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Background This study reports early mortality and survival from colorectal cancer in relation to the pattern of treatments delivered by the multidisciplinary team (MDT) meeting at a high-volume institution in England over 14 years. Methods All patients diagnosed with colorectal cancer and discussed during MDT meetings from 2003 to 2016 at a single institution were reviewed. Three time intervals (2003–2007, 2008–2012, and 2013–2016) were compared regarding initial surgical management (resection, local excision, non-resection surgery, and no surgery), initial oncological therapy, 90-day mortality, and crude 2-year survival for the whole cohort. Sub-analyses were performed according to age greater or less than 80 years. Results The MDT managed 4617 patients over 14 years (1496 in the first interval and 1389 in the last). Over this time, there was a reduction in emergency resections from 15.5 per cent to 9.0 per cent (P < 0.0001); use of oncological therapies increased from 34.6 per cent to 41.6 per cent (P < 0.0001). The 90-day mortality after diagnosis of colorectal cancer dropped from 14.8 per cent to 10.7 per cent (P < 0.001) and 2-year survival improved from 58.6 per cent to 65 per cent (P < 0.001). Among patients aged 80 years or older (425 and 446, in the first and last intervals respectively) there was, in addition, a progressive increase in ‘no surgery’ rate from 33.6 per cent to 50.2 per cent (P < 0.0001) and a reduction in elective resections from 42.4 per cent to 33.9 per cent (P = 0.010). The 90-day mortality after elective resection fell from 10.0 per cent (18 of 180) to 3.3 per cent (5 of 151; P = 0.013). Conclusions Survival from colorectal cancer improved significantly over 14 years. Among patients aged ≥80 years, major changes in the type of treatment delivered were associated with a decrease in postoperative mortality.

Objective: To undertake a randomized comparison of the Biodesign Surgisis anal fistula plug against surgeon's preference in treating cryptoglandular transsphincteric fistula-in-ano. Summary Background Data: The efficacy of the Biodesign Surgisis anal fistula plug in healing anal fistulae is uncertain. Methods: Participants were randomized to the fistula plug with surgeon's preference (advancement flap, cutting seton, fistulotomy, Ligation of the Intersphincteric Fistula Tract procedure). The primary outcome was faecal incontinence quality of life (FIQoL) at 12-months. Secondary outcomes were fistula healing, incontinence rates, and complication and reintervention rates. Results: Between May 2011 and March 2016, 304 participants were randomized to fistula plug or surgeon's preference. No differences were seen in FIQoL between the 2 groups at 12 months. Clinical fistula healing was reported in 66/122 (54%) of the fistula plug and 66/119 (55%) of the surgeon's preference groups at 12 months. Fecal incontinence rates improved marginally in both the groups. Complications and reinterventions were frequent, with significantly more complications in the fistula plug group at 6-weeks (49/142, 35% vs 25/137, 18%; P=0.002). The mean total costs were £2738 (s.d. £1151) for the fistula plug and £2308 (s.d. £1228) for the surgeon's preference group (mean difference +£430, P=0.0174). The average total quality adjusted life years (QALYs) gained was marginally higher in the fistula plug group. The fistula plug was 35% to 45% likely to be cost-effective across a willingness to pay threshold of £20,000 to £30,000 / QALY. Conclusions: The Biodesign Surgisis anal fistula plug is associated with similar FIQoL and healing rates to surgeon's preference at 12 months. Higher costs and highly uncertain gains in QALYs mean that the fistula plug may not be considered as a cost-effective treatment in the UK NHS.

The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.

Introduction The aim of our study was to analyze the short-term outcomes of laparoscopic surgery for a no medical responding ileocolic Cohn's disease in a single center according to the presence of obesity. Methods A cross-sectional study was performed including all consecutive patients who underwent laparoscopic resection for ileocecal Crohn's disease from November 2006 to November 2015. Patients were divided according to body mass index ≥30 kg/m2 in order to study influence of obesity in the short-term outcomes. The following variables were studied: characteristics of patients, surgical technique and postoperative results (complications, reintervention, readmission and mortality) during first 30 postoperative days. Results A total of 100 patients were included (42 males) with a mean age of 39.7±15.2 years (range 18–83). The overall complication rate was 20% and only 3 patients had an anastomotic leak. Seven patients needed reoperation in the first 30 days postop (7%). The median postoperative length of hospitalization was 5.0 days. Operative time was significantly longer in patients with obesity (130 vs 165 min, P=.007) but there were no significant differences among the postoperative results in patients with and without obesity. Conclusions This study confirmed that laparoscopic approach for ileocecal Cohn's disease is a safety and feasible technique in patients with obesity. In this last group of patients we only have to expect a longer operative time.

