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1.  Rare case of a liposarcoma in the brachial plexus 
A liposarcoma is a rare cancer of connective tissues that resemble fat cells under light microscopy.
Case History
A 73-year old female patient presented to our tertiary cancer centre with an eight-year history of a large, slow-growing painless mass in the right axilla. Magnetic resonance imaging showed a lipomatous, well-circumscribed mass of dimension 30 × 16 × 10cm extending towards the right clavicle and causing deformation to the right chest wall and right breast. Surgery revealed a large tumour that had stretched all three cords of the brachial plexus. Histopathology was consistent with a diagnosis of a low-grade liposarcoma. After a period of neuropraxia, the patient returned to normal activities 4 months after surgery.
Although extremely rare, low-grade liposarcomas of the brachial plexus should be considered in the differential diagnosis of a slow-growing axillary mass. Referral to a tertiary sarcoma centre is essential for an appropriate diagnosis, adequate treatment, and long-term follow-up.
PMCID: PMC5209984  PMID: 27241607
Axillary mass; Low-grade liposarcoma; Brachial plexus
3.  Medium-term durability of giant hiatus hernia repair without mesh 
This is the second report on objective review of 100 patients who underwent composite fundoplication-cardiopexy for repair of giant hiatus hernia (GHH) at a median of 24 months following surgery. Outcomes were objective follow-up by endoscopy and quality of life (QoL) by Gastrointestinal Quality of Life Index (GIQLI), modified Visick scores and dysphagia scores. The initial report for this cohort suggested a low objective recurrence rate (9%) and substantial improvements in QoL indices.
The rate of hernia recurrence was assessed with Kaplan–Meier analysis and covariates were analysed with the Cox proportional hazards model. Paired t-tests and related samples Wilcoxon signed-rank tests were used to compare QoL scores. Unpaired data were compared with the independent samples t-test and Mann–Whitney U test.
Objective review was obtained in 97% of the patients. There were five recurrences of hernias that had a vertical height of >2cm from the diaphragmatic hiatus, with three patients requiring reoperation for severe dysphagia. Small recurrences (<2cm) occurred in 20 patients. The median time to recurrence was 40 months (95% confidence interval: 34–46 months). At two years, recurrence of any size had occurred in 24% of cases. At follow-up review (median: 27 months), the mean GIQLI score was 109 (p=0.279), the median modified Visick score was 2 (p=0.954) and the median dysphagia score was 41 (p=0.623). There was no evidence that the GIQLI score (p=0.089), the modified Visick score (p=0.339) or the dysphagia score (p=0.445) changed significantly after recurrence.
There was a sustained improvement in overall QoL and reflux scores after GHH repair. QoL scores showed persistent improvement in reflux and overall health, even in the subgroup with recurrence. The majority (80%) of recurrences were small and recurrent herniation did not appear to significantly change QoL. The rates of recurrence and QoL are comparable with those for other methods of repair.
PMCID: PMC5209986  PMID: 27388542
Paraoesophageal hiatus hernia; Laparoscopy; Follow-up study; Quality of life
5.  Neonatal compartment syndrome 
A term neonate was born with a grossly swollen and discoloured left hand and forearm. He was transferred from the local hospital to the plastic surgical unit, where a diagnosis of compartment syndrome was made and he underwent emergency forearm fasciotomies at six hours of age. Following serial debridements of necrotic tissue, he underwent split-thickness skin grafting of the resultant defects of his forearm, hand and digits. At the clinic follow-up appointment two months after the procedure, he was found to have developed severe flexion contractures despite regular outpatient hand therapy and splintage. He has had further reconstruction with contracture release, use of artificial dermal matrix, and K-wire fixation of the thumb and wrist. Despite this, the long term outcome is likely to be an arm with poor function. The key learning point from this case is that despite prompt transfer, diagnosis and appropriate surgical management, the outcome for neonatal compartment syndrome may still be poor.
PMCID: PMC5209988  PMID: 27138850
Compartment syndrome; Neonatal; Fasciotomy; Volkmann
7.  Colonic casts: unexpected complications of colonic ischaemia 
Extensive colonic ischaemia can result in passage of a colonic ‘cast’ (CC) through the rectum.
Case Study
We report a 69-year-old male who initially underwent surgery to remove a sessile polyp. On postoperative day (POD)15, he was febrile, suffering from diarrhoea, and was treated conservatively. On POD18, the patient returned to our hospital with a CC that presented after defaecation. Computed tomography of the abdomen revealed a CC extending from the descending colon to the anal orifice with presentation of air between the affected colonic wall and the CC. The patient was treated conservatively and discharged on POD20 without complications having passed the CC (≈80cm) completely and becoming afebrile.
