Management of colorectal cancer and diabetes.

Colorectal cancer is associated with diabetes mellitus and both of these common conditions are often managed together by a surgeon. The surgical focus is usually upon cancer treatment rather than diabetes management. The relationship between colorectal cancer and diabetes is a complex one and can raise problems in both diagnosis and the management of patients with both conditions. This literature review explores the relationship between diabetes, diabetic treatment and colorectal cancer and addresses the issues that arise in diagnosing and treating this patient group. By highlighting these difficulties, this review aims to improve understanding and to provide clearer insight into both surgical and non-surgical management.

Staging colorectal cancer with the TNM 7(th): the presumption of innocence when applying the M category.

One of the main changes of the current TNM-7 is the elimination of the category MX, since it has been a source of ambiguity and misinterpretation, especially by pathologists. Therefore the ultimate staging would be better performed by the patient's clinician who can classify the disease M0 (no distant metastasis) or M1 (presence of distant metastasis), having access to the completeness of data resulting from clinical examination, imaging workup and pathology report. However this important change doesn't take into account the diagnostic value and the challenge of small indeterminate visceral lesions encountered, in particular, during radiological staging of patients with colorectal cancer. In this article the diagnosis of these lesions with multiple imaging modalities, their frequency, significance and relevance to staging and disease management are described in a multidisciplinary way. In particular the interplay between clinical, radiological and pathological staging, which are usually conducted independently, is discussed. The integrated approach shows that there are both advantages and disadvantages to abandoning the MX category. To avoid ambiguity arising both by applying and interpreting MX category for stage assigning, its abandoning seems reasonable. The recognition of the importance of small lesion characterization raises the need for applying a separate category; therefore a proposal for their categorization is put forward. By using the proposed categorization the lack of consideration for indeterminate visceral lesions with the current staging system will be overcome, also optimizing tailored follow-up.

Modernising medical careers and the British surgeons of the future.

The Modernising Medical Careers reforms in medical training have led to significant changes in the way junior doctors are trained. However, not all these changes have been welcomed by both trainees and trainers. This article seeks to examine some of the issues regarding training in surgery.

Intussusception in colorectal cancer.

Adult intussusception is a rare occurrence and, unlike in childhood, is usually associated with an underlying tumor. Although computed tomography (CT) imaging can identify an intussusception and point toward a cause, diagnosis is challenging if it is only intermittent. When an intussusception presents in the context of a known bowel cancer, it is possible to attribute nonspecific abdominal symptoms to the malignant process. Herein, we describe 2 cases of retrograde intussusception caused by cecal tumors that were not identified on preoperative CT scanning, only to be found during surgery. Both patients presented with intermittent severe abdominal pain and weight loss, which is not usually a feature of cecal cancer without metastases. These cases highlight the difficulty of diagnosing intermittent adult intussusception and that atypical abdominal pain might herald an otherwise occult colorectal cancer.

Perforated diverticulitis presenting as necrotising fasciitis of the leg.

Diverticulosis of the colon is a common condition of increasing age. Complications of diverticulitis including stricture, perforation and fistula formation often require surgery. Perforated diverticulitis may rarely present with spreading superficial sepsis. We describe for the first time, to our knowledge, a case of retroperitoneal diverticula perforation presenting as necrotising fasciitis of the leg necessitating hind-quarter amputation.

The management of haemorrhoids.

Haemorrhoidal disease is common, but there is still no consensus on optimal treatment. The most appropriate treatment is tailored to the individual patient. This article defines and classifies haemorrhoids, reviewing the efficacy of current treatments including the latest techniques.

A simple case of appendicitis? An increasingly recognised pitfall.

Acute appendicitis is the most common presentation of the acute abdomen in the UK. Although in most cases this is an easily reached diagnosis, presentation is not always typical and there are certain other conditions which may mimic appendicitis. Diagnostic adjuncts usually provide the additional information required to make a confident diagnosis; however, in some circumstances, the safest and most reliable course of action is appropriate surgical intervention. A case report is presented of a 43-year-old woman who presented with history of peri-umbilical pain migrating to the right iliac fossa. Following further investigation, with routine blood tests, plain radiographs, ultrasound examination of the abdomen and pelvis, and CT scanning not pointing towards a definitive diagnosis, she eventually underwent a diagnostic laparoscopy which revealed primary omental torsion. An open omentectomy was performed and 2 months on she remains well.

A diagnostic dilemma following risk-reducing surgery for BRCA1 mutation - a case report of primary papillary serous carcinoma presenting as sigmoid cancer.

BACKGROUND: Women that carry germ-line mutations for BRCA1 or BRCA2 genes are at an increased risk of developing breast, ovarian and peritoneal cancer. Primary peritoneal carcinoma is a rare tumour histologically identical to papillary serous ovarian carcinoma. Risk-reducing surgery in the form of mastectomy and oophorectomy in premenopausal women has been recommended to prevent breast and ovarian cancer occurrence and decrease the risk of developing primary peritoneal cancer. CASE PRESENTATION: We present a case report of a woman with a strong family history of breast cancer who underwent risk-reducing surgery in the form of bilateral salpingo-oophorectomy following a mastectomy for a right-sided breast tumour. Following the finding of a BRCA1 mutation, a prophylactic left-sided mastectomy was performed. After remaining well for twenty-seven years, she presented with rectal bleeding and altered bowel habit, and was found to have a secondary cancer of the sigmoid colon. She was finally diagnosed with primary papillary serous carcinoma of the peritoneum (PSCP). CONCLUSION: PSCP can present many years after risk-reducing surgery and be difficult to detect. Surveillance remains the best course of management for patients with known BRCA mutations.