More precise risk stratification is required to enable timely diagnosis of bowel cancer while avoiding unnecessary investigation, argue Michael Thompson and colleagues

Background: The Biodesign Surgisis anal fistula plug preserves continence, but its efficacy in healing anal fistulae is uncertain. Methods: A randomised trial involving 40 UK hospitals comparing the fistula plug with surgeon's preference (advancement flap, cutting seton, fistulotomy, LIFT procedure) for cryptoglandular transsphincteric anal fistulae. Randomisation was a one-to-one, minimised by age, ASA grade, planned surgery, and presence of secondary tracts. The primary outcome was faecal incontinence quality of life (FIQoL) at 12-months. Secondary outcomes were fistula healing, incontinence rates, and complication and re-intervention rates. A trial-based cost-utility analysis was undertaken. Findings: Between May 2011 and March 2016, 304 participants were equally randomised to fistula plug or surgeon's preference. No differences were seen in FIQoL between the two groups at 12-months. Clinical fistula healing was reported in 66/122 (54%) of the fistula plug and 66/119 (55%) of the surgeon's preference groups at 12-months. Faecal incontinence rates showed a marginal improvement in both groups. Complications and re-interventions were frequent, with significantly more complications in the fistula plug group at 6-weeks (49/142, 35% vs. 25/137, 18%; p=0.002). The mean total costs were £2,738 (s.d. £1,151) for the fistula plug and £2,308 (s.d. £1,228) for the surgeon's preference group (mean difference +£430, p=0.0174). The average total QALYs gained was marginally higher in the fistula plug group. Using multiple imputation and probabilistic sensitivity analysis the fistula plug was 35%-45% likely to be costeffective across a willingness to pay threshold of £20,000-£30,000/QALY. Interpretation: The Biodesign Surgisis® anal fistula plug is associated with similar FIQoL and healing rates to surgeon's preference at 12-months. Higher costs and highly uncertain gains in QALYs mean that the fistula plug may not be considered as a cost-effective treatment in the UK NHS. Trial Registration Number: (ISRCTN 78352529). Funding Statement: The FIAT trial was funded by the NIHR Health Technology Assessment Programme - 07/89/01. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Ethical committee approval was obtained (10/H0405/29). The trial was overseen by an independent Trial Steering Committee and Data Monitoring and Ethics Committee.

Aim The aim of the study was to determine the effect of major complications after colorectal cancer surgery on survival and time to recurrence. Method Patients having a curative colorectal cancer resection and a follow-up of at least 3 years were identified from a prospective database. Major complications were defined as Clavien–Dindo Grades 3b or 4 and their impact on time to recurrence and mortality was analysed by univariate and multivariable analysis. Postoperative death within 30 days or during the initial hospitalization (Clavien–Dindo Grade 5) was a priori excluded. Results From 2003 to 2012, 868 colorectal cancer resections resulting in 63 (7%) major postoperative complications including deaths (Clavien–Dindo ≥ 3b) were identified. After exclusion of Grade 5 complications (postoperative or in-hospital deaths), 844 resections with 39 (5%) major complications remained for analysis. Median follow-up time was 5.7 years. Using the Kaplan–Meier method, the estimated crude 5-year overall survival probability was 78% (95% CI 75–81) in the group without and 65% (95% CI 51–83) in the group with major complications (P = 0.009, log-rank test). Major complications were a significant negative predictor for overall survival (hazard ratio 2.42, 95% CI 1.41–4.14) when adjusted for sex, age, American Society of Anesthesiologists grade, tumour site (colon vs rectum), R stage and tumour stage. However, in both univariate and multivariable analysis, major complications were not a significant predictor for time to recurrence (hazard ratio 1.29, 95% CI 0.56–2.99). Conclusion Non-lethal major postoperative complications seem to have a negative long-term impact on survival but not on time to recurrence.