In most cases, the cause of CC passage is surgery for colorectal cancer or repair of an abdominal aortic aneurysm. A mild-to-severe presentation is dependent upon the bowel-wall layers affected by ischaemia and which therefore are included in the CC.
PMCID: PMC5209990  PMID: 27241609
Colonic cast; Colorectal surgery; Ischaemia
8.  A report on an acute, in-hours, outpatient review clinic with ultrasonography facilities for the early evaluation of general surgical patients 
In 2013 our hospital introduced an in-hours, consultant-led, outpatient acute surgical clinic (ASC) for emergency general surgical patients. In 2014 this clinic was equipped with a dedicated ultrasonography service. This prospective cohort study evaluated this service before and after the introduction of ultrasonography facilities.
Data were recorded prospectively for all patients attending the clinic during 2013 and 2014. The primary outcome was patient destination (whether there was follow-up/admission) after clinic attendance.
The ASC reviewed patients with a wide age range and array of general surgical complaints. In 2013, 186 patients attended the ASC. After the introduction of the ultrasonography service in 2014, 304 patients attended. In 2014, there was a reduction in the proportion of patients admitted to hospital from the clinic (18.3% vs 8.9%, p=0.002). However, the proportion of patients discharged after ASC review remained comparable with 2013 (30.1% in 2013 vs 38.8% in 2014, p=0.051). The proportion of patients undergoing computed tomography (CT) scans also fell (14.0% vs 4.9%, p<0.001).
The ASC assessed a wide array of general surgical complaints. Only a small proportion required hospital admission. The introduction of an ultrasonography service was associated with a further reduction in admission rates and computed tomography.
PMCID: PMC5209991  PMID: 27269242
General surgery; Outpatients; Emergencies; Ultrasonography; Ambulatory care facilities
9.  Spleen preserving management of a non-parasitic splenic cyst in pregnancy 
Non-parasitic splenic cysts are rare entities. In pregnancy, they are rarer still, with as few as seven cases reported in the literature. There is little consensus regarding the optimal management of this condition in pregnancy. Although small, the theoretical risk of intrapartum splenic rupture is associated with a fetal mortality rate as high as 70%. The authors of at least three case reports advocate total splenectomy as first-line management of splenic cyst in pregnancy. Paradoxically, spleen conserving surgery is the recognised gold standard treatment for symptomatic splenic cysts in non-pregnant patients. We present a case of a large maternal splenic cyst that was treated successfully with a laparoscopic cystectomy.
PMCID: PMC5209992  PMID: 27167310
Splenic cyst; Non-parasitic splenic cyst; Maternal splenic cyst; Pregnancy; Minimally invasive
10.  Silicone granuloma from ruptured breast implants as a cause of cervical lymphadenopathy 
A 56-year-old woman with a 10-year history of bilateral silicone breast implants presented to the ear, nose and throat outpatient clinic with a 2-month history of a right-sided neck lump. She was found to have a 1.3cm supraclavicular lymph node that gave the clinical impression of being reactive. Ultrasonography guided fine needle aspiration was inconclusive and initial review of subsequent computed tomography failed to identify a cause. This was followed by excisional biopsy of the lymph node, which revealed a silicone granuloma that was linked to a ruptured right-sided breast implant placed ten years previously. This case highlights the importance for otolaryngologists to consider silicone granuloma among the differential diagnoses of cervical lymphadenopathy in patients with a history of silicone breast implants. Recognising this differential diagnosis could avoid undue anxiety for patient and clinician regarding more serious pathology.
PMCID: PMC5209993  PMID: 27167311
Otolaryngology; Cervical lymphadenopathy; Silicone granuloma; Breast implants
13.  Hybrid tracheostomy 
PMCID: PMC5209996  PMID: 27269240
16.  Gallstone ileus in an ‘asymptomatic’ parastomal hernia 
Parastomal hernias are common and often asymptomatic. We report the first known case in which later, acute symptoms developed owing to gallstone ileus in a sac containing both omentum and small bowel. Urgent computed tomography established the diagnosis.
PMCID: PMC5209999  PMID: 27241611
Gallstone ileus; Parastomal hernia
17.  Portobiliary fistula following laparoscopic cholecystectomy 
The laparoscopic approach has replaced open surgery as the gold standard for cholecystectomy. This technique is, however, associated with a greater incidence of bile duct injuries (BDIs). We report a case of portobiliary fistula (PBF), a rare complication of BDI, occurring post laparoscopic cholecystectomy (LC). PBF has been reported after procedures such as endoscopic retrograde cholangiopancreatography and pathologies such as liver abscesses, but only once previously in the setting of LC. We discuss the management of this patient with apparent dual pathology, and summarise other aetiologies that may give rise to this condition.
