Falciform ligament torsion as a rare aetiology of the acute abdomen.

The falciform ligament is a remnant of the embryonic ventral mesentery containing the obliterated umbilical vein and round ligament. It extends from the umbilicus to the superior aspect of the diaphragm. We report about a 53-year-old fit and well patient who presented with acute upper abdominal pain with tenderness to palpation. Ultrasound scan was unremarkable, but blood tests revealed raised inflammatory markers. Thus, computed tomography was performed. This demonstrated acute torsion and fat necrosis of the falciform ligament, which was the aetiology of the upper abdominal pain. Such pathology is rare with 23 previously reported cases. Conservative management is usually proposed, but on occasion, surgical intervention may be warranted in cases that do not respond to initial supportive measures. We describe this case to demonstrate a rare cause of a common presentation to the surgical service.

Loin Pain Hematuria Syndrome-a case report.

Loin pain hematuria syndrome (LPHS) is a rare idiopathic condition. LPHS can present with both unilateral and bilateral loin pain, microscopic or macroscopic hematuria. It is a diagnosis of exclusion. The management options for this condition include pain management with narcotics or opioids, renal denervation, kidney autotransplantation and neurectomy or nephrectomy. However, these treatment modalities are the last resort.

Meta-analysis and trial sequential analysis of randomized evidence comparing general anesthesia vs regional anesthesia for laparoscopic cholecystectomy.

BACKGROUND: In an effort to further reduce the morbidity and mortality profile of laparoscopic cholecystectomy, the outcomes of such procedure under regional anesthesia (RA) have been evaluated. In the context of cholecystectomy, combining a minimally invasive surgical procedure with a minimally invasive anesthetic technique can potentially be associated with less postoperative pain and earlier ambulation. AIM: To evaluate comparative outcomes of RA and general anesthesia (GA) in patients undergoing laparoscopic cholecystectomy. METHODS: A comprehensive systematic review of randomized controlled trials with subsequent meta-analysis and trial sequential analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. RESULTS: Thirteen randomized controlled trials enrolling 1111 patients were included. The study populations in the RA and GA groups were of comparable age (P = 0.41), gender (P = 0.98) and body mass index (P = 0.24). The conversion rate from RA to GA was 2.3%. RA was associated with significantly less postoperative pain at 4 h [mean difference (MD): - 2.22, P < 0.00001], 8 h (MD: -1.53, P = 0.0006), 12 h (MD: -2.08, P < 0.00001), and 24 h (MD: -0.90, P < 0.00001) compared to GA. Moreover, it was associated with significantly lower rate of nausea and vomiting [risk ratio (RR): 0.40, P < 0.0001]. However, RA significantly increased postoperative headaches (RR: 4.69, P = 0.03), and urinary retention (RR: 2.73, P = 0.03). The trial sequential analysis demonstrated that the meta-analysis was conclusive for most outcomes, with the exception of a risk of type 1 error for headache and urinary retention and a risk of type 2 error for total procedure time. CONCLUSION: Our findings indicate that RA may be an attractive anesthetic modality for day-case laparoscopic cholecystectomy considering its associated lower postoperative pain and nausea and vomiting compared to GA. However, its associated risk of urinary retention and headache and lack of knowledge on its impact on procedure-related outcomes do not justify using RA as the first line anesthetic choice for laparoscopic cholecystectomy.

Acute appendicitis located within Amyand's hernia-a complex case with concurrent acute cholecystitis.

Amyand's hernia is the presence of the vermiform appendix within an inguinal hernia sac. It is rare, and even rarer is the presence of acute appendicitis within the sac. It presents in a variety of different ways and often is only diagnosed intra-operatively. We present the case of a 90 year old male with extensive co-morbidities presenting with right upper quadrant pain, who on computed tomography scan of the abdomen, had acute cholecystitis alongside acute appendicitis within Amyand's hernia. Ultimately given his co-morbidities, a conservative approach with prolonged antibiotic therapy was adopted, with a successful outcome. This case highlights that although classifications for treatment of Amyand's hernia exist, careful clinical assessment is warranted in each case to ensure optimal outcome based upon individual circumstances.

Septic arthritis of the manubriosternal joint presenting as a chest-wall swelling in an immunocompetent patient.

