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Colorectal cancer is associated with diabetes mellitus and both of these common conditions are often managed together by a surgeon. The surgical focus is usually upon cancer treatment rather than diabetes management. The relationship between colorectal cancer and diabetes is a complex one and can raise problems in both diagnosis and the management of patients with both conditions. This literature review explores the relationship between diabetes, diabetic treatment and colorectal cancer and addresses the issues that arise in diagnosing and treating this patient group. By highlighting these difficulties, this review aims to improve understanding and to provide clearer insight into both surgical and non-surgical management.

Adenocarcinoma of the prostate and rectum are common male pelvic cancers and may present synchronously or metachronously and, due to their anatomic proximity. The treatment of rectal or prostate cancer (in particular surgery and/or radiotherapy) may alter the presentation, incidence and management should a metachronous tumour develop. This review focuses on the interaction between prostatic and rectal cancer diagnosis and management. We have restricted the scope of this large topic to general considerations, management of rectal cancer after prostate cancer treatment and vice versa, management of synchronous disease and cancer follow-up issues.

Introduction: Iron deficiency anaemia (IDA) is commonly a result of colorectal cancer. Higher preoperative haemoglobin (Hb) is associated with an improved post-operative survival. The endpoint of normalising patients Hb is to reduce the need for perioperative blood transfusion which has oncological, safety and economic benefits. Methods: This study aims to compare the overall effect and cost between oral iron and two forms of parenteral iron, in raising the Hb of 53 consecutive colorectal cancer patients with IDA. The pre- and post-treatment Hb were measuring over time for oral and two formulations of parenteral iron (CosmoFer® and Venofer®), as were the need for supplemental pre-operative blood transfusions. The Total Hb rise and Hb rise/day were calculated as was the overall cost (including blood transfusions) in each of the three iron supplementation groups. Results: Both total Hb rise and Hb rise/day were significantly higher in the Venofer® (p=0.048, p=0.002) and CosmoFer® groups (p=0.034 & p=0.001) over oral iron. The oral iron group required significantly more blood than the Venofer® (p=0.04) and CosmoFer® groups (p=0.01). Although there was a trend for oral iron to cost more than parenteral, this did not reach significance. Conclusions: This study suggests that the end point of transfusion reduction is possible by the increased Hb rise rate of Venofer® or CosmoFer®. In addition, parenteral iron supplementation is no more costly than the traditional oral route, taking into account blood transfusion requirement.

The Modernising Medical Careers reforms in medical training have led to significant changes in the way junior doctors are trained. However, not all these changes have been welcomed by both trainees and trainers. This article seeks to examine some of the issues regarding training in surgery.

Surgical decision-making has evolved over time, and what was once an intuitive matter for surgeons has now become a multi-faceted decision with increased expectations from medical staff and patients, making the decision-making process itself often as challenging as the technical procedure. When planning the most appropriate treatment for a patient, it is important to distinguish what we aim to achieve with regards to treating the pathology from what can be realistically expected from the patient physiologically. In other words, has the patient the potential to withstand the insult of the treatment itself and what are the risks involved? By quantifying this risk and making it a key part of surgical decision-making, we can arrive at the safest modality of treatment for an individual patient. This allows realistic expectations for the patient, helping them to make an informed decision. This article aims to highlight some of the important aspects of surgical risk and the impact they have on patients.

Summary Blood transfusions are associated with recurrence of solid cancers. Angiogenesis is essential for cancer growth. Our aim was to determine for the first time in a prospective cohort study the effect of prestorage allogeneic leucodepleted SAGM (saline, adenine, glucose, mannitol) red cell transfusion on angiogenic factor levels and in vitro angiogenesis. Forty pretransfusion adult hospital inpatients were selected consecutively. Serum vascular endothelial growth factor (VEGF) and endostatin were measured in each patient before and after prestorage allogeneic leucodepleted SAGM red cell transfusion. All samples were exposed to an in vitro endothelial cell proliferation assay and 10 sample groups were also exposed to an in vitro whole angiogenesis assay. The median number of units transfused was 2 (minimum–maximum, 2–4). Twenty-nine (73%) patients had a rise in VEGF, with an overall increase of 118 pg/ml (quartiles −5, 306; P

The presence of platelets in association with cancer deposits has been recognised for over 100 years; however, the recognition of a two-way interaction has been more recent. The link between cancer spread and platelet stimulation is pivotal to understanding of the hypercoagulable state found in most cancer patients. The assistance of platelets in cancer spread may provide opportunities to interrupt this relation, thus inhibiting metastasis.

