Primary small intestine angiosarcoma mimicking Crohn's disease

A man in his 40s presented to an emergency department after experiencing worsening abdominal pain for 2 days. Contrast-enhanced CT of the abdomen and pelvis revealed circumferential mural thickening and luminal narrowing of the distal ileum and upstream dilatation of the small intestine, indicating small intestine obstruction. This prompted emergency laparotomy, where two lesions in the distal ileum were identified as the source of his bowel obstruction and resected. Immunohistochemistry of the resected segment revealed a primary small intestine angiosarcoma acting positively for vascular markers ERG and CD31. A subsequent positron emission tomography (PET) scan revealed positive mediastinal metastatic lymphadenopathy without organ metastases.Following his surgery, the patient recovered well and was promptly referred to an oncology unit at a specialised health centre for further treatment. Primary small intestine angiosarcoma is a rare entity in which patients present with non-specific symptoms requiring prompt tissue diagnosis to facilitate multidisciplinary management.

Acute surgical unit safely reduces unnecessary after-hours cholecystectomy

INTRODUCTION

The acute surgical model has been trialled in several institutions with mixed results. The aim of this study was to determine whether the acute surgical model provides better outcomes for patients with acute biliary presentation, compared with the traditional emergency surgery model of care.

METHODS

A retrospective review was carried out of patients who were admitted for management of acute biliary presentation, before and after the establishment of an acute surgical unit (ASU). Outcomes measured were time to operation, operating time, after-hours operation (6pm - 8am), length of stay and surgical complications.

RESULTS

A total of 342 patients presented with acute biliary symptoms and were managed operatively. The median time to operation was significantly reduced in the ASU group (32.4 vs 25.4 hours, p=0.047), as were the proportion of operations performed after hours (19.5% vs 2.5%, p<0.001) and the median length of stay (4 vs 3 days, p<0.001). The median operating time, rate of conversion to open cholecystectomy and wound infection rates remained similar.

CONCLUSIONS

Implementation of an ASU can lead to objective differences in outcomes for patients who present with acute cholecystitis. In our study, the ASU significantly reduced time to operation, the number of operations performed after hours and length of stay.

Post-operative wound management

BACKGROUND

Optimal management of post-operative wounds in the community is important to prevent potential complications such as surgi-cal-site infections and wound dehiscence from developing. As such, general practitioners, who play an important part in the sub-acute management of post-operative wounds, should appreciate the physiology of wound healing and the principles of post-operative wound care.

OBJECTIVE

The objective of this article is to update general practitioners on the important aspects of post-operative wound care. This includes a review of the physiology behind wound healing, an update on wound cleansing and dressing methods, as well as a guide on how common post-operative wound complications should be managed.

DISCUSSION

The key elements of post-operative wound care include timely review of the wound, appropriate cleansing and dressing, as well as early recognition and active treatment of wound complications.

Estrogen increases eNOS and NOx release in human coronary artery endothelium

Estrogen protects against the development of coronary heart disease in women. This study was designed to examine the direct effects of estrogen on nitric oxide release and endothelial nitric oxide synthase (eNOS) expression in cultured human coronary artery endothelial cells (HCAECs). NOx (nitrate, nitrite, and nitric oxide) was measured by the chemiluminescence method. Prolonged treatment (48 h) of the cells with 17beta-estradiol (E2beta), but not 17alpha-estradiol (E2alpha), resulted in a 2.3-fold increase in basal NOx release in HCAECs and an enhanced adenosine triphosphate (ATP)- and calcium ionophore A23187-induced NOx release. The effects of E2beta on endothelial NOx release were blocked by estrogen-receptor antagonist ICI 182,780. E2beta had no effect on basal and ATP-stimulated intracellular Ca2+ concentrations in HCAECs. However, E2beta significantly increased eNOS protein levels, as determined by Western analysis. We conclude that estrogen increases NOx release in HCAECs, which is independent of cytosolic Ca2+ mobilization and is mediated by the upregulation of eNOS.