Chemoradiotherapy (CRT) as a definitive treatment for esophageal cancer, is being used with increasing frequency and as a result, surgeons will be required to assess more patients who have residual or recurrent local malignancy. This article aimed to assess outcomes after esophagectomy following definitive CRT (dCRT) and compare any difference between them and patients who had preoperative neoadjuvant CRT (nCRT) using a similar regimen of chemotherapy. From a prospective database the details of patients who had a resection following nCRT and dCRT were analyzed. The main therapeutic difference between the groups was the dose of radiotherapy (35 vs 60 Gy) and the timing of the resection following completion of the CRT (median 4 vs 28 weeks). Fourteen patients had an esophagectomy following a dCRT and 53 had one following a nCRT. Preoperatively, the dCRT group had worse respiratory function and more ECG abnormalities. Preoperative tumor length, pathological TNM staging and R0 resection rates were the same in both groups. Post resection, the dCRT group had greater morbidity than the nCRT group, spending longer in the intensive care unit (median 48 vs 24 h), more days in hospital (median 31 vs 13) and having more severe respiratory complications (37%vs 6%). The operative mortality was higher in the dCRT group (7%vs 0%). The three-year survival was 24% after dCRT. Patients selected for salvage esophagectomy following dCRT are a major challenge in postoperative care. However, some patients survive for a reasonable period of time, making resection a worthwhile option.

Despite the apparent attractiveness of laparoscopic bile duct exploration at the time of cholecystectomy, ERCP remains the most common method of dealing with choledocholithiasis in the setting of an intact gallbladder in Australia.

Biliary injuries are still occurring at laparoscopic cholecystectomy. Guidelines about the management of a suspected biliary injury are discussed. Clinical, radiological and pathological assessment should enable prompt diagnosis and management should be instituted early, preferably with the involvement of a hepatobiliary specialist.

Our results confirm the high response rates and acceptable toxicity of preoperative treatment. Further studies are required to better define the impact of preoperative chemotherapy and radiotherapy on long-term outcomes.

Splenic metastases are a clinical rather than pathological rarity. The spleen is involved in metastatic malignancy in 6-13% of cases at autopsy study. 1,2 Although traditionally thought to imply widespread metastatic disease, the advent of increasingly sophisticated imaging techniques used in the follow up of neoplastic patients has recently challenged this notion. 3 Often asymptomatic, the clinical presentation of splenic metastases may be unusual and range from splenomegaly to left upper quadrant pain, spontaneous rupture, infarction or thrombocytopenia. 3,4 Currently, there are 21 case reports of spontaneous splenic rupture as a result of solid tumour metastases in the literature. We present the 22nd case, with a review of the previously reported cases and a discussion of the likely pathogenesis, clinical significance and prognostic implications of this rare but important condition. CASE REPORTA 54-year-old woman presented with an antral gastric carcinoma. The patient went on to have a distal gastrectomy with lymph node dissection, including hepatic artery and coeliac axis nodes. Histology revealed extension into the lesser omentum. Nine of 10 lesser curve and six of 11 oesophagogastric nodes were positive (total 15). The TNM stage was IIIB (T 3 N 2 M 0 ).Nine months later, at routine follow up, recurrence was diagnosed in a left supraclavicular lymph node. Computed tomography (CT) scan identified extensive retroperitoneal, mesenteric, posterior mediastinal and porta hepatis lymphadenopathy. Palliative chemotherapy was commenced with good clinical and radiological response. No abnormality was noted in the spleen at that time or at three subsequent CT scans over the following 3 months. Seven months later, the patient developed a right-sided above-knee deep venous thrombosis (DVT) and was commenced on warfarin. Upon development of recurrent DVT in the same limb while therapeutically anticoagulated, warfarin was ceased and the patient commenced on subcutaneous low molecular weight heparin (1 mg/kg b.d.).Seventeen months after the original diagnosis and surgery, the patient presented emergently with a 2-day history of gradual-onset left upper quadrant pain, which subsequently became severe. There was no history of recent trauma. While initially haemodynamically stable, the patient became acutely hypotensive and tachycardic in the emergency department. Initial full blood count revealed a haemoglobin of 81 g/L, normal white cell count and a platelet count of 42 × 10 9 /L. Following resuscitation, haemoglobin had dropped to 57 g/L. Abdominal CT revealed an enlarged nonperfusing spleen, non-opacification of both splenic artery and vein and a large amount of free intraperitoneal fluid (Fig. 1).At laparotomy via a left upper quadrant incision, an ischaemic spleen was identified with spontaneous rupture at the hilum. Two litres of free intraperitoneal blood was drained. An emergency splenectomy was performed. No free intraperitoneal metastatic disease was noted.The spleen weighed 830 g and measured 190 × 110 × 80 mm. Mac...