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OAGS Case of the Month

Hosted by OAGS President Dr. Ravinder Singh.


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Scroll down for previous case outcome summaries.

Unable to see the case below? Click here.    Conversation/results: download

Dr. Singh will share his previous case outcome here after a new one is posted each month.

JUNE 2024 - Actual Care Outcome (posted Sept.24, 2024

June Case of the Month Recap
A 33 year old Male obese but otherwise no systemic co-morbidities. Two year history of biliary colic and previous episode choledocholithiasis requiring ERCP. Got lost to follow-up over that 2 year period and didn’t get a cholecystectomy. Presented with cholangitis and required a repeat ERCP, sphincterotomy, and stent. Went on to have a sub-total cholecystectomy. No drain was left in-situ. Returns POD#5 with fevers, abdominal pain, and elevated WBC. He was admitted and put on IV ABX. CT image below. What would you do next?
1. IR Drainage
2. Surgical Drainage
3. Repeat ERCP and stent placement
4. Refer to HPB
Due to it being a weekend when he presented and he was getting septic, he was taken to the OR for a Laparoscopic Drainage of the biloma and peritoneal washout, and wide drainage. He went on to have a repeat ERCP and longer stent placed. He did well and was discharged home with outpatient follow-up with respect to the drain.

Conversation/results: download

MAY 2024 - Actual Care Outcome (posted June 11, 2024)

Actual Case Outcome:
A 35 Female with cervical cancer and left sided fluid collection with drain. She underwent a loop ileostomy and clinically got better. But unfortunately, follow-up CT showed a new mesenteric mass. She is seeing oncology in hopes of getting chemo- and immunotherapy (has positive markers sensitive to immunotherapy). Hoping if she responds, she can perhaps be considered for surgical resection or remain on palliative immunotherapy.
Original Case Query:
A 35 Female otherwise healthy was diagnosed with cervical cancer. She underwent TAH + BSO. Based on pathology she did not need adjuvant treatment. She developed recurrence at the vaginal cuff and then received radiation. Post-radiation, she developed intra-abdominal collections on the right and left side of the abdomen. The right one spontaneously resolved but the left persisted. A drain was inserted and cytology/cultures were sent. The cytology was negative initially and culture showed Gram Positive bacteria. Repeat cytology was done due to the lack of resolution of the collection and subsequently it showed cancer cells. Drain eventually started draining stool. What would you do? CT provided.
1. Upsize drain: radiologically or surgically
2. Refer to Surgical Oncology
3. Left Hemicolectomy with or without anastomoses
4. Loop Ileostomy
Results: download

APRIL 2024 - Actual Case Outcome (posted May 14, 2024)
16 Female with T4N0M0 NET of the appendix. Post-operatively, the initial step taken was doing a Chromogranin A serology, and 5-HIAA. These were normal. Given the T4 nature of the NET, a PET scan was ordered after discussing the case at tumour board rounds. The PET was negative. An opinion from the NET Specialty Clinic advised nothing further needed to be done.
Poll Results/Feedback: download
Original Case Query:
A 16 year old female with history of obesity presented with several day history of abdominal pain. CT showed acute appendicitis. She was taken to the OR and she had significant inflammation in the RLQ with sigmoid and ileum adhered to what was presumed to be the area of the appendix. She had a small abscess that was drained but further dissection was impossible. A JP drain was placed and she was kept on ABX. Folllow-up CT revealed a decrease in inflammation and no abscess; the drain was removed and she was booked for an interval appendectomy. Intra-operatively, she had less inflammation but had dense adhesions. The appendix was removed. Pathology revealed a T4N0 NET (NeuroEndocrine Tumour) at the tip 8mm in size. Of course she was M0 based on 2 CT scans. What would you do next?
1. PET scan
2. NET Metabolic work-up
3. Refer to Neuroendocrine Specialty Clinic
4. Right Hemicolectomy
MARCH 2024 - Actual Case Outcome (posted April 9, 2024)

82 M had presented with Acute Cholecystitis. He had an attempted laparoscopic cholecystectomy but there was significant inflammation and thus a cholecystostomy was placed (JP drain). The drain subsequently stopped draining, and the patient despite being stable was not improving. He complained of persistent RUQ pain. Repeat CT POD#10 showed active intra-mural hemorrhage in the gallbladder wall with a surrounding hematoma, and another intra-abdominal hematoma. Decision was then to transfer to HPB surgeon for further management. Subsequently he had an open sub-total cholecystectomy.
Poll Results: download
Original Case Query:
82 Male with a PMHx of Atrial Fibrillation on anticoagulation, and a pacemaker. Presents with upper abdominal pain, nausea, and vomiting. This has been periodic over the last several months but worse in the last several days. Otherwise stable. Blood work ok. CT scan is as follows: sludge in the gallbladder; no biliary dilatation; LFTs normal.

What would be your management?
a. Antibiotics alone and reassess need for cholecystectomy at a later date
b. Antibiotics and Cholecystostomy (after NOAC is held for 48-72h)
c. Antibiotics and Cholecystectomy (after NOAC is held for 48-72h)
d. Send to HPB

Case outcome will be shared with next month’s case!