Background Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site. Methods In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964.

SUMMARYGallstone ileus is a serious complication of cholelithiasis where mechanical small bowel obstruction occurs. The recurrence of gallstone ileus is rare. The 67-year-old woman in this case report had three known gallstones transit her small bowel with two causing obstruction and the third causing a 'tumbling phenomenon'. As we have an ageing population, and gallstone ileus has a higher incidence in the over 65 age group, associated with increased comorbidities and hence greater mortality rates, it is imperative to establish the best surgical intervention for it. This case report highlights the difference CT of the abdomen has made to the diagnosis of gallstone ileus and the pros and cons of the surgical management options. BACKGROUND

Recto-vaginal tears have been described in association with foreign bodies, rape and accidental trauma victims. We describe a case of upper recto-vaginal tear without involvement of perineum or sphincter following consensual heterosexual coitus, which has not been previously reported.

Chronic diarrhoea is a common condition that affects up to 5% of the population which heavily affects the quality of life for the patient. The British Society of Gastroenterology guidelines recommend that for those who suffer with chronic diarrhoea, a colonoscopy with a biopsy is recommended to exclude microscopic colitis. This retrospective audit included 147 patients who received endoscopic procedures in 2019 at Walsall Manor Hospital for chronic diarrhoea. The results show that a total of £56,797 was incurred through endoscopic and histological investigation with four patients (2.6%) diagnosed with microscopic colitis. Given the lack of diagnostic yield, there is room for advancement in the current guidelines for managing persistent diarrhoea.

Introduction Coronavirus disease (COVID-19) is an acute severe respiratory distress syndrome which resulted in an unprecedented impact on NHS service provision. We aimed to assess the impact of COVID-19 on general surgical services in a district general hospital. Method Electronic health care record data was retrospectively collected from 6th of April to 6th of May for both 2019 and 2020. Results Despite fewer referrals and admissions in 2020 (133 vs 177 admissions in 2019), there were more failed discharges (29 vs 17 in 2019) and higher associated costs. Higher numbers of biliary related pathologies and pancreatitis (50 in 2020 vs 25 in 2019), and fewer complaints of non-specific abdominal pain (10 in 2020 vs 22 in 2019) were observed. The use of outpatient investigations decreased by approximately 40% in 2020; however, utilisation of inpatient investigations was comparable. Conclusions Better utilisation of outpatient investigations and virtual clinic services may surmount pressures from further peaks of COVID-19. The increase in biliary related cases and pancreatitis may be consequent upon lifestyle changes during lockdown. This merits further investigation and if appropriate, public health intervention. In the absence of an efficacious vaccine, further research would be essential to streamline general surgical services based on clinical risk stratification.