Summary The coagulation system, which is activated in most cancer patients, has an important role in tumour biology. It may make a substantial contribution to tumour angiogenesis, which represents an imbalance in the normal mechanisms that allow organised healing after injury. The recently recognised, but steadily growing, knowledge of the relationship between the coagulation and angiogenesis pathways has research and clinical implications. Manipulation of these systems may minimise both the neoangiogenesis essential for tumour growth and associated thromboembolic complications. However, since surgery is the primary treatment for most cancers, the angiogenesis of wound healing and haemostatic competence must be maintained. In this article, we summarise the complex interactions between the coagulation system and the angiogenic process that occur in cancer growth. We focus upon the contributions of the vascular endothelium, platelets, and coagulation factors to the angiogenic process and explore the coagulation system as a therapeutic target.

Acute appendicitis is the most common presentation of the acute abdomen in the UK. Although in most cases this is an easily reached diagnosis, presentation is not always typical and there are certain other conditions which may mimic appendicitis. Diagnostic adjuncts usually provide the additional information required to make a confident diagnosis; however, in some circumstances, the safest and most reliable course of action is appropriate surgical intervention. A case report is presented of a 43-year-old woman who presented with history of peri-umbilical pain migrating to the right iliac fossa. Following further investigation, with routine blood tests, plain radiographs, ultrasound examination of the abdomen and pelvis, and CT scanning not pointing towards a definitive diagnosis, she eventually underwent a diagnostic laparoscopy which revealed primary omental torsion. An open omentectomy was performed and 2 months on she remains well.

The effects of diltiazem treatment on symptoms of chronic anal fissures and their long-term outcome were investigated. One hundred and twelve patients were supplied with 6-week course of 2% diltiazem cream for twice-daily topical application. The medical notes and extended follow-up by telephone for 112 patients were recorded and statistically analysed. The success rate and satisfaction of topical diltiazem were each over two thirds. Nearly 80% of patients reported no adverse effects, and it seems that those complaints attributed to diltiazem rarely led to reduced compliance. After diltiazem therapy for fissure, 59% of patients required further treatment (medical and/or surgical) over the average 2-year period of follow-up. The reported adverse effects of topical diltiazem treatment in patients with anal fissures were more common than previously thought, although compliance was rarely affected. During consultation regarding the advantages and disadvantages of surgical vs. chemical sphincterotomy, patients should be aware that the majority of patients receiving diltiazem as the primary treatment for anal fissure subsequently require further treatment.

The effective and maintained decompression of pseudo-obstruction using the novel approach of a Heald anal stent is described. The Heald stent was placed trans-anally without the need for an anaesthetic, reducing luminal pressure allowing both initial decompression and maintenance of decompression of the rectum. This allowed the patient with significant medical co-morbidities to be discharged after a week without the need for operative intervention and thus reducing considerable patient risk.

One of the main changes of the current TNM-7 is the elimination of the category MX, since it has been a source of ambiguity and misinterpretation, especially by pathologists. Therefore the ultimate staging would be better performed by the patient's clinician who can classify the disease M0 (no distant metastasis) or M1 (presence of distant metastasis), having access to the completeness of data resulting from clinical examination, imaging workup and pathology report. However this important change doesn't take into account the diagnostic value and the challenge of small indeterminate visceral lesions encountered, in particular, during radiological staging of patients with colorectal cancer. In this article the diagnosis of these lesions with multiple imaging modalities, their frequency, significance and relevance to staging and disease management are described in a multidisciplinary way. In particular the interplay between clinical, radiological and pathological staging, which are usually conducted independently, is discussed. The integrated approach shows that there are both advantages and disadvantages to abandoning the MX category. To avoid ambiguity arising both by applying and interpreting MX category for stage assigning, its abandoning seems reasonable. The recognition of the importance of small lesion characterization raises the need for applying a separate category; therefore a proposal for their categorization is put forward. By using the proposed categorization the lack of consideration for indeterminate visceral lesions with the current staging system will be overcome, also optimizing tailored follow-up.

