A carotid artery aneurysm with a twist: case report and review.

BACKGROUND: Since their original description in 1687, aneurysms of the extracranial internal carotid artery (ICA) remain rare and account for less than 2% of all carotid operations (Zwolak et al. in: J Vasc Surg 1:415-422, 1984; El-Sabrout, Cooley in: J Vasc Surg 31:702-712, 2000). Cerebrovascular morbidity and mortality rates remain high without intervention (Zwolak et al. in: Vasc Surg 1:415-422, 1984). CASE REPORT: We report an unusual case of a saccular extracranial ICA aneurysm associated with kinking of the ICA and highlight the potential complications and risks associated with such an extreme anatomical deformation. CONCLUSION: Extracranial ICA aneurysm can be associated with unusual anatomical variations which can lead to unstable clinical symptomatology due to the variable presence of atherosclerotic material. Despite advances in diagnosis and treatment, surgical repair is not without risks and patients need to be informed of the potential complications.

Laparoscopic adrenalectomy for a late solitary renal cell cancer metastasis to the ipsilateral adrenal gland.

BACKGROUND: Metastases to the adrenal gland are the second most common type of adrenal mass lesion after adrenocortical adenomas [1, 2]. However, less than 2% of those patients who develop a metachronous metastasis after resection of a primary renal tumour will present with a solitary adrenal tumour [3]. Most of these patients present within several years of the primary diagnosis [4]. CASE REPORT: A 66-year-old man with a history of left nephrectomy for renal cell carcinoma 18 years previously was investigated for recent weight loss. Computed tomography scanning identified a lesion in the ipsilateral adrenal gland. Hormonal investigations were consistent with a non-functioning mass. Magnetic resonance imaging and positron emission tomography scans suggested a malignant lesion. Laparoscopic adrenalectomy was performed without complication and histopathological examination confirmed metastatic renal cell carcinoma. The patient remains well with no evidence of recurrence at 6 months. CONCLUSION: Laparoscopic adrenalectomy is a safe, effective treatment in the treatment of late solitary renal cell cancer metastasis to the ipsilateral adrenal gland.

Peri-operative blood glucose management in general surgery - a potential element for improved diabetic patient outcomes - an observational cohort study.

BACKGROUND: Hyperglycaemia impairs many of the physiological processes involved in recovery from surgery but there is limited research on the effect of optimal peri-operative glucose control in diabetic general surgery patients. The objectives of this study were to assess blood glucose management in diabetic general surgical patients and to determine if protocol deviations were associated with adverse outcomes. METHODS: All diabetic patients undergoing elective and emergency general surgical procedures between August 2007 and July 2008 were included in the study. The hospital protocol for peri-operative blood glucose control was based on the Alberti Regimen. Data was collected regarding blood glucose measurements, adherence to protocol and complications following surgery. RESULTS: A total of 69 adult patients (M = 44, F = 25; median age 61, range 15-93 years; T1DM = 35, T2DM = 34) were included. 38 patients underwent elective surgery (cholecystectomy, hernia repair, varicose vein surgery) and 31 underwent emergency surgical procedures (laparotomy, incision and drainage of abscess). 10.3% of capillary blood glucose readings were less than 6.1 mmol/l, 32.8% were between 6.1 and 10.0 mmol/l, 44.6% were greater than 10.0 mmol/l 12.3% of scheduled blood glucose measurements were not completed. An insulin-dextrose infusion was indicated in 30 patients, of which 14 (46.7%) were treated according to protocol. In the 16 protocol-deviation cases, insulin was generally either administered according to a sliding scale (6 patients) or not at all during their time on the ward. While an insulin-dextrose infusion was not indicated in 39 patients, 14 (35.9%) of these patients were inappropriately given insulin either as an infusion (8 patients) or according to a sliding scale (6 patients). Overall, only 39 (56.5%) patients were treated according to protocol. The overall complication rate was 29%, which included 7 out of 39 (17.9%) and 13 out of 30 (43.3%) protocol-based and protocol-deviation patients respectively (p = 0.45). CONCLUSION: Although not statistically significant, optimal glucose homeostasis according to hospital protocol was associated with a 25.4% reduction in peri-operative complications. We recommend careful blood glucose management according to pre-defined guidelines in all diabetic patients undergoing general surgical procedures.

Ultrasound is a useful adjunct to mammography in the assessment of breast tumours in all patients.

BACKGROUND: Ultrasound is the first-line breast imaging modality in younger patients and an adjunct to mammography in older patients. The objectives of this study were to evaluate the complementary value of ultrasound to mammography in breast cancer and to investigate the use of ultrasound in patients above and below the age of 50 years. METHODS: Clinical presentation and investigations for consecutive patients undergoing triple assessment at a symptomatic breast clinic were prospectively recorded between January 2000 and August 2003. Clinical data were compared with pathological findings. Patients were divided into two groups, above and below 50 years of age for subgroup analyses. RESULTS: A total of 999 of 2185 patients had both mammography and ultrasound investigations performed and constituted the study population. Subgroup analysis of the 2185 patients demonstrated that 99 of the 127 patients who were diagnosed with breast cancer had both investigations performed (median age 57.0, range: 34-89 years). Mammography was normal/benign in 14.1%, indeterminate in 29.3% and suspicious of cancer in 56.6% of patients. Adjunctive ultrasound was normal/benign in 13.1%, indeterminate in 6.1% and suspicious of cancer in 80.8% of patients. In these 99 patients, adjunctive ultrasound was more sensitive than mammogram alone (80.8% vs. 56.6%, p < 0.001). Ultrasound upgraded nine of 14 mammographically normal and 16 of 29 mammographically indeterminate X-rays to a cancer. Mammography appeared to be more sensitive in patients over 50 years compared with those patients under 50 years (62.5% vs. 45.7%, p = 0.10). The sensitivity of ultrasound was comparable between patients above and below the age of 50 years (82.8% vs. 77.1%, p = 0.60). Further subgroup analysis demonstrated a higher sensitivity with combined mammography and ultrasound compared with mammography alone in either patient group (below 50: 45.7%-->77.1% and above 50: 62.5%-->82.8%). These results also suggested that the difference in the sensitivities of mammography vs. the combined investigation approach was more marked in patients under 50 years of age (below 50 = 31.4% vs. above 50 = 20.3%). CONCLUSION: Adjunctive ultrasound assessment improves breast cancer detection in women of all ages and should be routinely used in symptomatic breast clinics.