Hepatic or cystic artery pseudoaneurysms following a laparoscopic cholecystectomy - literature review of aetiopathogenesis, presentation, diagnosis and management

Pseudoaneurysms [PSAs] of the hepatic and/or cystic artery are a rare complication following a laparoscopic cholecystectomy [LC]. Generally, PSA cases present with haemobilia several weeks following the procedure. Transarterial embolisation [TAE] is considered the optimal management approach. We report a 70-year-old woman who presented to the Sultan Qaboos University Hospital, Muscat, Oman, in 2016 with massive hemoperitoneum two weeks after undergoing a LC procedure in another hospital. She was successfully managed using coil TAE. An extensive literature review revealed 101 cases of hepatic or cystic artery PSAs following a LC procedure. Haemobilia was the main presentation [85.1%] and the mean time of postoperative presentation was 36 days. The hepatic artery was involved in most cases [88.1%], followed by the cystic artery [7.9%] and a combination of both [4.0%]. Most cases were managed with TAE [72.3%], with a 94.5% success rate. The overall mortality rate was 2.0%

Use of prophylactic inferior vena cava filters in trauma

Venous thromboembolisms, specifically pulmonary embolisms [PEs], represent a significant burden on healthcare systems worldwide, particularly within the setting of trauma. According to the literature, PEs are the most common cause of in-hospital death; however, this condition can be prevented with a variety of prophylactic and therapeutic measures. This article aimed to examine current evidence on the use, indications for prophylaxis, outcomes and complications of prophylactic inferior vena cava filters in trauma patients

Mycotic aortic aneurysm treated by endovascular aneurysmal repair [EVAR] [first case report from Oman]

Mycotic aortic aneurysm is rare but life threatening disease. Endovascular aneurysm repair [EVAR] has become an established procedure for the treatment of many infrarenal aortic aneurysms

Although EVAR is obviously less invasive than open surgical repair but it is not without complications. Lower extremity ischemia is a known complication of endovascular abdominal aortic aneurysm repair [EVAR]. Limb occlusion, embolism or access related problems are the main causes. We hereby describe the first case of EVAR of infra renalmycotic aortic aneurysm in the history of Sultan Qaboos University Hospital Oman. A 67 years old lady known to have diabetes mellitus and hypertension admitted with fever and abdominal pain. On further evaluation found to have 4 cms infra-renal mycotic abdominal aortic aneurysm treated by EVAR but procedure was complicated by lower limb ischemia due to thrombosis at the puncture site which was successfully treated by aspirating thrombus and ischemia was relieved

Procedural and clinical utility of transulnar approach for coronary procedures following failure of radial route: Single centre experience

Objectives: To assess the feasibility and safety of transulnar approach whenever transradial access fails

Background: Radial access for coronary procedures has gained sound recognition. However, the method is not always successful

Methods: Between January 2010 and June 2013, diagnostic with or without percutaneous coronary intervention [PCI] was attempted in 2804 patients via the radial approach. Transradial approach was unsuccessful in 173 patients [6.2%] requiring crossover to either femoral [128 patients, 4.6%] or ulnar approach [45 patients, 1.6%]

Patients who had undergone ulnar approach constituted our study population. Selective forearm angiography was performed after ulnar sheath placement

We documented procedural characteristics and major adverse cardio-cerebrovascular events

Results: Radial artery spasm was the most common cause of crossover to the ulnar approach [64.4%] followed by failure to puncture the radial artery [33.4%]

Out of 45 patients [82.2%], 37 underwent successful ulnar approach

The eight failed cases [17.8%] were mainly due to absent or weak ulnar pulse [75%]. PCI was performed in 17 cases [37.8%], of which 8 patients underwent emergency interventions

Complications included transient numbness, non-significant hematoma, ulnar artery perforation, and minor stroke in 15.5%, 13.3%, 2.2% and 2.2%, respectively

No major cardiac-cerebrovascular events or hand ischemia were noted

Conclusion: Ulnar approach for coronary diagnostic or intervention procedures is a feasible alternative whenever radial route fails. It circumvents crossover to the femoral approach

Our study confirms satisfactory success rate of ulnar access in the presence of adequate ulnar pulse intensity and within acceptable rates of complications

[A] massive tuberculosis abscess at the erector spinae muscles and subcutaneous tissues in a young man

Tuberculosis [TB] is a chronic granulomatous infection which can present in an atypical form. Isolated muscle involvement is very rare. We report a 25-year-old man who presented with a massive cystic swelling on the right side of his back, extending from the lower thoracic to the gluteal region. He had a history of contact with a friend who was suspected of having TB. Magnetic resonance imaging [MRI] showed that the origin of the cyst was from the erector spinae muscles. The result of a fluid aspirate showed acid fast bacilli. The swelling disappeared after treatment with anti-tuberculous medications. Muscular involvement in TB is very rare. In our patient, the reports of an ultrasound and MRI confirmed isolated muscle and subcutaneous involvement without bony lesions. This case is reported to increase physician awareness regarding soft tissue TB. Although it is rare, similar cases may be seen in the future

Submyomatous cornual pregnancy managed surgically after failed medical management

