Interest has increased in the potential role of circulating tumour cells in cancer management. Most cell‐based studies have been designed to determine the number of circulating tumour cells in a given volume of blood. Ability to understand the biology of the cancer cells would increase the clinical potential. The purpose of this study was to develop and validate a novel, widely applicable method for detection and characterisation of circulating tumour cells. Cells were imaged with an ImageStreamX imaging flow cytometer which allows detection of expression of multiple biomarkers on each cell and produces high‐resolution images. Depletion of haematopoietic cells was by red cell lysis, leukocyte common antigen CD45 depletion and differential centrifugation. Expression of epithelial cell adhesion molecule, cytokeratins, tumour‐type‐specific biomarkers and CD45 was detected by immunofluorescence. Nuclei were identified with DAPI or DRAQ5 and brightfield images of cells were collected. The method is notable for the dearth of cell damage, recoveries greater than 50%, speed and absence of reliance on the expression of a single biomarker by the tumour cells. The high‐quality images obtained ensure confidence in the specificity of the method. Validation of the methodology on samples from patients with oesophageal, hepatocellular, thyroid and ovarian cancers confirms its utility and specificity. Importantly, this adaptable method is applicable to all tumour types including those of nonepithelial origin. The ability to measure simultaneously the expression of multiple biomarkers will facilitate analysis of the cancer cell biology of individual circulating tumour cells.

Objective: To establish whether UK emergency physicians could reliably perform focused ultrasound of the abdominal aorta in patients with suspected abdominal aortic aneurysm (AAA). Methods: A prospective cohort study was conducted in the emergency department of a tertiary level UK teaching hospital. All patients who underwent an abdominal aortic ultrasound by an emergency physician during a 12 month period from January to December 2005 were included. The principle outcomes were presence of an AAA (external wall diameter .3 cm) or death from ruptured AAA. Outcome data were obtained from paper and electronic patient records and primary care telephone follow up. Results: 120 focused ultrasound scans looking for AAA were performed by 19 different UK emergency physicians of various grades. Of the 120 scans, 26 (22%) were positive for an AAA, of which 17 cases represented a new diagnosis. Ruptured aneurysms represented 46% (12/26) of all positive scans, of which four patients underwent emergency repair. In the remaining 14 patients the AAA was an incidental finding that was not the reason for their presentation to the emergency department. Emergency ultrasound had a sensitivity of 96.3% (95% confidence interval (CI) 81.0% to 99.9%); a specificity of 100% (95% CI 91.8% to 100%); a negative predictive value of 98.6% (95% CI 88.0% to 99.9%); and positive predictive value of 100% (95% CI 86.8% to 100%) for the detection of AAA. Conclusion: Emergency ultrasound scanning by UK emergency physicians has high sensitivity and specificity for identifying AAA, consistent with international experience.T he use of ultrasound by emergency physicians is becoming increasingly popular in the UK. The immediacy and availability of bedside ultrasound in the emergency department means that critical management decisions can be made earlier. One of the key roles identified internationally for emergency physician performed ultrasound is early identification of abdominal aortic aneurysms (AAA). Clinical assessment of the abdominal aorta for AAA has shown to be unreliable. 1 Internationally, studies have demonstrated that emergency physicians can accurately perform aortic ultrasound scans with relatively little training. 2-5The current evidence for the diagnostic ability of emergency physician ultrasound for detection of AAA is based on a number of international small cohort studies.2-5 These series report high sensitivities (94-100%) and specificities (98-100%), but the prevalence of aortic aneurysm in these series varies widely. These studies are compromised because they are conducted on selected patients, and were all conducted abroad where ultrasound training differs. We aimed to establish whether UK emergency physicians could reliably perform focused ultrasound of the abdominal aorta in patients with suspected AAA. METHODSA prospective cohort study was conducted in the emergency department of a tertiary level UK teaching hospital. Emergency ultrasound for the detection of AAA, undertaken by emergency physicians, was introduced within a tig...

