Roland Fernandes

Emergency laparotomy in octogenarians: A 5-year study of morbidity and mortality.

AIM To determine the morbidity and mortality associated with emergency laparotomy for a clinically acute abdomen in patients aged ≥ 80 years. METHODS In this retrospective audit, octogenarians undergoing emergency laparotomy between 1st January 2005 and 1(st) January 2010 were identified using the Galaxy Theatre System. Patients undergoing abdominal surgery through groin crease incisions or Lanz or Gridiron incisions were excluded. Also simple appendectomies were excluded. All patients were aged 80 years or more at the time of their surgery. Data were obtained using casenote review with a standardised proforma to determine patient age, American Society of Anesthesiologists (ASA) grade, indications for surgery, early (within 30 d) and late (after 30 d) complications, mortality and length of stay. Data were inserted into a Microsoft Excel spreadsheet and analysed. RESULTS One hundred patients were identified from the database (Galaxy) as having undergone emergency laparotomy. Of those, 55 underwent the procedure for intestinal procedures and 37 for secondary peritonitis. There was a 2:1 female predominance; average age 85 and ASA grade 3. Bowel resection was required in 51 out of the 100 patients and 22 (43%) died. Other procedures included appendicectomy, adhesiolysis, repair of AAA graft leak and colostomies for the pathological process resulting in an acute abdomen. Twelve of 100 patients (12%) suffered intra-operative complications, including splenic and bowel-serosal tears. Seventy patients (70%) had postoperative complications including myocardial infarction, wound infection, haematoma and sepsis. Overall mortality was 45/100 patients (45%). The major causes of death were sepsis (19/45 patients, 42%), underlying cancer (13/45 patients, 29%); with others including bowel obstruction (2/45 patients, 4%), myocardial and intestinal ischaemia and dementia. CONCLUSION Emergency laparotomy in octogenarians carries a significant morbidity and mortality. In particular, surgery requiring bowel resection has higher mortality than without resection.

Possible association between statin use and bowel dysmotility

3-Hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors (statins) are a class of drug that has been proven to be effective in lowering serum lipid levels. Although generally well-tolerated side effects from this class of drug have been noted to include liver dysfunction, renal failure and myopathy. Statins are also known to effect nitric oxide levels through upregulation of nitric oxide synthase. There is some evidence to imply that nitric oxide acts on inhibitory nerves in the colon to produce impaired motility. The authors present a case of recurrent colonic dilatation and volvulus which was initially treated with a sigmoid colectomy. Unfortunately symptoms persisted and a trial of the omission of statins was undertaken resulting in symptomatic relief. Following admission into hospital, statins were inadvertently restarted which caused the symptoms to reoccur. The statin was discontinued and upon review several months later the patient reported symptomatic benefit.

Stomach in a parastomal hernia: uncommon presentation

Parastomal herniae are among the most common complications of stoma formation. The authors present an unusual case of a 41-year-old lady who presented with frequent early postprandial vomiting devoid of bile, upper abdominal distension and weight loss in the preceding 4 weeks losing weight for the last 4 weeks. Barium meal revealed herniation of the stomach through the gastric wall causing gastric outlet obstruction. Intraoperatively she was found to have a subcutaneous incarcerated parastomal hernia containing viable stomach and small bowel loops. The hernial contents were reduced back into the peritoneum and the abdominal wall defect repaired using the open sombrero repair technique.

Acute pancreatitis following paracetamol overdose

A 17-year-old woman presented with acute abdominal pain and vomiting 3 h after she attempted to commit suicide by ingesting 30×500 mg paracetamol tablets. The woman was found to have a raised amylase level, and a CT scan confirmed the diagnosis of acute pancreatitis. According to the Naranjo adverse drug reaction probability scale, it is likely that the pancreatitis was induced by the paracetamol ingestion. A literature search reported 36 cases of pancreatitis following excessive doses of paracetamol, however this possible drug reaction is not widely recognised and not documented in the British National Formulary (BNF) list of possible adverse reactions from paracetamol. Being aware of the possibility that abdominal pain following paracetamol overdose may be a manifestation of pancreatitis can help the early detection and initiation of treatment for pancreatitis.

Outcomes of elective laparoscopic colorectal operations in octogenarians at a district general hospital in South East England

AIM To assess the outcomes of laparoscopic colorectal cancer resection in the octogenarian population at our institution. METHODS Retrospective analysis of registry data accumulated prospectively were used in conjunction with the data obtained from patient notes to identify outcome data for octogenarians who had undergone elective laparoscopic colorectal cancer resection. RESULTS Laparoscopic colorectal cancer resections were performed in 68 octogenarians between 2003 and 2011 at our institution. Four operations (6%) were converted to an open technique. There were twelve cases of morbidity (18%) and two cases of mortality (3%). The overall median hospital stay was 8 d. The median time for a patient to be deemed surgically fit for discharge was 5 d reflecting a delay in provision of social care or stoma education. CONCLUSION Our results support the view that laparoscopic surgery in octogenarians is safe, feasible and with a reduced length of stay. This is well reflected in our results which are compatible with United Kingdom national figures.

