With the widespread introduction of preoperative radiotherapy for rectal cancer and the development of transanal endoscopic microsurgery for selected early lesions, preoperative radiological staging of these tumours has taken on increasing importance. This study is a systematic review to evaluate computed tomography (CT), endorectal sonography (ES) and magnetic resonance imaging (MRI) as preoperative staging modalities in rectal cancer. A Medline-based search identifying studies using CT, ES, or MRI in preoperative staging of rectal cancer between 1980 and 1998 was undertaken. The list of papers was supplemented by extensive cross-checking of citation lists. Studies were included if they met predetermined criteria. Data from the accepted studies were entered into pooled tables comparing radiological and pathological staging results for each modality both in determining bowel wall penetration and involvement of lymph nodes. Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were determined for the pooled results. Eighty-three studies from 78 papers including 4,897 patients met the inclusion criteria. In determining the wall penetration of the tumour the values for sensitivity for CT, ES, MRI and MRI with endorectal coil were 78%, 93%, 86% and 89%; for specificity 63%, 78%, 77% and 79%; and for accuracy 73%, 87%, 82% and 84%, respectively. In determining the nodal involvement by tumour the sensitivity values for CT, ES, MRI and MRI with endorectal coil 52%, 71%, 65% and 82%; for specificity 78%, 76%, 80% and 83%; and for accuracy 66%, 74%, 74% and 82%, respectively. MRI with an endorectal coil is the single investigation that most accurately predicts pathological stage in rectal cancer.

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ObjectiveTo quantify the sequential changes in metabolic response occurring in patients with severe sepsis after the onset of peritonitis. Summary Background DataUnderstanding the changes in energy expenditure and body composition is essential for the optimal management of severely septic patients; however, they have not been quantified in the context of modern surgical care. MethodsTwelve patients with severe sepsis secondary to peritonitis (median APACHE 11 score = 21.5) had measurements of energy expenditure and body composition as soon as they were hemodynamically stable and 5, 10, and 21 days later. Sequential measurements of acute-phase proteins and cytokine responses were also made. ResultsResting energy expenditure rose to 49% above predicted and remained elevated throughout the study period. Total energy expenditure was 1.25 x resting energy expenditure. Body fat was oxidized when energy intake was insufficient to achieve energy balance. There was a positive fluid balance of 12.5 over the first 2 days after onset of sepsis; thereafter, body water changes closely paralleled body weight changes and were largely accounted for by changes in extracellular water. During the 21-day study period, there was a loss of 1.21 kg (13%) of total body protein. During the first 10 days, 67% of the protein lost came from skeletal muscle, but after this time it was predominantly from viscera. Intracellular potassium levels were low but did not deteriorate further after hemodynamic stability had been reached. There was a reprioritization of hepatic protein synthesis that was obligatory and independent of changes in total body protein. The cytokine responses demonstrated the complexity, redundancy, and overlap of mediators. ConclusionsThe period of hypermetabolism in severely septic patients is similar to that previously described, but the fluid changes are larger and the protein loss is greater. Protein loss early on is predominantly from muscle, thereafter from viscera. Fat loss can be prevented and cell function preserved once hemodynamic stability is achieved.Patients with severe sepsis demonstrate a characteristic picture in which hypermetabolism occurs, protein and fat are consumed, and body water and salt are conserved.' These fundamental changes lie at the heart of present management of the severely septic patient; however, many of the changes described have not been quantified in the context of modem surgical care. The availability of body composition methodology, which has been adapted for use in