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Background: Cardiopulmonary exercise testing (CPET) identifies high-risk patients before major surgery. In addition to using oxygen uptake and ventilatory efficiency to assess functional capacity, CPET can be used to identify underlying myocardial dysfunction through the assessment of the oxygen uptake to heart rate response (oxygen pulse response). We examined the relationship of oxygen pulse response, in combination with other CPET variables and known cardiac risk factors, with mortality after colorectal cancer surgery. Methods: This work focused on a retrospective cohort study of patients who had CPET and underwent colorectal cancer surgery. The primary outcome was a composite of in-hospital and 30-day mortality. Ventilatory inefficiency (VE/VCO 2 >34) and exercise-induced myocardial dysfunction (abnormal oxygen pulse response) were investigated for an association with mortality using bivariable analysis and multivariable Cox regression. Results: A total of 1214 patients who underwent colorectal cancer surgery were included, and the primary outcome occurred in 26 patients (2.1%). Multivariable Cox regression showed abnormal oxygen pulse response was independently associated with the primary outcome (odds ratio [OR]¼2.75; 95% confidence interval [CI], 1.17e6.47). Bivariable analysis showed that VE/VCO 2 >34 was associated with the primary outcome (OR¼3.43; 95% CI, 1.47e8.01). Combining VE/VCO 2 >34 and abnormal oxygen pulse response conferred an increased risk for the primary outcome (OR¼4.47; 95% CI, 1.62e12.34), compared with VE/VCO 2 >34 and normal oxygen pulse response. Conclusion: Ventilatory inefficiency and an abnormal oxygen pulse response were independently associated with short-(30-day) and long-term (2-yr) mortality. Oxygen pulse response may provide additional information when considering perioperative risk stratification.

In our patients, CRP on POD 2 has been shown to be a good predictor of both minor and major complications and can therefore be used to guide clinicians in making decision as to which patients may need further investigation or who can be safely discharged.

Sialomucin change and colorectal cancer recurrence: P. M. Dawson et al. Acute reservoir ileitis (pouchitis) has been reported in 7-43 per cent of patients following colectomy and ileal reservoir formation' and is characterized by episodic diarrhoea in the presence of acute inflammatory changes in the pouch mucosa. As acute reservoir ileitis has only been described in patients with a previous diagnosis of ulcerative colitis2, the aetiology of pouchitis may be disease-related. However, the efficacy of metronidazole in the treatment of pouchitis suggests that faecal organisms may also have a role in the pathogenesis of pouchitis'.We report the first fully documented case of pouchitis in a patient following ileal reservoir construction for familiar adenomatous polyposis. Case reportA 23-year-old Caucasian male had an elective restorative proctocolectomy performed for familial adenomatous polyposis as a single-stage procedure using a double loop ileal J pouch. Mucosal proctectomy was completed to the dentate line before a sutured ileoanal anastomosis.Following an uncomplicated 10-month postoperative course the patient presented with sudden onset of malaise, increased frequency of defaecation by day (eight times) and night (two times), urgency and nocturnal leakage of faecal fluid per anum sufficient to require the use of two pads. Examination revealed mild diffuse abdominal tenderness with no evidence of an anal stricture.Sigmoidoscopy of the pouch revealed patchy mucosal erythema with spontaneous bleeding and multiple pouch biopsies demonstrated mucosal ulceration, villous atrophy, a heavy neutrophil infiltrate and crypt abscesses. Faecal bacterial culture failed to detect a specific enteropathogen or increased numbers of aerobic or anaerobic bacteria. An indium-labelled granulocyte scan showed increased activity in the region of the pouch which was confirmed by increased radioactivity in a concurrent 4-day faecal collection (4 per cent of total injected radioactive dose; normal < 2 per cent3).Following I month's treatment with metronidazole symptoms had improved with complete resolution of urgency and soiling. The endoscopic and histological appearances of the pouch mucosa were now indistinguishable from the appearances in healthy ileal reservoirs. A repeat indium-labelled granulocyte scan showed no abnormality and a repeat 4-day faecal collection did not show increased indium granulocyte excretion. DiscussionThis case demonstrates that pouchitis can occur in the absence of ulcerative colitis, anal stenosis, bacterial overgrowth or a specific enteropathogen. We have used sigmoidoscopic, histological and microbiological criteria for diagnosing pouchitis2 to exclude clinical syndromes causing diarrhoea that may mimic the features of acute reservoir ileitis such as overflow incontinence due to an anal stricture, Crohn's disease2 and jejunal bacterial overgrowth4. Acute inflammation in the pouch was confirmed objectively by a positive radiolabelled granulocyte scan and by increased faecal excretion of labelled granulocy...

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