The importance of discussing mortality risk prior to emergency laparotomy.

Emergency laparotomies are often required for life-threatening conditions and consequently are associated with high mortality. This risk should be discussed with patients and ideally their next of kin (NOK). Failure to do so denies patients and their relatives the opportunity to prepare, breaches consent guidance, and may result in complaints and negligent claims. Patients who underwent an emergency laparotomy over 6 months were retrospectively studied. Mortality risk discussion with patients and their NOK as evidenced by documentation on consent forms or clinical notes was recorded. Factors influencing these discussions included patient's age, American Society of Anaesthesiologists' score, pre-operative diagnosis, Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM); seniority of consenting surgeon was also investigated. Seventy-six consecutive patients underwent an emergency laparotomy. Sixty-nine had capacity to give consent. Mortality risk was discussed with 24 (34.8%). These patients were older (median age 77.5 v 65.5 years; P < 0.05) and had a higher median P-POSSUM score (11.5% v 7%; P = 0.313) compared to patient with whom mortality risk was not discussed. Mortality risk was discussed with 14 (18.4%) NOK. This was not influenced by any factor studied. For patients requiring an emergency laparotomy, mortality risk was infrequently discussed with both patients and their NOK. These patients have a higher mortality risk than any other and this "failure to inform" has the potential for serious ramifications.

Retroperitoneal seminoma, a rare cause of testicular pain.

Extragonadal retroperitoneal seminomas are a rare cause of testicular pain in males. We report the case of a 46-year-old man, who presented with right-sided testicular pain, clinically mimicking testicular torsion. The patient underwent a scrotal exploration, which revealed normal testes. He went on to have a contrast-enhanced CT abdomen and pelvis, which revealed a 55 mm para-aortic mass, displacing the duodenum and inferior vena cava, with an adjacent 22 mm lymph node. Histological analysis revealed that it was a seminoma.

Radiological evidence of subcutaneous emphysema leading to a diagnosis of retroperitoneal perforated diverticulum.

INTRODUCTION: This case report outlines the investigation and management of a young patient presenting with left iliac fossa pain and sepsis. A CT was performed which was initially reported as not showing a perforation, however closer analysis provided evidence of subcutaneous emphysema in the anterior abdominal wall. This evidence justified urgent operative intervention. We review the evidence with regard to this presentation. PRESENTATION OF CASE: A previously fit 24-year-old male presented with left iliac fossa pain and features of sepsis. A CT provided subtle but distinctive evidence of retroperitoneal perforation secondary to diverticulitis, in the form of surgical emphysema in the anterior abdominal wall. In view of this, urgent operation was considered justified on suspicion of visceral perforation. A diverticular perforation was confirmed intra-operatively, and a sigmoid colectomy with primary anastomosis was performed, together with a covering ileostomy. The patient made a good post-operative recovery. DISCUSSION: Diverticular disease and its complications are becoming more common in a younger age group, in whom perforation may present late or may not be suspected. In this context special attention must be paid to any radiological evidence of perforation. CONCLUSION: Surgical emphysema in the abdominal wall is an indicator of retroperitoneal perforation, and its presence should be excluded before the possibility of perforation is dismissed. This may be of especial value in younger age groups amongst whom perforation may be less clinically obvious.

Atypical distribution of pneumatosis intestinalis in a patient with AIDS.

An adult patient who had AIDS was admitted to hospital following a fall in which they sustained a T12 vertebral fracture. The patient incidentally was found to have pneumatosis intestinalis upon a thoracolumbar radiograph taken approximately 2 weeks after their admission to the hospital. At this point in time the patient reported having diarrhoea and a distended abdomen. The patient did not have any other medical history of note. Upon examination the patient appeared comfortable. The patient's abdomen was distended but soft and non-tender. Laboratory investigations revealed a chronic normocytic anaemia and neutropenia. It was likely that the pneumatosis intestinalis was AIDS related. A CT scan confirmed its presence but revealed an atypical distribution. Despite its dramatic appearance, the patient was successfully managed conservatively and remained well during admission.

Ulcerative colitis associated with the herbal weight loss supplement Hydroxycut.

A 25-year-old Iranian gentleman was admitted to hospital with severe bloody diarrhoea and abdominal pain. He had similar episodes in the past. On each occasion his symptoms developed following the consumption of the herbal weight loss supplement Hydroxycut Hardcore X. On this admission, a (CT) scan demonstrated bowel wall thickening and peri-colonic fat stranding in the sigmoid colon. On flexible sigmoidoscopy, a continuous length of congested mucosa with multiple small ulcers was seen extending up to the mid-transverse colon, in keeping with ulcerative colitis. Histological analysis of biopsies was taken at the time and confirmed this. He was started on steroids early during his admission but this only provided a transient clinical improvement. The addition of cyclosporine, which was later changed to azathioprine, did not improve his condition either. He therefore underwent an open subtotal colectomy with end ileostomy. He made a slow but steady recovery and was discharged 3 weeks later.

Gluteo-vaginal fistula: a long-term complication of posterior intravaginal slingplasty.

A 67-year-old lady presented to the surgical outpatient clinic with a 4 month history of recurrent purulent discharge from her left buttock. Four years and 4 months prior to this she underwent a posterior intravaginal slingoplasty for vaginal prolapse and urinary stress incontinence. An MRI demonstrated a long gluteo-vaginal fistula tract from the posterior wall of the vaginal vault through the left ischiorectal fossa to the skin. An examination under anaesthesia revealed that the fistulous tract was surrounding the intact mesh used for the posterior intravaginal slingoplasty. The mesh was removed, the fistula tract excised and the perineal wound marsupialised. The patient was discharged 5 days later. The wound healed within 4 weeks and she remains sepsis free 2 years on.