The use of TASER or stun guns has become increasingly popular among police agencies. They are proposed as an alternative non-lethal incapacitating device which can be used against aggressive or potentially violent individuals. It has been suggested that they produce no long-term medical problems. Such devices have been available to the police in the USA since the early 1980s, but have become more prevalent in the UK within the last few years. The police federation of the UK have stated that they want to further increase TASER availability to non-firearms officers in the field. If, as expected, the use of electrical guns becomes more common, there will no doubt be an increase in the number of victims presenting to the emergency department. Whether this is as a result of injuries secondary to being 'shot' or for removal of the electrical darts, medical practitioners will need to recognize the consequences, both short and long term, of such devices. Language: en

The implications of constructing a temporary ileostomy as part of the primary surgery for some rectal cancers must not be underestimated and many patients are particularly keen to have their stoma closed as early as possible. Currently, there are no set protocols in place which determine when this should take place, meaning that stoma reversal can be extremely variable between hospitals in the UK. We have created a policy to give patients a provisional date for ileostomy closure at discharge from primary surgery, which takes into account any necessary adjuvant treatment. We compared time to closure of ileostomy between two adjacent centres that share common stoma-care and oncology teams to see what benefit this policy provides. Patients were recruited over a 2-year period from 2005 to 2007 from two adjacent centres. Centre 1 had a policy to provide patients with a provisional date for closure of their ileostomy. The notes were studied retrospectively to determine time to closure of the ileostomy and reasons for any delays in closure. A total of 107 patients fulfilled the inclusion criteria, of which 83 patients (72%) had their stomas closed. Thirty patients had their stomas closed within 12 weeks (37%) - more than 67% (23/34) in centre 1 against 15% (7/48) in centre 2. At 1 year, all patients in centre 1 had their ileostomy closed, while 10% (5/48) were still waiting in centre 2. The mean time to closure was 13.47 and 25.25 weeks for centres 1 and 2 respectively -P-value < 0.0001. Offering patients a date for ileostomy closure at discharge from their primary resection results in the majority of stomas being closed within 12 weeks. For those patients who are to undergo adjuvant chemotherapy, we aim to perform this surgery in between the second and third cycles of treatment.

