IntroductionThe intrauterine device is a form of contraception with a long duration of action and few systemic side effects. Migration into the abdominal cavity may occur early or years after insertion giving rise to bowel obstruction, perforation, ischemia, mesenteric injury, strictures or fistulae. Colocolic fistula formation is a rare but serious complication of intrauterine device migration, which may lead to difficulties in diagnosis and device retrieval.Case presentationWe report the case of a 29-year-old Sri Lankan woman who became pregnant 5 years after intrauterine device insertion. The device could not be located during pregnancy. She was asymptomatic and defaulted follow up during the antenatal period. She had an uncomplicated vaginal delivery. A subsequent laparotomy for device retrieval failed due to technical difficulties. A repeat laparotomy identified a sigmoid colocolic fistula with adhesions to the fallopian tube. The device was removed and colonic defects primarily closed following which the patient made an uneventful recovery.ConclusionsAll translocated intrauterine devices should be removed regardless of type and location. This case illustrates that they may cause complex bowel lesions leading to serious technical difficulties during retrieval. With the increasing use of minimally invasive approaches for intrauterine device retrieval, a low threshold for open surgery in complicated cases is advocated.

IntroductionSchwannoma, otherwise known as a neurilemmoma, is a tumor arising from peripheral nerve sheaths. Although commonly noted in association with the eighth cranial nerve as intracranial acoustic neuroma, cases of schwannoma arising in other locations have been reported in the literature. These tumors usually cause symptoms as a result of their mass effect and, since they are benign, encapsulated and non-invasive tumors, complete surgical excision is considered curative.Case presentationWe report the case of a 46-year-old Sri Lankan man who presented to our facility with recent onset of difficulty evacuating his bowels. He was noted to have a giant presacral schwannoma on magnetic resonance imaging scan. The mass was surgically excised with improvement of our patient’s symptoms. A subsequent histopathological examination confirmed the presence of a benign schwannoma.ConclusionsAlthough schwannomas commonly occur in the extremities, a rare case of occurrence in the pelvis is reported here. Due to the limited space in the pelvis, the local mass effect may be the presenting feature of such a lesion and surgical excision is curative.

This study is one of the first more extensive patient series from a lower-middle income country (LMIC) to report outcomes following lower extremity vein bypass for chronic limb threatening ischaemia. Despite the high prevalence of diabetes mellitus, limb threat severity, and many economic and resource constraints, overall outcomes exceed expectations, are within international benchmarks, and are similar to those reported from high income countries. These outcomes point to the feasibility and efficacy of a "vein bypass first strategy" for amputation prevention in lower-middle income resource limited countries.Objective: Although high quality epidemiological data are lacking, the global increase in chronic limb threatening ischaemia may be disproportionately affecting low and LMICs. All available data for outcomes from bypass for limb salvage are from high income countries, with none from LMIC settings where the challenge is greatest. This study aimed to assess the clinical outcomes following vein lower extremity bypass for chronic limb threatening ischaemia at the University of Colombo, Sri Lanka, and to compare patients and outcomes with those described in the Society for Vascular Surgery (SVS) Objective Performance Goals (OPG) and United States National Surgical Quality Improvement Program (NSQIP). Methods: Consecutive patients (n ¼ 367) undergoing SVS-OPG eligible lower extremity bypass between 2015 and 2017 were studied. Thirty day major adverse cardiovascular events (MACE), major adverse limb events (MALE), deaths, and amputations are reported, along with one year overall survival, limb salvage, and amputation free survival.Results: Patients at University of Colombo had more diabetes mellitus (80% vs. SVS 57% vs. NSQIP 50%, p < .001) and tissue loss (100% vs. SVS 74% vs. NSQIP 59%, p < .001). The 30 day MALE was 7.6%, which is not a statistically significant difference from the SVS (6.1%) or NSQIP (9%). The 30 day MACE was 8.2%, statistically significantly higher than NSQIP (4.2%, p < .001) but not SVS (6.2%, p ¼ .20). At 12 months, the overall survival (82%) was within the OPG threshold, but limb salvage (81.8%) and amputation free survival (64.5%) were just outside. Conclusion: Outcomes following vein bypass for ischaemic necrosis at the University of Colombo, Sri Lanka, are acceptable and similar to those reported from high income countries despite greater limb threat severity and resource limitations. Further real world data from similar settings on outcomes following revascularisation are required. These data suggest that a vein bypass first strategy for advanced ischaemic necrosis is feasible and effective even in resource limited settings.

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