Lynch syndrome is currently under-recognised, underdiagnosed, and undermanaged, so opportunities to reduce cancer mortality are often missed. The new guideline from the National Institute for Health and Care Excellence recommends universal testing for Lynch syndrome in all people newly diagnosed as having colorectal cancer.1 This should prevent several hundred colorectal cancers annually, but several issues hinder good care …

Aim Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly and parous women. There is no accepted standard surgical treatment, with previous studies limited in methodological quality and size. PROSPER aimed to address these deficiencies by comparing the relative merits of different procedures. Method In a pragmatic, factorial (2 × 2) design trial, patients could be randomised between abdominal and perineal surgery (i), and suture vs resection rectopexy for those receiving an abdominal procedure (ii) or Altemeier's vs Delorme's for those receiving a perineal procedure (iii). Primary outcome measures were recurrence of the prolapse, incontinence, bowel function and quality of life scores (Vaizey, bowel thermometer and EQ-5D) measured up to 3 years. Results Two hundred and ninety-three patients were recruited: 49 were randomised between surgical approaches (i); 78 between abdominal procedures (ii); and 213 between perineal procedures (iii). Recurrence rates were higher than anticipated, but not significantly different in any comparison: Altemeier's vs Delorme's 24/102 (24%) and 31/99 (31%) [hazard ratio (HR) 0.81; 95% CI 0.47, 1.38; P = 0.4]; resection vs suture rectopexy 4/32 (13%) and 9/35 (26%) (HR 0.45; 95% CI 0.14, 1.46; P = 0.2); perineal vs abdominal 5/25 (20%) and 5/19 (26%) (HR 0.83; 95% CI 0.24, 2.86; P = 0.8). Vaizey, bowel thermometer and EQ-5D scores were not significantly different in any of the comparisons. Conclusion No significant differences were seen in any of the randomised comparisons, although substantial improvements from baseline in quality of life were noted following all procedures.

Incisional hernia at the extraction site (ESIH) is a common complication after laparoscopic colorectal resections. The aim of this study was to evaluate the prevalence and potential risk factors for ESIH in a large cohort study having standardized technique. A cross-sectional study was performed including all patients who underwent elective laparoscopic right or extended right colectomy for cancer from November 2006 to October 2013 using a standard technique. All patients have been followed up for a minimum of 1 year with abdominal CT scan. A total of 292 patients were included with a median follow-up of 42 months. Twenty patients (6.8 %) developed ESIH. Obesity (odds ratio (OR) = 3.76, 95 % confidence interval (CI) 1.39–10.15; p = 0.009) and incision length (OR 2.86, 95 % CI 1.077–7.60; p = 0.035) significantly predisposed to the development of ESIH. This study identified that the risk of ESIH is significant after colonic resections and there are several risk factors responsible for the development of ESIH.

Background Pilonidal disease is a common and usually minor disease. Although wide excisional surgery has been common practice, there are more simple alternatives. This review focused on the aetiology and management of pilonidal disease. Methods A comprehensive review of the literature on pilonidal disease was undertaken. MEDLINE searches for all articles listing pilonidal disease (1980–2010) were performed to determine the aetiology and results of surgical and non-surgical treatments. Single papers describing new techniques or minor modifications of established techniques were excluded. Further articles were traced through reference lists. Results Patients with minimal symptoms and those having drainage of a single acute abscess can be treated expectantly. Non-surgical treatments may be of value but their long-term results are unknown. There is no rational basis or need for wide excision of the abscess and sinus. Simple removal of midline skin pits, the primary cause of pilonidal disease, with lateral drainage of the abscess and sinus is effective in most instances. Hirsute patients with extensive primary disease and deep natal clefts, or with recurrent disease and unhealed midline wounds, may also require flattening of the natal cleft with off-midline skin closure. These more conservative procedures are usually done as a day case, require minimal care in the community and are associated with a rapid return to work. They also avoid the occasional debilitating complications of surgical treatment. Conclusion Simple day-case surgery to eradicate midline skin pits without wide excision of the abscesses and sinus is rational, safe and effective for patients with pilonidal sinus disease.

