Fourteen patients with inoperable cancer treated with peritoneovenous shunts for malignant ascites were studied post mortem. Clinical observations and findings at necropsy indicated that peritoneovenous shunting does not result in the establishment of clinically important haematogenous metastases and that metastases do not necessarily develop even when large numbers of viable tumour cells regularly enter the blood.Peritoneovenous shunting provides a unique opportunity for collecting data on the spread of tumours in man.

Endoscopic transanal resection (ETAR) of rectal tumours is a simple and inexpensive procedure, well tolerated in elderly patients or those undergoing palliation. We have performed 137 ETARs in 81 patients with a 30-day mortality rate of 11.1 per cent and a postoperative complication rate of 15.3 per cent. Thirty-one patients (38 per cent) had ETAR for palliation: in this group rectal bleeding was abolished or improved in 66 per cent of patients, altered bowel habit (diarrhoea) corrected in 77 per cent of patients, faecal incontinence improved in 50 per cent of patients and rectal pain (including tenesmus) improved in 50 per cent of patients. Twenty-three patients (28 per cent) were treated for large benign rectal polyps: in this group symptoms were universally abolished. The technique is particularly suited to the management of these patients. Twenty-seven elderly patients with theoretically 'curable' rectal cancer underwent ETAR with a 78 per cent crude survival rate at 1 year. While long-term results remain to be assessed, ETAR appears a useful technique for treating selected patients with rectal tumours.

Peritoneovenous shunts have been inserted into 26 patients to control malignant ascites. All benefitted and most required no further paracentesis until death from progressive malignancy. Shunt blockage, which is the major problem at present, occurred in 8 patients. Five patients suffering from far advanced malignancy died within a month of operation. There was no clinical evidence of enhanced tumour spread or disseminated intravascular coagulation. We do not consider that the procedure is the first line of management, neither has it much to offer the patient with viscous, bloodstained or loculated ascites. We suggest criteria which help to identify the patient most likely to benefit from a peritoneovenous shunt.

Forty‐three peritoneovenous shunts have been inserted to palliate malignant ascites in 33 patients. Ascites was controlled for a time in every patient, but 18 shunts eventually blocked. Further shunt revision successfully controlled ascites until death in five of these patients and for prolonged periods in another five. The authors observed a marked difference between the performances of the two available shunts, but emphasize that the two groups of patients were not selected at random and therefore may not be comparable. Twelve postmortem examinations have been performed in the 33 patients to ascertain causes of shunt malfunction and to identify possible evidence of abnormal or accelerated tumor spread. The postmortem findings highlight great variability in the capacity of iatrogenically introduced showers of tumor cells to seed. There was a spectrum of tumor growth in the lung from a complete absence of tumor cells through dormant tumor clumps to developing metastases. The authors found no evidence either clinically or at autopsy, that the procedure had adversely affected the prognosis, except in one patient who died from pulmonary edema immediately after the operation.

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