SummaryThe aim of this study was to assess monocyte/macrophage function, as defined by lipopolysaccharide (LPS)-induced production of tumour necrosis factor (TNF)-α, interleukin (IL)-10 and interferon (IFN)-γ by stimulated whole blood cultures in patients with colorectal carcinoma before and after surgical resection. Forty colorectal cancer patients prior to surgery and 31 healthy controls were studied. Heparinized venous blood was taken from colorectal cancer patients prior to surgery and from healthy controls. Serial samples were obtained at least 3-6 weeks post-operatively. Blood was stimulated with LPS for 24 h and supernatants were assayed for TNF-α, IFN-γ and IL-10 by enzyme-linked immunosorbent assay. LPS-induced production of TNF-α and of IFN-γ was reduced in patients with colorectal carcinoma compared to controls (TNF-α, 11 269 pg ml -1 {12 598}; IFN-γ, 0.00 pg ml -1 {226}; median {IQR}) (TNF-α, 20 576 pg ml -1 {11 637}, P < 0.0001; IFN-γ, 1048 {2428}, P = 0.0051, Mann-Whitney U-test). Production in patients after surgery had increased (TNF-α: 17 620 pg ml -1 {7986}; IFN-γ: 410 pg ml -1 {2696}; mean {s.d.}) and were no longer significantly reduced when compared to controls (TNF-α, P = 0.28; IFN-γ, P = 0.76). Production of TNF-α and IFN-γ prior to surgery were reduced to a greater extent in patients with Dukes' stage C tumours compared to those with Dukes' stage A and B stage. There was no difference in IL-10 production between any group. Monocytes/macrophages from patients with colorectal carcinoma are refractory to LPS stimulation as reflected by reduction in TNF-α and IFN-γ production and this is more pronounced in patients with advanced stage tumours. This suppression is not mediated by IL-10 and disappears following surgical resection of the tumour. This provides evidence for tumour induced suppression of immune function in patients with colorectal cancer and identifies a potential therapeutic avenue.

Background: There has been a significant increase in the number of hepatic resections performed. The aim of this review was to assess available techniques for liver resection and their application. Methods: A literature review was performed based on a Medline search to identify articles on liver resection. Keywords included liver resection, liver neoplasm, cancer, colorectal metastases and hepatocellular carcinoma. Results: Improved understanding of the segmental anatomy of the liver has resulted in the evolution of liver resection. The development of new approaches to the biliovascular tree, combined with clamping to produce ischaemic demarcation, has been important in demonstrating segmental boundaries for resection. The combination of methods of vascular control such as the Pringle manoeuvre and techniques of parenchymal resection such as ultrasonic dissection allows hepatic resection with minimal blood loss and morbidity. Conclusions: Application of refined techniques for liver resection by specialised units allows liver resection to be performed on both normal and cirrhotic livers with low morbidity and mortality.

Complete or partial metabolic response on PET following neoadjuvant chemoradiotherapy and surgery predicts a lower local recurrence rate and improved survival compared with patients with no metabolic response. Metabolic response may be used to stratify prognosis in patients with rectal cancer.

Intra-operative EAUS accurately identifies perianal disease and influences the surgical procedure performed. While not essential, it is a useful adjunct especially in recurrent perianal sepsis, undiagnosed anorectal pain and anal fissure.

C olorectal cancer remains the second commonest cause of cancer-related mortality resulting in over 19,000 deaths each year in the UK.1 Approximately a quarter of these patients have liver metastases at presentation 2,3 and another 20% will develop liver metastases following apparently curative surgery. 4 The 5-year survival of patients with untreated liver metastases is less than 3%. 5-7Hepatic resection for colorectal metastases -a national perspective AG Heriot, J Reynolds, CG Marks, N Karanjia Department of General Surgery, Royal Surrey County Hospital, Guildford, UKBackground: Many consultant surgeons are uncertain about peri-operative assessment and postoperative follow-up of patients for colorectal liver metastases, and indications for referral for hepatic resection. The aim of this study was to assess the views the consultant surgeons who manage these patients. Methods: A postal questionnaire was sent to all consultant members of the Association of Coloproctology of Great Britain and Ireland and of the Association of Upper GastrointestinalSurgeons of Great Britain and Ireland. The questionnaire assessed current practice for preoperative assessment and follow-up of patients with colorectal malignancy and timing of and criteria for hepatic resection of metastases. Number of referrals/resections were also assessed. Results: The response rate was 47%. Half of the consultants held joint clinics with an oncologist and 89% assessed the liver for secondaries prior to colorectal resection. Ultrasound was used by 75%. Whilst 99% would consider referring a patient with a solitary liver metastasis for resection, only 62% would consider resection for more than 3 unilobar metastases. The majority (83%) thought resections should be performed within the 6 months following colorectal resection. During follow-up, 52% requested blood CEA levels and 72% liver ultrasound. Half would consider chemotherapy prior to liver resection and 76% performed at least one hepatic resection per year with a median number of 2 resections each year. Conclusions: A substantial proportion of patients are assessed for colorectal liver metastases preoperatively and during follow-up though there is spectrum of frequency of assessment and modality for imaging. Virtually all patients with solitary hepatic metastases are considered for liver resection. Patients with more than one metastasis are likely to be not considered for resection. Many surgeons are carrying out less than 3 resections each year. Original article Hepatic resection for colorectal liver metastases has been shown to provide a significant survival benefit with 5-year survival approaching 40%, with an operative mortality of less than 5%. [8][9][10][11][12] The indications for resection of colorectal metastases have been extended over the last decade. Whilst some studies have shown that multiple metastases are a predictor of a less favourable outcome, 12 other studies have demonstrated that the outcome can still be satisfactory provided all the disease is resected. 8,9,13 Thus mu...

