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In rectal cancer, preoperative staging should identify early tumours suitable for treatment by surgery alone and locally advanced tumours that require therapy to induce tumour regression from the potential resection margin. Currently, local staging can be performed by digital rectal examination (DRE), endoluminal ultrasound (EUS) or magnetic resonance imaging (MRI). Each staging method was compared for clinical benefit and cost-effectiveness. The accuracy of high-resolution MRI, DRE and EUS in identifying favourable, unfavourable and locally advanced rectal carcinomas in 98 patients undergoing total mesorectal excision was compared prospectively against the resection specimen pathological as the gold standard. Agreement between each staging modality with pathology assessment of tumour favourability was calculated with the chance-corrected agreement given as the kappa statistic, based on marginal homogenised data. Differences in effectiveness of the staging modalities were compared with differences in costs of the staging modalities to generate cost effectiveness ratios. Agreement between staging and histologic assessment of tumour favourability was 94% for MRI (kappa=0.81, s.e.=0.05; kappa(W)=0.83), compared with very poor agreements of 65% for DRE (kappa=0.08, s.e.=0.068, kappa(W)=0.16) and 69% for EUS (kappa=0.17, s.e.=0.065, kappa(W)=0.17). The resource benefits resulting from the use of MRI rather than DRE was 67164 UK pounds and 92244 UK pounds when MRI was used rather than EUS. Magnetic resonance imaging dominated both DRE and EUS on cost and clinical effectiveness by selecting appropriate patients for neoadjuvant therapy and justifies its use for local staging of rectal cancer patients.

Background. There is indirect evidence that T cell responses can control the metastatic spread of colorectal cancer (CRC). However, an enrichment of CD4(+)Foxp3(+) regulatory T cells (Tregs) has also been documented. Objective. To evaluate whether CRC promotes Treg activity and how this influences anti-tumour immune responses and disease progression. Methods. A longitudinal study of Treg activity on a cohort of patients was performed before and after tumour resection. Specific CD4(+) T cell responses were also measured to the tumour associated antigens carcinoembryonic antigen (CEA) and 5T4. Results. Tregs from 62 preoperative CRC patients expressed a highly significant increase in levels of Foxp3 compared to healthy age-matched controls (p=0.007), which returned to normal after surgery (p=0.0075). CD4(+) T cell responses to one or both of the tumour associated antigens, CEA and 5T4, were observed in approximately two-thirds of patients and one third of these responses were suppressed by Tregs. Strikingly, in all patients with tumour recurrence at 12 months, significant preoperative suppression was observed of tumour-specific (p=0.003) but not control CD4(+) T cell responses. Conclusion. These findings demonstrate that the presence of CRC drives the activity of Tregs and accompanying suppression of CD4(+) T cell responses to tumour-associated antigens. Suppression is associated with recurrence of tumour at 12 months, implying that Tregs contribute to disease progression. These findings offer a rationale for the manipulation of Tregs for therapeutic intervention.

Appendicitis is the most commonly performed emergency abdominal surgery. The appendix can also be the site of a variety of neoplasms and unusual inflammatory conditions. A retrospective review was performed to determine the pathological diagnoses in appendicectomy specimens. This study is a retrospective analysis of 2660 appendicectomies performed from 1997 to 2003. The reports were analyzed for the following parameters: age-related incidence of acute appendicitis, seasonal variation in presentation, perforation rate, rate of negative and incidental appendicectomy, and the incidence of other pathologies encountered. Of the 2660 appendicectomy specimens, acute appendicitis was seen in 1718 patients (64.58%), with a peak in patients in their second decade (35.09% of cases of acute appendicitis). The perforation rate was 13.9% and was significantly higher in patients aged 70 years or more (P < 0.001). The negative appendicectomy rate was 28.8%, and was significantly higher in female patients (P < 0.001) and in the 11–30 year age group (P < 0.001). Other pathologies include carcinoid (0.52%), adenocarcinoma (0.39%), and mucinous cystadenoma (0.60%). The high rate of negative appendicectomy among female patients and the increased incidence of perforation in elderly patients reinforce the validity of the judicious use of laparoscopy in these populations. There are still a number of unusual histologies found in appendicectomy specimens supporting the continued use of routine histology.

