ABSTRACT
The peril of incorrect diagnostic labelling is highlighted by this case of acute respiratory distress caused by a retrosternal recurrent goitre. An initial clinical diagnosis which cannot be fully validated on investigation with unexpected or poor response to treatment should prompt consideration and investigation for an alternative explanation.
ABSTRACT
INTRODUCTION: Gallbladder perforation is common and occurs in 6 to 40% of laparoscopic cholecystectomy procedures. In up to a third of these cases, stones are not retrieved and complications can arise many years post-operatively. Diagnosis can be difficult and patients may present to many specialties within medicine and surgery. We seek to present our case and review the literature on prevention and management of "lost" stones. CASE PRESENTATION: Our patient is a 77-year-old woman who presented to the urology clinic with a loin abscess that developed five years after laparoscopic cholecystectomy. Radiological studies showed retained abdominal gallstones and an associated abscess formation. These were drained under ultrasound guidance on several occasions and the patient now suffers from chronic sinusitis. Due to her age and comorbidities, she has declined definitive surgical intervention to remove the stones. CONCLUSION: Gallbladder perforation during laparoscopic cholecystectomy is a reasonably common problem and may result in spilled and lost gallstones. Though uncommon, these stones may lead to early or late complications, which can be a diagnostic challenge and cause significant morbidity to the patient. Clear documentation and patient awareness of lost gallstones is of utmost importance, as this may enable prompt recognition and treatment of any complications.
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INTRODUCTION: Clostridium difficile associated diarrhoea has become an important health problem in UK hospitals but surgical intervention is rarely required. There is little evidence regarding best practice for patients requiring surgical intervention. The aim of this multicentre study was to review our experience in patients requiring surgery for C. difficile colitis. METHODS: Patients who underwent surgery for C. difficile colitis in 5 hospitals in Southeast England over a 7-year period (1 teaching hospital and 4 district general hospitals) were identified from histopathology databases. Data were collected regarding the presentation, indication for surgery and post-operative outcomes. RESULTS: 15 patients (9 males; mean age=71 years (range 35-84 years)) underwent surgery. 46% of patients (n=7) contracted C. difficile during their hospital admission for other medical reasons and 73% of patients were initially admitted under other medical specialties. Diagnosis was only made preoperatively in 8 patients (53%). Indications for surgery were peritonitis and systemic toxicity (n=12), failure of medical management (n=2) and unresolving large bowel dilatation (n=1). 12 patients underwent total colectomy and the rest underwent segmental resection. All patients were admitted to the intensive care unit post operatively with a mean stay of 6 days. 2 patients needed a second look laparotomy. Mortality rate was 67% (n=10), with all but 1 patient dying within the 30-day mortality period. The mean length of hospital stay of survivors was 30 days (range 17-72). CONCLUSIONS: Surgical intervention for C. difficile colitis remains uncommon. Total colectomy and end ileostomy is the procedure of choice. The outlook for patients requiring surgery remains poor.
