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Atraumatic splenic rupture is a complex surgical pathology owing to its rarity, non-specificity of symptoms and gravity of possible outcomes. This case outlines the investigation and management of a patient with atraumatic splenic rupture secondary to undiagnosed hairy cell leukaemia. While the patient was initially managed conservatively, they went on to have a splenectomy owing to ongoing transfusion requirements. A review of the literature has also been performed and presented to highlight the potential causes of atraumatic splenic rupture and the various options for confirming diagnosis and definitive management.

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Iatrogenic diaphragmatic herniation is rare. This case is an example of herniation of the liver into the pericardial space post-transdiaphragmatic pericardial window formation for recurrent pericarditis. This case highlights that transdiaphragmatic herniation of intra-abdominal organs should be considered in patients presenting with gastrointestinal or cardiorespiratory symptoms with history of iatrogenic diaphragmatic defect.

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Frantz tumors or solid pseudopapillary pancreatic neoplasm (SPN) are rare exocrine neoplasms that carry a favorable prognosis; they represent up to 3% of all tumors located in the region of the pancreas and have specific age and gender predispositions. In recent years, the rising curve of diagnosis is entitled to the evolution and access of diagnostic imaging. In this paper, we have retrospectively reviewed and described the clinical course of 40 patients with SPN from three institutions in Brazil, who had their diagnosis between 2005 and 2020, and analyzed the clinicopathological, genetic, and surgical aspects of these individuals. In accordance with the literature, most patients were women, 60% with unspecified symptoms at diagnosis, with tumors mainly located in the body and tail of the pancreas, of whom 70% underwent a distal pancreatectomy with sparing splenectomy as a standard procedure, and none of the cases have experienced recurrence to date. Surgery still remains the mainstay of treatment given the low metastatic potential, but more conservative approaches as observed in this cohort are evolving to become the standard of care. Herein, we present an in-depth analysis of cases focusing on the latest literature and report some of the smallest tumor cases in the literature. To our knowledge, this is the first report evaluating germline genetic testing and presenting a case of detected Li-Fraumeni syndrome.

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OBJECTIVE: To analyze abdominal drain on the first postoperative day and evaluate its predictive nature for the diagnosis of Pancreatic Fistula exclusion, seeking to establish a cutoff point from which lower values demonstrate safety in excluding the possibility of this complication. METHODS: From August 2017 to June 2020, data from 48 patients undergoing pancreatic resection were collected and analyzed from a prospective cohort. The patients were divided into two groups, one group consisting of patients who did not develop PF (Group A), and the other composed of patients who developed PF (Group B). The receiver operation characteristic curve was constructed, and cutoff points were evaluated by calculating sensitivity and specificity. RESULTS: Group A brought 30 patients together (62.5%) and Group B brought 18 patients together (37.5%). The 444 U/L value was the most satisfactory cutoff point for the receiver operation characteristic curve (CI 0.690-0.941), with a sensitivity of 94.4% and a specificity of 60%, thus being able to select 18 of 30 patients who did not succumb to PF. CONCLUSIONS: Abdominal drain on the first postoperative day can be used as a predictive factor in the diagnosis of PF exclusion (CI 0.690-0.941), with the value of 444 U/L being the best performance cutoff point.

