BACKGROUND: Anastomotic leak after colorectal surgery increases postoperative mortality, cancer recurrence, permanent stoma formation, and poor bowel function. Anastomosis between the colon and rectum is a particularly high risk. Traditional management mandates laparotomy, disassembly of the anastomosis, and formation of an often-permanent stoma. After laparoscopic colorectal surgery it may be possible to manage anastomotic failure with laparoscopy, thus avoiding laparotomy. OBJECTIVE: The purpose of this study was to determine the feasibility of the laparoscopic management of failed low colorectal anastomoses. SETTING: This was a single-institute case series. PATIENTS: A total of 555 laparoscopic patients undergoing anterior resection with primary anastomosis within 10 cm of the anus in the period 2000–2012 were included. MAIN OUTCOME MEASURES: Anastomotic failure, defined as any clinical or radiological demonstrable defect in the anastomosis; complications using the Clavien–Dindo system; mortality within 30 days; and patient demographics and risk factors, as defined by the Charlson index, were measured. RESULTS: Leakage occurred in 44 (7.9%) of 555 patients, 16 patients with a diverting ileostomy and 28 with no diverting ileostomy. Leakage was more common in those with anastomoses <5 cm form the anus, male patients, and those with a colonic J-pouch and rectal cancer. Diverting ileostomy was not protective of anastomotic leakage. In those patients with anastomotic leakage and a primary diverting ileostomy, recourse to the peritoneal cavity was required in 4 of 16 patients versus 24 of 28 without a diverting ileostomy (p = 0.0002). In 74% of those cases, access to the peritoneal cavity was achieved through laparoscopy. Permanent stoma rates were very low, including 14 (2.5%) of 555 total patients or 8 (18.0%) of 44 patients with anastomotic leakage. Thirty-day mortality was rare (0.6%). LIMITATIONS: This study was limited by the lack of a cohort of open cases for comparison. CONCLUSIONS: Laparoscopic anterior resection is associated with low levels of complications, including anastomotic leak, postoperative mortality, and permanent stoma formation. Anastomotic leakage can be managed with laparoscopy in the majority of cases. See Video Abstract at http://links.lww.com/DCR/A353.

Aim The aim of the study was to compare outcomes for emergency management of diverticulitis before and after the creation of a regional subspecialist colorectal unit. Method We retrieved data on all emergency admissions for diverticulitis from the regional surgical audit database and compared results before (January 1998 to August 2002) and after (August 2002 to December 2008) establishment of the subspecialist colorectal surgery unit in August 2002. Additional data were retrieved from electronic patient records. The primary outcome measures were mortality and rate of primary anastomosis following resection. Results There were 879 patients before and 1280 patients after subspecialization. Nonoperative management was undertaken in approximately 80% of cases. Total mortality fell from 3.3 to 1.5% (P=0.008), attributable to reduced operative mortality (9.6 to 4.2%; P=0.019). The primary anastomosis rate for all left colon resections increased from 50.3 to 77.9%; P <0.0001. Stoma formation of any type fell from 46.6 to 27.7%; P<0001). Conclusion Emergency management of diverticulitis by subspecialist colorectal surgeons is associated with low overall and operative mortality whilst safely achieving high rates of primary anastomosis.

This note presents a revised assessment of Goedel's proof. I show that the proof can be modified to establish that there exists a system P' such that: either P' is inconsistent (and P is also inconsistent) or P' is consistent and yet has no model. To define P' I firstly present a semantics for Goedel's P, and then define a theory P0 which is syntactically identical to P however the meaning of the type one variables differs in that for any interpretation of P0 these variables range over all and only the individuals assigned to the P0 numerals. P' is the theory obtained by adding the negation of a Goedel sentence for P0 to the proper axioms of P0.

This paper presents an account of the first-order logic of Principia Mathematica and preliminary evidence that the system is superior to currently accepted classical rivals. A widely accepted view that Whitehead and Russell's presentation of logic in Principia is essentially defective in departing from contemporary standards is considered. It is shown that the judgement is based on a number of arguments that do not withstand critical scrutiny. For example, the common presumption that the metatheory of contemporary first-order logic may be made precise in the expected way (using a first-order set theory equivalent to NBG) is shown to be false; on pain of contradiction, there cannot exist any such domain of interpretation of NBG. An alternative view of first-order logic, derived from Principia, is then presented. It is shown that Principia avoids the problem just discussed, as the first-order fragment may be made precise under an interpretation of the full system.

