We report a case of reduced cerebral oxygenation which had the possibility of leading to an adverse outcome if it had not been detected by the routine use of cerebral oximetry. This case study illustrates that an inadvertent re-adjustment of a single-stage venous cannula within the superior vena cava resulted only in the cerebral oximetry device alerting to a potential problem. All other monitoring devices remained within standard operating parameters, with no deviation throughout the duration of the incident.

Over the past decade, there has been an increase in endoscopic procedures within the thorax for diagnostic and therapeutic purposes. Each has its indications, techniques and complications. However, the one common denominator is that there is always the possibility that thoracotomy may be necessary. Occasionally, particularly if considerable haemorrhage occurs, thoracotomy may be required immediately. Consequently, the clinical examination and investigations should be orientated to this possibility. The medical and theatre staff should be prepared for, and trained to deal with, such an eventuality. GENERAL PREOPERATIVE CONSIDERATIONS Patients should undergo a complete evaluation for a full posterolateral thoracotomy. The goal is to define all of the problems and to ascertain if the patient is in the best possible condition. Factors known to increase the risk for patients undergoing thoracic surgery include cigarette smoking, advanced age, coronary artery disease, preoperative weight loss, obesity, poor pulmonary function and duration of anaesthesia. 47 Cardiac risk is determined by the severity of coronary artery disease, presence of cardiac arrhythmias, left ventricular dysfunction, age and associated medical conditions such as hypoxaemia, diabetes and renal insufficiency. 28 An exercise stress test should be performed as patients with ischaemia are at a higher risk of perioperative cardiac complications and death when undergoing major operations such as pneumonectomy. 22 Consideration should be given to cardiac catheterization and, if appropriate, coronary artery bypass grafting before major lung resection. However, it is not known if this is true for patients undergoing thoracoscopic pulmonary resection. The preoperative evaluation of the respiratory system involves taking a history, physical examination, exercise tolerance, routine laboratory tests, including arterial blood-gas tensions, radiography and pulmonary function tests. Patients who show an increase in peak expiratory flow rate by 15% or more after administration of bronchodilators should receive perioperative bronchodilators. A forced vital capacity (FVC) of at least three times the tidal volume is necessary for an effective cough and a value of less than 50% of predicted is an indicator of increased risk of

Retrograde intussusception is exceedingly rare and has not been reported after a pancreaticojejunostomy. Recurrent retrograde intussusception has been reported only once before. In adults retrograde intussusception has been associated with gastric resection, gastrojejunostomy, Roux- en-Y gastric bypass, and gastrostomy tube placement. We report a case of retrograde intussusception of the efferent limb into the anastomosis of a revised Roux- en-Y bypass of the pancreas. Two long side-to-side anastomoses with plication were performed to prevent a third episode of intussusception involving this patient's Roux- en-Y.

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