Transverse colon volvulus and the wandering liver.

INTRODUCTION AND IMPORTANCE: Transverse colon volvulus is a rare cause of colonic obstruction accounting for 1-3 % of colonic volvuli due to the short mesentery and hepatic and splenic attachments. Previous mobilisation of the flexures and conditions resulting in chronic dilatation of the colon predispose to the condition. The risk of mortality is high, ranging from 11 to 20 % highlighting the need for early diagnosis and intervention. CASE PRESENTATION: We present a case of a 90-year-old male who was referred with a large bowel obstruction with a transition at the splenic flexure and the liver rotated to the left upper quadrant. The patient was taken to the theatre and an emergency laparotomy was performed with findings of a transverse colon volvulus. The liver was initially found in the left upper quadrant and was freely mobile in the upper abdomen consistent with an absence of the hepatic ligament. A subtotal colectomy was performed. Unfortunately, the postoperative course was complicated by a cardiac event and the patient died on postoperative day six. CLINICAL DISCUSSION: Absence of hepatic ligaments is a rare cause of transverse colon volvulus which has only been described in one previous case report. Diagnosis of transverse colon volvulus can be challenging and early operative intervention with colectomy is required to minimise mortality. CONCLUSION: This case illustrates an unusual cause of transverse colon volvulus secondary to the absence of the hepatic ligaments and stresses the need for early diagnosis and intervention due to the high mortality associated with this condition.

Severe anorectal injury secondary to jet ski accident: An important and increasing mechanism of injury.

Introduction: Traumatic injuries from jet ski-related accidents have increased in incidence over the past few decades. Anorectal injuries are uncommon but typically arise from high-speed jet ski accidents. We present a case of a severe anorectal injury from a fall off the back of an accelerating jet ski. Case report: This case reports on the presentation, operative findings and management of a 22-year-old female with major internal and external anal sphincter disruption sustained via an unusual traumatic mechanism. Operative findings identified a complete internal and external anal sphincter disruption at the 1 and 7 O'clock positions and extra-peritoneal rectal perforation. Washout, suture repair and an end-colostomy were performed. Conclusion: Understanding the potential severity of injury from the insult mechanism is paramount to triaging and managing trauma patients. Although this case describes an inconspicuous mechanism, the resulting trauma is significant and should prompt consideration in future cases. In addition, the article describes an approach to the repair of such injuries and the difficult decision relating to the role and type of defunctioning colostomy to protect any possible missed injuries in a complex traumatic environment, and in the protection of the anorectal repair.

Measuring the Burden of Surgical Disease Averted by Emergency and Essential Surgical Care in a District Hospital in Papua New Guinea.

BACKGROUND: Timely access to emergency and essential surgical care (EESC) and anaesthesia in low- and middle-income countries (LMICs) prevents premature death, minimises lifelong disability and reduces their economic impact on families and communities. Papua New Guinea is one of the poorest countries in the Pacific region, and provides much of its surgical care at a district hospital level. We aimed to evaluate the surgical capacity of a district hospital in PNG and estimate the effectiveness of surgical interventions provided. METHODS: We performed a prospective study to calculate the number of DALYs averted for 465 patients treated with surgical care over a 3-month period (Sep-Nov 2013) in Alotau Hospital, Milne Bay Province, PNG (pop 210,000). Data were also collected on infrastructure, workforce, interventions provided and equipment available using the World Health Organization's Integrated Management of Emergency and Essential Surgical Care Toolkit, a survey to assess EESC and surgical capacity. We also performed a retrospective one-year audit of surgical, obstetric and anaesthetic care to provide context with regards to annual disease burden treated and surgical activity. RESULTS: EESC was provided by 11 Surgeons/Anaesthetists/Obstetricians (SAO) providers, equating to 5.7 per 100,000 population (including 4 nurse anaesthetists). They performed 783/100,000 procedures annually. Over the 3-month prospective study period, 4954 DALYs were averted by 465 surgical interventions, 52 % of which were elective. This equates to 18,330 DALYs averted annually or, approximately 18 % of the published but estimated disease burden in the Province in the 2013 Global Burden of Disease Study. The overall peri-operative mortality rate was 1.29 %, with 0.41 % for elective procedures and 2.25 % for emergencies. CONCLUSIONS: Much of the burden of surgical disease in Papua New Guinea presenting to Alotau General Hospital serving Milne Bay Province can be effectively treated by a small team providing emergency and essential surgical care. This is despite a relatively low surgical volume and limited numbers of trained surgical anaesthesia obstetric providers, and likely underservicing. The ability of surgical care to avert disease in Papua New Guinea highlights its importance to public health in LMICs.