Cornual pregnancy constitutes an emergency while its diagnosis and management remain a challenge. Anatomical abnormalities in the uterus, such as fibroids in the cornual region, make the management even more difficult. A nulliparous patient presented with an ectopic pregnancy at the right cornua under a huge fibroid. Despite multiple doses of methotrexate for a cornual ectopic gestation, the serum beta human chorionic gonadotropin [beta-hcG] levels doubled on the fifth day and a viable fetus was demonstrated on imaging. Thus surgical intervention in the form of laparoscopy followed by laparotomy, myomectomy of a large cornual fibroid and cornuostomy was performed. The serum beta human chorionic gonadotropin result was negative three weeks later. Surgical intervention in the form of myomectomy and cornuostomy was necessary to preserve fertility in this unusual presentation of cornual ectopic pregnancy

Myelomatous pleural effusion. Case report and review of the literature

Plasma cell myeloma is an uncommon disease which, besides primarily involving the bone marrow, has a tendency to involve other organs thus presenting with different clinical manifestations. While pleural effusions are infrequent in this disease, true myelomatous pleural effusions are extremely rare. We report the case of a middle-aged Omani man with relapsed plasma cell myeloma who developed bilateral pleural effusions. The diagnosis of myelomatous pleural effusion was made by finding many abnormal plasma cells as well as a high level of a monoclonal protein [IgG k] in the pleural fluid. In spite of a good initial response to therapy, the patient had progressive disease and died 6 months later with bacterial sepsis. We present a review of the literature that indicates the rarity of such a manifestation and its association with poor prognosis and short survival

Retrospective review of cross sectional imaging findings of pancreatic non functional islet cell tumor [NFICT] and its hepatic metastases

Review and correlate the computed tomography [CT] imaging features of pancreatic Non Functional Islet Cell Tumors [NFICT] and its hepatic metastases. CT examinations of 28 patients with pathologically proven diagnosis of pancreatic NFICT and no clinical symptoms or signs attributed to hormone overproduction, performed at Mallinkrodt Institute of Radiology, Saint Louis, Missouri, USA between March 2002-July 2006, were retrospectively reviewed by two abdominal radiologists. The imaging findings were analyzed and summarized. Pancreatic NFICT size ranged from 1.2-13 cm. The commonest pattern of enhancement was hypervascular and heterogenous enhancement. The spleen was the commonest invaded nearby local structure. The commonest pattern of enhancement noted in the metastatic liver lesions was hypervascular heterogenous enhancement. 26% of the liver metastatic lesions were associated with invasion/encasement of nearby vessels. Imaging features of pancreatic NFICT can overlap with other pancreatic neoplasms. Therefore combining the imaging features of pancreatic NFICT and its hepatic metastases helps in narrowing the differential diagnosis

Transplant renal artery false aneurysm: case report and literature review

This is a case report of a 59 years old male who had a commercial non-related living renal transplantation for his end stage renal insufficiency secondary to adult polycystic kidney disease. He suffered an immediate and early post-operative bleeding, which was managed conservatively. He was presented at Sultan Qaboos University Hospital four months after his transplant with abdominal pain, nausea, loss of appetite and a rise in serum creatinine levels. Ultrasonography and angiography have shown a 4 cm false aneurysm of the transplant renal artery at the anastomotic site with the external iliac artery. Surgical exploration with resection of the false aneurysm and reanastomosis of the donor renal artery to the external iliac artery was carried out successfully with preservation of the renal allograft. This is a rare case of an extra-renal false aneurysm at the anastomotic site of the transplant renal artery to the external iliac artery four months after renal allotransplantation. Literature review on the management and outcome of false aneurysms after renal transplant was carried out

Imaging of small bowel obstruction following gastric bypass surgery for morbid obesity a retrospective review

This study is a single institution retrospective evaluation of imaging findings of small bowel obstruction [SBO] after retrocolic antegastric Roux-en-Y gastric bypass surgery for morbid obesity. The radiological database of 490 patients who underwent gastric bypass surgery for morbid obesity from January 2001-2005 at the Royal Victoria Hospital McGill University Health Center was searched for SBO complications related to the procedure. There were 22 cases of small bowel obstruction related to the procedure. Ten patients had abdominal and pelvic computed tomography [CT] scans, 12 patients had upper gastrointestinal [UGI] and small bowel follow through [SBFT]. Among 22 cases of SBO, 14 cases were due to anastomotic stenosis or adhesion, 7 due to internal hernia and one to jejuno-jejunal intussusception. Among the 14 patients with SBO related to adhesion and anastomotic narrowing, 11 patients were managed medically and 3 cases managed surgically. CT scans correctly diagnosed 4 out of 5 cases including the 3 patients managed surgically and UGI and SBFT examinations diagnosed the remaining 9 cases that were managed medically. Among the 7 patients with internal hernias, CT scans correctly diagnosed 2 out of 4 cases, while UGI and SBFT examinations correctly diagnosed 1 out of 3. The jejuno-jejunal intussusception was correctly diagnosed by CT scan. The most frequent cause of SBO is anastomotic narrowing or adhesion. CT scan remains the most appropriate imaging modality in diagnosing acute presentation of SBO caused by internal hernia or adhesion/anastomotic narrowing. UGI and SBFT appear more appropriate for diagnosing the subacute insidious presentation of adhesive partial SBO