Background The aim of this study was to determine which of Bascom's simple techniques, Bascom's simple surgery or Bascom's cleft closure, is preferred in the management of moderate-severity pilonidal disease. Methods Fifty-five patients with chronic pilonidal disease were randomized to receive Bascom's simple surgery (n = 29) or cleft closure (n = 26) under local anesthetic. The primary end point was time to healing. Patients were followed up for a median of 3 years (range, .7–4 y). Results After Bascom's simple surgery, 5 of 29 patients did not heal and proceeded to cleft closure. The remaining patients healed at a median of 4 weeks (range, 3–35 wk). After cleft closure, 21 of 26 wounds healed primarily on removal of sutures at 10 to 13 days. The remaining 5 wounds healed at a median of 4.5 weeks (range, 2–5 wk). Fifty of 55 (91%) patients were contacted for follow-up evaluation, disease recurrence occurred in 2 of 24 after Bascom's simple surgery and in 0 of 26 after cleft closure. Conclusions Cleft closure offers more predictable healing than Bascom's simple surgery, with less need for re-operation. Disease recurrence is more prevalent after Bascom's simple surgery.

Diverticular disease of the colon is common in the Western world, with a prevalence of approximately 33% in patients over 60 years of age.1 Perforation associated with diverticular disease has concurrently increased in prevalence from 2.4 cases per 100,000 in 1986 to 3.8 cases per 100,000 in 2000.2 Surgical treatment has evolved from a three-stage procedure to a two-stage procedure of primary resection of the perforated segment and end colostomy (Hartmann's procedure [HP]) with subsequent restoration of intestinal continuity, after convincing evidence by two randomized trials.3,4 HP has been accepted as the “gold standard” for perforated diverticular disease by the great majority of colorectal surgeons in the United States and the United Kingdom.1 However, there is a growing body of evidence reporting on high complication rates with end stoma reversal procedures.3,5,6 Specifically, anastomotic leak rates of 2% to 30%7–9 and major complication rates of 5% to 25%10–13 have been reported. In addition, 20% to 50% of patients undergoing a Hartmann's procedure are never reversed.9,14,15 Primary resection and anastomosis (PRA) has been proposed as an alternative to Hartmann's procedure in the setting of peritonitis secondary to diverticular disease. Several published studies have reported on comparable morbidity and mortality rates after PRA when compared with HP for perforated diverticular disease.11,12,16 A systematic review by Salem and Flum has shown an overall mortality rate for PRA of 9.9% compared with 18.8% for HP.9 Furthermore, wound infection rate was reported as 9.6% for PRA versus 24.2% for HP. Overall anastomotic leak rate for PRA was 13.9%, whereas stoma-related complication rate for HP was 10.3%. Primary anastomosis with a proximal defunctioning stoma (PADS) was shown to result in even better outcomes in terms of anastomotic leak and wound infection compared with simple PRA. Limited conclusions can, however, be drawn from the existing studies due to significant selection bias in their results. Determining the optimal operative strategy for patients with perforated diverticular disease involves a balance of postoperative morbidity and mortality after the primary operation, morbidity and mortality from the stoma reversal operation, the risk of permanent stoma, and the quality of life associated with each variable. A randomized controlled trial on the subject is unlikely to be achieved due to difficulties in patient recruitment in the emergency setting and institutional preferences. Decision analysis is particularly useful for comparisons of such competing management strategies in the setting of multiple endpoints and high levels of clinical complexity.17 The aim of the present study was to use decision analytic techniques to determine the optimal operative strategy for a hypothetical 65-year-old patient with peritonitis secondary to perforated diverticulitis.

This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.

Diverticulosis coli is the presence of acquired herniations of colonic mucosa through the muscular wall, with a covering of colonic serosa (Figure 1).

