23-hour/next day discharge post-laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery is safe.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is well established, yet practice varies as to when patients should be discharged post operation. After noting that many LRYGB patients met our unit's discharge criteria sooner than anticipated, we implemented a policy of aiming for 23-h inpatient stay post LRYGB in January 2012. This retrospective study aimed to assess the safety of this policy. We reviewed data of all patients undergoing LRYGB at our unit from September 2010 to October 2013. We compared the lengths of inpatient stay, complication rates and re-admission rates of patients treated before and after the introduction of the 23-h length of stay policy. Of 161 LRYGB procedures, 38 patients (29 female) underwent LRYGB from September 2010 to December 2011 (pre-policy change) and 123 (107 female) underwent operation after this date (post-policy change). The two groups were similar in terms of mean age (46.5 vs. 46.7 years, p = 0.932), mean BMI (46.8 vs. 46.6 kg/m(2), p = 0.868) and median number of pre-operative comorbidities (3 vs. 3, p = 0.9). There were significant reductions in median length of inpatient stay (2 vs. 1 day, p < 0.0001), re-admission rate (21.1 to 6.5 %, p = 0.025) and complication rate (18.4 vs. 3.3 %, p = 0.004) after the policy change. There were seven complications pre-policy change: pulmonary embolus (n = 1), chest infection (n = 1), constipation and anal fissure (n = 1), umbilical hernia requiring operation (n = 2), adhesional obstruction (n = 1) and persistent food intolerance (n = 1). Post-policy changes, there were four complications: adhesional obstruction (n = 2), staple line bleeding (n = 1) and persistent dysphagia (n = 1). There were no deaths. Patients undergoing LRYGB can be safely discharged on the first post-operative day. This reduction in length of inpatient stay offers significant cost savings.

Assisted death: a basic right or a threat to the principal purpose of medicine?

There is much debate in the UK and abroad around whether the law should be changed to license doctors to prescribe lethal drugs to assist terminally ill patients to commit suicide. Here, Sir Graeme Catto argues that terminally ill mentally competent adults should be able to choose the time and place of their death. Opposing him, Baroness Ilora Finlay argues that both the Assisted Suicide (Scotland) Bill and Lord Falconer's private member's bill in the House of Lords endanger patients' safety and require doctors to assess patients against criteria that cannot be verified.

Quality of care in rectal cancer surgery. Exploring influencing factors in the West of Scotland.

AIM: To assess variability in the proportions of types of major resection for rectal cancer throughout the west of Scotland (WoS) and ascertain factors explaining the variability. METHOD: Retrospective cohort study of a regional population clinical audit database. This was linked to cancer registrations and death certificates in order that outcome analyses could be derived. Univariate and multivariate binary logistic regression analyses were used to explore determinants of survival. RESULTS: A total of 1574 patients met the inclusion criteria. The age range was from 22 to 97 years. The mean age was 67, median age 68 and the standard deviation was 11.5. The majority of patients (61%) were male. Unlike previous series, male patients and those with poorer socioeconomic circumstances (SEC) were no more likely to receive an abdominoperineal excision (APE) procedure for rectal cancer. CONCLUSION: Variation exists in the west of Scotland regarding surgical treatment for rectal cancer. We found no difference in the type of procedure offered according to sex, intent of operation or socioeconomic circumstances with reference to APE and anterior resection (AR) for rectal cancer. We conclude therefore that our region provides an equitable service on grounds of sex and SEC. This demonstrates that an equitable surgical service has been provided for those suffering from rectal cancer. Circumferential margin positivity was four times more likely in an APE than an AR for rectal cancer. This is not explained by age, stage, sex, socioeconomic circumstances (SEC), volume of surgery, intent of operation, type of admission or year of incidence.

The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: a qualitative study.

BACKGROUND: Terminal haemorrhage is a rare but devastating event that may occur in certain advanced cancers. The focus of management involves administration of 'crisis medicine' with the intention of relieving patient distress through sedative doses of anxiolytics or opioids. This practice, whilst widely accepted, is based on limited evidence and has never been formally evaluated. AIM: To evaluate the utility of crisis medication in the management of terminal haemorrhage, through the experiences of nurses who had personally managed such events. METHOD: Semi-structured interviews exploring the experiences of palliative care and head and neck oncology nurses were recorded, transcribed verbatim and analysed using interpretative phenomenological analysis. Saturation of themes occurred after interviewing 11 nurses with cumulative experience of managing 37 terminal haemorrhages. RESULTS: Participants reported crisis medication to have little, if any, role in the management of terminal haemorrhage, which was such a rapid event that patients died before it could be administered. As many events had not been predicted, anticipatory prescribing of crisis medication did not always occur. Staying with and supporting the patient, and using dark-coloured towels to camouflage blood were reported to be of more practical use. A focus on accessing crisis medicines had often been to the detriment of these simple yet beneficial measures. CONCLUSION: Anticipatory prescribing of crisis medication rarely benefits the patient and may unintentionally detract from nursing care. Guidelines on the management of terminal haemorrhage should reconsider the emphasis on crisis medication and focus on non-pharmacological approaches to this invariably fatal event.

