Since the introduction of spiral CT scanners, smaller lesions are being seen at the time of preoperative staging. Our study concludes that only a small proportion of indeterminate lung lesions did develop into definite metastases and those that did had node positive disease. Indeterminate lung lesions are not a reason to delay surgery for colorectal cancer.

SummaryThe majority of UK hospitals now have a Local Lead for Peri-operative Medicine (n = 115). They were asked to take part in an online survey to identify provision and practice of pre-operative assessment and optimisation in the UK. We received 86 completed questionnaires (response rate 75%). Our results demonstrate strengths in provision of shared decision-making clinics. Fifty-seven (65%, 95%CI 55.8-75.4%) had clinics for high-risk surgical patients. However, 80 (93%, 70.2-87.2%) expressed a desire for support and training in shared decision-making. We asked about management of pre-operative anaemia, and identified that 69 (80%, 71.5-88.1%) had a screening process for anaemia, with 72% and 68% having access to oral and intravenous iron therapy, respectively. A need for perioperative support in managing frailty and cognitive impairment was identified, as few (24%, 6.5-34.5%) respondents indicated that they had access to specific interventions. Respondents were asked to rank their 'top five' priority topics in Peri-operative Medicine from a list of 22. These were: shared decision-making; peri-operative team development; frailty screening and its management; postoperative morbidity prediction; and primary care collaboration. We found variation in practice across the UK, and propose to further explore this variation by examining barriers and facilitators to improvement, and highlighting examples of good practice.

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An 85-year-old man underwent a laparoscopic-assisted subtotal colectomy for widespread high-grade dysplasic changes caused by ulcerative colitis. A water-soluble contrast enema was performed on the post-operative day 8 to investigate a persistent ileus associated with a lowgrade temperature but no anastomotic leak was demonstrated. He remained clinically stable without evidence of peritonitis and started opening his bowels. However, ongoing signs of grumbling sepsis and diarrhoea prompted abdominopelvic computerized tomography (CT) on day 11. This showed a substantial gas/fluid collection in the left side of the abdomen originating from an anastomotic leak at the ileorectal anastomosis. A drain was inserted radiologically, which failed to improve the situation. Subsequent CT scanning demonstrated little resolution of the collection in comparison with previous films and a persistently dilated rectum was also noted. The risks of further major surgery in this now frail man were felt to be too great and a highly conservative surgical approach was therefore taken from basic surgical principals. First, the (relative) obstruction distal to the anastomosis caused by the ballooned rectum was relieved using a Heald Silastic Stent (Fig. 1) placed in the anal canal (Fig. 2). Secondly, the fine tube drain was replaced with a corrugated drain inserted into the residual collection via a 5 cm incision (under general anaesthesia). Concurrent treatment with parenteral nutrition and broad-spectrum antibiotics was also given. Four weeks after this management strategy was implemented his sepsis had improved and CT/gastrograffin enema showed the leak had become a controlled fistula, which subsequently closed prior to his discharge.The original objective of the Heald Silastic Stent was to protect low colorectal anastomosis by stenting open the anus for 6-8 days. A small randomized-controlled trial [1] has previously shown this approach to be a safe alternative to a temporary defunctioning loop stoma. This case shows that the transanal stent can be successfully used to decompress the rectum in other clinical (a) (b) Figure 2 Computerized tomography scan of the pelvis demonstrating decompression of the rectum, before (a) and after (b) insertion of the transanal stent. The top of the stent can be seen in the rectal ampulla (arrow).

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