Objective: To compare the acceptability and efficacy of two methods of self administered bowel preparation for flexible sigmoidoscopy screening: a single phosphate enema and a single sachet of Picolax. Design: Single blind, randomised trial. Setting: Endoscopy units of two general hospitals. Participants: 1442 men and women aged 55-64 years who had agreed to be screened by flexible sigmoidoscopy. Main outcome measures: Attendance rates, compliance with allocated preparations, adverse effects, quality of bowel preparation, procedure time, and yield of neoplasia. Results: Compliance with the enema was higher than with the Picolax (608 (84%) v 566 (79%); difference 6%, 95% confidence interval 2% to 10%). Almost half of those who refused Picolax used an enema at home. Wind, incontinence, and sleep disturbance were more frequent in the Picolax group than the enema group; bottom soreness was more frequent in the enema group. Around 30% (187) found the diet restriction required by Picolax difficult; 78% (471) found the enema easy to administer. The quality of preparation was better with the enema; the proportion of procedures complete to the descending colon was greater and the mean duration of the procedure was shorter. There was no significant difference in polyp detection rates. Conclusion: A single phosphate enema self administered around one hour before leaving home is a more acceptable and effective method of preparing the distal bowel for flexible sigmoidoscopy than Picolax.

This chapter outlines the specialist approach toward pilonidal sinus recurrence. The improved outcome obtained with off-midline flap closure has given way to more minimalist procedures. There have been more than 100 procedures described for the treatment of this condition, which clearly demonstrates that no one treatment is totally effective.

Diverticular disease affects up to 50% of people by the time they reach the age of 80. The major complications of diverticular disease (abscess, perforation, fistula, obstruction and bleeding) have their own management pathways, but the treatment of uncomplicated diverticulitis is controversial. On initial presentation, diverticulitis is always treated conservatively. Whether this should be followed by resectional surgery has been the subject of speculation for many decades. The American Society of Colon and Rectal Surgeons recommended in 2000 that an elective resection should follow two attacks of acute diverticulitis. Much of the work underpinning their policy was based on seminal studies by Parks in the 1960s and 1970s who followed cohorts of patients with diverticular disease and examined their outcomes. However, many of these studies were based on inaccurate diagnostic data where the diagnosis was made primarily on clinical grounds. Investigations such as barium enema or colonoscopy are not reliable in confirming the presence of inflammation. Since CT scanning has become routine, the diagnosis of acute diverticulitis can now be made accurately. In recent years much work has been done, such as by Ambrosetti, who has produced evidence predicting the outcome of diverticulitis based on CT findings. More recent papers, in which the diagnosis of acute diverticulitis is likely to have been made more accurately, confirm that although recurrent attacks of diverticulitis are fairly common, there is a very low incidence of serious complications after long-term follow-up. It has also become apparent that the majority of patients who present with the major complications of diverticulitis, specifically abscess, perforation and fistula, do so as their first presentation of the disease, without previous episodes of diverticulitis. The corollary of this is that patients having had acute diverticulitis do not run the risk of developing life-threatening complications without elective surgery. The complications of left-sided colonic resection are not inconsiderable with anastomotic leaks, the formation of a stoma, either temporary or permanent, as well as mortality. When these data are put alongside the very low risk of serious harm to the patient after diverticulitis, the balance of opinion has now swung heavily in favour of a more conservative approach. In addition to this there are modern and innovative medical therapeutic approaches to the treatment of diverticulitis such as 5ASAs, poorly absorbed antibiotics and probiotics.

Pilonidal sinus disease was first described in the nineteenth century [1]. Although a minor condition for most patients, it can result in pain and sepsis with long periods off work and education. It has caused severe disruption to the armed forces over the years. In one army center in the USA in the 1990s, over a 2-year period, 229 patients required 4,760 occupied-bed days, an average of 21 days per patient [2]. It is an acquired condition and is seldom seen before puberty. It is rarely seen in older patients. Risk factors include young age, male gender, hairiness, obesity, deep natal cleft, and poor hygiene [3, 4]. Pilonidal sinus disease is commoner in people from Mediterranean countries. It is thought to be caused by tethering of the midline raphe in the natal cleft to the underlying sacrum. Enlargement of hair follicles or skin crypts occurs resulting in sinuses, possibly as a result of changes to these follicles during puberty with blockage and subsequent sepsis within the follicles. Hair enters these sinuses and secondarily exacerbating the infection. This is facilitated by the movement of the buttocks and the barbed nature of the hairs [5, 6]. Although pilonidal pits occur elsewhere in the body due to direct puncture of the skin due to hairs, it is not thought to be the etiology in pilonidal sinus disease in the natal cleft [7].