Delivery of safe and effective care out of hours: the impact of the shared clinical record on a patient's out-of-hours contact with specialist palliative care.

Access to adequate clinical information is essential for out-of-hours palliative care teams and general practitioners, specific examples to illustrate and justify this need are surprisingly rare in the medical literature. Without access to the full clinical background the patient in this lesson may have been inappropriately admitted to a palliative care unit and delayed investigations would have misguided the admitting doctor's assessment, planned investigations and management.

Mechanical bowel preparation does not influence outcomes following colonic cancer resection.

BACKGROUND: Meta-analyses have indicated that preoperative mechanical bowel preparation (MBP) confers no clear benefit and may indeed be harmful for patients with colorectal cancer. The effects of bowel preparation on longer-term outcomes have not been reported. The aim was to compare long-term survival and surgical complications in patients who did or did not receive MBP before surgery for colonic cancer. METHODS: This was a retrospective cohort study of all patients undergoing potentially curative surgery for colonic cancer after routine hospital admission in the West of Scotland between January 2000 and December 2005. Clinical audit data were linked to cancer registrations and death certificates. Kaplan-Meier and Cox proportional hazards models were used to explore determinants of survival. RESULTS: A total of 1730 patients underwent potentially curative surgery for colonic cancer, of whom 886 (51·2 per cent) were men. The mean(s.d.) age was 69·7(10·6) years. Some 1460 patients (84·4 per cent) received MBP. Median follow-up was 3·5 (range 0·1-6·7) years. There were no statistically significant differences in 30-day postoperative complication rates between groups. The unadjusted hazard ratio (HR) for death from all causes for patients treated with MBP (versus no MBP) was 0·72 (95 per cent confidence interval 0·57 to 0·91). Multivariable analysis with adjustment for age, sex, socioeconomic circumstances, disease stage and presentation for surgery showed that MBP had no independent effect on all-cause mortality (HR 0·85, 0·67 to 1·10). CONCLUSION: Neither postoperative complications nor long-term survival are improved by MBP before colonic cancer surgery.

Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups--another perspective on Oregon's data.

Battin et al examined data on deaths from physician-assisted suicide (PAS) in Oregon and on PAS and voluntary euthanasia (VE) in The Netherlands. This paper reviews the methodology used in their examination and questions the conclusions drawn from it-namely, that there is for the most part 'no evidence of heightened risk' to vulnerable people from the legalisation of PAS or VE. This critique focuses on the evidence about PAS in Oregon. It suggests that vulnerability to PAS cannot be categorised simply by reference to race, gender or other socioeconomic status and that the impetus to seek PAS derives from factors, including emotional state, reactions to loss, personality type and situation and possibly to PAS contagion, all factors that apply across the social spectrum. It also argues, on the basis of official reports from the Oregon Health Department on the working of the Oregon Death with Dignity Act since 2008, that, contrary to the conclusions drawn by Battin et al, the highest resort to PAS in Oregon is among the elderly and, on the basis of research published since Battin et al reported, that there is reason to believe that some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS.

Telephone consultations on palliative sedation therapy and euthanasia in general practice in The Netherlands in 2003: a report from inside.

