Introduction Surgery is the first-line management option for patients with primary hyperparathyroidism (pHPT). Minimally invasive parathyroidectomy (MIP) is now preferable but few centres offer this service, mainly because of lack of intraoperative parathyroid hormone (IOPTH) testing. The aim of this study was to identify whether the measurement of IOPTH in patients having minimally invasive parathyroidectomy for pHPT alters their management. Methods A retrospective review was carried out of 78 consecutive patients who underwent parathyroid surgery by a single surgeon with a special interest in parathyroid surgery. The clinical impact of IOPTH monitoring was recorded postoperatively in a timely manner. Serum adjusted calcium levels were checked preoperatively (on admission) and one month postoperatively; normalisation was considered a cure. Results In the setting of curative MIP, IOPTH measurement did not influence the management in any of the patients but it could have led to bilateral parathyroid exploration (BPE) in three instances. Similarly, in cases that required lengthening of the MIP incision, IOPTH results did not influence patient management although it could have led to BPE in one case. Conclusion MIP offers an effective cure for patients with hyperparathyroidism. The addition of IOPTH testing adds increased expense, operating time and risk to patients otherwise suitable for MIP.

Introduction Without placing an endoscopic tattoo it may be difficult to accurately relocate the site of pathology after removal (eg, polypectomy). The National Bowel Cancer Screening Program (BCSP) have published guidelines on tattoo practice for suspected malignant polyps.1 2 We aimed to test the null hypothesis: there is no difference in tattoo practice between BCSP and non-BCSP lower GI endoscopy. Methods All reports for lower GI endoscopy performed at our unit over a 3 year period were reviewed. All polyps greater than 10 mm in diameter were identified. Lesions identified clinically and reported as a carcinoma were excluded. Colonoscopies were grouped by indication; either BCSP or non-BCSP. Information was gathered on polypectomy practice, tattoo practice, polyp size and the incidence of a histological diagnosis of polyp cancer. Statistical analysis was performed using χ2 with Yates correction. Results A total of 11 679 endoscopy reports were reviewed. A polyp >10 mm in diameter was identified n 556 procedures, 145 in the BCSP (21.9%) and 411 in the non-BCSP (3.7%)(p<0.0001). In the BCSP group 116 tattoos were placed (80% of procedures) while in the non-BCSP group 126 tattoos were placed (30.66% of procedures)(p<0.0001). Excluding caecal and rectal lesion did not significantly alter the tattoo results (83.45% BCSP, 36.63% non-BCSP (p<0.0001)). Polyp malignancy was diagnosed in 14 cases in the BCSP group (9.66%) and in 44 cases in the non-BCSP group (10.71%) (p=0.843). 10 of 14 polyp cancers were tattooed (71.42%) in the BCSP group. 14 of 44 polyp cancers in the non-BCSP group were tattooed (31.82%) (p=0.02). Polypectomy was performed in 142 (97.93%) cases in the BCSP group and in 316 (76.89%) cases in the non-BCSP group (p<0.0001). Conclusion There is a difference in the management of colonic polyps in our unit. Polyps > 10 mm were more likely to be treated at the index endoscopy and the site of the polyp or polypectomy was more likely to be tattooed if the procedure was performed within the BCSP. Current guidelines published by BCSP and JAG for tattooing of colonic polyps are broadly similar with no reference to polyp size. In our hospital BCSP practice seems to be following a separate BSG Polypectomy Guide3, which state that polyps >10 mm should be tattooed, with superior results. This would suggest that BCSP and non-BCSP colonoscopy guidelines should be updated to improve tattoo practice. Competing interests None.

INTRODUCTIONWith the development of a new curriculum, workplace based assessments such as procedure-based assessment (PBA) are becoming increasingly common within surgical training. However, there have been concerns about the impact of these assessments on clinical practice. This study assessed the time taken to complete PBA forms to determine whether it is feasible in clinical practice.MATERIALS AND METHODSPBAs for three colorectal procedures (anterior resection, right hemicolectomy and anal fistula) were undertaken by various trainers and trainees. A pilot study was performed to identify potential reasons for incomplete forms and procedural modifications subsequently applied in the main study. Times taken to complete the consenting and operative components of the forms were recorded.RESULTSIncomplete forms in the pilot were mainly attributable to time constraints. In the main study, all assessments were completed within 30 min. Assessment times increased with complexity of the procedure. Median times for completing the consenting and operative components in anterior resection were 13 min (range, 8-15 min) and 15 min (range, 10-18 min), respectively.CONCLUSIONSPBAs are feasible in clinical practice and are valued by trainees as a means of enabling focused feedback and targeted training. Commitment from trainers and trainees will be required but, with adequate planning, the assessment tool is effective with minimal impact on clinical practice.

