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.

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.

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.