BACKGROUND: GPs with a special interest and with specific training in palliative medicine (GP advisors) supported professional carers (mostly GPs) through a telephone advisory service. Each telephone call was formally documented on paper and subsequently evaluated. OBJECTIVE: Data from 2003 were analysed independently to reveal how often and in what way palliative sedation and euthanasia were discussed. METHODS: The telephone documentation forms and corresponding evaluation forms of two GP advisors were systematically analysed for problems relating to the role of sedation and/or euthanasia both quantitatively and qualitatively. RESULTS: In 87 (21%) of 415 analysed consultations, sedation and/or euthanasia were discussed either as the presenting question (sedation 26 times, euthanasia 37 times and both 10 times) or arising during discussion (sedation 11 times and euthanasia three times). Qualitative analysis revealed that GPs telephoned to explore therapeutic options and/or wanted specific information. Pressure on the GP (either internal or external) to relieve suffering (including shortening life by euthanasia) had often precipitated the call. On evaluation, 100% of the GPs reported that the advice received was of value in the patient's care. CONCLUSION: GPs caring for patients dying at home encountered complex clinical dilemmas in end-of-life care (including palliative sedation therapy and euthanasia). They valued practical advice from, and open discussion with, GP advisors. The advice often helped the GP find solutions to the patient's problems that did not require deliberately foreshortening life.

Duodenal obstruction by gallstone in the absence of cholecystoenteric fistula, an unusual complication of total gastrectomy: report of a case.

We present a case of gallstone obstruction of the duodenum in a post total gastrectomy patient without a cholecystoenteric fistula. The patient presented with epigastric pain. On abdominal computed tomography and percutaneous transhepatic choangiography imaging, the patient was found to have duodenal obstruction. At operation, the cause of obstruction was found to be a large gallstone in the third part of the duodenum, but there was no associated cholecystoenteric fistula. This report is the first to describe duodenal obstruction by a gallstone formed within the duodenum, in a patient post total gastrectomy with Roux-en-Y reconstruction, and highlights what can be a difficult diagnosis in such patients.

Free radical activity and lipid soluble anti-oxidant vitamin status in patients with long-term ileal pouch-anal anastomosis.

OBJECTIVE: Ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis. Free radical activity and the status of lipid soluble antioxidant vitamins have not been previously assessed in patients with IPAA. The aim of the present study was to measure the plasma concentrations of lipophyllic antioxidants and free radical activity in IPAA patients and compare them with normal subjects. METHOD: Forty-eight IPAA patients and 50 healthy controls were studied. A dietary assessment of vitamin E (alpha-tocopherol) and carotene was undertaken and plasma antioxidant status was assessed. Plasma malondialdehyde (MDA) was measured to assess the extent of free radical damage. In IPAA patients, association between the degree of inflammation in the pouch mucosa and the plasma concentration of lipophyllic antioxidants and extent of free radical activity was investigated. RESULTS: The dietary intake of carotene was similar in both groups. Intake of vitamin E was significantly lower in patients than controls (P = 0.01). In the IPAA group plasma concentrations of alpha-carotene, beta-carotene and lycopene were significantly lower (P < 0.001) and alpha-tocopherol:cholesterol ratio significantly higher (P < 0.001). Free radical damage was significantly greater in patients than controls (P < 0.01). There were no significant correlations between the degree of inflammation in the pouch and plasma concentrations of MDA, carotenoids, alpha-tocopherol:cholesterol ratio or intake of vitamins. CONCLUSION: Compared with normal subjects, patients with IPAA have significantly lower plasma concentrations of lipophyllic antioxidants alpha-carotene, beta-carotene and lycopene and higher free radical activity suggesting increased oxidative stress. These differences do not appear to be related to diet and do not correlate with histological severity of pouch inflammation.

Factors influencing hospice thromboprophylaxis policy: a qualitative study.

Despite level 1 evidence supporting the use of low-molecular weight heparin thromboprophylaxis in hospitalised cancer patients, only 7% of specialist palliative care units (SCPU) have thromboprophylaxis guidelines. The reasons for this are unclear. To explore specialist palliative care units (SPCU) directors' views on thromboprophylaxis in the inpatient unit, audiotaped semi-structured interviews were conducted with SCPU medical directors to explore factors influencing thromboprophylaxis practice. Purposive sampling of units known not to have thromboprophylaxis guidelines was conducted (as identified from previous research). The hospice directory was used to sample from units in each region of Great Britain and Ireland to ensure representation across the specialty. Interviews were transcribed and analysed using interpretative phenomenological analysis (IPA). Four major and four sub themes were identified. Participants were progressive in their attitudes to palliative care and comfortable with instigating active interventions for patient benefit. Symptomatic venous thromboembolism (VTE) was rarely seen and therefore not considered important enough to warrant guidelines. There was concern that evidence informing thromboprophylaxis guidelines in the general population was not transferable to the advanced cancer population and that the outcome measures from these studies were less meaningful to a palliative care patient. Thromboprophylaxis was considered a life prolonging intervention which may result in a poorer death than one because of VTE. Nevertheless, participants were receptive to change if presented with convincing evidence derived from a representative population. Until the true prevalence and symptomatic burden of VTE is known, the role of thromboprophylaxis in the SPCU setting will remain controversial. There is a need for a well-designed study to explore the utility of thromboprophylaxis in the palliative care inpatient setting. However, this will require meaningful outcome measures to be used within a clinically applicable population.

