Our results suggest that after ELAPE the application of a negative pressure system to the perineal wound closed with biologic mesh may reduce perineal wound complications and may reduce the need for major perineal reconstruction.

Xanthoderma: an unusual presentation of hypothyroidism presenting symptom is a matter of choice for the patient, as this case illustrates. Of the multiple symptoms she had, yellow skin was chosen as the presenting feature. Although the general practitioner realised that the yellow tinge of her skin sparing the sclerae was probably not jaundice, he did request liver function tests to exclude this condition. The chemical pathology staff were alert enough to recognise the possibility of hypercarotenaemia and underlying hypothyroidism and to instigate the necessary tests to prove it.It is acknowledged that hypothyroidism confers a yellow tint to the skin in many patients, especially if the palms and soles are examined.' However, we feel that yellowing of the whole body skin as a sole presenting feature of hypothyroidism must be extremely rare as other signs and symptoms usually dominate the clinical picture. In this case the patient did admit having symptoms suggestive of thyroid hormone deficiency for 18 months, a duration long enough perhaps to increase the chance of development of hypercarotenaemia to such a degree.It has long been noted that sera from cases of myxoedema and cretinism are characteristically of a deeper orange-yellow colour than normal due to increased concentration of the carotenoid pigments that are carried by specific lipoproteins."2Furthermore, administration of fl-carotene to hypothyroid patients results in a sharp increase and delayed clearance of its plasma concentration compared with normal subjects.3 The hypercarotenaemia of myxoedema is thought to be due to reduced conversion of carotenoids to retinol, and it has been suggested that vitamin A deficiency may ensue as a result, causing the dry scaly skin typical of hypothyroid patients.4The concentration of plasma carotene is greatly influenced by dietary intake but our patient denied excessive consumption of carotene-rich foods. High concentrations are also found in hyperlipidaemia associated with diabetes mellitus and chronic renal failure.5This patient represents an excellent case example from the chemical pathology point of view, as she displayed all the biochemical abnormalities describable in hypothyroidism, which were successfully corrected by thyroxine replacement. The main message from this case is that the patient whose yellow skin is not due to jaundice is worth investigating for hypercarotenaemia and possible hypothyroidism.

Background Colorectal cancer often presents with obstruction needing urgent, potentially life-saving decompression. The comparative efficacy and safety of endoluminal stenting versus emergency surgery as initial treatment for such patients is uncertain. Methods Patients with left-sided colonic obstruction and radiological features of carcinoma were randomized to endoluminal stenting using a combined endoscopic/fluoroscopic technique followed by elective surgery 1–4 weeks later, or surgical decompression with or without tumour resection. Treatment allocation was via a central randomization service using a minimization procedure stratified by curative intent, primary tumour site, and severity score (Acute Physiology And Chronic Health Evaluation). Co-primary outcome measures were duration of hospital stay and 30-day mortality. Secondary outcomes were stoma formation, stenting completion and complication rates, perioperative morbidity, 6-month survival, 3-year recurrence, resource use, adherence to chemotherapy, and quality of life. Analyses were undertaken by intention to treat. Results Between 23 April 2009 and 22 December 2014, 245 patients from 39 hospitals were randomized. Stenting was attempted in 119 of 123 allocated patients (96.7 per cent), achieving relief of obstruction in 98 of 119 (82.4 per cent). For the 89 per cent treated with curative intent, there were no significant differences in 30-day postoperative mortality (3.6 per cent (4 of 110) versus 5.6 per cent (6 of 107); P = 0.48), or duration of hospital stay (median 19 (i.q.r. 11–34) versus 18 (10–28) days; P = 0.94) between stenting followed by delayed elective surgery and emergency surgery. Among patients undergoing potentially curative treatment, stoma formation occurred less frequently in those allocated to stenting than those allocated to immediate surgery (47 of 99 (47.5 per cent) versus 72 of 106 (67.9 per cent); P = 0.003). There were no significant differences in perioperative morbidity, critical care use, quality of life, 3-year recurrence or mortality between treatment groups. Conclusion Stenting as a bridge to surgery reduces stoma formation without detrimental effects. Registration number: ISRCTN13846816 (http://www.controlled-trials.com).

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