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BACKGROUND: The prevalence of colorectal cancer in the elderly is rising, with increasing numbers of older patients undergoing surgery. However, there is a paucity of information on the surgical outcomes and operative techniques used in this population. AIM: To evaluate the post-operative outcomes for patients ≥ 85 years old following colorectal cancer resection as well as evaluating the outcomes of laparoscopic resection of colorectal cancer in patients over 85. METHODS: Patients who underwent colorectal cancer resection at our institution between January 2010 and December 2018 were included. The study was divided into two parts. For part one, patients were divided into two groups based on age: Those age ≥ 85 years old (n = 48) and those aged 75-84 years old (n = 136). Short term surgical outcomes and clinicopathological features were compared using appropriate parametric and non-parametric testing. For part two, patient's over 85 years old were divided into two groups based upon operative technique: Laparoscopic (n = 37) vs open (n = 11) colorectal resection. Short-term post-operative outcomes of each approach were assessed. RESULTS: The median length of stay between patients over 85 and those aged 75-85 was eight days, with no statistically significant difference between the groups (P = 0.29). No significant difference was identified between the older and younger groups with regards to severity of complications (P = 0.93), American Society of Anaesthesiologists grading (P = 0.43) or 30-d mortality (2% vs 2%, P = 0.96). Patients over 85 who underwent laparoscopic colorectal resection were compared to those who underwent an open resection. The median length of stay between the groups was similar (8 vs 9 d respectively) with no significant difference in length of stay (P = 0.18). There was no significant difference in 30-d mortality rates (0% vs 9%, P = 0.063) or severity of complication grades (P = 0.46) between the laparoscopic and open surgical groups. CONCLUSION: No significant short term surgical differences were identified in patients ≥ 85 years old when compared to those 75-85 years old. There is no difference in short term surgical outcomes between laparoscopic or open colorectal resections in patients over 85.

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SUMMARY OBJECTIVE: To analyze abdominal drain on the first postoperative day and evaluate its predictive nature for the diagnosis of Pancreatic Fistula exclusion, seeking to establish a cutoff point from which lower values demonstrate safety in excluding the possibility of this complication. METHODS: From August 2017 to June 2020, data from 48 patients undergoing pancreatic resection were collected and analyzed from a prospective cohort. The patients were divided into two groups, one group consisting of patients who did not develop PF (Group A), and the other composed of patients who developed PF (Group B). The receiver operation characteristic curve was constructed, and cutoff points were evaluated by calculating sensitivity and specificity. RESULTS: Group A brought 30 patients together (62.5%) and Group B brought 18 patients together (37.5%). The 444 U/L value was the most satisfactory cutoff point for the receiver operation characteristic curve (CI 0.690-0.941), with a sensitivity of 94.4% and a specificity of 60%, thus being able to select 18 of 30 patients who did not succumb to PF. CONCLUSIONS: Abdominal drain on the first postoperative day can be used as a predictive factor in the diagnosis of PF exclusion (CI 0.690-0.941), with the value of 444 U/L being the best performance cutoff point.

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BACKGROUND: Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series. METHODS: A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population. RESULTS: Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126 min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8 mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23). CONCLUSION: This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.

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Coronavirus disease 2019 (COVID-19) is primarily a pulmonary disease, but also affects the cardiovascular system in multiple ways. In this review, we will summarise and put into perspective findings and debates relating to the diverse aspects of cardiovascular involvement of COVID-19. We will review evidence for the role of the renin-angiotensin-aldosterone system (RAAS), the risk of pre-existing cardiovascular disease in COVID-19 susceptibility and course, and the mechanism of acute and long-term myocardial injury. The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) uses membrane-bound angiotensin converting-enzyme-2 (ACE2) as a receptor for cell entry. ACE2 is part of an important counter-regulatory circuit antagonising the harmful effects of angiotensin II on lung and heart. Modulation of ACE2 may therefore affect disease susceptibility and disease course. However, observational clinical studies and one randomised trial have so far not yielded evidence for harmful or beneficial effects of blockers of the RAAS during COVID-19. Age, gender, and multi-morbidity all increase susceptibility to SARS-CoV-2. In contrast, pre-existing cardiovascular diseases do so only minimally, but they may aggravate the disease course. Direct SARS-CoV-2 infection of the heart tissue and myocytes is rare. Nevertheless, COVID-19 may lead to myocarditis-like acute cardiac injury, characterised by myocardial oedema, but lacking extensive myocyte loss and lymphocytic infiltration. Independent of this, increases in cardiac biomarkers (troponin, N-terminal pro-brain natriuretic peptide, D-dimer) are frequent, especially in the phase of severe systemic inflammation and acute respiratory distress syndrome, and quantitatively associated with poor outcome. The pulmonary infection may result initially in right ventricular dysfunction, but in cases with severe systemic infection hypoxia, hyperinflammation and cytokine storm heart failure may eventually ensue. Unlike other infections and inflammatory states, COVID-19 does not appear to trigger acute coronary syndromes. In children, even mild COVID-19 can induce a multisystem inflammatory syndrome with Kawasaki-like symptoms frequently accompanied by cardiogenic shock.

