A spontaneous retroperitoneal haemorrhage resulting in abdominal compartment syndrome requiring laparotomy: A case report and proposed management algorithm

Introduction and importance

Spontaneous Retroperitoneal Haemorrhage (SRH) is a rare condition, which in its extreme state can result in Abdominal Compartment Syndrome (ACS). The aim of this case report is to provide an overview of the diagnosis and management of SRH and to present an algorithm to inform and guide clinical decision-making in the context of ACS.

Case presentation

A 74-year-old woman with multiple risk factors for SRH developed a tense abdomen in ICU post-cardiac graft study. Radiological imaging confirmed multiple bleeding points to the contralateral side of the graft access site. She underwent endovascular treatment for her condition, however, developed ACS necessitating surgical evacuation of the haematoma.

Clinical discussion

SRH is a rare condition that may be difficult to diagnose on physical exam. Medical, endovascular and surgical approaches are recognised treatments. ACS is an extreme variant of SRH and although endovascular management can specifically address the acute bleed, surgical evacuation of the haematoma is the only treatment that can effectively reduce abdominal compartment pressures.

Conclusion

SRH can cause abdominal compartment syndrome with subsequent multiorgan failure. Ultimately, as outlined in this case, surgical evacuation of the haematoma was the only treatment able to reduce abdominal compartment pressures.

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Retroperitoneal haemorrhage can cause ACS and multiorgan failure.

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Medical, endovascular and surgical approaches are recognised treatments.

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Endovascular management should be considered in patients with ongoing bleeding.

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Endovascular approaches may cease bleeding but not alleviate any mass effects.

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Surgical management is indicated if conservative or endovascular measures fail.

Prognostic role of alpha-fetoprotein in patients with hepatocellular carcinoma treated with repeat transarterial chemoembolisation

BACKGROUND

Repeat transarterial chemoembolisation (rTACE) is often required for hepatocellular carcinoma (HCC) to achieve disease control, however, current practice guidelines regarding treatment allocation vary significantly. This study aims to identify key factors associated with patient survival following rTACE to facilitate treatment allocation and prognostic discussion.

METHOD

Patients with HCC undergoing rTACE at six Australian tertiary centers from 2009 to 2014 were included. Variables encompassing clinical, tumour, treatment type and response factors were analysed against the primary outcome of overall survival. Univariate analysis and multivariate Cox regression modelling were used to identify factors pre- and post-TACE therapy significantly associated with survival.

RESULTS

Total of 292 consecutive patients underwent rTACE with mainly Child Pugh A cirrhosis (61%) and BCLC stage A (57%) disease. Median overall survival (OS) was 30 months (IQR 15.2-50.2) from initial TACE. On multivariate analysis greater tumour number (p = 0.02), higher serum bilirubin (p = 0.007) post initial TACE, and hepatic decompensation (p = 0.001) post second TACE were associated with reduced survival. Patients with serum AFP ≥ 200 ng/ml following initial TACE had lower survival (p = 0.001), compared to patients with serum AFP level that remained < 200 ng/ml post-initial TACE, with an overall survival of 19.4 months versus 34.7 months (p = 0.0001) respectively.

CONCLUSION

Serum AFP level following initial treatment in patients undergoing repeat TACE for HCC is a simple and useful clinical prognostic marker. Moreover, it has the potential to facilitate appropriate patient selection for rTACE particularly when used in conjunction with baseline tumour burden and severity of hepatic dysfunction post-initial TACE.

Case report: Iatrogenic brachial artery dissection with complete anterograde occlusion during elective arterial line placement

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Brachial arterial catheterisation is a safe and reliable procedure with a low risk of serious complications.

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Brachial arterial catheters provide a more accurate reflection of central aortic arterial pressure compared to their radial counterparts.

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In adults, brachial artery catheter related complications can be minimized by using smaller gauge catheters.

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Point of care ultrasonography can enhance diagnostic and procedural accuracy compared to a “blind-bedside” procedure.

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Postoperative neurological monitoring after brachial line catheterization should be routinely performed for timely identification and management of catheter complications.

Introduction

Brachial arterial catheters provide a more accurate reflection of central aortic arterial pressure compared to their radial counterparts. Although brachial arterial line complications are uncommon, we report a case of a rare iatrogenic brachial artery dissection with complete anterograde occlusion from elective arterial line placement.

Presentation of case

A 41-year-old female presented for a right upper and middle lobe resection of a large neuroendocrine lung cancer. A brachial arterial line was inserted for continuous blood pressure monitoring using clinical landmarks. Six hours postoperatively the left hand was noted to be pale, cool and pulseless with complete paraesthesia. Thrombus was initially suspected on computed tomography angiography. Upon return to theatre, extensive dissection of the posterior brachial arterial wall was identified.