A rare case of a ball and socket ankle joint

A 50-year-old otherwise well gentleman presented with mild pain and stiffness in his right ankle. Remarkably, radiographs revealed gross congenital deformities. The ankle mortice was semicircular and the subtalar joints fused (figure 1). There were only three metatarsals. The bases of the …

Diaphragmatic hernia: an unusual presentation.

A 53-year-old lady presented to A&E with a 3-day history of severe epigastric pain and vomiting. This was preceded by a 3-month history of generalised abdominal discomfort, early satiety and increasing shortness of breath. A CT scan showed a left-sided posterior diaphragmatic defect. Urgent repair of the hernia showed herniation of three-quarter of the stomach, half of the transverse colon, the 13 cm spleen and the pancreas in the chest. There were no postoperative complications. Traumatic diaphragmatic hernias are known to be a complication of major trauma. However, the patient in this case report presented acutely, after mild physical trauma related to using a rowing machine. This exercise, when not performed correctly can raise intra-abdominal pressure. It is plausible that this trauma, although mild, was sufficient in causing the ladys diaphragmatic hernia. This case would suggest that the trauma required to cause a diaphragmatic hernia need not be as severe as originally thought.

Haemoperitoneum secondary to rupture of an omental artery aneurysm

A 66-year-old man (a Jehovah’s Witness), who was fully anticoagulated with warfarin for atrial fibrillation, was admitted with epigastric pain and collapse secondary to hypovolaemic shock. His haemoglobin had dropped to 4.5g/dl and his international normalised ratio (INR) was 2.8. An urgent computed tomography (CT) scan revealed a large haemoperitoneum; no …

Spontaneous ruptured iliac artery aneurysm causing acute secondary AV fistula

A 73-year-old woman presented with a 6-hour history of sudden onset lower abdominal pain. Her comorbidities included chronic obstructive pulmonary disease and hypertension. She was under surveillance for a known thoracoabdominal aneurysm. On presentation, she was hypotensive with a systolic blood pressure of 50 mm Hg and a pulse of 60 beats per minute. On examination, she had a pulsatile mass with bruit in her right lower abdomen. Pedal pulses were palpable in both feet. Blood gas analysis revealed a metabolic acidosis with a pH of 7.21 and a lactate of 7.1. Haemoglobin remained stable between 90–100 g/dL. Her other routine blood tests were unremarkable, and blood cultures were negative. Imaging showed a ruptured right common iliac artery aneurysm into the right common iliac vein with secondary arteriovenous fistula communication. Surgical intervention was discussed with the patient but due to her frailty, it was deemed not in the patient’s best interests.

Colorectal malignant polyps: the surveillance dilemma

A 61-year-old man presented to our hospital with left-sided abdominal pains and fever. He had a history of primary cutaneous melanomas excised in 2003 and 2005, small bowel melanoma metastases excised in 2011 and radiologically confirmed metastases in the mediastinum, lung and liver. His tumour was BRAF V600 mutation positive. He was taking vemurafanib as part of the COMBI-V trial, resulting in dramatic reduction in volume of a palpable cervical metastasis. Vemurafanib has been shown to prolong progression-free survival in advanced melanoma by inhibiting the BRAF cell signalling pathway. Abdominal computed tomography scan suggested visceral perforation with free fluid and gas in the left upper quadrant (Fig. 1). At laparotomy, an abscess was found adjacent to perforated small bowel segment. The small bowel was resected with primary anastomosis and the patient made a good recovery. Histological findings were of multiple metastatic melanoma deposits with mucosal ulceration and serosal exudate at the area of oversewn perforation. Between melanoma deposits, the small bowel appeared microscopically normal. Small bowel metastases are found in over 25% of advanced melanoma patients undergoing autopsy. However, only 0.8–4.4% of patients with primary melanoma developed symptoms from intestinal metastases before death. Many intestinal metastases are therefore occult. Intestinal melanomas may present with symptoms of partial obstruction or bleeding, but perforation itself is exceptionally rare, with only six previous cases documented in the literature. Colonic perforation secondary to drug-induced colitis has been reported with other new anti-melanoma agents including ipilimumab; however, our case differs as the perforation was at the site of a small bowel metastasis. As far as we are aware, our case is the first example of a perforation that occurred while the patient was taking vemurafanib. We hypothesize that vemurafanib may have contributed to visceral perforation, although drug-induced necrosis was not proven histologically.