two concentric circles are formed due to the intussusception) and the presence of a tubular structure extending into the stomach. Jejunogastric intussusception can be classified into three subtypes depending on the involved loop: type 1, afferent loop; type 2, efferent loop; and type 3, both afferent and efferent loop invagination. Most cases, including the one presented in this paper, are type 2 jejunogastric intussusceptions.5 These originate in the efferent limb and extend in a retrograde fashion against peristalsis. Because of the high risk of incarceration and strangulation jejunogastric intussusception generally warrants surgical intervention. This can range from simple reduction of the intussusception to resection and re-fashioning the gastroenterostomy. In the majority of cases resection is undertaken because of either the risk of an associated lead point caused by a small bowel lesion or ischaemic changes in the involved segment. Delay in surgical intervention is associated with a significant increase in mortality especially after 48 h.6 Our case highlights how this unusual presentation needs to be considered even years after gastrojejunostomies.

Images for surgeons

2. Robertson DS, Weder C. Acute jejunosgastric intussusception. Can. J. Surg. 1968; 1: 210–4. 3. Tokue H, Tsushima Y, Arai Y, Endo K. Jejunogastric intussusception: life-threatening complication occurring 55 years after gastrojejunostomy. Int. Med. 2009; 48: 1657–1660. 4. Shackman R. Jejunogastric intussusception. Br. J. Surg. 1940; 27: 475– 80. 5. Achyut JM, Ishwar JM, Jayantkumar BD et al. Jejunogastric intussusception: case report and review of the literature. Dig. Endosc. 2004; 16: 88–90. 6. Marx WJ. Reduction of jejunogastric intussusception during upper gastrointestinal examination. ARA Am. J. Roentgenol. 1978; 131: 334–5.

Christopher William Lehane, MBBS Amirala Khalessi, MBBS, FRACS Adeeb J. Majid, MBBS, FRACS Hajir Nabi, MBBS, FRACS Amitabha Das, MBBS, FRACS Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12393

References 1. Bozzi E. Annotation. Boll. Acad. Med. 1914; 122: 3–4.

Tension pneumomediastinum after blunt chest trauma .These images are of a 25-year-old man who suffered severe multitrauma after a high-speed motorcycle crash. His main injuries were severe blunt head and chest trauma. The head injury was devastating and unsurvivable with the patient considered early for organ donation. However, this had to be delayed until relatives arrived from abroad to give formal donation consent. Initially, he suffered a right-sided pneumothorax that was successfully treated by tube thoracostomy. However, while ventilated in the intensive care unit, he became increasingly haemodynamically

Fig. 1. Computed tomography chest tension pneumomediastinum.

unstable, thus requiring increased inotropic support. The patient was sent immediately for a computed tomography (CT) chest scan which showed a large tension pneumomediastinum (Fig. 1). The CT chest clearly displayed free mediastinal air with intact bilateral pleurae and significant compression of the anterior cardiac contour.1 The effect causing a situation similar to an acute cardiac tamponade that rapidly compromised cardiac output.2 Standard anterior-posterior chest X-ray taken prior to the CT chest did not display signs of a tension pneumomediastinum indicating its quick progression.

Fig. 2. Large anterior mediastinal air-pockets bulging during decompressive sternotomy.

© 2013 Royal Australasian College of Surgeons

Images for surgeons

An urgent decompressive sternotomy was performed revealing extensive air-pockets, under pressure, in the mediastinum, overlying the right ventricular outflow tract and the pulmonary arteries (Fig. 2). The air-pockets were decompressed with intraoperative haemodynamic improvement immediately noted. Tissues also removed from the mediastinum during sternotomy exhibited widespread pneumatization giving a ‘bubbled’ appearance. No significant bleeding was noted during sternotomy with mediastinal and bilateral pleural drains placed. The chest was closed in standard fashion with stainless steel sternotomy wires and layered closure technique. Drains were placed on −3 kPa suction with negligible bleeding and no air leak observed. The patient remained stable and was returned to the intensive care unit. Several days later, formal neurological testing confirmed brain death with next of kin consenting to organ donation shortly thereafter. Organ retrieval of heart and lungs occurred expediently and without complication. It is hoped the sharing of these images will alert fellow clinicians to the possibility of tension


pneumomediastinum, especially in ventilated, chest trauma patients and to reinforce the vital importance of organ donation

References 1. Katabathina V, Restrepo C, Martinez-Jimenez S, Riascos R. Nonvascular, non-traumatic mediastinal emergencies in adults: a comprehensive review of imaging findings. Radiographics 2011; 31: 1141–60. 2. Beg M, Reyazuddin M, Ansari M. Traumatic tension pneumomediastinum mimicking cardiac tamponade. Thorax 1988; 43: 576–7.

Scott Jennings, MBBS (Hons) Sheen Peeceeyen, FRACS Matthew Horton, FRACS Department of Cardiothoracic Surgery, St George Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12378

Pyoderma gangrenosum of the penis: an important lesson In this case report, we describe an unusual case of localized pyoderma gangrenosum of the penis in a 62-year-old man. Pyoderma gangrenosum is an inflammatory ulcerative disease that usually occurs with systemic manifestations. Presently, there are fewer than 15 reports of isolated pyoderma gangrenosum of the penis.1–10 A previously healthy 62-year-old man initially presented to the urology clinic with a 16-month history of a chronic penile lesion, secondary to squeezing a small pustule noted on the distal dorsal shaft of his penis.3 There was no prior history of any ulcers, vascular pathology or diabetes in the patient. There was also no associated arthritis, inflammatory bowel disease or known haematological dyscrasias stated. Apart from occasional dysuria, he was able to pass urine normally with no fistulous urine leakage from his ulcer site. Serological and penile swab testing were negative for any sexually transmitted diseases. Tissue penile biopsies were obtained and flow cytometry testing for lymphoma as well as histochemical staining for viral or fungal micro-organisms were performed, all of which were negative. On macroscopic examination, there were multiple deep tender ulcerated areas with purulent discharge on the distal dorsal aspect of the penile shaft and glans. Sloughing was present over most of the ulcer surface. The glans, scrotum and testicles were otherwise all normal and no femoro-inguinal adenopathy was noted. Microscopically, findings were consistent with a chronic inflammatory change. The patient received multiple debridements for his chronic ulcer over a period of 2 years with no improvement in his symptoms and subsequently underwent a penile skin flap with incorporation of his penile shaft into the scrotum for management of his symptoms. Unfortunately, he represented to the acute clinic 2 weeks later with urine leak from the skin flap site while voiding and © 2013 Royal Australasian College of Surgeons



Fig. 1. Macroscopic appearance of the male patient’s genitalia on presentation to acute urology clinic. Circumferential wound breakdown was noted with associated urine leak. The glans penis was atrophic and was tethered to the penile shaft by a sliver of viable corpus spongiosum. He subsequently underwent a distal penectomy and indwelling catheter insertion.

circumferential wound breakdown. By this time, the glans penis was atrophic and was tethered to the penile shaft by a sliver of viable corpus spongiosum (Fig. 1). He subsequently underwent a distal penectomy and indwelling catheter insertion (Fig. 2a). All previous histopathological findings were reviewed by an expert panel (Fig. 2b,c) and a diagnosis of pyoderma gangrenosum was made. He was subsequently referred to dermatology and was commenced on a regime of stepped high-dose steroids and immunosuppressants, consisting of prednisolone (50 mg once daily), azathioprine (50 mg once daily) and potassium permanganate baths. Mupirocin cream was also administered topically with oral ciprofloxacin and metronidazole for antibacterial cover. This regime

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Tension pneumomediastinum after blunt chest trauma.

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