Conclusion

We review our diagnostic pathway and treatment of this rare complication. Recommendations to minimise the risks of complications from brachial arterial line insertion are also overviewed. We recommend the routine utilization of ultrasound-guided technique and regular post-insertion neurovascular monitoring for the prevention and early recognition of complications from brachial artery catheter insertion.

Transjugular biopsy case report of inferior vena cava hepatocellular carcinoma with intracardiac extension

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Transjugular biopsy of IVC or right sided cardiac masses can be safely performed without sedation or anaesthesia.

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Transjugular biopsy of right atrial lesions may serve as a minimally invasive technique for definitive tissue diagnosis.

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Multidisciplinary management is paramount for patients with advanced cirrhosis to prevent morbidity and mortality.

Background

Diagnosis of hepatocellular carcinoma (HCC) can be established with near certainty by correlating radiological imaging with clinical presentation. However, in the absence of diagnostic certainty, biopsy of liver tissue is mandatory for optimal management. We present our management of a patient with advanced liver disease who presented with an IVC mass extending into the right atrium, with co-existing liver lesions not meeting criteria for an imaging diagnosis of HCC.

Case presentation

A 62-year-old male with Child-Pugh C liver cirrhosis presented with decompensated liver failure. Multiple imaging modalities demonstrated an inferior vena cava (IVC) mass extending into the right atrium with co-existing liver lesions not meeting radiological criteria for an imaging diagnosis of HCC. There was no contiguous evidence of HCC in the liver, yet there was extensive tumour burden in the IVC representing a separate metastatic lesion without any indication of direct tumour spread. Under fluoroscopic and angiographic guidance, a biopsy catheter was advanced through the right atrium into the IVC. Histology from the biopsy demonstrated fragments of malignant tumour with features consistent with moderately differentiated HCC without thrombus. Given the poor prognosis associated with metastatic HCC with IVC and intracardiac involvement, a multidisciplinary decision was made with the patient’s family for palliation care.

Conclusion

Transjugular biopsy of IVC masses can be performed effectively, in an awake patient, without the need for sedation or anaesthesia. Where multiple imaging modalities fail to confirm a diagnosis for liver or IVC pathology, transluminal biopsy can assist with definitive diagnosis and treatment planning.

Preoperative left hepatic lobe devascularisation to minimize perioperative bleeding in a Jehovah's Witness undergoing left hepatectomy

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Liver resection in a Jehovah’s Witness patient requires multimodal blood minimization strategies to improve patient centred outcomes.

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Combination portal vein embolization and hepatic lobe revascularization for total vascular inflow occlusion can allow a bloodless resection.

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Preoperative angio-embolization should be researched in a larger patient cohort to reduce blood loss and blood transfusion

Introduction

Major liver resection in a Jehovah’s Witness presents unique clinical challenges requiring multimodal blood minimization strategies to reduce perioperative complications. We report a case where complete left hepatic lobe devascularisation was undertaken to minimize bleeding in a Jehovah’s Witness undergoing left hepatectomy.

Presentation of case

A 65-year-old male Jehovah’s Witness presented for open left hepatectomy for a large left-sided hepatocellular carcinoma involving segment IV of the liver. Three weeks prior to surgery, the patient underwent left portal vein embolization. To isolate and devascularise the left lobe, the gastroduodenal artery and left hepatic artery were then occluded with coils. The bed of the left hepatic artery was then embolised to stasis with particles. Finally, the anastomosis back to the right hepatic artery was also occluded by coils. The patient underwent uneventful surgery with an estimated blood loss of 450 mls.

Discussion

Left hepatectomy in a Jehovah’s Witness patient is feasible but requires careful planning and a multidisciplinary approach. Major liver resection represents a well defined but complex haemostatic challenge from tissue and vascular injury, further complicated by hepatic dysfunction, and activation of inflammatory, haemostatic and fibrinolytic pathways. In addition to the haemoglobin optimization strategies utilized preoperatively, the use of interventional radiology techniques to further reduce perioperative bleeding should be considered in all complex cases.

Conclusion

Combination of portal vein embolization and hepatic lobe devascularisation to produce total vascular occlusion of inflow to the left lobe radiologically allowed a near bloodless surgical field during major liver resection in a Jehovah’s Witness patient.

Postoperative wristwatch-induced compressive neuropathy of the hand: a case report

INTRODUCTION

Postoperative peripheral nerve injuries are well-recognised complications of both surgery and anaesthesia and a leading cause of litigation claims. We present a rare cause of compressive sensory and motor neuropraxia of the median, ulnar and radial nerves of the right hand resulting from a wristwatch that was worn on the first postoperative night following minor surgery. Mechanisms of this compressive neuropathy are discussed, with specific recommendations made regarding the wearing of wristwatches, jewellery and constrictive clothing in the immediate postoperative period.

