Fibrin glue is increasingly used in the treatment of anal fistulae. This review aims to establish its longterm efficacy and clarify its role in this setting. A search of Medline and Pubmed databases was performed from 1966 to 2004. Data were collated regarding the type of study, fistula aetiology and complexity, technical aspects of glue application, and short- and long-term healing rates. The majority of studies comprised prospective series with fistulae of mixed aetiology. The overall healing rate was 53% with a wide variation between studies (10%-78%). The only factor that could account for this diversity was fistula complexity, with series including a high proportion of complex fistulae reporting worse outcomes. The quality of data to assess the efficacy of fibrin glue in the treatment of anal fistulae is poor and further clinical trials are needed. Fistula complexity is the main factor that adversely influences long-term healing rates.

Ann R Coll Surg Engl 2010; 92: [225][226][227][228][229][230] 225 Despite significant advances in cancer treatment over the past decade, colorectal cancer (CRC) remains a major source of cancer-related mortality, being the second commonest malignancy in the UK and accounting for 10% of all cancer-related deaths.1 The majority of these deaths result from the development of metastatic disease. Approximately one-third of patients with CRC present with synchronous liver or lung metastases, with a further 8-25% developing metachronous disease following primary tumour resection.2,3 Changes in surgical and radiological techniques, in addition to new chemotherapeutic regimens, now enable patients with advanced disease, whose only option in the past would have been palliation, to be considered for potentially curative treatment. 4The so-called 'postcode' provision of healthcare services and treatments in the UK has been investigated and highlighted across a range of medical specialities.5-10 However, the majority of these studies have been conducted on a national level, subdividing populations into either strategic health authorities, primary care trusts or medical specialty. 5,6,10 Few investigators have examined the potential inequality of provision at a truly local level within one region. Inequalities in access to healthcare services have previously caused conflict between patients and healthcare HEPATOBILIARY SURGERY Ann R Coll Surg Engl 2010; 92: 225-230

Introduction: Patients with gastrointestinal bleeding admitted out of hours or at the weekends may have an excess mortality rate. The literature reports around this are conflicting. Aims and methods: We aimed to analyze the outcomes of emergency endoscopies performed out of hours and over the weekends in our center. We retrospectively analyzed data from April 2008 to June 2012. Results: A total of 507 ‘high risk’ emergency gastroscopies were carried out over the study period for various indications. Patients who died within 30 days of the index procedure [22 % (114 /510)] had a significantly higher Rockall score (7.6 vs. 6.0, P < 0.0001), a higher American Society of Anesthesiologists (ASA) status (3.5 vs. 2.7, P < 0.001), and a lower systolic blood pressure (BP) at the time of the examination (94.8 vs 103, P = 0.025). These patients were significantly older (77.7 vs. 67.5 years, P = 0.006), and required more blood transfusion (5.9 versus 3.8 units). Emergency out-of-hours endoscopy was not associated with an increased risk of death [relative risk (RR) 1.09, 95 % confidence interval (CI) 1.12 – 1.95]. Whether the examination was carried out by a senior specialist registrar (senior trainee) or a consultant made no difference to the survival of the patient (RR 0.98, CI 0.77 – 1.32). Conclusion: Higher pre-endoscopy Rockall score and ASA status contributed significantly to the 30-day mortality following upper gastrointestinal bleeding, whereas lower BP tended towards significance. Outcomes did not vary with the time of the endoscopy nor was there any difference between a consultant and a senior specialist registrar led service.