Fishbone perforation of the small bowel mimicking internal herniation and obstruction in a patient with previous gastric bypass surgery.

Intestinal perforation following the ingestion of fishbone is unusual and rarely diagnosed preoperatively, as clinical and radiological findings are non-specific. We report a case of a female patient post Roux-en-Y gastric bypass (RYGBP) for obesity, who presented with severe abdominal pain and guarding in left iliac fossa. Computed tomography (CT) suggested internal herniation with compromised vascular supply to the bowel. Exploratory laparotomy identified a perforation site in the blind loop of the RYGBP due to a protruding fishbone. After extraction, primary suture repair was performed. In retrospect, the fishbone was identified on CT but misinterpreted as suture line at the enteroenterostomy site. This case emphasizes that although rare, the ingestion of fishbone can lead to severe complications and should therefore be included in the differential for an acute abdomen. On CT, it should be noted that fishbone may simulate suture line within the bowel if the patient has history of previous surgery.

A case of successful surgical management of primary retroperitoneal mucinous cystadenoma.

Primary retroperitoneal mucinous cystadenoma (PRMC) is a rare tumour. It was first reported in 1965, and since then, less than 100 cases have been reported. It is cystic in nature and most commonly affects the female population. It becomes symptomatic in later stages due to its mass effect, making the diagnosis challenging in its early asymptomatic stage. We report a case of a 32-year-old female who presented with abdominal pain and a mass in left iliac fossa. Diagnostic imaging revealed a large cystic lesion in retroperitoneum. A midline laparotomy was performed, and a complete surgical excision was accomplished without any spillage. Surgical histology confirmed the diagnosis of PRMC. The patient was discharged on postoperative day 2. There was no evidence of tumour recurrence on repeat imaging at 90-day follow-up. Surgical approach, with complete resection and without any spillage, remains the most effective and appropriate treatment for this tumour.

Spontaneous bowel perforation in the setting of colonic involvement with scleroderma.

Here we present a rare case of spontaneous colonic perforation in a middle-aged woman affected by systemic sclerosis (SSc). In spite of maximal medical support and prompt emergency laparotomy for source control the patient died due to multiorgan failure within 48 hours of admission. This case emphasises that although rarely, patients with scleroderma can present with colonic perforation which unfortunately due to their decreased physiological reserve, can lead to rapid and irreversible deterioration and subsequent death. It is therefore essential that clinicians faced with abdominal symptoms and signs in patients affected by SSc are able to quickly differentiate acute visceral perforation from benign causes.

Laparoscopic peritoneal lavage versus laparoscopic sigmoidectomy in complicated acute diverticulitis: a multicenter prospective observational study.

PURPOSE: Laparoscopic peritoneal lavage (LPL) is feasible in selected patients with pelvic abscess and generalized purulent peritonitis caused by acute diverticulitis. We aimed to compare LPL and laparoscopic sigmoidectomy (LS) in complicated acute diverticulitis. METHODS: This prospective, observational, multicenter study included patients with a pelvic abscess not amenable to conservative management and patients with Hinchey III acute diverticulitis, from 2015 to 2018. Sixty-six patients were enrolled: 28 (42%) underwent LPL and 38 (58%) underwent LS. In LS, patients had a primary anastomosis, with or without ileostomy, or an end colostomy (HA). Major outcomes were mortality, morbidity, failure of source control, reoperation, length of stay, and diverticulitis recurrence. RESULTS: Patient demographics were similar in the two groups. In LPL, ASA score > 2 and Mannheim Peritonitis Index were significantly higher (p = 0.05 and 0.004). In LS, 24 patients (63%) had a PA and 14 (37%) an HA. No death was recorded. Overall, morbidity was 33% in LPL and 18% in LS (p = 0.169). However, failure to achieve source control of the peritoneal infection and the need to return to the operating room were more frequent in LPL (p = 0.002 and p = 0.006). Mean postoperative length of stay was comparable (p = 0.08). Diverticular recurrence was significantly higher in LPL (p = 0.003). CONCLUSION: LPL is related to a higher reoperation rate, more frequent postoperative ongoing sepsis, and higher recurrence rates. Therefore, laparoscopic lavage for perforated diverticulitis carries a high risk of failure in daily practice.

Grynfeltt-Lesshaft lumbar hernia: a rare cause of bowel obstruction misdiagnosed as a lipoma.

Grynfeltt-Leschaft hernia is a type of lumbar hernia occurring in the superior lumbar triangle. Because of its rarity and non-specific presentation, lumbar hernia often poses a diagnostic challenge, and it can be easily misdiagnosed as a lipoma. If the correct diagnosis is missed, there is a significant risk of complications including hernia incarceration or strangulation. Here, we present a case of Grynfeltt-Lesshaft hernia which was repeatedly misdiagnosed as a lipoma and presented acutely with large bowel obstruction. A definite diagnosis was made by a computed tomography scan and the patient had emergency laparotomy and successful mesh repair of the hernia defect.