Myles R. Joyce

Gossypiboma: a case report and review of the literature

IntroductionPost-operative complications in surgery may frequently be unavoidable. However, some complications result from human error, both in the intra-operative and post-operative period. One such complication, which is frequently underreported, is the retained swab, or gossypiboma.Case reportWe report a case from our hospital of a patient who presented with unexplained pyrexia, 4 years post-gynaecological surgery in another institution. A 67-year-old woman from overseas presented to our emergency department with a 2-day-history of pyrexia, collapse and confusion. Following a CT guided biopsy, which was inconclusive, she was scheduled for retroperitoneal biopsy. In theatre, a retained swab was discovered.ConclusionPrevention of gossypiboma is far better than cure. Strict adherence to swab counts, and the avoidance of change of staff during procedures is important in decreasing the incidence. Perhaps, with the increasing use of minimally invasive procedures, the incidence of gossypiboma will fall dramatically.

Management of Complex Gastrointestinal Fistula

espite all the medical advances over the last 2 decades the management f gastrointestinal fistula still remains a significant challenge and carries mortality rate of up to 10%. This mortality rate is even higher when the stula is associated with an open abdominal wound. These fistulas are ost often seen in the postoperative period due to anastomotic leakage. hey typically occur following surgery for intestinal obstruction, cancer, r inflammatory bowel disease. Thus, 75% to 85% are iatrogenic in rigin. Their management requires input from a wide range of personnel, ith attention to the control of sepsis, fluid and electrolyte balance, aintenance of nutrition, and attention to wound/stoma care. The prinipal participants in patient management include nutritionists, enterosomal therapists (ET), radiologists, psychiatrists/psychotherapists, nurses, nternists, surgeons, and other personnel (Table 1). It is a condition that laces a considerable economic burden on the healthcare provider. egardless of the pathogenesis, the management most often requires onsiderable lengths of hospital stay and extensive multidisciplinary nput. The development of an intestinal fistula following surgery is a evastating complication for the patient and their family. It may lead to ignificant anxiety, loss of self-esteem, depression, and considerable loss f earnings and financial hardship. Fistulas are defined as an abnormal communication between 2 epitheized surfaces. This article focuses on acquired as opposed to congenital stulas. Several classification systems have been used in their descripion. The anatomic classification names the fistula according to the rgans involved. The high pressure organ from which the fistula arises is amed first (eg, colovesical, aortoenteric, or gastrocutaneous). The hysiological classification is based on their output over 24 hours. igh-output fistulas produce more than 500 mL/24 h and lead to onsiderable difficulties with fluid management and skin care. These enerally originate from the small bowel and the patient may require total arenteral nutrition (TPN). Moderate-output fistulas produce 200 to 500

In a select group of patients meeting strict clinical criteria and undergoing ileal pouch-anal anastomosis, the omission of a diverting ileostomy offers cost savings to the hospital.

PURPOSE: Ileal pouch-anal anastomosis is the standard care for the majority of patients with ulcerative colitis or familial adenomatous polyposis requiring surgery. The aim of this study is to determine whether the omission of an ileostomy in patients undergoing ileal pouch surgery offers cost savings to the hospital. METHODS: Patients who underwent open ileal pouch-anal anastomosis between 2000 and 2007 were identified. They were grouped according to the absence or presence of an ileostomy at the time of their surgery. Direct costs were calculated from the hospitals accounting database. Costs analyzed included those from the index surgery, ileostomy closure, and 6-month complications. RESULTS: Cost data were available for 835 patients undergoing ileal pouch-anal anastomosis. Seven hundred fifteen (86%) had a diverting ileostomy, and the ileostomy was omitted in 120 (14%). Patients without an ileostomy had a longer length of stay (8.7 vs 6.0 days; P < .001) and a 15% greater cost (P < .001) at the time of index surgery than did those with an ileostomy. There was no significant difference between the 2 groups in costs related to complications. The total costs, including ileal pouch-anal anastomosis, ileostomy closure, and complications, were 25% greater in the ileostomy group than in the group who had the ileostomy omitted at the index surgery (

Ureteric obstruction in familial adenomatous polyposis-associated desmoid disease.

9176 (+/- 6559) vs

Magnetic Resonance Imaging in the Management of Anal Fistula and Anorectal Sepsis

11,451 (+/- 8791); P < .001). CONCLUSION: The above data shows that in a select group of patients meeting well-defined clinical criteria, the omission of a diverting ileostomy will provide significant cost savings for the hospital.

Haematoma in a hydrocele of the canal of Nuck mimicking a Richter’s hernia

PURPOSE: Intra-abdominal desmoid disease is the second leading cause of death in familial adenomatous polyposis patients. The aim of this study was to identify the incidence, management, and outcomes for familial adenomatous polyposis associated intra-abdominal desmoids causing ureteric obstruction. METHODS: Clinical data were abstracted from an institutional review board–approved, prospectively maintained familial polyposis registry. RESULTS: Of 107 patients identified with familial adenomatous polyposis related desmoid disease, 30 (28%) had documented CT scan evidence of ureteric obstruction. There was a 1:2.3 female predominance. Preceding surgery was the most prominent risk factor for development of desmoid disease (28 of 30 patients); 2 patients were diagnosed with desmoids before abdominal surgery. Overall, 11 patients had ureteric obstruction at the time of diagnosis. In the other 19 patients, median time from desmoid diagnosis to ureteric obstruction was 2 years. Pharmacologic management alone was effective in 8 patients. Eighteen patients (60%) underwent retrograde ureteric stent insertion. Five patients (17%) required percutaneous nephrostomy tubes. Three patients (10%) underwent autotransplant of 4 kidneys, and 4 patients (13%) required nephrectomy. One patient underwent ureterolysis, and another underwent ureteric resection with reimplantation. One-third of patients required more than one urologic procedure, and 63% had extensive small-bowel involvement with desmoid. CONCLUSIONS: The majority of patients with familial adenomatous polyposis associated desmoid disease who develop hydronephrosis require stenting. Complete obstruction may necessitate a nephrostomy. Renal autotransplant is an option for persistent symptomatic obstruction. Physicians treating patients with familial adenomatous polyposis and desmoid disease must be aware of the potential for development of ureteric obstruction and available treatment options.

Ileal Pouch Prolapse: Prevalence, Management, and Outcomes

Complex perianal disease may be extremely debilitating for the patient with significant impingement on quality of life. The accurate identification of anatomical areas of involvement and subsequent appropriate management is crucial to achieving a successful outcome when treating anorectal sepsis and anal fistulae. Magnetic resonance imaging (MRI) has become a powerful tool in the evaluation of anal anatomy. In patients with complex disease MRI is an important adjunct in delineating disease location and extent, its relationship to sphincter muscles, and in planning management. MRI also plays an important role in evaluating the response to medical and surgical therapies.

Impact of smoking on disease phenotype and postoperative outcomes for Crohn’s disease patients undergoing surgery

We report a haematoma in a hydrocele of the canal of Nuck in a 69-year-old female. She presented with a right-sided groin swelling, the differential for which included an irreducible inguinal hernia or haematoma given her aspirin and clopidegrel use. Successful treatment involved evacuation of the haematoma with excision of the sac. Despite a high index of suspicion for a haematoma, these swellings should ideally be explored given the potential for co-existence of a hernia.