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The cause of this black spleen is Rituximab treatment before ABO-incompatible solid organ transplantation. The recipients undergo antibody titre reduction by means of rituximab treatment and one or more episodes of plasmapheresis. Previously, splenectomy was done to reduce the B cell load; rituximab therapy means that surgical splenectomy can be avoided. This 50-year-old woman underwent successful ABO-incompatible liver transplantation after preoperative antibody titre reduction by rituximab therapy and plasmapheresis. The spleen was black and atrophied secondary to rituximab therapy.
The cause of this lady’s spontaneous neck haematoma, illustrated in the right image, is parathyroid adenoma. This 74-year-old woman presented with a large bruise over her neck. Blood tests revealed hypercalcaemia (12·0 mg/dl; range 8·4–10·2 mg/dl) and a high parathyroid hormone level (661 pg/ml; range 11–67 pg/ml). Functional imaging showed likely hyperfunction of the left superior parathyroid gland. A left hemithyroidectomy was done with left superior parathyroidectomy. Histopathology was consistent with parathyroid adenoma, with focal haemorrhagic infarction.
This lesion on the stomach, seen at laparoscopy, is a thermal injury to the stomach. Bleeding occurred during endoscopic mucosectomy, which was controlled with intense cauterization. After the procedure, the patient had abdominal pain and pneumoperitoneum on X-ray. Laparoscopy showed a thermal injury with a small perforation in the major curve of the stomach.
The cause of this patient’s symptoms, which started after an open appendicectomy, was isolated hypoglossal nerve palsy. This is a rare complication following orotracheal intubation. Manipulation of the neck during intubation and/or direct compression of the nerve are proposed mechanisms of injury. Patients present with weakness/deviation of the tongue and dysphagia. Symptoms usually resolve within 6 months.
A 55-year-old woman presented with a 12-month history of iron deficiency anaemia and abdominal pain. Oesophagogastroduodenoscopy and colonoscopy were negative, whereas videocapsule enteroscopy identified an endo-luminal jejunal mass. CT showed thickening of the jejunal wall without contrast enhancement. Push enteroscopy confirmed the presence of a proximal jejunal stenosis, caused by a lesion presenting a yellowish-white and foamy appearance of the mucosa, with enlarged submucosal veins (a). An endoscopic tattoo was placed adjacent to the lesion, and the patient underwent a laparoscopic segmental resection of the jejunum. The resected specimen consisted of a 10-cm jejunal segment, hosting a tumour involving the entire visceral circumference (b). The final diagnosis was cavernous lymphangioma of the small bowel: a rare, benign, hamartomatous lesion that may occur in the mesentery, retroperitoneum and visceral organs.
This specimen shows the resected left liver lobe from a patient with hepatolithiasis and lobar atrophy. Intrahepatic stones (hepatolithiasis) are concretions in the bile ducts proximal to the confluence. Stones may form primarily or can result secondary to choledochal cyst or anastomotic stricture. These stonesmay be asymptomatic or can present with recurrent cholangitis or obstructive jaundice, secondary cirrhosis or cholangiocarcinoma. Asymptomatic patients are usually observed. Percutaneous transhepatic cholangioscopic stone removal is possible in patients who are symptomatic. Resection is indicated in a symptomatic patient, when there is atrophy of a lobe or a segment, or suspicion of cholangiocarcinoma.
This is phlegmasia cerulea dolens. A 79-year-old man presented with sudden onset of right foot numbness. (a) On examination, the right leg was cold, swollen and cyanosed with no other sensory or motor loss. (b) CT angiography revealed no arterial occlusion, but thrombus in the distal inferior vena cava (blue arrow). The thrombus extended to the right common and external iliac veins. The diagnosis was phlegmasia cerulea dolens (painful blue swelling). The symptoms are caused by extensive deep venous thrombosis; co-existing malignancy is found in about 50 per cent of patients. This man had metastatic prostate cancer. He was treated with low molecular weight heparin but died shortly after admission.
A 58-year-old woman with iron deficiency anaemia was diagnosed with a stricturing adenocarcinoma of the distal transverse colon at colonoscopy. CT revealed hepatic and peritoneal metastases. She proceeded to therapeutic
colonic stenting. Within hours of stenting she complained of new abdominal pain and had generalized peritonism.
At laparotomy the stent was found perforated through the distal transverse colon at the site of the carcinoma. The
affected segment was resected with the perforated stent in situ and an end colostomy fashioned. The patient proceeded to
palliative oncological follow-up. A recent Cochrane review (1) suggests a 5·9 per cent risk of colonic perforation following
1 Sagar J. Colorectal stents for the management of malignant colonic obstructions. Cochrane Database Syst Rev 2011;
Click here to watch a discussion of the BJS Special Issue on surgery in the elderly. Three scenarios on vascular interventions in the elderly are discussed and are included in a Leading Article on the subject entitled "Vascular interventions in the elderly" by J.J. Earnshaw and R.J. Hinchliffe.
Three authors included in the special issue on surgery in the elderly (due out mid-January 2016), discuss the issues surrounding treatment and care of the older patient. Click here to listen.
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