284 Wunderlich Syndrome - Case Report of a Surgical Emergency Due to Spontaneous Non-Traumatic Retroperitoneal Haemorrhage

A 42-year-old female with no other significant co-morbidities presented with complaints of sudden onset abdominal pain, she was in state of shock- her haemoglobin dropped drastically to 6.8g/dl from 11.8g/dl. She was resuscitated and was given blood transfusion.

CT Scan was suggestive of retroperitoneal haemorrhage due to rupture of Renal angiomyolipoma (RAML). Patient underwent selective embolization of renal artery the next day and was discharged after 3 days of post-operative stay.

Wunderlich Syndrome-is a rare condition in which spontaneous nontraumatic renal haemorrhage occurs into the subcapsular and perirenal spaces is most commonly caused due to spontaneous rupture of RAML.It is characterized by Lenk’s triad – Acute flank pain, flank mass, hypovolemic shock. Size of AML (>4 cm), prothrombotic states such as pregnancy are main causes of AML rupture. Patients are managed conservatively or with help of selective arterial embolization. Nephrectomy is last resort in a hemodynamically unstable patient or in cases of embolization failure.

When dealing with acute abdomen with haemodynamic instability in non-traumatic cases it is essential to consider possibility of Wunderlich Syndrome. Early diagnosis, availability of Interventional radiology is key to successful management and potentially avoiding a Nephrectomy.

282 Cholecystoappendicular Fistula- 1st Ever Reported Case

A 30-year-old male presented with a history of recurrent episodes of acute cholecystitis; first acute attack associated with fever and nausea was 18 months prior to this presentation, for which he was managed conservatively for acute cholecystitis with antibiotics and analgesia following an ultrasound that showed features of acute cholecystitis with no obvious gallstones.

The patient had further episodes of acute cholecystitis with no signs of obstructive jaundice and subsequent ultrasound showed multiple small gallstones. Due to the severity of his symptoms, he was scheduled for a planned cholecystectomy.

During surgery (right subcostal incision)- findings were that of a contracted gall bladder with dense adhesions, after careful dissection a fistulous tract between the appendix and gallbladder was identified along with a cholecystoduodenal fistula.

An en-bloc cholecystectomy plus appendicectomy was performed with the duodenotomy repaired. On the first day post op there was approximately 300 ml of bilious effluent in drain, a white cell count-8.1 x 109 and hemoglobin -12.1 g/dL, Serum bilirubin-1.4mg/dL, ALP-104mg/dL. The second and third post-operative days were uneventful with minimal bile mixed serous fluid in drain respectively with no other complains, following which the drains were removed and patient discharged home.

Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is a cholecystoduodenal (70%), followed by cholecystocolic (10–20%), and the least common is the cholecystogastric fistula accounting for the remainder of cases.

No case of cholecystoappendicular fistula has been reported so far.

45 Easier Recognition and Better Communication of The Surgical Team Across the Hospital

Introduction

Recognition & communication of a surgical team is of paramount significance especially in catastrophic scenarios- like a crowded trauma call in ED, and ward rounds as surgical patients are dispersed across the hospital. Hence implementing posters across all key wards and special ID could play a key role.

Method

Aim was to improve the recognition & communication of the surgical team by means of posters of surgical members(Trainees/ Trust Grades/ Associates)including their name, designation & bleep; and color coded ID/Lanyard for the surgical team. An online survey was conducted for the surgical team(N = 25) and separately for the nursing staff(N = 40) across the hospital to understand how well the surgical team is recognised across the hospital and how changes would bring about a difference in communication and recognition of the surgical team.

Results

Surgical team was poorly recognised across the hospital(12.5%), and most of the surgical & nursing staff thought implementing the changes would play a key role.

Conclusions

It is vital to have posters of surgical team (trainees/ trust grades) across all key wards and in Emergency, along with unique ID for efficient recognition of Surgical team in urgent scenarios & to develop an effective communication with the nursing staff across the hospital.

44 Hipec Therapy-A New Development to Fight Cancer; Report Of 3 Cases

Introduction

HIPEC is highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery. HIPEC delivers chemotherapy directly to cancer cells in abdomen. Cytoreductive surgery(CRS) combined with perioperative intraperitoneal chemotherapy is currently a valid treatment option for peritoneal dissemination of gastrointestinal, gynaecological cancers or primary peritoneal neoplasms.

Method

3 patients with peritoneal surface malignancy were selected. PET scan was done for all the patients to assess metastasis and peritoneal carcinomatosis index(PCI) calculated was<20 for all 3 patients They were then treated with CRS+HIPEC therapy with disease-specific chemotherapeutic agents like Cisplatin, Mitomycin and Doxorubicin and Oxaliplatin . Aim was

Results

All the 3 patients had a good post-operative recovery with no recurrence in the follow-up period

Conclusions

HIPEC and CRS plays synergistic role. A complete CRS followed by HIPEC with the disease-specific chemotherapeutic agent at 41-43ºC constitutes optimal treatment for certain malignancies. High regional concentration with low systemic concentration of chemotherapy, increased tissue penetration and thermal enhancement of cytotoxicity are some of the advantages with HIPEC therapy