Background: To validate the usefulness of virtual reality surgical simulators, we investigated the transfer of skills achieved by their use to real tasks. Methods: Thirty medical students underwent a pretest using a real laparoscopic trainer. They were then randomized to the following three groups: group I received no training; group II received training using the Minimal Invasive Surgical Trainer in Virtual Reality (MIST-VR); and group III received training using conventional training exercises. Each group then underwent a posttest. Using the Imperial College Surgical Assessment Device (ICSAD), scores were generated for time taken, distance traveled, number of movements made, and speed of instrument movement. Results: Significant changes between the MIST-VR group (group II) and the conventionally trained group (group III), were observed in the speed of movement of the left hand and the numbers of movements taken by each hand, when compared to the untrained group (group I). Conclusion: The training of novices using MIST-VR yields quantifiable changes in skill that are transferable to a simple real task and are similar to the results achieved with conventional training.

Background: This study assesses the transfer of laparoscopic skills to a group of Basic Surgical Trainees (BST) attending the Basic Surgical Skills (BSS) course. Methods: The virtual reality simulator MIST-VR was used to assess 13 trainees before and after the course and again 3 weeks and 3 months later. Analysis of kinematic data using the Imperial College Surgical Assessment Device gave measures of distance traveled, distance efficiency ratio, time taken, number of errors made, and number of movements made in completing a virtual laparoscopic task. The performance of the group was compared to a control group who underwent no training. Results: All parameters improved significantly after the course, with the exception of distance traveled by the instruments. All outcome measures were significantly improved at 3 weeks. The control group showed a nonsignificant trend toward improvement in all parameters. Conclusions: The Basic Surgical Skills course produces quantifiable improvements in laparoscopic skill that are measurable by MIST-VR. There is a learning effect associated with using MIST-VR alone.

Background A wealth of evidence obtained using mouse models indicates that CD4(+)CD25(+)FOXP3(+) regulatory T cells (Treg) maintain peripheral tolerance to self-antigens and also inhibit anti-tumor immune responses. To date there is limited information about CD4(+) T cell responses in patients with colorectal cancer (CRC). We set out to measure T cell responses to a tumor-associated antigen and examine whether Treg impinge on those anti-tumor immune responses in CRC patients. Methodology and principal findings Treg were identified and characterized as CD4(+)CD25(+)FOXP3(+) using flow cytometry. An increased frequency of Treg was demonstrated in both peripheral blood and mesenteric lymph nodes of patients with colorectal cancer (CRC) compared with either healthy controls or patients with inflammatory bowel disease (IBD). Depletion of Treg from peripheral blood mononuclear cells (PBMC) of CRC patients unmasked CD4(+) T cell responses, as observed by IFNgamma release, to the tumor associated antigen 5T4, whereas no effect was observed in a healthy age-matched control group. Conclusions/significance Collectively, these data demonstrate that Treg capable of inhibiting tumor associated antigen-specific immune responses are enriched in patients with CRC. These results support a rationale for manipulating Treg to enhance cancer immunotherapy.

Persistent symptoms after cholecystectomy are common, occurring in up to 40 per cent of patients. Severe pain persists in 10 per cent of cases. A total of 450 patients were studied, 200 after open cholecystectomy and 250 after the laparoscopic operation. Patient notes were reviewed and a postal questionnaire was circulated. Responses were obtained from 155 patients (77·5 per cent) undergoing opencholecystectomy and 205 (82·0 per cent) having the laparoscopic operation. Mean(s.d.) follow-up was 32(23) months after open cholecystectomy and 15(7) months after the laparoscopic procedure. Right upper quadrant pain was more common after open cholecystectomy (9·7 versus 3·4 per cent, P < 0·05). Indigestion and heartburn were equally prevalent in the two groups. Some 59·4 per cent of patients were free from symptoms after open cholecystectomy compared with 63·4 per cent following the laparoscopic operation; there was symptomatic improvement in 30·3 and 31·7 per cent respectively. Symptoms were the same or worse in 10·3 per cent of patients after open cholecystectomy compared with 4·9 per cent after the laparoscopic operation (P < 0·05). Patients report significantly less right upper quadrant pain after laparoscopic than after open cholecystectomy.