OBJECTIVES:The TWR system was introduced in July 2000. The purpose of this study was to investigate whether patients below the age of 50 years with colorectal cancer (CRC) are experiencing delays in treatment.METHODS:The CRC database was searched for all newly diagnosed colorectal cancers between January 2001 and December 2005 in patients who were aged less than 50 years.RESULTS:There were 911 patients with CRC during the study period. Of these, 41 patients (4.5%) were aged under 50. Thirty-eight case notes were retrieved and reviewed; the median age was 47 years. Fourteen (37%) presented as an emergency, 9 (24%) via the TWR, 8 (21%) were non-TWR referrals to outpatients and the remainder were referred via miscellaneous routes. The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the miscellaneous (direct endoscopy, in-hospital physician's referral) group. The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the outpatient group and 96 days (range 27-270 days) in the miscellaneous group. Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria.CONCLUSION:Patients with symptoms of CRC below the age of 50 years may face referral and diagnostic delay if not referred via the TWR system; many of these would be eligible if age was not a deciding factor.

Objective: Self-expanding metallic stents (SEMS) are an important addition to the treatment of large bowel obstruction. The aim of this study was firstly to assess bowel function following SEMS placement and secondly to identify any potential factors which might aid in the prediction of technical failure of stent insertion.Methods: A review of all patients undergoing attempted SEMS placement for palliation of malignant left-sided colorectal obstruction over a four-year period (1st May 2000 - 30th April 2004) was performed.Results: Twenty-one patients (12 male) with a median age of 76 years (range 48 - 92 years) were included, 11 with metastatic disease and 10 severe comorbidity. SEMS insertion was technically successful in 16 (76%) of 21 cases. Contrast successfully passed through the obstructing lesion in all 16 cases where SEMS placement was technically successful. It only passed through 1 of 5 cases where stenting was not possible (P = 0.0008, Fisher's Exact test). Complications included colonic perforation (1 case), stent migration (1 case) and tumour ingrowth requiring a second stent (1 case). Median survival after SEMS was 12 months (range 1 - 30 months), and 9 patients died during follow-up. Median bowel frequency following SEMS was 3.5 times per day (range 1 - 7). Eight patients always passed a liquid stool, 3 others regularly required laxatives and one further patient with poor function after stenting requested a defunctioning stoma.Conclusion: Failure of contrast to pass through the obstructing lesion may predict those cases where stenting will not be technically possible. Median survival following SEMS insertion is encouraging in this series, but bowel function is often poor. Expected bowel function should be discussed fully when consenting patients for a SEMS, particularly those with metastatic disease who are otherwise fit for resectional surgery.

To assess anal sphincter structure and functional outcomes following third-degree perineal tears and the effect of its disruption on the development of anal incontinence. Fifty-one consecutive patients, 41 primigravidae and 10 multigravidae, with third-degree intrapartum perineal tears, primarily repaired, were recruited 4 months postpartum. Patients completed questionnaires assessing faecal incontinence. Anal manometry and endosonography were then performed. No patient reported incontinence prior to pregnancy. The incidence of faecal incontinence was 12 per cent. Six patients were incontinent of faeces and 10 incontinent of either flatus and/or fluid. Eighty-one per cent of anal incontinent patients were primigravidae (OR 0.96). Three women had previous third-degree tears, with one anal incontinence on subsequent delivery. Disruption of the external anal sphincter (EAS) was identified endosonographically in 26 patients. In 13 patients, there was an associated internal anal sphincter (IAS) defect. Clinically unsuspected tears of the Anal sphincter mechanism were diagnosed by anal endosonography in 46 per cent of asymptomatic patients. The EAS alone was involved in 14, IAS in three, and both in five patients. Clinical examination of women with anal incontinence identified an anal sphincter defect in 46 per cent. Ultrasound in anal incontinent patients showed an IAS defect in 42 per cent and an EAS defect in 52 per cent. All patients with faecal incontinence had a disruption of the EAS identified by endosonography (P < 0.05). No significant relationship was demonstrated between symptoms and anal manometry (P = 1.0, n.s.). Third-degree tears cause significant, although clinically unsuspected anal sphincter defects. It may be that anal manometry alone is not sufficient to exclude sphincter injury.

Background: Low anterior resection (LAR) with total mesorectal excision (TME) may be the optimal operation for carcinoma of the mid or lower rectum. Routine formation of a temporary defunctioning stoma has been recommended with TME. The impact of this strategy on health-related quality of fife (HRQOL) has not been addressed.Methods: A prospective longitudinal study was conducted among 24 patients undergoing LAR with TME and loop ileostomy for rectal cancer. Clinical outcomes were documented. HRQOL was assessed using Short Form 36 (SF-36). Twenty-three patients undergoing high anterior resection (HAR) for rectosigmoid cancer were studied concurrently to determine the effects of major colorectal resection without a stoma.Results: Time to resume normal diet, length of stay in hospital and time to return to non-work activities were similar after HAR or LAR with TME and loop ileostomy. Twelve weeks after HAR SF-36 scores were stable or improved compared with preoperative levels. In contrast, 12 weeks after LAR + TME patients had a reduction in physical functioning scores on SF-36. SF-36 scores improved after ileostomy closure. Ileostomy closure increased total hospital stay and time off non-work activities.Conclusion: LAR with TME and temporary loop ileostomy for rectal cancer results in a long total hospital stay and impairs aspects of HRQOL. Prompt stoma closure should be a priority in these patients.

