Intrahepatic perforation of the gallbladder causing liver abscesses: case studies and literature review of a rare complication.

A spontaneous (non-traumatic) gallbladder perforation with gallstone disease is not common. Concomitant development of a liver abscess is a very rare complication observed in such cases. A few cases of intrahepatic gallbladder perforations with chronic liver abscesses have been described. However, a patient series summarising classical and atypical presentations, relevant imaging studies, and the role of surgical and non-surgical options are lacking. We report a short case series on this rare complication of intrahepatic gallbladder perforations and share our experience of management of this condition.

Malignant sigmoidoduodenal fistula.

INTRODUCTION: Duodenocolic fistula is a rare complication of malignant colonic disease especially when involving and originating from the sigmoid colon. We aim to discuss the unusual clinical presentation of this case as well as the investigation and management of duodenocolic fistulas. PRESENTATION OF CASE: A 91 year old lady presented as an emergency to a general surgical service at a District General Hospital with diarrhoea, vomiting and weight loss. Computed Tomography (CT) reported a large ovarian cyst elevating the sigmoid colon into immediate proximity of the duodenum. Adenocarcinoma was confirmed on histology obtained by colonoscopy. A classic apple core lesion with fistulating tract from the sigmoid colon to the duodenum was synchronously demonstrated on barium enema. DISCUSSION: Sigmoido-duodenal fistulae represent a complex manifestation of gastrointestinal pathologies. CONCLUSION: Management options must be considered in the context of patient wishes, their co-morbidities, and predicted post-operative outcome. In most cases this is likely to represent a non-operative approach, however surgical resection may benefit selected cases on occasion.

Colo-vesical fistula: Complete healing without surgical intervention.

INTRODUCTION: Colo-vesical (CV) fistulae are the most common type of fistulae associated with diverticular disease. Surgery remains the mainstay of treatment, without which, CV fistulae rarely achieve complete healing. PRESENTATION OF CASE: Herein, we report the case of a 62-year-old man who developed a CV fistula after reversal of Hartmann's procedure (initially for management of diverticular abscess), which healed with conservative management alone. DISCUSSION: We discuss possibilities of the aetiology of this fistula. The CV fistula may have been initially present, which came to light only after his reversal. Or an iatrogenic fistula that developed at the time of reversal of Hartmann's. CONCLUSION: This is the first time that such a fistula has been demonstrated clinically and radiologically to have healed spontaneously without surgery. We recommend that conservative management of CV fistulae should be considered.

Spontaneously perforated pyometra: an unusual cause of acute abdomen and pneumoperitoneum.

Pneumoperitoneum is usually associated with gastrointestinal perforation or following surgical and endoscopic procedures. We report a rare case of spontaneously perforated pyometra presenting with generalised peritonitis and pneumoperitoneum. Perforation of the uterus is also unusual and often associated with the presence of an intrauterine device, a gravid uterus or malignancy. Our case illustrates the importance of clinical knowledge of acute and neoplastic gynaecological diseases, which are not uncommonly encountered by the general surgeon. Moreover, good appreciation of pelvic anatomy and close collaboration with gynaecology colleagues is essential as operative intervention is often required.

Comparison of short-and long-term outcomes following either insertion of self-expanding metallic stents or emergency surgery in malignant large bowel obstruction.

BACKGROUND: Self-expanding metallic stents (SEMS) are now regarded as a safe and effective treatment for an acute obstructing colorectal cancer. SEMS insertion is an invasive procedure that could potentially worsen prognosis. This study assessed the short-and long-term outcomes in patients stented for acute large bowel obstruction and in patients who underwent primary emergency surgery. METHODS: We retrospectively identified 19 patients who underwent SEMS insertion and 23 patients who had primary emergency surgery for left-sided large bowel obstruction as the first presentation of colorectal cancer. RESULTS: There were no significant differences between the 19 patients in the SEMS group and the 23 patients in the primary emergency surgery group in terms of demographics and tumour location and stage. Stent insertion was successful in 16 patients (84%). One patient died from a stent-related perforation and another had a stoma fashioned for stent migration. Stents were a definitive procedure in 2 patients with advanced disease and acted as a "bridge to surgery" in the remaining 12 patients. Compared to the primary surgery group, there was a trend towards a higher primary anastomosis rate in the SEMS group (p=0.08); there were no significant differences in length of hospital stay, 30-day mortality or complication rates between the groups. Long-term prognosis (estimated 3-year survival) did not differ significantly between the groups (p=0.54); this persisted when only curative resections were considered (p=0.80). CONCLUSIONS: Preoperative stent insertion is a safe and effective treatment for large bowel obstruction, and may result in a higher primary anastomosis rate. Stent insertion does not seem to have a deleterious effect on prognosis.

Colovesical fistula--is a surgical approach always justified?

OBJECTIVE: There is a tendency to over investigate patients with colovesical fistula and to advise surgical intervention as the sole course of action. Most patients are elderly and operative intervention often carries a high morbidity and mortality. PATIENTS AND METHODS: A retrospective study of 50 patients diagnosed with a colovesical fistula over a 12-year period was undertaken at our institution. The notes of all these patients were reviewed using a standardized proforma to look at the referral pattern, symtomatology, investigation, treatment and outcomes. RESULTS: Data analysis showed the median age of these patients to be 70 years with 92% having either pneumaturia or faecaluria or both as a symptom. There was no significant difference in disease-specific mortality in patients with benign colovesical fistula undergoing surgical intervention and patients treated conservatively. There was not a single documented case of septicaemia despite untreated colovesical fistula being present for a cumulative total of 3254 weeks. There was no statistically significant decline in the renal function due to the disease. CONCLUSION: We suggest that fewer investigations be performed for the diagnosis of colovesical fistula and conservative management offered to patients with benign pathology.