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Objective: To review demographics of patients with acute pyelonephritis, their outcomes of severe upper urinary tract infection, and to identify risk factors for long hospital stay and mortality.Design: Case series.Setting: A regional hospital in Hong Kong. Patients:Patients admitted between June 2007 and June 2012 for acute pyelonephritis were identified. Those with the most severe outcomes were analysed of their mortality, need for care in the intensive care unit, or necessitation of urological intervention. Results:Overall, 68 patients fulfilled our criteria for severe acute pyelonephritis. The female-to-male ratio was 7:3. Their mean age was 58 years. Overall, 57% of the patients had impaired renal function and 37% were diabetic; 47% developed shock after admission and 56% required further intensive care unit care; 75% of the patients demonstrated radiological evidence of urinary tract obstruction and required subsequent drainage procedures. Five patients died due to severe acute pyelonephritis. The prevalence of bacteraemia and bacteriuria was 57% and 74%, respectively. Escherichia coli accounted for the majority of causative organisms. Four risk factors-bacteraemia, shock, need for intensive care, and suppurative pyelonephritis-were associated

This is a retrospective review of the role of laparoscopic exploration of common bile duct (LECBD) in the management of difficult choledocholithiasis performed in our centre during the period 1995–2003. 97 LECBDs were performed during this period. Twenty‐five of them were performed for difficult choledocholithiasis. Difficult choledocholithiasis was defined as those which ERCP failed to retrieve because of various reasons including access and cannulation difficulty (7), difficult nature of the common bile duct (CBD) stones (16) and presence of endoscopic retrograde cholangiopancreatography (ERCP) related complications (2). Altogether 2 transcystic duct explorations and 23 choledochotomies were performed. Mean operative time was 149.4 ± 49.3 min and there were three conversions (12%). Stone clearance rate was 100% and no recurrence was detected upon a mean follow‐up of 16.8 months. Only five complications were encountered which included three bile leak and two wound infections. When the results were compared to the remaining 72 LECBD for non‐difficult stone during the same period, the complication rate, conversion rate and residual stone rate were similar despite longer operation time (149.4 ± 49.4 min vs 121.6 ± 50.5 min, P=0.025) Conclusion: LECBD is the solution to difficult CBD stones where ERCP is impossible or stone retrieval is incomplete.

Objectives:To investigate the clinical predictors and the aetiologies for surgery in patients with Naja atra (Taiwan or Chinese cobra) envenomation.Methods: This case series was conducted in the only tertiary care centre in eastern Taiwan. Patients who presented to the emergency department with Naja atra bite between January 2008 and September 2014 were included. Clinical information was collected and compared between surgical and non-surgical patients.Results: A total of 28 patients with Naja atra envenomation presented to the emergency department during the study period. Of these, 60.7% (n=17) required surgery. Necrotising fasciitis (76.5%) was the main finding in surgery. Comparisons between surgical and non-surgical patients showed skin ecchymosis (odds ratio=34.36; 95% confidence interval, 2.20-536.08; P=0.012) and a high total dose of antivenin (≥6 vials; odds ratio=14.59; 95% confidence interval, 1.10-192.72; P=0.042) to be the most significant predictors of surgery. The rate of bacterial isolation from the surgical wound was 88.2%. Morganella morganii (76.5%), Enterococcus faecalis (58.8%), and Bacteroides fragilis (29.4%) were the most common pathogens involved. Bacterial susceptibility testing indicated that combined broadspectrum antibiotics were needed to cover mixed aerobic and anaerobic bacterial infection.

Dropped gallstones due to accidental perforation of gallbladder wall during laparoscopic cholecystectomy are often encountered. However, dropped gallstones as nidus of infection with subsequent abscess formation is a rare complication of laparoscopic cholecystectomy (0.3%). Most of the reported cases of complicated dropped stones required open surgical drainage. Minimally invasive measures were less frequently employed. We report a case of dropped gallstones that were removed endoscopically through a percutaneous drainage tract.