Liposarcoma is an uncommon sarcoma. Its presentation can be deceptive, varying from innocuous to frank malignancy. Liposarcoma behaves differently from other sarcomas. This article highlights the key prognostic factors of liposarcoma, based on current literature, and suggests a plan of management.

Summary The survival of young patients (⩽ 50 years of age) with carcinoma of the oesophagus or stomach has been reported to be poorer than that of their older counterparts. The aim of the current study was to review the outcome of such young patients with oesophagogastric cancer and to compare the outcome in patients with carcinoma of the oesophagus/cardia with patients with carcinoma of the more distal stomach. The study population was 50 patients. Tumour location was oesophagus/cardia (n=33) and gastric body/antrum (n=17). The most common presenting symptoms were weight loss (66%), epigastric pain (54%), dysphagia (50%), and heartburn (40%). Seventeen patients had experienced foregut symptoms for a period of ⩾6 months. These patients were more likely to have symptoms of gastro-oesophageal reflux disease and to have received acid suppression therapy than patients with shorter symptom durations. Only 20 patients underwent a potentially curative resection, while 10 underwent open and close laparotomy. The overall median survival was 7 months and the 5-year survival was 8%. Multivariate analysis revealed that surgical resection and UICC stage were the only factors that significantly influenced survival. There was no difference in the survival of patients with proximally situated tumours compared to those with distally located tumours. Wide variations in clinical practice were seen between different surgeons. Consequently, a multidisciplinary team designed to manage all patients with oesophagogastric cancer according to nationally agreed protocols has been established in our hospital. Earlier diagnosis of these tumours is to be encouraged, even if this necessitates the more liberal use of endoscopy in the evaluation of young patients with persistent foregut symptoms.

Summary Two siblings with extrinsic duodenal obstruction caused by congenital peritoneal bands are reported. Attention is drawn to the unusual physical sign of halitosis as a presenting feature. It is suggested that this physical sign may be an indication for barium studies.

Patients with complicated Crohn's disease often require several surgical procedures resulting in multiple adhesions. They also have an increased incidence of gallstones. Laparoscopic cholecystectomy is associated with several advantages but is problematic for the inexperienced surgeon in the presence of multiple adhesions. Laparoscopic cholecystectomy was performed successfully in three patients with Crohn's disease who had previous extensive abdominal surgery. The average operative time was 75 min, with an average hospital stay of 2 days and minimal blood loss. There were no postoperative complications. Provided specific precautions are taken during establishment of the pneumoperitoneum, an adequate adhesiolysis can be performed, rendering laparoscopic cholecystectomy feasible and safe in such patients.

The establishment of a gastrostomy by the percutaneous endoscopic route (PEG) is now accepted as a safe and easy procedure which can be performed under combined sedation and infiltration of local anaesthetic at the chosen site on the anterior abdominal wall. However, surgeons are still not infrequently called upon to perform an open gastrostomy in a selected group of patients, namely: (1) those with extensive laryngeal and pharyngeal tumours in whom it is impossible to pass even a paediatric gastroscope; (2) neonates with oesophageal atresia. Various forms of open gastrostomy have been described through the years. The Foley and dePezzer catheters are commonly used for such gastrostomies. These latex catheters are prone to problems such as tube migration (causing intestinal obstruction), fractures and balloon rupture. The mushroom catheter used in the PEG procedure is easier to manage and lasts longer without requiring replacement. It has a retaining disc at its skin exit site, preventing migration, and can also be closed to prevent leakage of gastric contents. We report a quick and easy way of performing an open gastrostomy utilizing the advantages of the mushroom catheter where the wound and the gastrostomy site are also separate.

A prospective microbiological analysis of evacuated pneumoperitoneum air in 20 patients following laparoscopic cholecystectomy for benign gallbladder disease is reported. In six patients (30%) a positive culture was obtained, out of which five had bowel derived organisms. Bile specimens taken at the same time as the air specimens were similarly cultured but failed to yield any organisms. There were no post-operative septic complications. There were no deaths. The initial results suggest that the evacuated peritoneal air is a potential source of contamination to the theatre staff and environment. This must be borne in mind when advocating laparoscopic procedures for treatment of high-risk patients.

