A rare presentation of spontaneous splenic rupture from plasma cell leukaemia-a case report.

Spontaneous/atraumatic splenic rupture is rare, and often associated with underlying infectious disease, or haematological malignancy. Plasma cell leukaemia (PCL) is a rare and aggressive subtype of multiple myeloma, with a higher prevalence of hepatosplenomegaly with a bleeding diathesis from secondary to thrombocytopaenia. We report the case of an 82-year-old male presenting to the emergency department with altered mentation and complaints of left abdominal pain. He presented with haemorrhagic shock. Imaging revealed a spontaneous splenic rupture. He underwent emergency laparotomy and splenectomy for which the histopathology yielded a diagnosis of PCL as the cause for rupture. He received four courses of bortezomib and hyperCVAD 1A therapy. After a long 64-day admission, he recovered well and was discharged home with outpatient haematology/oncology follow-up.

Saksenaea mucormycosis: a rare and dangerous cause of necrotising fasciitis.

Necrotising fasciitis is a rapidly progressing soft tissue infection requiring early and adequate surgical debridement and appropriate antibiotic cover. The present case highlights bacterial fasciitis associated with fungal (Mucor) infection with insidious angioinvasive nature (Saksenaea vasiformis) which required amputation, negative-pressure vacuum dressings and amphotericin B for definitive treatment. This demonstrates a relatively rare case of the group IV classification of necrotising fasciitis, which we must consider when there is slowly progressing tissue death despite seemingly adequate treatment.

Learning curves and surgical outcomes for proctored adoption of laparoscopic ventral mesh rectopexy: cumulative sum curve analysis.

BACKGROUND: Laparoscopic ventral mesh rectopexy (VMR) is an effective and well-recognised treatment for symptoms of obstructive defecation in the context of rectal prolapse and recto-rectal intussusception. However, due to the technical complexity of VMR, a significant learning curve has been previously described. This paper examines the effect of proctored adoption of VMR on learning curves, operative times, and outcomes. METHODS: A retrospective database analysis of two district general hospitals was conducted, with inclusion of all cases performed by two surgeons since first adoption of the procedure in 2007-2015. Operative time, length of stay, and in-hospital complications were evaluated, with learning curves assessed using cumulative sum curves. RESULTS: Three hundred and eleven patients underwent VMR during the study period and were included for analysis. Patients were near-equally distributed between surgeons (surgeon A: n = 151, surgeon B, n = 160) with no significant differences between gender, age, or ASA grade. In-hospital morbidity was 3.2 %, with 0 % mortality. Cumulative sum curve analysis suggested a change point of between 25 and 30 cases based on operative times and length of stay and was similar between both surgeons. No significant change point was seen for morbidity or mortality. CONCLUSION: VMR is an effective and safe treatment for rectal prolapse. Surgeons in this study were proctored during the adoption process by another surgeon experienced in VMR; this may contribute to increased safety and abbreviated learning curve. In the context of proctored adoption, this study estimates a learning curve of 25-30 cases, without detrimental impact on patient outcomes.

Short-term Outcomes of a Randomized Pilot Trial of 2 Treatment Regimens of Transcutaneous Tibial Nerve Stimulation for Fecal Incontinence.

BACKGROUND: Fecal incontinence is a socially disabling condition that affects ≤15% of adults. Neuromodulatory treatments for fecal incontinence are now well established. Less invasive, cheaper, and more ambulatory forms of neuromodulation are under exploration. OBJECTIVE: The purpose of this study was to assess the acceptability and safety of a new ambulatory tibial nerve stimulation device and to determine clinical effect size for 2 differing regimens of therapy. DESIGN: This was a randomized, investigator-blinded, parallel-arm, 6-week pilot trial. SETTINGS: The study was conducted at 7 United Kingdom trial centers. Patients were initially reviewed in the trial center, with subsequent applications of the device performed in the patients home setting. PATIENTS: A total of 43 eligible patients (38 women) who failed conservative management of fecal incontinence were included in the study. INTERVENTION: The study intervention involved twice-weekly, 1- versus 4-hour transcutaneous tibial nerve stimulation for 6 weeks (total of 12 treatments). MAIN OUTCOME MEASURES: Standard fecal incontinence outcome tools (bowel diary, symptom severity score, and generic quality-of-life instruments) were used to collect data at baseline and at 2 weeks posttreatment cessation. RESULTS: A total of 22 patients were randomly assigned to the 1-hour group and 21 to the 4-hour group. Improvements in fecal incontinence outcomes were observed for both groups, including median urge incontinence episodes per week at baseline and posttreatment (1-hour group 2.0 to 0.5 versus 4-hour group 4.0 to 1.0) and deferment time (1-hour group 2.0 to 2.0 minutes versus 4-hour group 0.5 to 5.0 minutes). Accompanying changes were observed in physical functioning domains of quality-of-life instruments. There were no adverse events, and the treatment was highly acceptable to patients. LIMITATIONS: Limitations included the pilot design and lack of control arm in the study. Future trials would need to address these limitations. CONCLUSIONS: This pilot study provides evidence that transcutaneous tibial nerve stimulation with a new ambulatory device is safe and acceptable for the management of fecal incontinence. Additional study is warranted to investigate clinical effectiveness.

Delayed recurrence of renal cell carcinoma presenting as a haemorrhoid.

Metastatic non-colorectal cancer of the anal canal is a rare entity. To date, only four cases have been described in the literature. We present a 76-year-old man who was referred with an unusual perianal lesion. He had a history of renal cell carcinoma 7 years previously. Histologically, the lesion revealed clear cell carcinoma in keeping with metastasis. To our knowledge, this is only the second time a renal carcinoma metastasis to the anal canal has been identified.

A rare case of umbilical hernia containing the pancreas.

We present an extremely rare case of anterior abdominal wall hernia containing multiple viscera and the pancreas in a morbidly obese patient.

Surgery results in significant improvement in growth in children with Crohn's disease refractory to medical therapy.

Inflammatory bowel disease (IBD) in children can cause significant impairment in linear growth, and delay in pubertal onset. The aim of this study was to assess the impact of surgery on linear growth in children with Crohn's disease (CD) who were resistant to medical therapy, and had documented evidence of growth impairment. We performed a retrospective study on eight consecutive patients with refractory disease who had attended the paediatric IBD clinic. All patients underwent surgery as part of their treatment. Height and weight were recorded at least 6 months prior to surgery, at the time of surgery, and 6 months post surgery. Growth velocities and height Z-scores were calculated. All patients had evidence of sustained growth suppression prior to surgery. Three patients had evidence of growth failure. There was a significant increase in height velocity from 0.15 cm/month before surgery to 0.54 cm/month after surgery (P = 0.006). There was also a significant decrease in the modified Harvey-Bradshaw index (HBI) of disease activity from 2.00 before surgery, to 0.84 after surgery (P = 0.003). Improvements in height Z-score and weight velocity after surgery were not significant on statistical analysis. Our study demonstrates that before surgery, children with CD refractory to therapy have sustained growth suppression, and in some cases may even have growth failure. Surgical intervention before puberty appears to result in a significant improvement in height velocity and disease activity. These findings need to be further investigated with carefully designed prospective studies.

A rare case of adenocarcinoma arising within a duplication cyst of the rectum: curative excision with 9-year follow-up.

This case report is novel in that it describes the successful excision of an adenocarcinoma arising within a rectal duplication cyst without evidence of disease recurrence at 9-years of follow-up.