PMCID: PMC5210000  PMID: 27269438
Laparoscopic cholecystectomy; Bile ducts; Fistula
18.  General paediatric surgery for patients aged under 5 years: a 5-year experience at a district general hospital 
The gradual shift of general paediatric surgery (GPS) provision from district general hospitals (DGH) to specialised units is well recognised in the UK. The consequences of centralisation include a reduction in exposure to GPS for current surgical trainees. The GPS practice of a DGH is examined here.
All operations performed on children aged under 5 years over a 5-year period were identified using the local electronic operation database. Electronic hospital records and clinic letters were accessed to collect data on demographics, operations performed and outcome measures.
472 GPS operations were performed on children between the age of 22 days and 5 years between 2009 and 2014, of which 43 were on an emergency basis and 105 were performed on patients aged less than 1 year. Three patients were admitted following day case surgery. Six patients were readmitted within 30 days. Complication rates for all procedures and the four most common procedures were similar to those found in published literature.
GPS for patients aged less than 5 years is comparatively safe in the DGH setting. The training opportunities available at DGHs are invaluable to surgical trainees and vital for sustaining the future provision of GPS by such hospitals.
PMCID: PMC5210001  PMID: 27269243
General surgery; District hospital; Medical audit; Paediatric surgery
19.  An unusual case of lipoma arborescens 
Lipoma arborescens is a rare condition of the synovial lining. It is particularly uncommon in the bicipitoradial bursae of the elbow.
Case Report
A 68-year-old woman presented with a 5-month history of anterior elbow pain and swelling causing discomfort. Radiography demonstrated reactive changes of radial tuberosity and magnetic resonance imaging confirmed lipoma arborescens of the bicipitoradial bursa with distal biceps tendinopathy. A bicipital bursa bursectomy and lipoma excision was performed. Gross pathology and histology was consistent with lipoma arborescens. Three months postoperatively, our patient had full range of motion and good strength.
To our knowledge, this is the first published case report of lipoma arborescens affecting the elbow. Recognising the differential diagnoses of anterior elbow pain and the characteristic imaging is essential for accurate diagnosis.
PMCID: PMC5210002  PMID: 27241604
Bicipitoradial bursa; Elbow; Histology; Lipoma arborescens; Magnetic resonance imaging
20.  Necrotising fasciitis secondary to a colocutaneous fistula 
Colocutaneous fistulae secondary to diverticular disease are rare, especially spontaneous fistulae. We report a case of a 74-year-old lady, with no previous history of diverticular disease, presenting with necrotising fasciitis of the anterior abdominal wall in the left iliac fossa, without any other symptoms. Urgent surgery was performed. An initial diagnostic laparoscopy demonstrated a perforated sigmoid diverticulum forming a fistula to the anterior abdominal wall. Following soft tissue debridement, a sigmoid colectomy was performed through a midline laparotomy.
Gastrointestinal pathology should be considered as a potential cause of abdominal wall necrotising fasciitis. Our approach of using laparoscopic visualisation to assess for intra-abdominal sources in this context (in the absence of preoperative imaging when imaging could delay treatment) has not been described before. To our knowledge, only two cases of abdominal wall necrotising fasciitis secondary to diverticular disease with a colocutaneous fistula have been reported in the English literature.
PMCID: PMC5210003  PMID: 27241606
General surgery; Necrotising fasciitis; Colonic diverticulosis
21.  Traumatic abdominal wall hernia with concealed colonic perforation 
Traumatic abdominal wall hernia (TAWH) is a rare clinical entity in terms of aetiology. It occurs following a blunt abdominal injury with energy high enough to cause disruption of the musculoaponeurotic layer but not the elastic skin layer. It is often associated with underlying intra-abdominal injuries, which can be diagnosed either clinically or radiologically. We report a case of TAWH in a young man with associated large bowel transection, which remained undiagnosed in the preoperative period owing to its masked features. He was managed surgically, with no recurrence to date. Considering the high volume of blunt abdominal trauma cases that present to the accident and emergency department, only few cases of TAWH have been reported in the literature. Confusion still exists regarding the timing and mode of management of this condition.
PMCID: PMC5210004  PMID: 27241601
Abdominal wall; Traffic accidents; Abdominal hernia; Aetiology; Motorcycles
22.  Right iliac fossa pain from a grossly enlarged and torted appendix in a patient with known colitis 
A 27-year-old man with a background of well controlled colitis presented with a 12-hour history of central abdominal pain, nausea, vomiting and fever. A diagnostic laparoscopy revealed an extremely large, gangrenous appendix, which had descended into the pelvis posterior to adhesions in the right iliac fossa and was torted 720°. The decision was taken to convert to a lower midline laparotomy and as the base appeared healthy, a standard appendicectomy was performed. The patient recovered well and was discharged after two days. The appendix measured 104mm x 53mm x 51mm. Histology revealed acute haemorrhagic and necrotising appendicitis with foci of impending perforation. There was no malignancy or mucocoele. Acute torsion (or volvulus) of the appendix is an unusual cause of this common general surgical emergency.
