Introduction McKittrick–Wheelock syndrome describes the condition of extreme electrolyte and fluid depletion caused by large distal colorectal tumours, usually the benign villous adenoma. Patients generally present critically unwell with severe hyponatraemia, hypokalaemia and/or acute kidney injury. Methods A structured literature review was undertaken to discover what is known about this condition, which is almost universally described as rare. Important features of the syndrome were identified, including common presenting symptoms, blood results, tumour location and size. Findings Our literature search identified 257 cases reported across all languages. The most remarkable features were the long duration of symptoms (median 24 months) and the significant electrolyte derangements (median sodium of 122mmol/l and median potassium of 2.7mmol/l at initial presentation). Five key recommendations are made to improve diagnosis, including aggressive fluid resuscitation to match rectal losses and surgical intervention on the index admission. The advantages and disadvantages of different treatment options are discussed, including minimally invasive alternatives to traditional resectional surgery. Conclusions McKittrick–Wheelock syndrome describes a normally benign condition that can cause patients to become critically unwell and so it behoves all clinicians to be aware of it. By publishing recommendations based on a comprehensive literature review, we aim to improve diagnosis and management of this life threatening condition.

Background: Deep infiltrating endometriosis (DE) is a particularly severe disease which affects 10-20% of women with endometriosis. 90% of DE is rectovaginal and when suspected, some clinicians have suggested the routine use of flexible sigmoidoscopy to identify intraluminal disease. We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE, both in terms of diagnosis and planning management. Objectives: We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE. Materials and Methods: A retrospective case series study was performed from a consecutive cohort of patients with DE referred for outpatient flexible sigmoidoscopy between January 2010 and January 2020. All patients were under the care of a specialist endometriosis multidisciplinary team. Main outcome measures: The primary outcome measure was the incidence of luminal disease. Results: 102 consecutive cases were analysed with no cases confirming intraluminal disease. Non-specific evidence of endometriosis such as tight angulation of the bowel was found in 36.3%. Following sigmoidoscopy 100 patients proceeded to surgery and the risk of bowel resection during surgery was 4%. Conclusions: Due to the low incidence of luminal endometriosis, performing sigmoidoscopy routinely is of limited benefit. We recommend the selective use of sigmoidoscopy where serious pathology such as colorectal neoplasia is considered or to determine the location of endometriosis lesions which aids subsequent resectional surgery planning. What is new? This large case series details a very low incidence of intraluminal disease and makes recommendations for the specific scenarios where flexible sigmoidoscopy should be used.

Aim Surgical registrars are under increasing pressure to achieve their competencies for ARCP under the constraints of EWTD, service provision and on call requirements. Less than full time (LTFT) and academic trainees can struggle to get fair allocation of training opportunities. These pressures can lead to competition between registrars for training opportunities and resentment can develop. We created a novel rota allocation method by which theatre, clinic and endoscopy training sessions were allocated based on percentage of elective days worked across the month, ensuring all trainees had the same opportunities. Method The system was implemented for 3 months in the colorectal departments at 2 hospitals. Full time, LTFT and academic trainees were treated equally with theatre, endoscopy and clinics allocated by percentage of elective days per month. The spreadsheet of allocations was viewable by all trainees to ensure transparency. All surgical registrars involved were invited to complete a feedback questionnaire on the new system. Results The rota was implemented for 3 months with full allocation of shifts during the study period. Trainees were successfully allocated training sessions proportionally to elective days. 7/ 10 registrars gave feedback, 85% of whom felt the system was fair and 71% thought it improved working relationships between trainees. Comments included “scrupulously fair”, “highly efficient” and gives “more transparency”. Conclusions Allocation of trainees to clinical training opportunities can be difficult. We present an innovative method by which trainees get equal and fair access to the training opportunities available and has consequently helped to improve working relationships between peers.