Although the therapeutic benefits of endoscopic retrograde cholangiopancreatography (ERCP) usually outweigh the risks, there can be rare complications, including stent migration leading to perforation, intestinal obstruction or penetration. An 87-year-old woman presented with symptomatic choledocholithiasis. Two previous endoscopic attempts at stone removal were unsuccessful. On repeat ERCP at our institution, multiple large stones were removed, but complete duct clearance could not be achieved. A plastic biliary stent was placed with plans to reattempt in 6 weeks. Postoperatively, she had mild back pain radiating into her right leg that gradually worsened to the point where she was unable to ambulate. An abdominal CT scan showed the distal aspect of the biliary stent extending through the wall of the duodenum with the tip positioned within the right psoas muscle. The stent was successfully removed via a rat-toothed forceps. Our case illustrates an extremely rare complication of biliary stent placement.

Pruritus is a manifestation of chronic liver disease. Epstein-Barr virus (EBV) infection often presents as infectious mononucleosis and mild hepatitis. Severe pruritus in the setting of infectious mononucleosis and persistent marked hyperbilirubinaemia is exceedingly uncommon. To the best of our knowledge, we present the first case of a patient with EBV hepatitis and severe pruritus that was successfully treated with an ultra-low dose of intravenous naltraxone.

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Purpose. Peroneus longus tendon graft is not a popular first choice for ACL reconstruction. However, newer literature has shown good outcomes with its use. This study compares functional outcome and donor site morbidity of peroneus longus with hamstring tendon autograft to assess if it can be considered as one of the first choices for ACLR. Methods. This prospective cohort study involves 54 patients who underwent arthroscopic single-bundle ACLR. 27 patients each were operated on with hamstring and peroneus longus autografts. At 2 years follow-up, functional outcome was compared between groups using International Knee Documentation Committee (IKDC), Modified Cincinnati, and Tegner-Lysholm scores. Donor site morbidity in the peroneus longus group was assessed using Foot and Ankle Disability Index (FADI) and The American Orthopaedic Foot and Ankle Society (AOFAS) scores. Results. At 2 years follow-up, there was no statistically significant difference in the mean IKDC (77.26 vs 80.78), Modified Cincinnati (84.41 vs 89.07), and Tegner-Lysholm scores (85.19 vs 88.78) between the hamstring and peroneus groups respectively. Mean FADI and AOFAS scores at 2 years follow up were 96.11 and 91.67 respectively in the peroneus group suggesting no significant donor site morbidity as compared to preoperative scores. Conclusions. Peroneus longus performs similar to hamstring grafts and can be considered as one of the first choices for arthroscopic ACL reconstruction.

SUMMARYA 57-year-old man presented with chest pain, dyspnoea and coffee grounds emesis. He was haemodynamically stable without significant drop in haemoglobin. He suddenly developed cardiac arrest with wide complex tachycardia and became comatose. CT scan of the head revealed pneumocephalus and multiple infarcts. Given the recent history of radiofrequency ablation for atrial fibrillation, atrio-oesophageal fistula (AOF) was suspected. CT angiography of the thorax showed a 5 mm diverticulum on the posterior wall of the left atrium, also raising suspicion for AOF. The patient was taken to the operating room. An AOF was found and repaired. He did not have any further gastrointestinal bleeding. There was no neurological recovery at day 11 and life support was withdrawn per his family's request. This case highlights the importance of obtaining history of recent cardiac procedures in patients presenting with an upper gastrointestinal bleed. An oesophagogastroduodenoscopy in this patient could have been instantaneously deadly. BACKGROUND