Bowel dysfunction in patients with multiple sclerosis (MS) is highly prevalent. Constipation and fecal incontinence can coexist and alternate, impacting on the patient’s quality of life and social interactions, as well as burdening the caregivers. The cost for the health care providers is also significant, with increased number of hospital admissions, treatment-related costs, and hospital appointments. The origin is multifactorial, and includes alteration of neurological pathways, polypharmacy, behavioral elements, and ability to access the toilet. Every patient with MS should be sensitively questioned about bowel function, and red flag symptoms should prompt adequate investigations. Manipulation of life style factors and establishment of a bowel regime should be attempted in the first place, and if this fails, other measures such as biofeedback and transanal irrigation should be included. A stoma can improve quality of life, and is not necessarily a last-ditch option. Antegrade colonic enemas can also be an effective option, whilst neuromodulation has not proved its role yet. Effective treatment of bowel dysfunction improves quality of life, reduces incidence of urinary tract infection, and reduces health care costs.

INTRODUCTION In the UK, the majority of breast cancers are diagnosed through symptomatic breast clinics and the breast screening programmes. With increased use of computed tomography (CT) to assess various pathologies, breast lesions are picked up incidentally. The aim of this study was to investigate the incidence and outcomes of breast lesions detected incidentally on CT scans. PATIENTS AND METHODS A retrospective study was conducted to assess the incidence and outcome of incidentally found breast lesions, which were detected on chest CT scans that were conducted for other pathologies during the period from February 2007 to October 2008. RESULTS A total of 432 chest CT scans were performed over 18 months. Thirty-three (7.63%) patients were found to have an incidental breast lesion. The mean age was 73 years (range, 50–86 years). Of these, 17 (52%) were benign, eight (24%) were primary breast cancer and the remaining eight (24%) had no definite pathology. The detection rate of breast cancer was 1.85%. CONCLUSIONS CT is emerging as an important contributor to the detection of occult breast lesions. Radiological awareness of incidental breast lesions is important so that appropriate referral to a specialised breast unit is made.

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Tumors of the peripheral nerve sheath including schwannomas are known for their rarity and can present with neurological deficit. We report an interesting case of schwannoma of the infrapatellar branch of saphenous nerve presenting with anteromedial knee pain and proximal tibial metaphyseal defect. A 26-year-old man presented with pain and swelling (for the past 2 months) in the anteromedial aspect of knee. Investigations revealed scalloping lesion in the anteromedial aspect of proximal tibia with sclerosed margins. Surgical exploration identified an encapsulated tumor lying over the defect in the proximal tibial metaphysis. Histopathological examination confirmed benign schwannoma and the patient became symptom-free after the surgery. Schwannoma of the infrapatellar branch of saphenous nerve can present with anteromedial knee pain. In patients with an eccentrically placed metaphyseal defect of the anteromedial tibia with sclerosed smooth margins, the possibility of nerve sheath tumors should always be considered.

Enhanced recovery after surgery (ERAS) protocols are gradually becoming the gold standard in the perioperative management of rectal patients. It is a multimodal and multidisciplinary approach that has the great merit to involve and empower the patient and bring him or her back to the centre of the strategy of care. If applied correctly, ERAS can improve the postoperative recovery, reduce the rate of complications and reduce the postoperative length of stay, in patients who had extensive pelvic dissection. The factors within ERAS and their application do not represent rigid schematizations but fluid concepts that may undergo substantial changes as soon as new evidence becomes available. The ERAS principles must be adapted to the specific environment and each team is expected to set up their own programme and quality control criteria. In this comprehensive review, the latest evidence and trend on enhanced recovery after rectal surgery have been critically appraised and presented.