Intraoperative hypercarbia and massive surgical emphysema secondary to transanal endoscopic microsurgery (TEMS).

We describe a case where full-thickness excision of a rectal lesion caused massive surgical emphysema and subsequent hypercarbia with associated difficulties with ventilation. This unique case highlights the risks of respiratory failure with extraperitoneal insufflation as in this case and as more commonly with intraperitoneal insufflation. Transanal endoscopic microsurgery (TEMS) is a technique that is being increasingly used in the management of large and early malignant rectal polyps. We reviewed the literature in order to understand the case and to highlight factors that should minimise any adverse sequelae. In the presence of ventilatory difficulties secondary to postoperative surgical emphysema, whether via extraperitoneal insufflation as described here or with intraperitoneal insufflation (as in laparoscopy), consider decreasing gas pressures, expediting the procedure, delaying extubation and prolonged close monitoring in recovery with possible admission to a high dependency unit (HDU) or intensive care unit (ICU).

Upper gastrointestinal bleeding due to gastric stromal tumour: a case report.

INTRODUCTION: Gastro-intestinal stromal tumours are the most common mesenchymal tumours of the gastro-intestinal tract. This case report highlights the necessity of early surgical intervention in such cases to avoid mortality due to rebleeding and to raise the awareness of rare causes of upper gastrointestinal bleed and their management. CASE PRESENTATION: A 61-year-old male presented to the accident and emergency department with a one-day history of haemetemesis with coffee ground vomiting. After initial resuscitation, he underwent upper gastrointestinal endoscopy under sedation which demonstrated a large, bleeding, gastric mass with a central crater along the greater curvature of the stomach. A partial gastrectomy was performed taking a wedge of the stomach with clearance from the tumour, with no signs of extraperitoneal disease. CONCLUSION: Early surgical intervention, either open or laparoscopic resection, is the treatment of choice to prevent rebleeds. In general, complete surgical resection is accomplished in 40-60% of all gastro-intestinal stromal tumours patients, and in >70% of those with primary non- metastatic gastro-intestinal stromal tumour. In our case we had completely excised the tumour. Following surgery, all patients must be referred to centres which have more experience in treating gastro-intestinal stromal tumours. Imatinib is proven to be the first effective systemic therapy in cases of unresectable or metastatic disease. All gastro-intestinal stromal tumours have the potential for aggressive behaviour with the risk being estimated from tumour size and mitotic count.

Occult small bowel perforation in a patient with Ehlers Danlos syndrome: a case report and review of the literature.

Patients who present with a co-existing connective tissue disorder add a degree of complexity to operative intervention. We present an unusual case of a 53-year-old Caucasian female patient with Ehlers Danlos syndrome who presented with an occult perforation of the distal ileum. The patient had known small bowel diverticulae yet the perforation occurred within the normal bowel wall. The pre-operative CT only showed malrotation of the large bowel and did not correlate with the intra-operative findings. Our case has highlighted that although small bowel perforation is a rare occurrence, it may be more common in Ehlers Danlos and may present with atypical features. Perforation may also occur alongside normal bowel as well as diverticulae within the bowel. Where diverticulae exists within a patient with Ehlers Danlos syndrome and there is some diagnostic uncertainty, there should be a lower threshold for operative intervention. We present in the discussion a number of salient features and learning points.

A review of risk scoring systems utilised in patients undergoing gastrointestinal surgery.

INTRODUCTION: Adequate stratification and scoring of risk is essential to optimise clinical practice; the ability to predict operative mortality and morbidity is important. This review aims to outline the essential elements of available risk scoring systems in patients undergoing gastrointestinal surgery and their differences in order to enable effective utilisation. METHODS: The English literature was searched over the last 50 years to provide an overview of systems pertaining to the adult surgical patient. DISCUSSION: Scoring systems can provide objectivity and mortality prediction enabling communication and understanding of severity of illness. Incorporating subjective factors within scoring systems can allow clinicians to apply their experience and understanding of the situation to an individual but are not reproducible. Limitations relating to obtaining variables, calculating predicted mortality and applicability were present in most systems. Over time scoring systems have become out-dated which may reflect continuing improvement in care. APACHE II shows the importance of reproducibility and comparability particularly when assessing critically ill patients. Both NSQIP in the USA and P-POSSUM in the UK seem to have many benefits which derive from their comprehensive dataset. The "Surgical Apgar" score offers relatively objective criteria which contrasts against the subjective nature of the ASA score. CONCLUSION: P-POSSUM and NSQIP are comprehensive but are difficult to calculate. In the search for a simple and easy to calculate score, the "Surgical Apgar" score may be a potential answer. However, more studies need to be performed before it becomes as widely taken up as APACHE II, NSQIP and P-POSSUM.

A primary adenocarcinoma of the transverse colon mimicking Crohn's disease: a case report and literature review.

Diarrhoea and weight loss are presenting features of both Crohn's disease and colorectal cancer; however, the two conditions can usually be distinguished on the basis of characteristic patterns of abnormalities observed at the time of initial blood testing and imaging. In patients with suspected Crohn's disease these are often considered sufficient grounds to commence empirical treatment before the results of histology are available. This case report describes a 45-year-old man whose initial clinical, endoscopic and radiological investigations were strongly suggestive of a diagnosis of Crohn's disease, but who subsequently was found to have an adenocarcinoma of the mid-transverse colon. He went on to have an emergency extended right hemi-colectomy.

A rare case of isolated wound implantation of colorectal adenocarcinoma complicating an incisional hernia: case report and review of the literature.

BACKGROUND: The reported case illustrates an instance of colonic adenocarcinoma presenting as an isolated tumour 3 1/2 years after open surgery. The presentation was in some respects unique as it was complicated by an incisional hernia and occurred in the anterior abdominal wall. A literature review was performed. CASE PRESENTATION: An 83 year old lady initially underwent an extended right open hemicolectomy for a mid-transverse colonic adenocarcinoma (T4N2M0). No adjacent structures were involved. After adjuvant chemotherapy, she was kept under regular surveillance. A CT scan and colonoscopy at one year were normal. At 18 months investigations including an ultrasound scan of the liver and a radioisotope bone scan were all negative. Over three and half years later the patient presented with an incisional hernia. Repeat CT scan and tumour markers were reported as negative. At operation, a mass was found within the anterior abdominal wall complicating the incisional hernia. This mass was widely resected and a laparotomy performed. Histology confirmed an adenocarcinoma of colonic origin extending to one of the lateral margins. A post-operative PET scan confirmed the absence of intra-abdominal pathology. CONCLUSION: The literature regarding recurrence of colonic tumours after open surgery reports low incidences of this occurring within abdominal incisions. The literature indicates prognosis is poor, but the numbers are small and distinction is often not made between isolated recurrence and those with other sites of tumour recurrence. In order to avoid missing isolated wound implantation, careful consideration should be given to those who present with new pathology related to previous cancer surgery incisions, both clinically and radiologically.