second-look operative exploration, irrigation and debridement, completion of volar fasciotomy and ulnar nerve decompression. No complications were seen. Discussion Our experience highlights two important clinical implications. First, telemedicine can be successfully implemented to facilitate clinical diagnosis of surgical emergencies in the rural setting. Second, telementoring can effectively allow surgeons to guide physicians remotely to perform emergency decompressive fasciotomy, which can help salvage the affected limb and significantly decrease the risk of debilitating complications.