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BACKGROUND: Colorectal cancer surgery is complex and can result in severe post-operative complications. Optimisation of surgical outcomes requires a thorough understanding of the background complexity and comorbid status of patients. AIM: The aim of this study is to determine whether certain pre-existing comorbidities are associated with high grade post-operative complications following colorectal cancer surgery. The study also aims to define the prevalence of demographic, comorbid and surgical features in a population undergoing colorectal cancer resection. METHOD: A colorectal cancer database at The Prince Charles Hospital was established to capture detailed information on patient background, comorbidities and clinicopathological features. A single-centre retrospective study was undertaken to assess the effect of comorbidities on post-operative outcomes following colorectal cancer resection. Five hundred and thirty-three patients were reviewed between 2010-2018 to assess if specific comorbidities were associated with higher grade post-operative complications. A Clavien-Dindo grade of three or higher was defined as a high grade complication. RESULTS: Fifty-eight percent of all patients had an ASA grade of ASA III or above. The average BMI of patients undergoing resection was 28 ± 6.0. Sixteen percent of all patients experienced a high grade complications. Patients with high grade complications had a higher mean average age compared to patients with low grade or no post-operative complications (74 years vs 70 years, p = 0.01). Univariate analysis revealed patients with atrial fibrillation, COPD, ischaemic heart disease and heart failure had an increased risk of high grade complications. Multivariate analysis revealed pre-existing atrial fibrillation (OR 2.70, 95% CI 1.53-4.89, p <0.01) and COPD (OR 2.02 1.07-3.80, p = 0.029) were independently associated with an increased risk of high grade complications. CONCLUSION: Pre-existing atrial fibrillation and COPD are independent risk factors for high grade complications. Targeted perioperative management is necessary to optimise outcomes.

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AIM: The present article aimed to evaluate the feasibility of implementing a very low calorie diet (VLCD) weight loss program into the pre-operative model of care for elective general surgery patients with obesity. METHODS: A prospective, randomised control trial of adults with obesity awaiting elective general surgery was conducted at an outpatient clinic at a tertiary hospital. Patients were randomised to the intervention group, an 8-week VLCD program incorporating Optifast (Nestle Health, Germany) shakes, or to standard care (generic healthy eating information). Data were collected at baseline, week 8 and at 30 days post-surgery. The primary outcome of the study was feasibility, which was evaluated through demand, practicality, integration and acceptability measures. RESULTS: Forty-six participants (M 17: F 23, mean age 51.6 (13.1) years) with a mean body mass index ≥ 30 kg/m2 (40.5 kg/m2 (5.9)) were recruited. There was a higher mean weight loss in the intervention group (n = 23) compared to the control group (n = 14) (-6.5 vs +0.15 kg; P = <.001), with no excessive loss of muscle mass (MM), measured by bioelectrical impedance analysis. The reduction in waist circumference was greater for the intervention (n = 21) compared to control group (n = 5) (-6.11 vs +1.36 cm; P = .003). Quality of life increased significantly in the intervention group (P < .001). CONCLUSIONS: The pre-operative VLCD program produced clinically meaningful rapid weight loss pre-surgery and improved quality of life without an excessive loss of MM.