Challenges faced by palliative care physicians when caring for doctors with advanced cancer.

BACKGROUND: It is possible that patients with advanced cancer, who are from the medical profession, have different or additional care needs than other patients. Previous training, professional experiences and access to information and services may influence their needs and subsequent illness behaviour. Caring for ;one of our own' may also evoke particular feelings and emotions from health professionals involved in their care and pose unique challenges in the delivery of equitable patient-centred care. AIM: To explore the experiences of palliative care physicians when caring for members of the medical profession with advanced incurable cancer. PARTICIPANTS AND METHODS: Semi-structured interviews exploring the experiences of senior palliative care physicians were recorded and transcribed verbatim. Transcripts were analysed using interpretative phenomenological analysis (IPA) for emergent themes. Data were collected from ten senior palliative care physicians with a combined total of 107 years of palliative care career experience, caring for a reported combined estimate of 120 doctor-patients. RESULTS: On the basis of their reflections, palliative care physicians reported that doctor-patients appear to find it difficult to assume a patient role, especially at a time they are likely to be truly vulnerable. This patient group will routinely attempt to maintain control of their care and environment using various strategies. These include self-referrals, accessing their own tests, directing the consultation and putting barriers up to psychosocial aspects of palliative care. Doctor-patients' general practitioners are at risk of exclusion from the management of care, and referral to palliative care services appears to occur later in the illness journey of doctor-patients compared to lay patients. Participants recalled how caring for colleagues evokes powerful emotional responses, such as a strong desire to provide the best care possible as well as feelings of anxiety. They frequently find themselves under pressure to disclose confidential information from medical colleagues not involved in the doctor-patients' care. Doctor-patients frequently receive what other healthcare professionals perceive as preferential treatment, which may unintentionally result in suboptimal care. CONCLUSION: The core needs of doctors with advanced cancer could be assumed to be the same as other patients. However, the juxtaposition of role from professional to patient appears to evoke unique care needs from the patient, and behaviour responses from the professional. Forewarning and awareness of these issues may help prevent potential problems in this patient group's cancer journey as well as the experience of the professionals involved in their management.

The use of long-term low-molecular weight heparin for the treatment of venous thromboembolism in palliative care patients with advanced cancer: a case series of sixty two patients.

The advantages of low-molecular weight heparin (LMWH) over warfarin, in the treatment of cancer associated venous thromboembolism (VTE) are well reported. However the studies supporting LMWH include few patients representative of the palliative care population. Although LMWH has advantages over warfarin it is still unclear, within the palliative care environment, how long anticoagulation should be continued, what dose of LMWH should be used and whether palliative care patients experience different complication rates such as bleeding, heparin-induced thrombocytopenia and osteoporosis. We report a case series of 62 patients with advanced malignancy and VTE treated with long-term LMWH according to either the CLOT (full dose) or Montreal (reduced dose) regime. Seventy-four percent of patients self-administered LMWH, whereas 24% had it given by a carer and 2% by the district nurse. LMWH was given for median duration of 97 days; the most common reason for discontinuation of therapy being admission to die or commencement of the care pathway (n = 50, 81%). A further 11% (n = 7) stopped after 6 months of treatment. Of these 3 (43%) developed clinical symptomatic recurrence of VTE. The overall minor bleeding rate was 8.1% (95% confidence interval 3.5-17.5%), and this was not associated with NSAID or steroid use. No major bleeding events were observed. No patients developed evidence of heparin-induced thrombocytopenia or osteoporosis.Long-term LMWH appears effective in treatment of VTE in the palliative care population with advanced cancer. A randomised control trial is required to identify the best dose required to ensure optimum efficacy and safety.

Vitamin B12 deficiency following restorative proctocolectomy.