CASE PRESENTATION

A 12-year-old white boy presented with a complete glove and stocking sensory and motor neuropathy involving his right hand from a wristwatch that was worn on the first postoperative night following uneventful surgery for a minor procedure. Over the following 12 hours the oedema and erythema resolved with complete return of motor function. After 18 hours, the sensory deficit completely resolved.

CONCLUSIONS

Postoperative neuropraxia is often preventable. Paediatric patients, especially if thin, may be particularly susceptible to a compression neuropathy from constrictive clothing or jewellery, in particular circumferential varieties such as wristwatches. These items should not be worn in the immediate postoperative period as pressure on peripheral nerves can result in severe and debilitating nerve injury. Education should be given to all medical staff, carers or parents of children undergoing surgery on the avoidance of wearing wristwatches, jewellery or constrictive clothing in the immediate postoperative period. Early medical evaluation of any postoperative nerve injury is of paramount importance.

Missed Carotid Artery Cannulation: A Line Crossed and Lessons Learnt

We report a case of an infusion of intra-aortic propofol after the missed inadvertent placement of a centra venous catheter into the right common carotid artery. Radiological imaging revealed bilateral ischaemic infarct in the posterior fossa and right cerebral artery territories consistent with an embolic source. The potential cause of the neurological injuries sustained in this case are explored. Discussion focuses on the sequelae, managemen and prevention of an iatrogenic carotid artery injury from a central venous catheter insertion. Finally, we propose an algorithm for management of iatrogenic carotid artery cannulation.

Large vessel calcification in Takayasu arteritis

We report the novel case of a young woman with Takayasu arteritis, with extensive large vessel disease. The case demonstrates that while mechanisms of vascular calcification are poorly understood, inflammation per se might be sufficient to mediate increased mineral stress leading to vessel calcification, even in the absence of renal impairment.

Gallbladder perforation following transarterial chemoembolisation; a rare but serious complication

Transarterial chemoembolisation (TACE) is the mainstay of treatment for large or multifocal hepatocellular carcinoma (HCC). However, this procedure is not without potential complications. We report the case of a 72-year-old man with cirrhosis with HCC treated by TACE using drug-eluting beads. He developed persistent fever and severe right upper quadrant pain post-procedure. CT abdomen revealed a large fluid collection closely abutting the gallbladder and tracking inferiorly along the right flank. This fluid collection originated from the gallbladder and contained locules of gas with a contrast-enhancing wall, consistent with an infected biloma. These imaging findings confirmed gallbladder perforation complicating TACE. The development of gallbladder perforation post-TACE from acute ischaemic cholecystitis producing gallbladder wall necrosis is exceedingly rare. The presence of gallbladder perforation must be recognised in patients with persisting symptoms and imaging evidence of a perihepatic fluid collection because specific treatment with intravenous antibiotics and percutaneous drainage of the biloma is necessary.

Incidental maxillary sinus findings in patients referred for head and neck CT angiography

BACKGROUND

Maxillary sinus pathology is a common finding on routine CT scans of the head and neck. The purpose of this study was to assess the incidental findings in the maxillary sinus on CT scans in patients who presented for head and neck CT angiography.

STUDY DESIGN

Images of patients referred for head and neck CT angiography were reviewed over a 5-month period. All maxillary sinus incidental findings were recorded and categorised into mucosal thickening, polypoid mucosal thickening, partial and total opacification. The age and gender of the patients and the side of mucosal pathology was also recorded.

RESULTS

A total of 262 CT scans were reviewed (524 maxillary sinuses). Seventy-two patients had pathological changes (27.5%), 44 (16.8%) had mucosal thickening, 20 (8.0%) had polypoid thickening, 6 (2.3%) had partial and another 7 (2.7%) had complete opacification.

CONCLUSIONS

There is a high rate of undiagnosed maxillary sinus pathology incidentally found on CT scans. Clinicians reviewing head and neck CT scans such as dentists, general medical practitioners, maxillofacial and ENT surgeons should be vigilant and aware of maxillary sinus disease when interpreting CT scans of the maxilla and patients should be followed up appropriately.

Intravascular papillary endothelial hyperplasia (Masson's tumor) manifesting as a lateral neck mass

Intravascular papillary endothelial hyperplasia is a benign lesion of vascular origin that is caused by an excessive proliferation of endothelial cells in normal blood vessels or vascular malformations. We report the case of a 26-year-old man who had such a lesion deep within the soft tissues of his neck. Imaging studies revealed a 6-cm-diameter mass, with its epicenter in the right retromandibular space. The mass extended into the right parapharyngeal space and compressed the pharynx. The mass was excised, and the patient recovered uneventfully. We discuss the management of this lesion, with emphasis on radiologic and histologic assessment and the differential diagnosis.