Septic arthritis of the manubriosternal joint is a rare pathology, often mistaken for other disease processes given its location and chest pain symptoms. We present a case of a 58-year-old man presenting with a dull ache in his chest after returning from a holiday. Initially under the care of the physicians locally, he was investigated for respiratory and cardiac causes of chest pain with no findings. Eventually, a lump was noted on examination of the chest prompting further imaging, which confirmed a diagnosis of manubriosternal septic arthritis. He was discussed and referred to tertiary cardiothoracics, who recommended conservative treatment with 6 weeks of antibiotics. To date, there has been a good recovery. We present this case alongside a discussion of the limited literature, in particular highlighting how difficult a diagnosis it is to make but one that surgeons and medics alike should be aware of.

De Garengeot's hernia with appendicitis-a rare cause of an acutely painful groin swelling.

De Garengeot hernia is a rare subtype of femoral hernia whereby the vermiform appendix is located within the hernial sac. Even rarer is the presence of appendicitis within the hernia sac. De Garengeot's hernia is difficult to diagnose pre-operatively and can prove technically difficult at operation particularly with regards to mobilization of the caecum and appendix in order to perform appendicectomy. Laparoscopic, open, with and without mesh repair of de Garengeot hernia have all been described in the literature with varying degrees of success. We present a case of an 82 year old lady presenting with an acutely painful right sided groin lump. CT scan revealed the presence of de Garengeot hernia with acute appendicitis. We describe in text and photo format our approach to the hernia repair, appendicectomy and provide a short review of the literature with regards to the different operative approaches to such a patient.

Unusual presentation of acute pancreatitis following high tibial osteotomy.

We report a case of a 55-year-old man taxi driver admitted electively for high tibial osteotomy for relief of bilateral medial compartment osteoarthritis. He was obese and an ex-smoker but medical history was otherwise unremarkable. Day 1 postoperatively the patient started to suffer vomiting episodes and the abdomen was distended. C Reactive protein and white cell count were both elevated but other bloods were normal. CT abdomen and pelvis was performed which showed acute interstitial pancreatitis. Glasgow score was calculated as 2. He was treated aggressively with analgesia, intravenous fluid and intravenous antibiotics. He has made a good recovery following these conservative measures. To our knowledge, this is the first case in the literature reporting pancreatitis as a complication of high tibial osteotomy. This case highlights the importance of close monitoring for abdominal complications even in the setting of elective orthopaedic surgery where it is a rare phenomenon.

A study of fecal coliform sources at a coastal site using colored dissolved organic matter (CDOM) as a water source tracer.

Optical properties of colored dissolved organic matter (CDOM) were measured as a tracer of polluted waters in a Southern California surf-zone with consistently high levels of fecal indicator bacteria. Salinity, temperature, fecal coliform, absorbance (200-700nm) and fluorescence (lambda(excitation)=350nm; lambda(emission)=360-650nm) were measured in the creek and surf-zone during a dry and rain event. Fluorescence to absorption ratios for CDOM were used to distinguish water masses, with two distinct CDOM end-members identified as creek (flu/abs=8.7+/-0.8x10(4)) and coastal (flu/abs=2.2+/-0.3x10(4)). Waters containing the same CDOM end-member had highly variable bacterial levels during the dry event, suggesting intermittent sources of bacteria added to a uniform water source, consistent with marine birds. During the rain event, increased levels of the creek end-member and bacteria indicated a second bacteria source from runoff.

Molecular ontogeny of the human antibody repertoire to the Haemophilus influenzae type B polysaccharide: expression of canonical variable regions and their variants in vaccinated infants.

A structurally conserved antibody combining site, encoded by the IGH V3-23 and kappa A2 variable (V) region gene segments, predominates the adult immune response to the Haemophilus influenzae type b (Hib) capsular polysaccharide (PS). This site has been elevated to canonical status based upon its relative molecular uniformity and prevalence in adults. To date, no studies have examined the primary structure of Hib PS-specific antibodies in young infants, who are the primary targets of Hib vaccination. In this study we show that canonical Hib PS-specific heavy (H) and light (L) chain V regions are present in 4-month-old infants following two vaccinations with Hib PS-protein conjugates. The infant V regions contain sequence polymorphisms that resemble those found in adult antibodies, as well as polymorphisms at position 95a of the A2 L chain not previously observed in adults. In vitro studies of Fab fragments and recombinant IgG2 antibodies using these V regions identify sequence polymorphisms that impact Hib PS binding affinity and bactericidal activity. These results demonstrate the establishment of canonical V regions in early ontogeny and provide a structural explanation of how canonical antibodies in the infant can vary in their affinity and protective activity against Hib.