The demands of surgical evolution necessitate constant improvement, but may some technological advances be ultimately detrimental to what we set out to achieve? Natural Orifice Transendoluminal Surgery (NOTES) is a novel surgical technique which shatters the traditional boundaries of minimally-invasive surgery. Potentially the most exciting surgical innovation since the inception of laparoscopic surgery, encouraging reports of NOTES procedures have been seen in animal models, ranging from diagnostic biopsies to cholecystectomies. But with reports of the first human trials recently published – the operation Anubis – there is a danger that such technological advances, rather than benefit patients, may present safety risks similar to those experienced early in the history of laparoscopic surgery. Since the introduction of laparoscopic surgery, many traditional open procedures have been largely replaced by more minimally invasive techniques. This is particularly so in the case of gallbladder surgery, where the majority of today's trainee surgeons have not been exposed to elective open cholecystectomies. Such a transition in the surgical approach for cholecystectomy has occurred in less than 20 years, confirming the acceptance of the laparoscope. There is plenty of evidence supporting the advantages of laparoscopy, including faster recovery, less postoperative pain, better cosmesis, improved pulmonary function and a decreased inflammatory response.1–3 These benefits are largely attributed to smaller incision sizes. By extrapolating this argument, one may hypothesize that by removing the need for skin incisions, one would maximize such benefits. At the same time, endoscopy has evolved so that many gastrointestinal conditions are now managed without the need for surgical intervention. This has been successfully demonstrated in the case of therapeutic gastroscopy, which has reduced the role of upper gastrointestinal haemostatic surgery. These advances have no doubt had a beneficial effect on patients, with a reduction in patient morbidity and mortality. In theory at least, NOTES is the ultimate in surgery, avoiding unnecessary incisions by using the available orifices of the human body. It has combined the advances in therapeutic endoscopy and laparoscopic surgery to create a new hybrid form of surgery. This proposes to be the extreme of minimal invasive surgery; a truly scar-less operation. Allowing the surgeon to use orifices to access the body cavity, target organs can be reached without the need to create surgical access ( Figure 1). The operating instruments are housed within the channels of a flexible endoscope which perforate the stomach, bladder or colon to provide access to the abdominal and thoracic cavities. These are then insufflated with carbon dioxide, as in a laparoscopic procedure, allowing visualization of the object organs. The scope is withdrawn at the end of the procedure and the hollow organ perforation is repaired. In addition to the benefits of minimally-invasive surgery already described, the access may in fact be improved compared with both traditional open and laparoscopic procedures.4 It is notable that the first reported laparoscopic and NOTES procedures were cholecystectomies performed by French surgeons. Figure 1 Example of NOTES: transrectal cholecystectomy New surgical techniques have historically been met with some scepticism and NOTES is no different. Some surgeons still refute the laparoscope and one must appreciate that pioneering surgical techniques may bring about new complications. Using endoscopy to directly access intraluminal pathology may be seen as advantageous over other approaches. In the mind of some surgeons, however, breaching a contaminated cavity to access a sterile one seems foolhardy. One must remember that iatrogenic perforation of the gastrointestinal tract is a potentially fatal complication of endoscopy. Consider TEMS (Trans-anal Endoscopic Microsurgery), which may be thought of as a more basic form of surgery than NOTES. A quarter of a century after TEMS was introduced by Buess, its role is largely restricted to small, early stage rectal lesions and it has yet to find an accepted place in many surgical practices. Buess himself questions the motives of surgeons who may be keener to break new ground than preserve common sense.5 Pioneering work in surgery must be encouraged, but this must be tempered with reality. Surgeons must not pursue advancement of new techniques without a true realization of the cost. For any new technique to become widespread, it must be deemed safe, efficient, cost-effective and, if it does not improve on previous techniques, at least compliment the repertoire of treatments available at the time. If this new technique aims to challenge laparoscopic appendectomy or cholecystectomy with transgastric or even transcolonic surgery, it must have truly impressive results. These will only be likely after the learning curve is passed, though this may be both long and steep. Furthermore, it is unlikely that published reports will include such learning-curve failures. Current laparoscopic procedures cause minimal postoperative pain, are associated with few complications, cause little or no contamination and are often day-case procedures. How can NOTES supersede these well-accepted techniques? There are no external scars, assuming conversion is not required, which initially at least will confuse patients and doctors who may not know which organs have undergone surgery. We wonder whether all the additional risks of such an approach will outweigh the seemingly slim advantages of avoiding incision complications. It is important to appreciate that NOTES is not yet in its infancy, and there are scarce published reports of operations performed via this route in humans. Most work has been conducted using porcine models and relatively simple operations such as biopsies, cholecystectomy and tubal ligation.6–8 The results show future promise, but even at this early stage there are many key issues which will need to be addressed to avoid this promise remaining tantalisingly out of reach. Initial problems will include safely gaining optimal access (i.e. transgastric, transvaginal, transurethral or transcolonic). This will no doubt depend on the target organ and certainly the sex of the patient. Other issues are potential sepsis, closure of the visceral perforation and training issues.9 The operator will not only be required to be an experienced laparoscopist but also a highly-skilled endoscopist. Currently, laparoscopy is increasingly being used by all types of surgeons whereas endoscopy is predominantly practised by surgeons concerned with either upper or lower gastrointestinal surgery. Yet NOTES will not be exclusive to gastrointestinal procedures and it is surgeons within fields such as gynaecology and thoracic surgery who will be required to become proficient in endoscopy. Alternatively, surgical procedures within specific branches of surgery may be limited to forms of access which are familiar to them. For example, a gynaecologist may be restricted to using hysteroscopy while a thoracic surgeon is restricted to bronchoscopy. This in itself is an interesting evolutionary point and may well lead to a new breed of surgeon who will be required to demonstrate competency in both general laparoscopic and generic endoscopic skills, regardless of the access route. It seems likely and indeed sensible to share both the responsibility and acclaim between at least two senior surgeons during the inevitable learning curve. Both early and late complications must carefully be audited and it behoves the surgeon to accept external inspection of results. With this is mind, it is appropriate that the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) has been created to oversee the development of this branch of surgery. A website has been established allowing researchers to join the debate and provide accounts of their experiences (http://www.noscar.org). There is little doubt that NOTES does provide an exciting and potentially revolutionary direction for surgery in the 21st century – some have even gone as far as touting it as evidence that there are no limits to how human ingenuity and technology can reduce the physical and emotional trauma related to surgery – but we offer a note of caution in light of the lessons learned with the advent of laparoscopic surgery. There is a fine line between what we can do and what we should do.

Haemorrhoidal disease is common, but there is still no consensus on optimal treatment. The most appropriate treatment is tailored to the individual patient. This article defines and classifies haemorrhoids, reviewing the efficacy of current treatments including the latest techniques.