In a 21-year period between June 1974 and May 1995, eight children required surgery for the treatment of complications after ingestion of corrosive substances. There were six oesophageal injuries due to alkali ingestion and two gastric injuries secondary to acid ingestion. Of those ingesting alkali, diagnosis of stricture was made at a mean of 28 days and all children underwent endoscopic dilatation with a mean of six treatments (range 2-13). Two children subsequently required oesophageal replacement and colonic interposition. One of the children ingesting acid presented as an emergency with peritonitis and required laparotomy at which partial gastrectomy and pyloroplasty were performed. The second child presented 3 weeks after ingestion with a gastric stricture and required gastrostomy. All children are currently alive and well and are asymptomatic. The details of management are discussed, together with a review of the literature.

Laparoscopic cholecystectomy is now an accepted part of general surgery. With the recent upsurge of interest in laparoscopic techniques, an optimum method of ensuring secure haemostasis is important particularly during dissection of the gall bladder from its mesenteric attachments. The use of laser to ensure haemostasis has been well practised in the treatment of peptic ulceration. Electrocautery is a time-honoured method of controlling local bleeding points by coagulation of tissue. The aim of this study was to assess whether one procedure showed any advantage over the other in terms of the length of operation time, postoperative drainage volume, time to dissect the gall bladder and length of the hospital stay.

Recent interest in laparoscopic surgery has led to an increasing number of procedures being performed by minimally invasive techniques. Initial experience with laparoscopic cholecystectomy and advances in instrument design and surgical technique have enabled more sophisticated procedures such as laparoscopic colectomy to be performed.

The technique of laparoscopic cholecystectomy is probably the most significant major surgical advance of the last decade. It allows shorter hospitalization, rapid recovery and early return to work. Significant financial savings may be achieved over current conventional treatment. In this article the procedure is reviewed and its advantages and drawbacks are discussed.

David Lewis Crosby performed the first renal transplant operation in Wales and established the principle of high dependency units in acute medical care. He was born, bred, educated, and spent most of his professional life in Cardiff. After house jobs in Cardiff, he did his national service with the British Army on the Rhine as medical officer to the 77th Heavy Anti-Aircraft Regiment. David made the most of this time, enjoying the many varied experiences of army medical life and learning German to a standard that often surprised both German patients and visiting medical students. He was casualty officer in Cardiff Royal Infirmary and registrar in general surgery in Swansea but realised that to improve his opportunities he needed research experience. He applied successfully for a post in the Peter Bent Brigham Hospital, Boston, …

A recent literature review of the rare anomalies of choledochal cysts is undertaken. Successful long-term outcome is dependent upon the operation performed. Cyst excision and hepaticojejunostomy is recommended to prevent the development of carcinoma and other serious complications.

Splenectomy for symptomatic splenic cyst is curative. The uncertainty regarding the incidence of post-splenectomy overwhelming sepsis has made surgeons re-evaluate the indications for splenectomy. We describe a minimal invasive approach for the treatment of symptomatic splenic cyst with the added benetit of splenic preservation.

Aims: A radical shift in management of abdominal sepsis from surgery to radiological drainage occurred in 20 years. This is safe and in majority it avoids the need for conventional surgery. When surgery is indicated it provides the roadmap by showing the exact nature of the abscess and its contents. This is a retrospective study from single centre to look at the outcome of management of localized intra-abdominal sepsis by using radiological guided drainage. Methods: All the patients who underwent radiological intervention for abdominal sepsis between 1995 and 2001 were included in the study. These were scanned and drains were inserted under radiological guidance under local anaesthetic. All these patients were followed up with antibiotics and drainograms when appropriate. Results: These patients were between ages of 14 and 84 years. A total of 216 procedures were performed. Twenty-four of them were diagnostic in that the patients were subjected to laparotomy or conservative management. A total of 192 patients had therapeutic aspiration or drainage. One hundred and forty-five patients had catheters inserted for continuous drainage and the rest had therapeutic aspiration. These patients included pelvic abscess (15 per cent), perinephric collections (12.4 per cent), subdiaphragmatic abscess (12 per cent), liver abscesses (8 per cent), pseudocysts (7 per cent), pericolic abscess (7.5 per cent), sub-hepatic abscess (5 per cent), psoas abscess (3.4 per cent), appendicular abscess (3.4 per cent), empyema gall bladder and pancreatic abscesses. Complications were minimal including transient sepsis, residual collection, haemorrhage into the cavity and persistent sinus. Our results include bacteriological studies of aspirates, which will be presented in detail at the time of presentation. Conclusion: Percutaneuos guided aspiration and drainage is a safe and effective alternative to conventional open surgical drainage. We recommend this as the first line of management.