Background and Objectives: The excellent outcomes reported for laparoscopic colorectal surgery in selected patients could also be potentially advantageous for high risk patients. This prospective study was designed to examine the feasibility and safety of laparoscopic resection in high risk patients with colorectal cancer. Methods: Between 2006 and 2008 consecutive patients undergoing elective surgery for colorectal cancer were stratified into high and low risk groups. High risk was defined as ≥80 years, American Society of Anesthesiologists ≥3, preoperative radiotherapy, T4 tumor and BMI ≥30. Outcomes included median length of stay, lymph node yield, resection margins, 30-day hospital readmission, postoperative mortality and major postoperative complications requiring reoperation within 30 days of surgery. Results: A total of 424 patients underwent elective laparoscopic (224) and open (200) resections. Overall mortality rate for laparoscopic resection was 1 of 224 (0.4%) versus 4 of 200 (2%) for open resection. Median length of stay was 4 (2-33) versus 10 (1-69) days (P < 0.0001), and rate of complications requiring reoperation was 2 of 224 (0.8%) compared with 10 of 200 (5%) (P = 0.02). Among the 280 (66%) "high risk" patients, 146 had laparoscopic resection (8 conversions; 5%) and 134 had open resections. Median hospital stay was 4 (2-33) days in the laparoscopic group versus 11 (1-69) days in the open group (P < 0.0001). Complications requiring reoperation were 2 of 146 (1.4%) after laparoscopic resection versus 7 of 134 (5.2%) after open resection (P < 0.09). Readmission rate after laparoscopic resection was 12.3% versus 5.2% after open resection (P = 0.06). Conclusion: Laparoscopic resection of colorectal cancer can achieve excellent results even in "high risk" patients and is associated with significant reductions in length of stay compared with open resection.

A clear understanding of the changes in the theories on the aetiology of pilonidal sinus disease is essential to understand how these have influenced the evolution of its treatment and to select appropriate modes of treatment in the future. This condition may be self-limiting, and successful non-surgical treatments have been reported using simple removal of hairs, careful natal-cleft hygiene and injections with phenol. For patients with minor symptoms, this could be the correct initial approach.

The deep circumflex iliac artery flap (DCIA) has been well described as an autograft flap used in head and neck reconstructions, particularly for large maxillary and mandibular defects. Complications, particularly at the donor site, have been well documented. Although it is considered a minor complication, herniation should not be underestimated as it can potentially lead to bowel obstruction, necessitating an emergency operation. We report a case of acute obstruction of the small bowel secondary to herniation at the donor site after harvesting a DCIA free flap for a maxillary defect, a complication that to our knowledge has been reported only once. We review the pathogenesis and possible ways to reduce the likelihood of developing this serious complication.

Background The aim was to identify the patients with colorectal symptoms most likely to benefit from whole colonic imaging (WCI) to diagnose colorectal cancer and those for whom flexible sigmoidoscopy (FS) may be initially sufficient. Methods This prospective observational study (16 years) included 16 433 newly referred patients with symptoms or signs of colorectal cancer. Results Colorectal cancer was diagnosed in 946 patients (diagnostic yield 5·8 per cent), 815 (86·2 per cent) in the rectum or sigmoid (distal) and 131 (13·8 per cent) in the proximal colon. Some 15 829 patients (96·3 per cent) presented with symptoms alone (without iron deficiency anaemia or abdominal mass). Of 787 cancers in these patients, 750 (95·3 per cent) were distal. The prevalence of proximal cancer above and below the age of 60 years was 0·4 per cent (33 of 8249) and 0·1 per cent (four of 7580) respectively. Of 16 256 patients having FS, 5665 (34·8 per cent) had WCI. Of the other 10 591, five subsequently presented with proximal cancers. FS missed ten (1·3 per cent) of 796 cancers. Conclusion Patients with iron deficiency anaemia or a mass require WCI. However, in patients with symptoms alone, FS detects 95 per cent of cancers, and the diagnostic yield of WCI after FS is very low. Alternative management strategies need to be developed to avoid unnecessary investigations in this low-risk group.