Background Women that carry germ-line mutations for BRCA1 or BRCA2 genes are at an increased risk of developing breast, ovarian and peritoneal cancer. Primary peritoneal carcinoma is a rare tumour histologically identical to papillary serous ovarian carcinoma. Risk-reducing surgery in the form of mastectomy and oophorectomy in premenopausal women has been recommended to prevent breast and ovarian cancer occurrence and decrease the risk of developing primary peritoneal cancer. Case presentation We present a case report of a woman with a strong family history of breast cancer who underwent risk-reducing surgery in the form of bilateral salpingo-oophorectomy following a mastectomy for a right-sided breast tumour. Following the finding of a BRCA1 mutation, a prophylactic left-sided mastectomy was performed. After remaining well for twenty-seven years, she presented with rectal bleeding and altered bowel habit, and was found to have a secondary cancer of the sigmoid colon. She was finally diagnosed with primary papillary serous carcinoma of the peritoneum (PSCP). Conclusion PSCP can present many years after risk-reducing surgery and be difficult to detect. Surveillance remains the best course of management for patients with known BRCA mutations.

Referrals of younger patients with ‘painful piles’ who have already applied steroid cream are common. Ninety per cent of acute anal fissures heal, but in nearly all those that …

Last year in the JRSM, Woywodt and Kiss recorded the history of earth-eating,1 and Grewal and Fitzgerald2 described the case of a learning-disabled man who consumed metal objects and pieces of clothing. Some workers hypothesize that such habits (pica) are related to dietary deficiencies. Here we report some evidence in support. A woman of 67 was being investigated for longstanding iron deficiency. Upper gastrointestinal endoscopy had been negative, but on colonoscopy the bowel contained several clumps of what appeared to be fabric. A dietary history, taken thereafter, revealed that she was in the habit of consuming whole woollen jumpers at a single sitting; also her iron intake was low. After iron supplementation and nutritional advice, both her urge to eat wool and the anaemia gradually resolved. Pica has been linked with severe iron-deficiency anaemia in children3 and adults.4 The question of cause and effect has not been resolved. In the past the habit has been seen as a manifestation of other disorders rather than an entity.5,6 Here, cessation of pica after successful treatment of the anaemia indicates that iron deficiency might have contributed to the causation.

Diverticulosis of the colon is a common condition of increasing age. Complications of diverticulitis including stricture, perforation and fistula formation often require surgery. Perforated diverticulitis may rarely present with spreading superficial sepsis. We describe for the first time, to our knowledge, a case of retroperitoneal diverticula perforation presenting as necrotising fasciitis of the leg necessitating hind-quarter amputation.

This review by Kuhry et al. [1] certainly tempts the reader with a question yet to be adequately answered, namely is open total extraperitoneal (TEP) or laparoscopic TEP the gold standard for inguinal hernia repair. However in fact the review seems to equate open repair with Lichtenstein for the majority of its data, but also includes other different open techniques such the Stoppa. As the Stoppa repair places the mesh in the same extraperitoneal site as TEP and TAPP the major long term complication (chronic groin pain) may be expected to be similar. However as this major complication was not addressed, it is difficult to conclude which technique really is superior. There are major problems with comparisons between hernia repair techniques which may explain the large differences between the groups. For example, every surgeon has a different idea of the actual Lichtenstein technique which makes comparison impossible. Also the learning curve particularly for the laparoscopic groups will bias against its early results compared to later results. Until these factors are taken into account perhaps the conclusions will still be unclear.

Professor Ellis's review of the legal consequences of intra-abdominal adhesions (July 2001, JRSM pp. 331-332) was timely. We have been investigating surgeons' attitudes to this common problem. Though there is little clinical evidence, barrier agents such as Seprafilm have been shown experimentally to lessen adhesions without importantly reducing anastomotic strength1. Perhaps recent adverse events2 have caused some surgeons to abstain from using such agents. Three points mentioned by Professor Ellis's article were included in a questionnaire sent online to our Forum for Registrars In Surgical Training (www.frist.org/temp/guynash.html ). General surgeons were asked whether they routinely warn patients, before laparotomy, of the risk of adhesions; whether they believe that covering a bowel anastomosis with omentum decreases the risk of future adhesions; and whether they use an agent, if available, in the hope of avoiding further adhesions in a patient with multiple previous laparotomies. Of the 50 who replied initially, 7 routinely warn about adhesions, 12 favour omental covering and 25 would not currently use an agent such as Seprafilm. On the evidence of this small survey, the lack of consensus on aetiology and epidemiology extends to practical management.

Background Acinar cell carcinoma (ACC) is a rare pancreatic neoplasm, and its presentation with acute pancreatitis has not been reported previously. Case outline A 70-year-old man presented with acute pancreatitis, and a spiral CT scan showed a 5-cm tumour in the body of the pancreas. Distal pancreatectomy was performed, and histological examination showed an ACC. Discussion This is a newly reported mode of presentation for a rare pancreatic tumour