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First-principles evolutionary algorithms are employed to shed light on the phase stability of Al⁻Nb intermetallics. While the tetragonal Al3Nb and AlNb2 structures are correctly identified as stable, the experimentally reported Laves phase of AlNb3 yields soft phonon modes implying its dynamical instability at 0 K. The soft phonon modes do not disappear even upon elevating the temperature in the simulation up to 1500 K. X-Ray diffraction patterns recorded for our powder-metallurgically produced arc cathodes, however, clearly show that the AlNb3 phase exists. We propose that AlNb3 is dynamically stabilised by ordered antisite defects at the Al sublattice, leading also to a shift of the Nb content from 75 to ∼81 at.%. Unlike the defect-free AlNb3, the antisite-stabilised variant hence falls into the compositional range consistent with our CALPHAD-based phase diagram as well as with the previous reports.

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Background and study aims Eosinophilic pancreatitis (EP) is a rare etiology of chronic pancreatitis, and few cases have been reported. It is characterized by eosinophilic infiltration of the pancreas and elevated IgE levels. EP is difficult to distinguish from pancreatic cancer based on clinical symptoms and auxiliary exams. We present a case of EP and debate the routine performance of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for resectable pancreatic mass.

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Spontaneous acalculous gallbladder perforation is a rare radiological and clinical phenomenon with life-threatening consequences. In the setting of recent cardiac transplantation, the condition is increasingly uncommon and difficult to diagnose preoperatively. We describe a case of spontaneous acalculous gallbladder perforation in an intensive care unit (ICU) patient, most likely due to a combination of cardiac transplantation and immunosuppression. There are no such documented cases in the literature with an established preoperative diagnosis, to the best of our knowledge. Abdominal CT and targeted ultrasound proved complimentary in establishing the diagnosis, facilitating successful and timely treatment with urgent cholecystectomy.

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BACKGROUND: Medium-sized, non-trauma hospitals experience many of the same difficulties as tertiary centres do when it comes to managing emergency general surgery patients. However, acute surgical units are not a financially viable option in these hospitals. To improve the care of emergency general surgery patients at one such hospital, a Rapid Assessment Medical Surgical (RAMS) unit was developed to decrease the time to review and increase the efficiency in caring for these patients. METHODS: To assess the unit's effect, a prospective analysis was completed of the patients who came through the RAMS unit over a 6-month period and compared with a retrospective analysis of patients presenting in the same 6-month period the year prior to the unit's instigation. RESULTS: The RAMS unit was effective in providing an avenue for faster review by the surgical team. This resulted in patients leaving the emergency department faster, decreased the number of patients that breached emergency department time-targets and increased the number of patients discharged after a period of observation or basic treatments. CONCLUSION: General surgery patients were managed more efficiently with the RAMS unit in place. However, a full cost analysis is required to determine if such units are cost-effective.

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Laparoscopic-adjustable gastric band (LAGB) complications are increasingly recognised as follow-up time increases. These are most commonly related to the gastric band or port site, but complications of the connecting tubing are also reported. We present a case of LAGB tubing penetration through the transverse colon causing abdominal sepsis in a complex surgical abdomen and review prior published cases of abdominal viscus penetration by LAGB tubing. Like complications involving all LAGB components, these often present with non-specific abdominal signs and symptoms and undergo abdominal CT as an early investigation. This makes knowledge of normal and pathological imaging features of LAGB components important in radiology practice.

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A major obstacle in the utilization of Mo thin films in flexible electronics is their brittle fracture behavior. Within this study, alloying with Re is explored as a potential strategy to improve the resistance to fracture. The sputter-deposited Mo1-xRex films (with 0 ≤ x ≤ 0.31) were characterized in terms of structural and mechanical properties, residual stresses as well as electrical resistivity. Their deformation behavior was assessed by straining 50 nm thin films on polyimide substrates in uniaxial tension, while monitoring crack initiation and propagation in situ by optical microscopy and electrical resistance measurements. A significant toughness enhancement occurs with increasing Re content for all body-centered cubic solid solution films (x ≤ 0.23). However, at higher Re concentrations (x > 0.23) the positive effect of Re is inhibited due to the formation of dual-phase films with the additional close packed A15 Mo3Re phase. The mechanisms responsible for the observed toughness behavior are discussed based on experimental observations and electronic structure calculations. Re gives rise to both increased plasticity and bond strengthening in these Mo-Re solid solutions.