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A 72-year-old woman presented with progressive shortness of breath and coughing while exercising. CT showed a right-sided extrapulmonary multinodal cystic tumour. Considering her progressive complaints and possible malignancy, a right-sided thoracotomy was performed. An 11-cmmass proved to be a low-grade B-cell thymoma. Over 50 per cent of all anterior mediastinal tumours are thymomas. Myasthenia gravis was absent in this patient. Surgical removal is first-choice therapy.
Discussion of the July 2015 issue (102:8), which carries a selection of articles on aortic aneurysms. Click on the podcast logo.
A 74-year-old woman presented to the emergency department with a painful ulcerated necrotic lesion on the right side of her tongue. She had a 2-week history of new-onset headache, blurred vision and jaw claudication. A temporal artery biopsy confirmed the initial diagnosis of giant cell arteritis. On physical examination both superficial temporal arteries had palpable pulses with no tenderness or enlargement. Her neurological, opthalmic and vascular examinations were normal, as was CT of the neck and head. Tongue necrosis is an atypical presentation of temporal arteritis. This rare complication is commonly reversible with prompt steroid therapy.
Listen to Lord Darzi share his opinion of this BJS Special Issue and where he believes surgical innovation is crucial in the global arena. Click here to watch the video.
An otherwise fit 34-year-old man presented with acute appendicitis. He was taken to theatre for laparoscopic appendicectomy. A 23-cm mildly inflamed and faecolith-laden appendix was found in the retrocaecal position with some periappendiceal inflammation. The procedure had to be converted to open operation owing to technical difficulty resulting from the length of appendix. The patient made an uneventful postoperative recovery. The Guinness Book of Records informs that the longest appendix recorded was removed at autopsy from a 72-yearold Croatian man: 26 cm. http://www.guinnessworldrecords.com/world-records/1000/largest-appendix-removed
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.
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