A 3 cm sealed pyloric perforation discovered during emergency cholecystectomy.

The diagnosis of acute cholecystitis is made on clinical, haematological, biochemical and radiological grounds, and laparoscopic cholecystectomy is commonly performed in the emergency setting. We report a case in which a patient diagnosed with acute cholecystitis was found to have a sealed pyloric perforation at laparoscopy as well as cholecystitis.

Necrotising fasciitis following inguinal hernia repair.

We report a case of necrotising fasciitis following inguinal hernia repair. It is rare for clean operations such as hernia repair to be associated with infection, and even rarer for them to be associated with necrotising fasciitis, with only a few reports in the literature.

Failure of conservative management after the passage of a distal colonic "cast": report of a case.

PURPOSE: The spontaneous passage per rectum of a full-thickness colon "cast" is a rare consequence of acute colonic ischemia. Previous cases have undergone surgery soon afterward because of intractable symptoms. We report a patient who was managed conservatively for 11 months but ultimately required definitive surgery. METHODS: The clinical, radiographic, pathologic, and endoscopic findings were obtained from the case notes and compared with previously reported cases. RESULTS: A 67-year-old obese patient underwent a Hartmann's procedure for a perforated diverticular abscess, which was reversed six months later. On the first postoperative night after the reversal, she had a brief hypotensive episode, and three weeks later passed a 21-cm, full-thickness infarcted piece of colon. She did not develop peritonitis and for 11 months experienced only mild symptoms. Under colonoscopic surveillance, the granulation tissue conduit connecting the remaining viable bowel became increasingly stenosed proximally and difficult to dilate. After three rapidly consecutive episodes of large-bowel obstruction, she required a laparotomy to resect the stricture and restore bowel continuity. From a literature review, this is the eighth case of its kind and the first in which such prolonged conservative management has been possible. CONCLUSIONS: When symptoms permit, it is feasible to manage patients conservatively in the short-term after this unusual event to allow recovery from the initial insult and planning of future surgery. However, definitive treatment is surgical and colonoscopic management should not delay this once the patient is fit for surgery.