Gastric band erosion, infection and migration causing jejunal obstruction.

Complications of laparoscopic adjustable gastric bands (LAGB) are well documented and may include migration, erosion, slippage, infection, pouch dilatation and, rarely, gastric perforation. We describe a rare case involving three such complications simultaneously, namely, gastric erosion, infection and migration through the pylorus-causing proximal jejunal obstruction. As LAGB is now the commonest performed bariatric procedure for the treatment of morbid obesity, we encourage the practising surgeon to be vigilant of these rare but potentially life-threatening complications.

Appendiceal metastasis 10 years following 'curative' resection for low-grade primary endometrial carcinoma.

Metastasis of primary endometrial adenocarcinoma to unusual sites has been occasionally reported. However, the authors believe this to be the first case report of metastasis to the appendix. This occurred more than 10 years after curative resection, and presented as sepsis with an intra-abdominal focus.

Gangrenous cystitis in a 42-year-old male.

Gangrenous cystitis is now an extremely rare condition since the widespread use of antibiotics. The authors report a case of gangrenous cystitis in a previously fit and normal 42-year-old male who presented in acute urinary retention. He underwent a partial cystectomy during an exploratory laparotomy for clinical deterioration and peritonitis. Diagnosis of this rare disease is challenged by its low incidence and lack of characteristic pathognomic features, resulting in delayed diagnosis and increased morbidity and mortality. The authors review the literature to date on the aetiology, presentation, diagnosis and management of gangrenous cystitis and emphasise the importance of early and aggressive surgical management.

A pre-operative elevated neutrophil: lymphocyte ratio does not predict survival from oesophageal cancer resection.

BACKGROUND: Elevated pre-operative neutrophil: lymphocyte ratio (NLR) has been identified as a predictor of survival in patients with hepatocellular and colorectal cancer. The aim of this study was to examine the prognostic value of an elevated preoperative NLR following resection for oesophageal cancer. METHODS: Patients who underwent resection for oesophageal carcinoma from June 1997 to September 2007 were identified from a local cancer database. Data on demographics, conventional prognostic markers, laboratory analyses including blood count results, and histopathology were collected and analysed. RESULTS: A total of 294 patients were identified with a median age at diagnosis of 65.2 (IQR 59-72) years. The median pre-operative time of blood sample collection was three days (IQR 1-8). The median neutrophil count was 64.2 x 10-9/litre, median lymphocyte count 23.9 x 10-9/litre, whilst the NLR was 2.69 (IQR 1.95-4.02). NLR did not prove to be a significant predictor of number of involved lymph nodes (Cox regression, p = 0.754), disease recurrence (p = 0.288) or death (Cox regression, p = 0.374). Furthermore, survival time was not significantly different between patients with high (>or= 3.5) or low (< 3.5) NLR (p = 0.49). CONCLUSION: Preoperative NLR does not appear to offer useful predictive ability for outcome, disease-free and overall survival following oesophageal cancer resection.

Is harmonic scalpel an effective tool for oesophagectomy?

INTRODUCTION: Use of electrocautery in oesophagectomy is standard; however, the introduction of the harmonic scalpel (HS) and its use has changed the methodology of oesophagectomy in recent years. We have assessed the efficiency of HS in oesophageal cancer surgery. The parameters studied were blood loss, transfusion rates, and postoperative complications. METHODS: Our cohort included 142 patients who underwent elective oesophagectomy from January 1999 to December 2004. The control group was the patients undergoing electrocautery oesophagectomy (n=98) between 1999 and 2002. Furthermore, 44 patients who were operated with the HS were included in the study group. RESULTS: The numbers of units transfused were significantly less in HS group (median 0) in comparison with controls (median 2), p=0.003. Median blood loss in HS and the controls was 500 and 700 ml respectively (p=0.123). Mortality in HS group was 2.27%compared to 3.06% in controls (p=0.14). The complication (principally respiratory) rate was only 13.6% of patients in HS group compared to 17.3% in the controls. CONCLUSION: Our study shows that HS reduces transfusion rates and postoperative complications, highlighting it as a safe and effective alternative to traditional electrocautery.

Vibrator-induced fatal rectal perforation.

A middle-aged man was admitted to our hospital with abdominal pain and bleeding per rectum. Subsequent laparotomy indicated an established faecal peritonitis in relation to an anterior perforation of the upper rectum. He later volunteered that he had anal intercourse 2 days previously with a vibrator at an erotic party. His partner volunteered further information regarding devient practice such as regular insertion of other foreign objects (e.g. shower hose). Tearing of the rectal mucosa following such practices is a recognised complication. However mortality following foreign body perforation is reported as extremely rare in the medical literature. Surgical repair of rectal perforation and intensive treatment did not prevent development of acute respiratory distress syndrome (ARDS) and systemic inflammatory response syndrome (SIRS) hence leading to multiple organ dysfunction syndrome (MODS) and death. This case report highlights the seriousness of rectal injuries following unusual sexual practices. Death in this case can be attributed to the late presentation and established faecal peritonitis. Death due to retroperitoneal perforation following such accidents have been reported in the literature. However previously no cases have been recorded where death occurred due to anterior rectal wall perforation.