Introduction UK and European guidelines recommend consideration of a self-expandable metallic stent (SEMS) as an alternative to emergency surgery in left-sided colonic obstruction. However, there is no clear consensus on stenting owing to concern for complications and long-term outcomes. Our study is the first to explore SEMS provision across England. Methods All colorectal surgery department leads in England were contacted in 2018 and invited to complete an objective multiple choice questionnaire pertaining to service provision of colorectal stenting (including referrals, time, location and specialty). Results Of 182 hospitals contacted, 79 responded (24 teaching hospitals, 55 district general hospitals). All hospitals considered stenting, with 92% performing stenting and the remainder referring. The majority (93%) performed fewer than four stenting procedures per month. Most (96%) stented during normal weekday hours, with only 25% stenting out of hours and 23% at weekends. Compared with district general hospitals, a higher proportion of teaching hospitals stented out of hours and at weekends. Stenting was performed in the radiology department (64%), the endoscopy department (44%) and operating theatres (15%), by surgeons (63%), radiologists (60%) and gastroenterologists (48%). A radiologist was present in 66% of cases. Of 14 hospitals that received referrals, 3 had a protocol, 3 returned patients the same day and 4 returned patients for management in the event of failure. Conclusions All responding hospitals in England consider the use of SEMS in colonic obstruction. Nevertheless, there is great variation in stenting practices, and challenges in terms of access and expertise. Centralisation and regional referral networks may help maximise availability and expertise but more work is needed to support this.

Sarcomatoid renal cell carcinoma (SRCC) is a highly aggressive form of dedifferentiated renal cell carcinoma. We report a 65-year-old man who presented to the emergency department with respiratory symptoms, obstructive jaundice with deranged liver function tests and raised inflammatory marker. General physical examination showed a swelling in left supraclavicular region. The initial differential diagnosis was pancreatic cancer, bronchogenic carcinoma, gastric cancer and lymphoma. Computer tomography (CT) scan showed a solid right renal lesion, multiple liver metastases, florid chest, lymphadenopathy in left supraclavicular region and a right adrenal mass. Patient had biopsy of left supraclavicular node which diagnosed it as a metastatic high grade sarcomatoid renal cell carcinoma. We present the findings and a brief review.

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There are patients who complain of giving off a fishy smell through the skin and sweat, which can be a cause of stress in which the doctor often fails to accept this situation, or even the patient or his family members are ashamed of communicate these symptoms, causing their isolation.Trimethylaminuria, also called fish smell syndrome or fish smell syndrome [1], is a very rare metabolic disorder that presents an autosomal recessive inheritance pattern, causing an alteration in the function of the enzyme flavinmonooxygenase 3 (FMO3 ) [2,3].On the other hand, the presence of alterations in the inflammatory chain that governs the complement cascade is responsible for clinical situations that require an accurate diagnosis, such as Hereditary Angioedema, since their evolution can be the origin of clinical complications, serious times We present a case of family Trimethylaminuria in which the affected are two brothers of 2 and 6 years, and whose diagnosis could be obtained since the male patient presented an outbreak of inflammation of the face finally identified as Hereditary Angioedema.