Background The choice of operation for complicated diverticular disease is contentious. The aim of this study was to investigate adverse events following restorative (primary resection and anastomosis, PRA) and non-restorative (Hartmann's procedure, HP) surgery for complicated diverticular disease. Methods Five hundred and thirty-nine patients who presented with complicated diverticular disease in 42 centres over a 12-month period from January 2003 were considered for the study. Data were collected prospectively from 248 patients (46·0 per cent) who underwent PRA and 167 (31·0 per cent) who had HP. A propensity score was developed for case-mix adjustment. Multifactorial logistic regression was used to evaluate differences in operative outcomes. Results Mortality, surgical and medical complication rates were 4·0, 31·0 and 13·7 per cent respectively after PRA, and 23·4, 53·3 and 40·7 per cent for HP (all P < 0·001). After adjusting for the propensity score, the HP group had a 2·1- and 1·9-fold increase in medical and surgical complications respectively compared with those who had PRA, whereas the operative mortality rate was not significantly different. Non-colorectal surgeons performed a significantly higher proportion of HPs in the non-elective setting than colorectal surgeons (80·6 versus 60·4 per cent; χ2 = 8·31, 1 d.f., P = 0·004). Conclusion PRA with or without a proximal diversion is more often performed non-electively by specialist colorectal surgeons. It may be a safe procedure for complicated diverticular disease in selected patients as it may be associated with fewer postoperative adverse events.

This study was designed to evaluate the accuracy of the Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, Portsmouth–Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, colorectal–Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, and the Surgical Risk Scale for the treatment of patients with complicated diverticular disease. Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity variables were prospectively recorded for 324 patients undergoing colorectal resections in 42 hospitals in the United Kingdom from January to December 2003. The accuracy of each model was evaluated by measures of discrimination, calibration, and subgroup analysis. The overall operative mortality was 10.8 percent (Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 21.9 percent; Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 10.5 percent; colorectal–Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 10 percent; Surgical Risk Scale-estimated mortality rate, 38.2 percent). Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity and the Surgical Risk Scale over-predicted mortality in young patients (P < 0.001) and Portsmouth–Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity underpredicted mortality in elderly patients (P < 0.001). Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity and the Surgical Risk Scale overpredicted mortality in patients with generalized peritonitis (Hinchey III and IV). There was no significant difference between the observed and colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity predicted mortality across patient subgroups and when the overall sample was considered. The study suggested a lack of calibration of Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, Portsmouth–Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, and the Surgical Risk Scale at the extreme of age and for patients with severe peritoneal contamination. Colorectal–Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity was found to accurately evaluate mortality arising from complicated diverticular disease.

Background Many treatments for symptomatic pilonidal sinus disease have been described. Ambulatory treatment with minimal morbidity and a rapid return to normal activity is desirable. Bascom's operation fulfils these requirements. This paper describes the operative technique and results of treatment. Methods Some 218 patients of mean age 27 years were treated as day cases. The mean duration of symptoms was 2·4 years. Sixty-eight per cent of patients had complex disease with more than two midline pits and/or a lateral discharging sinus. One hundred and eighty-three patients (84 per cent) were operated on under local anaesthesia. Results Ninety-five per cent of patients have been followed up for a mean of 12·1 (range 1–60) months. All except one midline wound healed. Lateral wounds healed after a mean of 4·0 (range 1–15) weeks. Postoperative complications were few, including bleeding in 4 per cent and abscess formation treated by reopening the lateral incision in 6 per cent. Twenty-one patients (10 per cent) have had recurrence and have needed reoperation. Conclusion Bascom's operation is simple and results in considerable financial savings with minimal social disruption and an early return to work. Recurrent disease is no more frequent than after other treatments.

PURPOSE: This study was designed to examine the results of Delorme's procedure. METHODS: Thirty-two patients (24 males and 8 females, mean age, 70 years) underwent Delorme's procedure between 1978 and 1990 following symptoms lasting between two weeks and ten years. Thirteen patients had had 21 previous operations for prolapse. RESULTS: The mean operation time was 65 minutes. No blood transfusions were needed, there was no operative mortality, and only two patients had complications (one chest infection and one anastomotic dehiscence). No patients were lost to follow-up. Over a mean follow-up of 24 months (4 months to 4 years), 9 patients died of unrelated conditions. There were four recurrences (12.5 percent), two in patients who had each had two previous procedures. Incontinence improved in 46 percent. No patient became constipated and 50 percent of those constipated preoperatively improved. CONCLUSION: Although abdominal rectopexy is safe and has a low recurrence rate (