This paper describes a system S' obtained by modifying first-order arithmetic to 'parameterise' the individual variables so that under any interpretation of S', the individual variables range over all and only the individuals assigned to the numerals under this interpretation. Since S' contains Peano arithmetic and is recursively axiomatised we can modify Goedel's technique to define a Goedel sentence for S', say (x)R[x]. S' may be shown to be inconsistent since (x)R[x] must be an S' theorem. Since the syntax of S' and S are identical however the inconsistency of S itself is implied by this result.

This paper demonstrates that the intuitions underlying the formalist first-order theory of arithmetic are false; more specifically, focusing on the case of Mendelson's first-order number theory S I show that the standard interpretation is not a model of this theory. For the proof I exhibit an inconsistent system S' such that: if the standard interpretation is a model of S then S' is consistent. S' results from Mendelson's S when: 'a2' is added to the primitive symbols (and formation rules appropriately modified); the notion of an 'interpretation' is modified so that 'a2' is informally, an arbitrary numeral; every formula that is an instance of the following schema is added as a proper axiom: B[a2] => (x)B[x] (where B[a2] is the result of substituting 'a2' for every free occurrence of x in B[x]). Since S' contains Peano arithmetic and is recursively axiomatised we can modify Goedel's technique to define a Goedel sentence for S', say (x)R[x]. S' may be shown to be inconsistent since(x)R[x] must be an S' theorem. To avoid the conclusion that the metatheory of S is subject to paradox the formalist must assert that there exists an S-theorem that is false under the standard interpretation.

This paper shows that the metatheory of the classical, first-order predicate calculus is subject to paradox. Let the domain D of an interpretation M of the calculus consist of the interpretations N that are not identical with any individual in their own domain. Then M is identical with some individual in its own domain D if and only if it is not. Since the conclusion is absurd, the hypothesis that the metatheory provides a correct account of the calculus should be rejected. The calculus may be unfit for purpose since the possibility of unsound inferences cannot be excluded.

This paper examines the metatheory of the formalist account of an arbitrary first-order theory. The paper considers whether the metatheory can be expressed (using Tarskian semantics) in a model of a first-order theory that, roughly speaking, contains a proper axiom (schema) corresponding to a set-theoretic axiom (schema) of subsets. The hypothesis is reduced to absurdity.

The technique of partial hepatectomy is widely used to model liver regeneration and cell cycle dynamics in vivo. Because murine gene expression can be manipulated relatively easily, partial hepatectomy in mice is a useful tool for exploring the contributions of different genes to such hepatic processes. The authors present a straightforward method of partial hepatectomy in the mouse.

Laparoscopic gastric banding is an established and increasingly popular surgical treatment for morbid obesity. Iatrogenic diaphragmatic injury can complicate upper abdominal and esophageal surgery. We describe here the case of a patient who had undergone revisional surgery to replace a laparoscopic band, who presented acutely, years following surgery, with breathlessness and abdominal pain. CT of the chest and abdomen demonstrated small bowel loops in the left chest and significant mediastinal shift. The patient required an emergency laparotomy to reduce the small bowel contents from the chest and repair the hernial defect. The small bowel contained within the hernia was ischemic though did not require resection. The patient made a prompt recovery. Iatrogenic diaphragmatic injury is a rare, though potentially life-threatening, complication of laparoscopic gastric band placement.

We report the case of 65-year-old man who developed massive rectal bleeding associated with the use of a fecal collecting device: the Flexi-Seal® Fecal Management System. A colonoscopy showed an acute laceration of the anterior rectal wall mucosa, 6 cm from the anal verge, with active bleeding. The tear was most likely the result of an acute event, such as sudden movement of the device within the rectum or trauma sustained during insertion. Massive transfusion was required, and surgical endoscopic treatment was necessary to ensure hemostasis. This is, to our knowledge, the first such case to be reported.