Colorectal cancer presenting with dysarthria and ataxia: a case of isolated leptomeningeal metastasis

We report the case of a 72-year-old man who presented with weight loss, anorexia and a change in bowel habit. Computed tomography (CT) of the chest, abdomen and pelvis demonstrated widespread thoracic and abdominal lymphadenopathy and a lesion within the splenic flexure. This was confirmed as an adenocarcinoma after a colonoscopic biopsy. A CT guided biopsy of the abdominal lymph node confirmed the adenocarcinoma. Within three days of admission, the patient developed worsening, progressive cerebellar symptoms that left the patient aphasic and bed bound. CT of the head was reported as normal. Magnetic resonance imaging of the head demonstrated widespread leptomeningeal metastases. We describe a case of isolated leptomeningeal metastasis from a colorectal primary tumour.

A problem in diagnostic imaging

Many pathological processes can present as a swelling in the groin. We present a case of complex, ruptured pyonephrosis causing a psoas collection, which in turn presented clinically as an apparent right "incarcerated inguinal hernia." The patient was successfully treated with antibiotics and ultrasound-guided drainage of the abscess. The anatomical basis of the inguinal presentation of this complex pyonephrosis can be understood in the arrangement of the renal (Gerota's) fascia.

Genitalia strangulation--fireman to the rescue!

The incidence of metallic rings causing genitalia strangulation has been widely reported. The removal of the constricting rings can be challenging and might need resources not usually available in the hospital. We report one such case where the assistance of a fire crew was required to remove the ring.

General paediatric surgical provision of percutaneous endoscopic gastrostomy in a district general hospital--a 12-year experience

INTRODUCTION

A small, but significant, number of children require long-term nutritional support. The aim of this study was to demonstrate the safety and efficacy of providing a percutaneous endoscopic gastrostomy (PEG) service for children in a district general hospital and to raise awareness of the suitability of the procedure to be performed on paediatric surgery lists in similar hospitals across the UK.

PATIENTS AND METHODS

A multidisciplinary paediatric nutrition team was established and all children accepted for PEG insertion between 1995 and 2007 were entered onto a database prospectively and are included in this study. PEG tubes were inserted by the standard pull-through technique under general anaesthetic.

RESULTS

A total of 172 procedures were performed in 76 children. The median age at first tube insertion was 3 years (range, 0.5-18 years). Length of follow-up ranged from 1 month to 12.6 years. Fifty-eight children (76%) had a neurological abnormality, the commonest being cerebral palsy. All but one procedure were performed successfully, of which 63 (37%) were new insertions, 99 change of tube, 4 changed from surgical gastrostomy and 6 from PEG to button gastrostomy. The median hospital stay was 2 days (range, 2-7 days) for new insertions and 1 day for tube changes. There were 10 (6%) early complications within 30 days, the commonest being peritubal infection (6). The 39 late complications included 16 peritubal infection/granulomata, 9 'buried bumpers', 4 worsening of gastro-oesophageal reflux disease, 2 gastrocolic fistulae, 3 gastrocutaneous fistulae and 4 tubal migration. There was no mortality.

CONCLUSIONS

We have demonstrated that paediatric PEG procedures and continuing management by a supporting team can be successfully and efficiently provided in the district general hospital. It should be possible for the majority of similar hospitals to provide local access and increase the availability of PEG feeding for children.

Spilled gall stones during laparoscopic cholecystectomy: a review of the literature

Laparoscopic cholecystectomy is associated with spillage of gall stones in 5%-40% of procedures, but complications occur very rarely. There are, however, isolated case reports describing a range of complications occurring both at a distance from and near to the subhepatic area. This review looks into the various modes of presentation, ways to minimise spillage, treating the complications, and the legal implications.