Aims: Sub-specialization for elective surgery may de-skill ‘general’ surgeons, potentially reducing the safe care of general surgical emergencies. This study aimed to determine how often a mismatch occurs between a sub-specialist surgeon and major specialist emergency operations. Methods: In a DGH with a population of 500 000, where all the surgeons are sub-specialized and with a separate vascular take, the mismatch between major emergency operations and the sub-speciality of surgeon on-call in a 1-year period was determined. The complexity of the surgery was determined according to BUPA classification. Results: In 1 year, there were 4225 non-elective admissions, of whom 1554 had an emergency operation. A total of 266 were at least major or of greater complexity from which there were 65 mismatches between surgeons and major operations, as shown below. Sixty-nine per cent (45/65) of mismatches were between LGI (lower gastrointestinal) operations and UGI (upper gastrointestinal) and breast surgeons. Fifty-five per cent (11/20) of major UGI operations were for simple suture-perforated ulcer, 15 per cent (3/20) cholecystectomies, 20 per cent (4/20) under-running bleeding peptic ulcers and 10 per cent (2/20) gastrectomies. Seventy-eight per cent (51/65) mismatches occurred out of normal working hours of which 31 per cent (16/51) were done by consultants. Conclusion: The major problem in the future will be for UGI and breast surgeons to maintain their skills in LGI surgery. However, mismatches occurring out of hours requiring consultant participation are uncommon.

Twenty-five patients with ingrowing toenails were treated conservatively by inserting cotton wool under the ingrowing nail edge. Seventy-nine percent were relieved of their symptoms after follow up for a mean of 23.7 weeks. Thirty-six percent had a history of previous surgery to the nail, 75% of whom had a good or excellent result. Although conservative management was first described in the eighteenth century and has been reported sporadically since, only a few doctors treat their patients in this way. There is, however, a distinct place for this highly effective, low cost method as the initial treatment of these patients without the need for hospital referral.

Zinc levels in plasma and leucocytes of elderly patients with and without cutaneous ulcers and in hospital were compared with those of a group of healthy elderly living at home and of a younger group. The groups in hospital had lower levels of plasma and leucocyte zinc than the control groups, but these were not associated with cutaneous ulcers. The zinc intake of the patients in hospital was well below the recommended daily allowance. Tissue zinc levels were found to be low in elderly patients in hospital, probably due to poor intake, but their contribution to the formation of skin ulcers was unproven.

Two patients with duplicated cystic ducts are reported. This is a rare and poorly reported anomaly. The hazards of misdiagnosis are discussed.

Although day case surgery is recommended, its widespread feasibility in an urban environment is unclear. We studied 100 consecutive unselected patients admitted for surgical procedures considered to be suitable for day case surgery. Their age, fitness and social details were recorded and they were asked both before surgery and after discharge by a postal questionnaire, whether they would have preferred treatment as an outpatient. There were 47 men and 53 women with a mean age of 42.5 years. Ninety-six were considered to be medically fit for day case surgery but 10 patients lived alone, seven had no suitable companion, 22 had too many stairs to climb, 13 lived too far from the hospital and two could not provide a lift home. Thus 58 of the patients were unsuitable for day case surgery. Seventy-eight of the patients replied to the postal questionnaire. Before the operation 51 patients preferred the idea of day care but only 14 felt the same way afterwards. The single postoperative complication was one case of acute retention after a hernia repair. In our experience, over half the patients initially deemed suitable for day case surgery would be unsuitable.

Zinc is required for protein synthesis and therefore for wound healing. Zinc levels were 50 per cent higher in muscle and skin from abdominal wounds of rats during the maturation phase of wound healing, but mild deficiency greatly reduced this accumulation. The results suggest that zinc takes part in the late stages of wound healing when protein is laid down, and that such extra local demands expose otherwise marginal zinc deficiency.

It has been suggested that patients with abdominal aortic aneurysms are deficient in tissue copper. Levels of copper and zinc in liver and aortic wall were therefore measured in 11 patients with aortic aneurysms and 11 fresh cadavers with normal aortas. The concentrations of copper were similar in both groups. Zinc concentration was higher in the normal aortic wall, probably because of the greater thickness of the media in the normal aorta. We found no evidence that aortic aneurysms are associated with reduced tissue copper concentrations.