Volvulus with bowel necrosis after laparoscopic appendectomy. Migration of Clip?

About 2.8% of patients develop small bowel obstruction, mostly following an open approach appendectomy. CASE REPORT: we present an 18-year-old girl with acute abdomen 10 days following laparoscopic appendectomy. An emergency laparotomy was performed which revealed bowel necrosis and an impacted slipped clip on the mesenterial side of the bowel with signs of bowel strangulation and necrosis. Bowel resection was carried out with primary enteroenteric anastomosis. We suspect the sharp ends of the open clip allowed it to become lodged in the bowel segment resulting in bowel obstruction and subsequent necrosis. It is possible that the clip migrated or was a failed deployment. To our knowledge, this is the first report of mechanical bowel obstruction after laparoscopic appendectomy caused by aberrant surgical clip.

Sterile abscess mimicking an abdominal tumor 8 years after laparoscopic cholecystectomy.

Spillage of gallstones (6-40%) are common during laparoscopic cholecystectomy. Development of intraperitoneal and perihepatic abscesses are relatively rare (<0.1%). However, it may pose a diagnostic dilemma mimicking intra-abdominal tumor due to their similar radiologic appearance. CASE REPORT: We present a 57-year-old woman with history of cholecystectomy 8 years prior who presented with a suspected diagnosis of incarcerated port site hernia with associated radiological evidence of an intra-abdominal tumor. The histological examination of the resected tumor revealed a chronic abscess. It reminds us the importance of careful removal of the stones especially in the setting of acute cholecystitis and should prompt the treating physician about this late possible complication.

Long-term survival after extended resection of primary atrial myxosarcoma.

The vast majority of adult primary cardiac tumours (75%) are benign. The differentiation between malignant and benign lesions based on imaging is often difficult. Furthermore, it is challenging to distinguish between a cardiac myxoma and a myxosarcoma histologically. We report the case of a 48-year-old female who underwent resection of myxoma. Fourteen months postoperatively, she developed dyspnoea and evidence of local recurrence was observed. An open biopsy was performed and compared with the initially resected specimen. A primary cardiac myxosarcoma was diagnosed. Extended resection of the tumour including a part of the left atrium and the left lung was performed. Follow-up at 4 years shows no radiological evidence of any further recurrence and the patient is satisfied with a good quality of life. Despite the infrequent nature and particularly in view of the poor prognosis of cardiac myxosarcoma with a median overall survival of ∼12-17 months, we were able to demonstrate in our case that, with an extensive medical and surgical therapy and an interdisciplinary approach, a long-term disease-free survival can be achieved.

Treatment of slipped capital femoral epiphysis with a modified Dunn procedure.

BACKGROUND: Surgical procedures with use of traditional techniques to reposition the proximal femoral epiphysis in the treatment of slipped capital femoral epiphysis are associated with a high rate of femoral head osteonecrosis. Therefore, most surgeons advocate in situ fixation of the slipped epiphysis with acceptance of any persistent deformity in the proximal part of the femur. This residual deformity can lead to secondary osteoarthritis resulting from femoroacetabular cam impingement. METHODS: We retrospectively assessed the cases of twenty-three patients with slipped capital femoral epiphysis after surgical correction with a modified Dunn procedure, an approach that included surgical hip dislocation. The study reviewed the clinical status and radiographs made at the time of surgery, as well as the intraoperative findings. At a minimum follow-up of twenty-four months after surgery, the motion of the treated hip was compared with the motion of the contralateral hip, and the radiographic findings related to the anatomy of the femoral head-neck junction, as well as signs of early osteoarthritis or osteonecrosis, were evaluated. RESULTS: Twenty-one patients had excellent clinical and radiographic outcomes with respect to hip function and radiographic parameters. Two patients who developed severe osteoarthritis and osteonecrosis had a poor outcome. The mean slip angle of the femoral head of 47.6° preoperatively was corrected to a normal value of 4.6° (p < 0.0001). The mean flexion and internal rotation postoperatively were 107.3° and 37.8°, respectively. The mean range of motion of the treated hips was not significantly different (p > 0.05) from that of the normal, contralateral hips. Of the eight hips that were considered unstable in the intraoperative clinical assessment, six had been considered stable preoperatively. CONCLUSIONS: The treatment of slipped capital femoral epiphysis with the modified Dunn procedure allows the restoration of more normal proximal femoral anatomy by complete correction of the slip angle, such that probability of secondary osteoarthritis and femoroacetabular cam impingement may be minimized. The complication rate from this procedure in our series was low, even in the treatment of unstable slipped capital femoral epiphysis, compared with alternative procedures described in the literature for fixation of slipped capital femoral epiphysis.

The ischial spine sign: does pelvic tilt and rotation matter?

Although the ischial spine sign (ISS) has been advocated to detect acetabular retroversion, it is unknown whether the sign is valid on anteroposterior (AP) pelvic radiographs with tilted or rotated pelves. We therefore evaluated reliability of the ISS as a tool for diagnosing acetabular retroversion in the presence of considerable pelvic tilt and/or malrotation. We obtained radiographs of 20 cadaver pelves in 19 different malorientations resulting in 380 pelvis images (760 hips) for evaluation. In addition, 129 clinical radiographs of patients' hips that had varying pelvis orientations were reviewed. We found an overall sensitivity of 81% (90%), specificity of 70% (71%), positive predictive value of 77% (80.7%), and negative predictive value of 75% (85%) in the cadaver (patient) hips. Our data suggest the ISS is a valid tool for diagnosing acetabular retroversion on plain radiographs taken using a standardized technique regardless of the degree of pelvic tilt and rotation.