Thriving, not just surviving, with motor neurone disease. The outcome of the first pre-emptive 'triple-ostomy'.

The following report details the multidisciplinary treatment of a patient with motor neurone disease. The patient, who requested publication of this case, is a highly intelligent and distinguished robotic scientist. He was diagnosed with amyotrophic lateral sclerosis in 2017 and his personal approach to his condition has been to use modern technology and all treatment options to maximise his quality and duration of life. After his research, the patient decided that his life would be significantly improved by formation of an elective 'triple-ostomy', this being an end colostomy and suprapubic catheter (for continence), and a percutaneous gastrostomy (for nutrition). We report the peri-operative multidisciplinary approach taken with this case, the surgical procedures, the potential risks and the outcome. The patient is delighted with the result and aims to raise awareness that this may be a treatment option in highly selected patients.

Delayed presentation of an isolated gallbladder rupture following blunt abdominal trauma: a case report.

BACKGROUND: Blunt injuries to the gallbladder occur rarely, and the incidence of isolated damage to the gallbladder is even smaller. We report a case of delayed presentation of isolated rupture of the gallbladder following blunt trauma to the abdomen. CASE PRESENTATION: A 65 year old lady presented through the Emergency Department with a 1 week history of blunt trauma to her abdomen. She complained of continued epigastric pain which radiated through to her back and right upper quadrant. On presentation, the patient had a low grade temperature, hypotension and mild tachycardia. Abdominal examination revealed right upper quadrant tenderness with no localised peritonism. C-reactive protein was 451. An abdominal CT showed a moderate amount of ascitic fluid in the perihepatic space. The patient underwent a laparotomy, which revealed a ruptured gallbladder with free bile. There was no evidence of any associated injuries to the surrounding organs. Partial cholecystectomy was done in view of the friable nature of the gallbladder. Post operatively, a persistent bile leak was managed successfully with endoscopic sphincterotomy and stenting. CONCLUSION: Rupture of the gallbladder due to blunt injuries to the abdomen occurs from time to time and may constitute a diagnostic challenge especially with delayed presentation. Partial cholecystectomy is a safe option in cases where friability of the wall renders formal cholecystectomy inadvisable. Endoscopic sphincterotomy and stenting is a safe and effective treatment for persistent post operative bile leaks.