OBJECTIVE: Restorative proctocolectomy (RP) involves terminal ileal resection and formation of a small bowel reservoir that predisposes to bacterial overgrowth. It was anticipated that these patients would be at risk of vitamin B12 deficiency. METHOD: Vitamin B12 levels were measured sequentially in 171 patients who underwent RP. Prospective results were obtained from all 20 patients undergoing pouch formation after the commencement of the study. Further results were obtained retrospectively from case notes and computerized laboratory records of the 151 patients who underwent RP prior to the commencement of the study and these were correlated with the results of follow-up samples taken prospectively from the same patients after the commencement of the study. The median age of the patients was 40 years (range: 13-67) and the median duration of follow up was 5.4 years (range: 1-12). Patients with an abnormally low serum B12 level underwent both a Schilling and a hydrogen breath test. Eight of these patients were then treated with oral vitamin B12. RESULTS: Abnormally low serum B12 levels were found in 25% of patients. Forty per cent of our patient group had three or more sequential B12 measurements and of these, 66% showed steadily declining B12 levels. Ninety-four per cent of patients with low B12 had a normal Schilling test and were negative for bacterial overgrowth. CONCLUSION: Subnormal vitamin B12 levels develop in almost one-quarter of patients after pouch surgery. The exact mechanism for B12 deficiency in these patients is uncertain. In the majority of patients undergoing RP, vitamin B12 levels fall on sequential measurement. Serum B12 levels should be measured during follow up and pouch patients with subnormal B12 levels, should see them successfully restored to a normal value after treatment with oral B12 replacement therapy.

Long-term cancer risk of the anorectal cuff following restorative proctocolectomy assessed by p53 expression and cuff dysplasia.

OBJECTIVE: Restorative proctocolectomy (RP) for ulcerative colitis (UC) retains a 'cuff' of columnar rectal epithelium that has unknown risk of malignant change. Markers of malignant potential in UC include aberrant p53 expression and dysplasia. We undertook a prospective study comprising serial surveillance biopsy and assessed the occurrence of aberrant p53 expression, epithelial dysplasia and carcinoma in the retained anorectal cuff following stapled RP. METHOD: A total of 110 patients who underwent stapled RP for UC between 1988 and 1998 were followed up by cuff surveillance biopsies under general anaesthesia. Histological samples were analysed by a specialist colorectal pathologist for the presence of rectal mucosa, dysplasia and carcinoma. Immunohistochemistry for p53 expression was performed for each most recent cuff biopsy. Median follow-up was 56 months (12-145) and median time since diagnosis of UC was 8.8 years (2-32). RESULTS: Rectal mucosa was obtained from the cuff in 65% of biopsies. No overt carcinomas developed during the follow-up period and there was no dysplasia or carcinoma in any cuff biopsy. The p53 overexpression was identified in 38 specimens (50.6%), but was also identified in controls (3/3 colitis, 3/3 ileal pouch and 6/6 stapled haemorrhoidectomy donuts). CONCLUSION: The lack of carcinoma and dysplasia in the columnar cuff epithelium specimens is reassuring. The lack of stabilized p53 and absence of a relationship between p53 stabilization and dysplasia up to 12 years after pouch formation suggests neoplastic transformation is a rare event. Furthermore, p53 expression was not useful in surveillance of cuff biopsies from patients who have undergone RP for UC and the search should continue for alternative predysplastic markers. These data suggest that in patients who do not have high-grade dysplasia or colorectal cancer at the time of RP, cuff surveillance in the first decade after pouch formation is unnecessary. However, we consider regular cuff surveillance biopsies should continue for patients with high-grade dysplasia, whether or not there was a carcinoma in the original colectomy specimen.

Design of trials with dying patients: a feasibility study of cluster randomisation versus randomised consent.

There is little rigorous evidence to underpin clinical guidelines for palliative care. However, research in palliative care is difficult, especially with dying patients. Consent is a major issue, since staff do not wish to invite dying patients to participate in trials. We, therefore, conducted a feasibility study in two units within the North West Wales NHS Trust. We explored two novel approaches to research in palliative care -cluster randomisation and randomised consent. All patients admitted to the two units during the study were asked for permission to use their data for research. We allocated the two units, at random, to use cluster randomisation or randomised consent for three months, and then to crossover to the other design. Of 24 patients dying during cluster-randomised phases, 13 gave consent on admission to use their data and were, thus, eligible to enter the trial; however, defined eligibility criteria reduced these to six active participants. Of 29 patients dying during randomised consent phases, seven gave consent on admission to use their data; although two were eligible for randomisation, neither entered the trial. We judge that cluster randomisation is the more effective design for research with dying patients. Computer simulation, based on data from 1500 dying patients on the Welsh Integrated Care Pathway, shows that crossover cluster trials need much smaller samples than simple cluster trials. Furthermore, this study has shown that crossover cluster trials are entirely feasible. We recommend a 'definitive' trial to test the crossover design more widely.

