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Background: The significance of magnetic resonance imaging (MRI)-suspected pelvic sidewall (PSW) lymph node involvement in rectal cancer is uncertain. Methods: Magnetic resonance images were reviewed retrospectively by specialist gastrointestinal radiologists for the presence of suspicious PSW nodes. Scans and outcome data were from patients with biopsy-proven rectal cancer and a minimum of 5 years' follow-up in the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study. Overall disease-free survival (DFS) was analysed using the Kaplan-Meier product-limit method and stratified according to preoperative therapy. Binary logistic regression was used to match patients for propensity of clinical and staging characteristics, and further survival analysis was carried out to determine associations between suspicious PSW nodes on MRI and survival outcomes. Results: Of 325 patients, 38 (11·7 per cent) had MRI-identified suspicious PSW nodes on baseline scans. Such nodes were associated with poor outcomes. Five-year DFS was 42 and 70·7 per cent respectively for patients with, and without suspicious PSW nodes (P < 0·001). Among patients undergoing primary surgery, MRI-suspected PSW node involvement was associated with worse 5-year DFS (31 versus 76·3 per cent; P = 0·001), but the presence of suspicious nodes had no impact on survival among patients who received preoperative therapy. After propensity matching for clinical and tumour characteristics, the presence of suspicious PSW nodes on MRI was not an independent prognostic variable. Conclusion: Patients with suspicious PSW nodes on MRI had significantly worse DFS that appeared improved with the use of preoperative therapy. These nodes were associated with adverse features of the primary tumour and were not an independent prognostic factor. [ABSTRACT FROM AUTHOR]

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Surgeons will sometimes advise against an operation because the patient is ‘old and frail’. A simple starring system (one to five), based on performance and lifestyles, has been devised to assess the biological age of elderly patients. 10 consultant surgeons and 10 trainees answered questions about their treatment recommendations for hypothetical patients of standard age and medical history various star ratings and surgical conditions. 1000 decisions were available for analysis. The four and five star patients (those leading an independent existence) were recommended 266 interventions, the one and two star patients 55. Trainees were more inclined to intervene than consultants, recommending operations in half the patients rather than one-third. These results indicate that decisions on surgical management are strongly influenced by the patient's rating or biological age. If the starring method proves reproducible in other patient groups and settings, it could allow better communication on an important factor in clinical decisions. [ABSTRACT FROM AUTHOR]

Need for centres and training standards [ABSTRACT FROM AUTHOR]

Pseudomyxoma peritonei (PMP) is a borderline malignancy, simulating carcinomatosis and generally arising from perforation of an appendiceal mucinous tumour. Some patients have coincidental dual pathology. Liver abnormalities in particular may be overlooked and/or misclassified. We report 2 cases of patients who had diffuse PMP with synchronous hepatic pathology to highlight the need for vigilance and appropriate assessment of coincidental liver lesions. An assessment and management strategy is outlined. [ABSTRACT FROM AUTHOR]

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article focuses on the anatomically based terminology of extralevator abdominoperineal excision (ELAPE). It states that ELAPE can be applied regardless of whether a patient is in the right lateral, prone, or supine positions, but ELAPE in the supine position does not appear to have many adverse effects. However, ELAPE was suggested to be associated with more adverse outcomes such as perineal hernia and perineal wound complications.

Presents an abstract for the article "Complete Cytoreduction For Pseudomyxoma Peritonei Requires Complex Multivisceral Resections in a Lengthy Procedure," by A. Mukherjee, M. Croxford, S. Banerjee, R. Sexton, S. M. Farquharson, T. D. Cecil, and B. J. Moran.

A response by Margaret Farquahson and B. J. Moran to a letter to the editor in response to their article about the study on the important role of doctors in the advocacy for the medical care of the people with mental disabilities that was published in the May 2001 issue is presented.

Aim The National Development Programme for Low Rectal Cancer in England ( LOREC) was commissioned in response to wide variation in the outcome of patients with low rectal cancer. One of the aims of LOREC was to enhance surgical techniques in managing low rectal cancer. This study reports on the development and evaluation of a novel national technical skills cadaveric training curriculum in extralevator abdominoperineal excision. Method Three sites were commissioned for the cadaveric workshops, each delivering the same training curriculum. Training was undertaken in pairs using a fresh-frozen cadaveric model under the supervision of expert mentors. Global assessment score ( GAS) forms were developed to promote reflective learning. Feedback on the impact of the workshop was obtained from a sample of delegates at the end of the course, and also after 3-23 months via an online questionnaire. Results Overall 112 consultant colorectal surgeons attended one of 15 cadaveric technical skills training workshops. Seventy-six per cent of delegates reported easy identification of anatomy in the cadaveric model; 67% found tissue planes easy to interpret. Ninety-six per cent of delegates felt the workshop would influence their future practice; 96% reported increased awareness of important anatomy. Only 2% of delegates wished to pursue supplementary formal training from LOREC. Conclusion Fresh-frozen cadavers could provide an effective training model for low rectal surgery. A structured 1-day cadaveric workshop has facilitated the dissemination of technical skills for management of low rectal cancer. Attending the cadaveric workshop enhanced delegates' confidence in performing this procedure. [ABSTRACT FROM AUTHOR]

Aim The optimal strategy for intravenous ( IV) fluid management during administration of hyperthermic intraperitoneal chemotherapy ( HIPEC) is unclear. In this prospective study we describe the use of a Li DCO rapid™ (Li DCO, Cambridge, UK) cardiac output monitor to guide IV fluid management during cytoreductive surgery ( CRS) with HIPEC. The aim of this study was to determine whether cardiac output monitoring will allow close maintenance of physiological parameters during the HIPEC phase. Method Twenty-five patients who underwent CRS combined with HIPEC were included in the study. Intra-operative IV fluid boluses were titrated using parameters measured by the Li DCO rapid™ monitor. Stroke volume variation was maintained below 10% with fluid boluses and mean arterial pressure was maintained within 20% of the baseline figure with vasopressors. Results There was no significant change in heart rate and cardiac output. The systemic vascular resistance dropped from an average of 966 dyn.s/cm-5 to 797 dyn s/cm5 at 60 min during the HIPEC phase ( P = 0.62) despite an increase in the dose of phenylepherine. The average total volume of fluid given was 748 ml in the first 30 min and 630 ml in the second 30 min with an average urine output of 307 and 445 ml, respectively. The change in lactate levels was not statistically or clinically significant. Conclusion Li DCO rapid™ is an effective noninvasive tool for guiding fluid management in this population. It allows the anaesthesiologist to maintain tight control of essential physiological parameters during a phase of the procedure in which there is a risk of renal injury. [ABSTRACT FROM AUTHOR]

Aim Extralevator abdominoperineal excision in the prone position has been reported as a method to improve the poor outcome sometimes observed after abdominoperineal excision (APE) for low rectal cancer. In this paper a pictorial guide is presented describing the key anatomical steps and landmarks of the operation. Method Intraoperative footage of five APE operations filmed in high definition was reviewed and key stages of the operation were identified. Still frames were captured from these sequences to illustrate this guide. An edited video sequence was produced from one of these operations to accompany this paper. Conclusion The prone APE allows improved visualization of the perineal portion of the operation by the surgeon, assistants and observers. It permits clear demonstration for teaching. Prospective evaluation is still required to identify patients who would benefit from extralevator APE. [ABSTRACT FROM AUTHOR]