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A 75-year-old man presented with a 3-day history of epigastric pain. The diagnosis of rupture of hydatid cyst was highly suspected on CT (a). Note the red arrows showing free peritoneal fluid indicating cyst rupture. He had urgent laparotomy and cyst removal (b). The water-lily sign on CT is seen when there is detachment of the endocyst membrane, which results in floating membranes within the pericyst that mimic the appearance of a water lily. Although rarely seen, it is pathognomonic for Echinococcus. Urgent surgery for ruptured hydatid cyst affects postoperative morbidity and mortality favourably.
In the March 2015 issue of the Journal (102:4), a leading article, three invited reviews and an original article on the subject of endocrine surgery are published and discussed by President of the British Association of Endocrine and Thyroid Surgeons, Mr David Scott-Coombes. Specific areas covered are adrenocortical cancer, primary aldosteronism, subclinical Cushing's syndrome and preservation of parathryoid glands during total thyroidectomy. Click on the podcast logo opposite to listen to Mr Scott-Coombes' comments.
This CT angiogram shows a paraganglioma, a rare neuroendocrine tumour arising from the extra-adrenal autonomic paraganglia. This tumour was found in a 44-year-old man presenting with severe arterial hypertension that proved refractory to antihypertensive therapy. As was the case here, paragangliomas can be hormonally active and secrete catecholamines. Preoperative blood pressure control was achieved with α- and β-adrenergic blockade and the patient proceeded to surgical excision.
This lesion in a small bowel resection of a 43-year-old man with a recent diagnosis of Crohn’s disease is small bowel adenocarcinoma. Small bowel adenocarcinoma is a rare complication of Crohn’s disease (1). Its ability to mimic acute exacerbation of Crohn’s stresses the importance of a high index of suspicion (2,3). Stricture dilatation should not be done in suspicious obstructive lesions as it could further disseminate tumour cells. Surgical treatment includes segmental small bowel resection with mesenteric lymphadenectomy and primary anastomosis.
1 Canavan C, Abrams KR, Mayberry J. Meta-analysis: colorectal and small bowel cancer risk in patients with Crohn’s
disease. Aliment Pharmacol Ther 2006; 23: 1097–1104.
2 Dossett LA, White LM, Welch DC, Herline AJ, Muldoon RL, Schwartz DA et al. Small bowel adenocarcinoma
complicating Crohn’s disease: case series and review of the literature. Am Surg 2007; 73: 1181–1187.
3 Widmar M, Greenstein AJ, Sachar DB, Harpaz N, Bauer JJ, Greenstein AJ. Small bowel adenocarcinoma in Crohn’s
disease. J Gastrointest Surg 2011; 15: 797–802.
ALPPS technique modification placing a tourniquet in the Cantlie section line and portal vein ligation. Click here to watch the video (Supporting Information) and read the article.
Bullosis diabeticorum is a rare skin manifestation of diabetes mellitus. Historically, the lesions were termed ‘phlyctenar’, owing to their resemblance to blisters caused by burns. Tense painless blisters appear rapidly, most commonly over the feet. The causes of these bullae are unclear, with multiple pathophysiologies hypothesized. The condition should be managed by a multidisciplinary diabetic foot care team. Treatment includes early surgical debridement and topical negative pressure wound therapy. This allows better management of the high levels of wound exudate and therefore helps restore plantar skin integrity.
Julie Brittenden, Bruce Campbell and Dan Carradice discuss the various treatment options available for varicose veins, and their associated quality of life outcomes and cost-effectiveness.
Anastomotic failures in laparoscopic colorectal surgery
Prosthesis-free repair of pectus chest deformity. Click here to watch the video (Supporting Information) and read the article.
This patient was admitted because of a tender irreducible perineal mass. He had an abdominoperineal resection for rectal cancer 9 years previously. The pelvic floor was reconstructed with a gluteal muscle flap. CT shows herniation of small bowel below and behind the sacral bone. At laparotomy, 150 cm of gangrenous small bowel was resected with primary anastomosis. The perineal defect was closed with a biological mesh (porcine collagen). Posterior perineal hernias are only seen as a surgical complication.
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