PMCID: PMC5210005  PMID: 27269435
Appendix; Appendicitis; Torsion abnormality
23.  A comparative audit of gunshot wounds and stab wounds to the neck in a South African metropolitan trauma service 
The aim of this comparative study of gunshot wounds (GSWs) and stab wounds (SWs) to the neck was to quantify the impact of the mechanism of injury on the outcome and management of penetrating neck injury (PNI).
A prospective trauma registry was interrogated retrospectively. Data were analysed pertaining to demographics and injury severity score (ISS), physiology on presentation, anatomical site of wounds and injuries sustained, investigations, management, outcome and complications.
There were 452 SW and 58 GSW cases over the 46 months of the study. Patients with GSWs were more likely to have extracervical injuries than those with SWs (69% vs 63%). The incidence of a ‘significant cervical injury’ was almost twice as high in the GSW cohort (55% vs 31%). For patients with transcervical GSWs, this increased to 80%. The mean ISS was 17 for GSW and 11 for SW patients.
Those in the GSW cohort presented with threatened airways and a requirement for an emergency airway three times as often as patients with SWs (24% vs 7% and 14% vs 5% respectively). The incidence among GSW and SW patients respectively was 5% and 6% for airway injuries, 12% and 8% for injuries to the digestive tract, 21% and 16% for vascular injuries, 59% and 10% for associated cervical injuries, 36% and 14% for maxillofacial injuries, 16% and 9% for injuries to the head, and 35% and 45% for injuries to the chest. In the GSW group, 91% underwent computed tomography angiography (CTA), with 23% of these being positive for a vascular injury. For SWs, 74% of patients underwent CTA, with 17% positive for a vascular injury. Slightly more patients with GSWs required operative intervention than those with SWs (29% vs 26%).
Patients with GSWs to the neck have a worse outcome than those with injuries secondary to SWs. However, the proportion of neck injuries actually requiring direct surgical intervention is not increased and most cases with PNI secondary to GSWs can be managed conservatively with a good outcome. Imaging should be performed for all GSWs to the neck.
PMCID: PMC5210006  PMID: 27269237
Penetrating neck injury; Gunshot wounds; Stab wounds
24.  Management of a pseudo-aneurysm in the hepatic artery after a laparoscopic cholecystectomy 
Symptomatic hepatic-artery pseudoaneurysm (HAP) after bile-duct injury (BDI) is a rare complication with a varied (but clinically urgent) presentation.
A prospectively maintained database of all patients with BDI at laparoscopic cholecystectomy (LC) referred to a tertiary specialist hepatobiliary centre between 1992 and 2011 was searched systematically to identify patients with a symptomatic HAP. Care and outcome of these patients was studied.
Eight (6 men) of 236 patients with BDI (3.4%) with a median age of 65 (range: 54?6) years presented with symptomatic HAP. Median time of presentation of the HAP from the index LC was 31 (range: 13?16) days. Bleeding was the dominant presentation in 7 patients. One patient presented late (>2 years) with abdominal pain alone. Computed tomography angiography was the most useful investigation. Angioembolisation was successful in 7 patients. One patient died, and another patient developed liver infarction. Three patients (38%) developed biliary strictures after embolisation. Seven patients are alive and well at a median follow-up of 66 months.
Presentation of HAP is often delayed. A high index of suspicion is necessary for the diagnosis. Computed tomography angiography is the first-line investigation and selective angioembolisation can yield successful outcomes.
PMCID: PMC5210007  PMID: 27580308
Cholecystectomy; Bile-duct injury; Pseudoaneurysm
25.  Appendiceal mucocoele with midgut malrotation 
Malrotation of the midgut and appendiceal mucocoele are both extremely rare pathological conditions in adults. To our knowledge, there are only two reported cases in the English literature with a combination of both conditions.
Case History
A 65-year-old man presented with a 10-day history of upper abdominal pain associated with abdominal bloating and weight loss. He was otherwise fit and healthy with no significant past medical history. On examination, his abdomen was soft with tenderness and palpable fullness over the left upper quadrant. The initial blood test, chest x-ray and abdominal x-ray demonstrated no significant abnormality. Computed tomography showed a 17cm x 8cm x 6cm elongated cystic mass with possible malrotation of the intestines. Histopathology showed a low grade mucinous tumour of the appendix. At 12 months following surgery, there was no evidence of recurrence or postoperative complications and the patient was discharged from the care of the colorectal team.
We report a patient with a combination of two rare conditions. This case illustrates how a combination of pathologies can present a challenge to the unwary general surgeon.
PMCID: PMC5210008  PMID: 27269433
Abdominal pain; Intestinal malrotation; Mucocoele; Appendix

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