Background: Oesophageal perforations are associated with high mortality and morbidity rates. A spectrum of aetiologies and clinical presentations has resulted in a variety of operative and non-operative management strategies. This analysis focused on the impact of these strategies in a single specialist centre.Methods: All patients with oesophageal perforation managed in a single oesophagogastric unit in the UK between January 2002 and December 2012 were identified. Gastric perforations and anastomotic leaks were excluded. Data were verified using an endoscopy database, electronic and paper records. Aetiology of perforation, management and outcomes were analysed.Results: There were 101 adult patients with oesophageal perforation. Complete records were not available for five patients and they were excluded from the analysis. The median age was 69·5 years. Thoracic perforations were present in 84 per cent of patients. There were 51 spontaneous perforations, 41 iatrogenic and four related to foreign bodies. Oesophageal malignancy was present in 11 patients. Forty-four patients were managed surgically, 47 without operation and five patients were considered unfit for active treatment. The in-hospital mortality rate for treated patients was 24 per cent and median length of hospital stay was 31·5 days. Conclusion:The management of oesophageal perforation requires specialist multidisciplinary input. It is best provided in an environment familiar with the range of treatment modalities. Management decisions should be guided primarily by the degree of contamination rather than the aetiology of the defect. The routine use of stents is unproven and controversial.

These findings demonstrate that patient outcomes are not compromised by supervised trainee involvement in transthoracic esophagectomy. Training is an essential role of all surgical units and training data should be more widely reported especially in areas of high-risk surgery.

Leaks can be managed with excellent outcomes without using oesophageal stents. The results do not support the widespread adoption of endoscopic stenting.

Lipomas of the alimentary tract are rare tumours that can mimic malignant lesions. They are often small and asymptomatic although larger tumours can present with intusussception or as abdominal masses. We present a case of a transverse colon submucosal lipoma masquerading as a colonic adenocarcinoma leading to resection.A 74 year-old-man was referred urgently for assessment with altered bowel habits, and lower abdominal discomfort along with a positive Faecal-Occult-Blood sample. Colonoscopy demonstrated a large polypoidal lesion at the hepatic flexure with ulceration. Biopsies were inconclusive. A staging CT scan confirmed a 3.3 x 4.3 x 3.4cm Polyp with colonic wall thickening suspicious of malignancy. An extended right hemi-colectomy was performed. Histology showed a large submucosal lipoma with 12 reactive lymph nodes.Colonic lipoma often present as incidental findings detected on either imaging or endoscopically whilst investigating other symptoms. Their appearances can mimic colonic malignancy and surgical resection may be required.

Ann R Coll Surg Engl 2010; 92:1 Pregnancy is a recognised risk factor for the development of inguinal hernias due to an increase in intra-abdominal pressure. Whilst often managed conservatively until after the pregnancy, if the hernia presents acutely as a painful or tender groin lump, urgent or emergency repair may be required. Many clinicians rely heavily on clinical examination alone in order to diagnose the presence of such a hernia. In pregnancy, however, in order to prevent unnecessary surgery, the use of ultrasound has a more important role to play in reaching this diagnosis. We report a cautionary case that highlights the need for ultrasound evaluation of all painful groin lumps in pregnant women prior to considering surgery. Case historyA 28-year-old woman was admitted acutely to hospital with a painful lump in her left groin. The patient was 20 weeks into an uncomplicated first pregnancy. She had first noticed the lump several days earlier and her pain had gradually increased in severity. The lump was most prominent when standing. There was no history of obstructive gastrointestinal symptoms. Her only past medical history was a previous laparotomy for a perforated appendix.Examination revealed a soft, non-tender abdomen with a tender palpable lump approximately 5 cm in diameter in the region of the left inguinal canal. The lump was most noticeable on standing and appeared to reduce on lying flat. A provisional diagnosis of an inguinal hernia was made. Pregnancy is a recognised risk factor for the development of inguinal hernias due to an increase in intra-abdominal pressure. Whilst often managed conservatively until after the pregnancy, if the hernia presents acutely as a painful or tender groin lump, urgent or emergency repair may be required. Many clinicians rely heavily on clinical examination alone in order to diagnose the presence of such a hernia. In pregnancy, however, in order to prevent unnecessary surgery, the use of ultrasound has a more important role to play in reaching this diagnosis. We report a cautionary case that highlights the need for ultrasound evaluation of all painful groin lumps in pregnant women prior to considering surgery. ON-LINE CASE REPORT

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