Use of the Alvarado scoring system was assessed prospectively in a consecutive. series of 215 patients with suspected appendicitis over a 12 month period at the University Hospital of Wales, Cardiff. In comparison the high negative appendicectomy rate during the year prior to the study was reduced considerably with the scoring system without increasing morbidity or mortality.

The long-term effect of prednisone in Crohn's disease has been examined in a double-blind controlled trial. Clinical relapse, recurrence, and extension of the disease were examined in 64 patients followed-up for up to three years. Fourteen patients were withdrawn because of severe symptoms (eight on prednisone and six controls); the withdrawal rate in both groups was 30% at three years. Nine other patients had radiological recurrence or extension of disease (five prednisone and four controls). Prednisone did not improve the relapse rate, nor did it affect recurrence or extension of disease.

A method of removal of retained common bile duct stones under radiological control is described and its use in 16 patients reported. The case of the method, the minimal associated morbidibity and the inexpensiveness of the equipment suggest that this should be the primary method of removal of retained stones when a T tube has been placed into the common bile duct.

Two cases in which the ureter was obstructed by an inflammatory diverticular mass are presented. The difficulties of distinguishing such a mass from a carcinoma both clinically and at operation are emphasized. In order to minimize the risk of ureteric injury and to facilitate planning of the operative procedure, it is recommended that intravenous pyelography should be performed before resection of a suspected diverticular mass.

Two cases of metastasis to the penis from a primary rectal carcinoma are described. The clinical features, treatment and prognosis together with the probable modes of metastasis are discussed. All previously reported cases of penile metastasis from the rectum are reviewed. It is suggested that contrary to previous reports the prognosis is not uniformly poor and hence a more aggressive attitude to treatment should be adopted. Metastatic lesions in the penis should also be considered as a cause of urinary obstruction following abdominoperineal excision of the rectum.

1 Pharmacological experiments were performed on circular and longitudinal muscle strips of sigmoid colon from diverticular disease specimens, and their responses compared with those of similar muscle strips from sigmoid colon resected from carcinoma (control). 2 The longitudinal muscle strips from diverticular disease specimens were significantly less responsive to acetylcholine, histamine or noradrenaline than control longitudinal muscle strips. 3 The responses of the diverticular circular muscle strips showed a small decrease to acetylcholine, a small increase to noradrenaline and no change to histamine when compared to control strips.

Thirty patients with nipple retraction associated with duct ectasia have been studied to determine the clinical features of this condition. This association is a common one and the similarity of these nipple changes to those produced by cancer is emphasized. While clinical evaluation of the nipple changes may give an indication of the diagnosis, it is by no means absolute and mammography is advocated in all cases. Combined clinical and mammographic assessment will allow confident differentiation of the two causes in many cases, and a policy for management of nipple retraction is presented.

Three children with chronic intussusception are reported together with a review of the literature. Neither the palpation of a mass nor the passage of blood per rectum was necessary for the diagnosis. Weight loss was seen in each case and I child was investigated for malabsorption. In all 3 children there was a delay in diagnosis, and it is suggested that a chronic intussusception should be considered more frequently in children with persistent abdominal symptoms for which no cause can be found. Although a barium enema was helpful diagnostically, it did not result in the reduction of the intussusception. The problem of a recurrence after a reduction arid its subsequent management is discussed.