C. L. Ingham Clark

A study of pre-registration house officers’ clinical skills

Little is known about the ability of pre‐registration house officers (PRHOs) to perform basic clinical skills just prior to entering the medical register.

Changing trends in the management of colorectal cancers and its impact on cancer waiting times.

Objective  The aim of this study was to compare the differences in the presentation, management and waiting times for new colorectal cancer (CRC) patients over 5 years in a single metropolitan cancer centre.

Where exactly is the deep inguinal ring in patients with inguinal hernias

It is difficult to distinguish direct from indirect inguinal hernias on clinical examination. This study attempted to determine an anatomical basis for this finding. Fifty adult patients with primary inguinal hernias were assessed. The position of the deep inguinal ring (DIR) was estimated from the position of the anterior superior iliac spine (ASIS) and the pubic tubercle (PT) pre-operatively and then the actual distance from these landmarks was measured intra-operatively. The DIR was actually located at a mean of 41% (95% confidence interval (CI) 26–56%) of the way along the inguinal ligament from the PT towards the ASIS (regression slope 1.203; 95% CI 1.141–1.127), compared with the 50% which would be expected from traditional clinical methodology. The DIR was actually found at a mean of 51% (95% CI 33–69%) of the way along a line from the pubic symphysis to the ASIS (regression slope 1.421; 95% CI 1.343–1.499). Pre-operative estimates of the position of the DIR are not accurate measures of its true position in patients with inguinal hernias. Clinical examination of inguinal hernias cannot rely on a constant position of the DIR to determine whether a hernia is direct or indirect.

Telephonic management of rectal bleeding in young adults – a prospective randomized controlled trial

Objective  The majority of young adults referred with rectal bleeding to a colorectal specialist clinic have a very low risk of serious disease such as cancer, and a high chance of gaining symptom relief by simple dietary changes.

The use of symptoms to predict colorectal cancer site. Can we reduce the pressure on our endoscopy services

Dear Sir, We read with interest the article of Steensma and colleagues [1] and agree with their approach. However, we believe that some points should be clarified. First, it is necessary to perform the ultrasonographic evaluation with mild pressure of the probe to the perineum, because inadequate contact can limit the pelvic floor movements and change the results. Moreover, the most useful information obtained from evacuation proctography is obtained during the evacuation phase, in which the rectum is maximally stressed and the posterior pelvic floor prolapse becomes more evident. Unfortunately, the evacuation phase is not reproducible on transperineal ultrasound. The authors do not mention contrast medium, but we usually instil about 30 ml of ultrasonographic gel into the rectum and vagina and ask the patient to have a half-filled bladder before the ultrasound examination. We have experience in these types of examination, and we agree that there is a good agreement for the detection of enterocele, rectocele and rectal intussusception. It is, however, important to understand the role of evacuation proctography and transperineal ultrasound in the management of these patients. Rectocele and rectal intussusception are frequent findings in women, but <25% of patients are symptomatic. [2] Moreover, defecography demonstrates a rectocele in 81% of asymptomatic females [3] and intussusception in 35% of asymptomatic individuals [4]. If patients with obstructed defecation are treated surgically for an anatomical alteration, we believe that the accuracy of transperineal ultrasound cannot be compared with evacuation proctography. If on the other hand patients are treated for their symptoms and all that is needed is to confirm the anatomical alteration, they could be evaluated with transperineal ultrasound. Transperineal ultrasound is fast, effective, noninvasive, nonexpensive and well tolerated. It should be considered as an important tool for the evaluation of patients with symptoms of obstructed defecation, but its role still needs to be evaluated and supported by a better understanding of the correct management and the true indications for treatment of these patients.

Peri‐operative management of patients having external anal sphincter repairs: temporary prevention of defaecation does not improve outcomes

To determine whether there was any detectable difference in outcomes of external anal sphincter repair depending on whether patients were managed routinely with a covering stoma, a constipating dietary regimen or a laxative dietary regimen in the early postoperative period.