Acceptability of low molecular weight heparin thromboprophylaxis for inpatients receiving palliative care: qualitative study.

OBJECTIVE: To find out what inpatients with advanced cancer who are receiving palliative care think about the effect of thromoprophylaxis on overall quality of life. DESIGN: Qualitative study using audiotaping of semistructured interviews. SETTING: Regional cancer centre in Wales. PARTICIPANTS: 28 inpatients with advanced metastatic cancer receiving palliative care and low molecular weight heparin. MAIN OUTCOME MEASURES: Recurring themes on the effect of thromboprophylaxis on overall quality of life. RESULTS: Major emerging themes showed that patients knew about the risks of venous thromboembolism and the purpose of treatment with heparin. Media coverage had raised awareness about venous thromboembolism, and many had previous experience of thromboprophylaxis. All found low molecular weight heparin an acceptable intervention, and many said that it improved their quality of life by giving them a feeling of safety and reassurance. Antiembolic stockings were considered uncomfortable and had a negative impact on quality of life. Patients were concerned that because they had advanced disease they might not be eligible for thromboprophylaxis. CONCLUSION: Low molecular weight heparin is acceptable to inpatients with advanced cancer receiving palliative care and has a positive impact on overall quality of life. Antiembolic stockings are an unacceptable intervention in this patient group. Guidelines on thromboprophylaxis are urgently needed for palliative care inpatient units and hospices.

The feasibility, reliability and validity of the Malay McGill Quality of Life Questionnaire--Cardiff Short Form (MMQOL-CSF) in Malaysian advanced cancer population.

Health-related quality of life (HRQoL) assessment is important in healthcare outcomes. This study aimed to determine the feasibility, reliability and validity of the Malay McGill Quality of Life Questionnaire--Cardiff Short Form (MMQOL-CSF) in advanced cancer population. Patients either completed the MMQOL-CSF alone or in addition to its long version. The study recruited 116 participants (average age = 44 years old). On average, MMQOL-CSF was completed in 5.4 minutes. Most domains showed evidence of reliability (Cronbach's alpha = 0.76-0.92). Correlation with its long version was moderate to strong (r(s) = 0.54-0.87). The MMQOL-CSF was a feasible, reliable and valid HRQoL instrument in this population.

The House of Lords Select Committee on the Assisted Dying for the Terminally III Bill: implications for specialist palliative care.

The Assisted Dying for the Terminally III Bill proposed to legalise both euthanasia and physician-assisted suicide for those with a terminal illness in the UK. A House of Lords Select Committee was convened to scrutinise this Bill and has recently published its report, which will be debated in Parliament on October 10th 2005. The written and oral evidence submitted to the Select Committee represented a wide range of views on 'assisted dying'. Much of the evidence from those countries which have legalised euthanasia/physician-assisted suicide (The Netherlands, Belgium, Switzerland and Oregon, USA) dealt with the practicalities of ending life, and the legal procedures and safeguards instigated in these countries. All the written and oral evidence in the public domain was scrutinised by the authors whilst the Select Committee was sitting. We have extracted those themes relevant to specialist palliative care practice and present them in this paper. We hope that this will provide a useful resource to inform the forthcoming public debate on assisted dying. The evidence of harms inherent in making such a change in the law, as presented to the Select Committee, has moved all three authors to oppose a change in the law.

Prospective study of the effect of rectopexy on colonic motility in patients with rectal prolapse.

BACKGROUND: Patients with rectal prolapse have abnormal hindgut motility. This study examined the effect of rectal prolapse surgery on colonic motility. METHODS: Twelve patients undergoing sutured rectopexy were studied before and 6 months after surgery by colonic manometry, colonic transit study and clinical assessment of bowel function. The results were compared with those from seven control subjects. RESULTS: Before surgery colonic pressure was greater in patients than controls (P < 0.050). Controls responded to a meal stimulus by increasing colonic pressure; this increase was absent in patients. After rectopexy, colonic pressure reduced towards control values and patients' colonic pressure response to a meal returned. High-amplitude propagated contractions (HAPCs) were seen in all controls but in only three patients before and two patients after surgery. Three patients had prolonged colonic transit before and eight after rectopexy. CONCLUSION: Patients with rectal prolapse have abnormal colonic motility associated with reduced HAPC activity. Rectopexy reduces colonic pressure but fails to restore HAPCs, reduce constipation or improve colonic transit. These observations help explain the pathophysiology of constipation associated with rectal prolapse.