Superior vena cava farcinica by the Division of Bacterial and Mycotic Diseases, Centers for Disease Control syndrome associated (Atlanta, Georgia, USA). Positive biochemical tests which allowed differentiation from Nowith Nocardia farcinica cardia asteroides included growth at 45°C for three days, hydrolysis of acetamide, and reinfection sistance to cefamandole and tobramycin in vitro. 1 2 The strain was sensitive to amikacin and imipenem and moderately susceptible to sulphamethoxazole/trimethoprim (minimum Sofia Abdelkafi, Didier Dubail, inhibitory concentration 38/2 g/ml). Co-tri-Thierry Bosschaerts, Alain Brunet, moxazole (trimethoprim 1600 mg and sulpha-Guy Van Camp, Michel de Marneffe, methoxazole 8000 mg) four times daily was Jeanne-Marie De Vaster, Vincent Ninane instituted and mediastinal and pericardial drainage were continued for five days. The patient's condition improved quickly. A CT Abstract scan of the thorax showed a major resolution A case is described of severe Nocardia of the mediastinal widening and complete resfarcinica infection which mimicked a olution of the pericardial effusion. Two weeks pulmonary neoplasm with pneumonia, superior vena cava syndrome, pericarditis, and hypertrophic osteoarthropathy. Treatment with trimethoprim-sulphamethoxazole and surgery resulted in complete recovery.

Background A resection with clear margins (R0 resection) is the most important prognostic factor in patients with locally recurrent rectal cancer (LRRC). However, this is achieved in only 60 per cent of patients. The aim of this study is to investigate whether the addition of induction chemotherapy to neoadjuvant chemo(re)irradiation improves the R0 resection rate in LRRC. Methods This multicentre, international, open-label, phase III, parallel-arms study will enrol 364 patients with resectable LRRC after previous partial or total mesorectal resection without synchronous distant metastases or recent chemo- and/or radiotherapy treatment. Patients will be randomized to receive either induction chemotherapy (three 3-week cycles of CAPOX (capecitabine, oxaliplatin), four 2-week cycles of FOLFOX (5-fluorouracil, leucovorin, oxaliplatin) or FOLFORI (5-fluorouracil, leucovorin, irinotecan)) followed by neoadjuvant chemoradiotherapy and surgery (experimental arm) or neoadjuvant chemoradiotherapy and surgery alone (control arm). Tumours will be restaged using MRI and, in the experimental arm, a further cycle of CAPOX or two cycles of FOLFOX/FOLFIRI will be administered before chemoradiotherapy in case of stable or responsive disease. The radiotherapy dose will be 25 × 2.0 Gy or 28 × 1.8 Gy in radiotherapy-naive patients, and 15 × 2.0 Gy in previously irradiated patients. The concomitant chemotherapy agent will be capecitabine administered twice daily at a dose of 825 mg/m2 on radiotherapy days. The primary endpoint of the study is the R0 resection rate. Secondary endpoints are long-term oncological outcomes, radiological and pathological response, toxicity, postoperative complications, costs, and quality of life. Discussion This trial protocol describes the PelvEx II study. PelvEx II, designed as a multicentre, open-label, phase III, parallel-arms study, is the first randomized study to compare induction chemotherapy followed by neoadjuvant chemo(re)irradiation and surgery with neoadjuvant chemo(re)irradiation and surgery alone in patients with locally recurrent rectal cancer, with the aim of improving the number of R0 resections.

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