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Bariatric surgery has been shown to improve a patient's QoL. More research is needed to explain the reasons why there was a difference between Sleeve and Bypass procedures in emotional changes to patients.

The management of abdominal pain in cystic fibrosis can be complicated. Distal intestinal obstruction syndrome is a common cause of pain and obstruction in these patients. Knowledge of the diagnosis and management and of similar presenting symptoms is essential for the hospital doctor.

INTRODUCTION Anecdotally, surgeons claim splenic flexure mobilisation is more difficult in male patients. There have been no scientific studies to confirm or disprove this hypothesis. The implications in colorectal surgery could be profound. The aim of this study was to assess quantitatively whether there is an anatomical difference in the position of the splenic flexure between men and women using computed tomography (CT). METHODS Portal venous phase CT performed for preoperative assessment of colorectal malignancy was analysed using the hospital picture archiving and communication system. The splenic flexure was compared between men and women using two variables: anatomical height corresponding to the adjacent vertebral level (converted to ordinal values between 1 and 17) and distance from the midline. RESULTS In total, 100 CT images were analysed. Sex distribution was even. The mean ages of the male and female patients were 68.1 years and 66.7 years respectively (p=0.630). The mean vertebral level for men was 8.88, equating to the inferior half of the T11 vertebral body (range: 1-17 [superior half of T9 to inferior half of L2]), and 11.36 for women, equating to the inferior half of the T12 vertebral body (range: 4-16 [superior half of T10 to superior half of L2]). This difference was statistically significant (p=0.0001) and is equivalent to one whole vertebra. The mean distance from the midline was 160.8mm (range: 124-203mm) for men and 138.2mm (range: 107-185mm) for women (p<0.0001). CONCLUSIONS The splenic flexure is both higher and further from the midline in men than in women. This provides one theory as to why mobilising the splenic flexure may be more difficult in male patients.

SummaryWe describe an infant who presented with a combination of upper airway obstruction and atlantoaxial subluxation, secondary to a pharyngeal abscess resulting from cosmetic ear piercing. This combination posed a number of dif®culties for the anaesthetist and a detailed plan was formulated to prepare the child for anaesthesia.Keywords Complications: pharyngeal abscess; atlanto-axial subluxation. Intubation: tracheal; dif®cult. Anaesthesia: paediatric. Parapharyngeal abscess is rare in the early infant period and the association of subluxation of the cervical spine with pharyngeal abscess is rare at any age [1].This combination of conditions poses a number of problems for the anaesthetist; the possibility of dif®cult intubation, worsened by the inability to¯ex or extend the cervical spine, the presence of atlanto-axial subluxation and the potential of damage to the spinal cord, and the age of the child, which would make awake ®breoptic intubation extremely dif®cult. Case historyThree weeks after cosmetic piercing of both ear lobes, a 6-month-old 8.8 kg baby was admitted to a local hospital with a 3-week history of swelling of the right side of his neck, pyrexia and malaise. He was transferred to The Birmingham Children's Hospital when he developed an expiratory wheeze, inspiratory stridor and intercostal recession, requiring supplementary oxygen therapy.On examination, the infant was apyrexial and there was a tender cystic mass measuring 7 cm in diameter in the right lateral cervical area (Fig. 1). The inspiratory stridor and intercostal recession were minimal at rest and he did not require supplementary oxygen. The patient preferred to have his head positioned looking to the left, although he would move it into the neutral position. Investigations revealed a reactive leucocytosis (white cell count 54.41 0 9 .l À1 ). A chest radiograph indicated changes consistent with bronchiolitis and a lateral X-ray of the cervical spine demonstrated a large parapharyngeal mass associated with gross atlanto-axial subluxation.An ultrasound of the neck con®rmed the large pharyngeal mass (6.8´4.5´4.9 cm), suggestive of suppurative lymphadenitis. An examination by a neurosurgeon did not show any neurological signs, and a magnetic resonance imaging (MRI) scan was requested to look for compression of the spinal cord. A consultant ear nose and throat (ENT) surgeon requested general anaesthesia to drain the mass.At a pre-operative visit we con®rmed the absence of neurological signs, and the child's ability to move his head into the neutral position spontaneously. Although his stridor, while present at rest, was minimal, we felt that an MRI scan was necessary before attempting tracheal intubation, to establish the degree of laryngeal or tracheal compression by the mass. The child was therefore sedated with chloral hydrate and transferred to the MRI suite, accompanied by two anaesthetists.During the MRI scan the child was monitored with pulse oximetry, noninvasive blood pressure and electrocardiograph. The scan proceeded uneventfull...