Liver abscess formation is a rare complication of gall bladder perforation with cholecystohepatic communication. We describe a patient who presented with right upper quadrant pain and progressive confusion, and was found to have an intrahepatic perforation of the gall bladder. We discuss the diagnostic work-up and the management of this rare entity. In particular, we look at the increasing role of interventional radiology and the limits of laparoscopic cholecystectomy in the management of such cases. The discrepancies and the modifications in the classification of gall bladder perforation (Niemeier's classification) are also discussed.

The results of the 2-year follow-up in this study (incidence of parastomal herniation 9.5%) along with available evidence in the literature (incidence 0-8.3%), compared to the results of repair make a strong case for the use of a mesh at the time of initial surgery for the formation of any permanent stoma to prevent parastomal herniation.

IntroductionPeutz-Jeghers syndrome (PJS) is a rare familial disorder characterised by mucocutaneous pigmentation, gastrointestinal and extragastrointestinal hamartomatous polyps and an increased risk of malignancy. Peutz-Jeghers polyps in the bowel may result in intussusception. This complication usually manifests with abdominal pain and signs of intestinal obstruction.Case PresentationWe report the case of a 24-year-old Caucasian male who presented with melaena. Pigmentation of the buccal mucosa was noted but he was pain-free and examination of the abdomen was unremarkable. Upper gastrointestinal endoscopy revealed multiple polyps. An urgent abdominal computed tomography (CT) scan revealed multiple small bowel intussusceptions. Laparotomy was undertaken on our patient, reducing the intussusceptions and removing the polyps by enterotomies. Bowel resection was not needed.ConclusionMelaena in PJS needs to be urgently investigated through a CT scan even in the absence of abdominal pain and when clinical examination of the abdomen shows normal findings. Although rare, the underlying cause could be intussusception, which if missed could result in grave consequences.

Age determination is crucial in medicolegal cases. Various factors are considered for determination of age, out of which teeth are the most durable structures in human body which are better preserved even in the acidic soil. In many archaeological sites and forensic cases, teeth are the only available human remains for the identification and age determination purpose. We conducted this study to know the changes in teeth with advancement of age. In our study, 80 cases in the age group of 26-70 years were studied, out of which 58 were men and 22 women. The six physiological changes in teeth, viz. attrition, periodontosis, secondary dentin deposition, root translucency, cementum apposition and root resorption, were studied with each parameter having score ranging from 0 to 3. Total score was calculated by adding the scores of all the six physiological factors. The regression analysis was done by plotting the total score allotted against the actual age of the person. This regression line was used to derive the regression formula which came out as y = 3.71x + 16.03 and from this, age of the person was calculated. The average age difference between known and estimated age in this study was found to be ±4.43 years.

Aim:The Enhanced Recovery After Surgery (ERAS®) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units.Method: An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017.Subgroup analyses based on hospital characteristics were conducted.Results: Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017.Conclusions: Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.