Background: There is widespread antipathy to digital dilatation of the anus (DDA) for medically resistant anal fissure. A retrospective study was therefore undertaken to test the validity of the criticism of this technique.Methods: Some 273 patients who underwent DDA for fissure between November 1982 and July 1997 were sent a questionnaire and/or telephoned. Those with impaired control were offered investigation. In addition, routine clinic follow-up data were scrutinized in the 302 available notes of the 307 patients who had undergone DDA for fissure to determine its efficacy.Results: Some 241 patients (88.3 per cent) were contacted successfully a median of 7.8 years after operation. Follow-up records showed the fissure to have healed in 89.1 per cent of 302 patients. No patient was rendered incontinent. Fifteen patients indicated persistently impaired control in the questionnaire, nine (3.8 per cent) as a result of the DDA and six preceding it. All 23 patients who had experienced either temporary or permanent impairment, whether or not pre-existing, were invited to attend for ultrasonography and manometric measurements, of whom 18 accepted. No sphincteric fragmentation was seen, and resting and squeeze pressures did not differ from normal.Conclusion: A single DDA appears to heal 89 per cent of chronic anal fissures. Consequent impairment of control is infrequent and minor if the procedure is performed carefully and with the patient paralysed.

OBJECTIVES:To identify whether abdominal aortic aneurysm screening causes anxiety in those screened and whether the diagnosis of an aneurysm produces sustained anxiety in subjects in comparison with those in whom no abnormality is detected. DESIGN:Prospective case controlled study. MATERIALS AND METHODS:The 28-item General Health Questionnaire (GHQ) was used to assess psychological morbidity in 161 men attending for routine aneurysm screening in the Gloucestershire Aneurysm Screening Programme. One hundred men had a normal aorta and 61 were identified as having aneurysms. The GHQ was administered just before screening and 1 month later. An anxiety linear analogue scale was also used. RESULTS:There was no difference in anxiety levels between those men with normal aortas and those with aneurysms either before or after screening. There was a statistically significant reduction in both these groups 1 month after screening. CONCLUSION:This study shows that although the invitation to aneurysm screening may cause some mild anxiety, this is not prolonged even when an asymptomatic aneurysm is diagnosed.

Entrapment of the popliteal artery is an uncommon congenital anomaly that usually affects young men (aged 30 to 40 years) as the most common of several unusual entities that can cause intermittent claudication in young adults. It has been classified by the causes of compression of the artery which include congenital abnormalities of muscle insertion and acquired hypertrophy of surrounding structures. 1 Operation is normally advised because of the risk of embolisation from mural thromus on an intimal lesion in the compressed segment or from the wall of a post stenotic aneurysm. We present an unusual case with all the features of popliteal entrapment syndrome but with spontaneous resolution. film (Fig. 1) and corresponding distortion on lateral views both in flexion and extension of the knee (Figs 2 and 3). A diagnosis of popliteal entrapment was made and the patient was admitted 6 weeks later for surgery. On admission he reported that his symptoms had disappeared completely. Foot pulses were easily palpable and repeat Doppler pressures before and after exercise were normal. Duplex scanning was performed as a non-invasive alternative to arteriography and the appearances of the popliteal artery were normal with a normal pattern of flow. The patient was reviewed 12 months later and still

32 patients with clinical and biopsy proven Paget's disease of the nipple were treated over a 25-year period at three Bristol hospitals. Four additional cases which had Paget's change found histologically are included. 16 patients had a palpable mass in addition to nipple changes. Definitive treatment included; a modified radical mastectomy (18), simple mastectomy (11), wedge excision (4) wide local excision and radiotherapy (2) and tamoxifen alone (1). An associated invasive palpable tumour proved the most significant prognostic factor being present in 7 of 8 patients demonstrating recurrence within 5 years. Mammography revealed a high false negative rate (8 of 17) but was the single positive investigation in one patient. Scrape smear cytology of the nipple skin eruption was positive in the 6 cases examined and may be the preferred choice of diagnostic technique.

There is controversy on the advisability of one-stage proctocolectomy and the formation of an ileoanal pouch. Accurate preoperative diagnosis is essential to avoid the error of constructing a pouch in a patient with Crohn's disease. Twenty-four consecutive patients undergoing subtotal colectomy for inflammatory bowel disease were reviewed. All patients had been treated with systemic steroids, 23 were on 5-aminosalicylates and 11 on azathioprine. The preoperative diagnoses, based on a combination of clinical features, colonoscopy, barium enema and biopsy histology, were ulcerative colitis (19), Crohn's disease (four) and inflammatory bowel disease (unclassified) (one). The final diagnosis was made on histological examination of the resected specimen. A discrepancy between initial and final diagnosis occurred in eight patients. In three, the diagnosis was changed from ulcerative colitis to Crohn's disease. Three preoperative diagnoses of Crohn's disease were changed to ulcerative colitis (one), Behcet's disease (one) and diverticulitis (one) on final histology. These data suggest that caution should be exercised in performing synchronous proctocolectomy with the formation of an ileoanal pouch.