The lack of detail in trial reports about surgical interventions creates difficulties in understanding which operations were actually evaluated. Methods for designing and reporting surgical interventions in RCTs, contributing to the quality of the overall study design, are required. This should allow better implementation of trial results into practice.

INTRODUCTION Intestinal malrotation is a rare developmental abnormality occurring as a result of incomplete rotation during fetal life. It usually presents in the first few weeks of life, but may persist unrecognised into adult life. We report two interesting cases in elderly patients both characterised by a significant diagnostic challenge due to atypical clinical and radiological signs and in one case an unusual complication following laparotomy. CASE REPORTS The first case was a 64-year-old man initially treated for diverticulitis but at laparotomy was found to have malrotation of the midgut and a perforated left-sided appendicitis. The second case was a 76-year-old woman admitted with multiple fractures and increasing abdominal distension following a fall. Ten days after admission, she underwent right hemicolectomy to treat faecal peritonitis due to multiple caecal perforations complicating volvulus in the presence of midgut malrotation. CONCLUSIONS These cases illustrate challenges associated with managing patients with undiagnosed intestinal malrotation. Delayed diagnosis is a common feature in several case reports describing atypical presentation of appendicitis in patients with malrotation. While abdominal CT scan can remove much of the diagnostic uncertainty, the diagnosis of malrotation can be missed unless there is a high index of suspicion.

Intraductal papillary mucinous neoplasms (IPMNs) are associated with risk of pancreatic ductal adenocarcinoma (PDAC). It is unclear if an IPMN in individuals at high risk of PDAC should be considered as a positive screening result or as an incidental finding. Stratified familial pancreatic cancer (FPC) populations were used to determine if IPMN risk is linked to familial risk of PDAC. METHODS: This is a cohort study of 321 individuals from 258 kindreds suspected of being FPC and undergoing secondary screening for PDAC through the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Computerised tomography, endoscopic ultrasound of the pancreas and magnetic resonance imaging were used. The risk of being a carrier of a dominant mutation predisposing to pancreatic cancer was stratified into three even categories (low, medium and high) based on: Mendelian probability, the number of PDAC cases and the number of people at risk in a kindred. RESULTS: There was a median (interquartile range (IQR)) follow-up of 2 (0-5) years and a median (IQR) number of investigations per participant of 4 (2-6). One PDAC, two low-grade neuroendocrine tumours and 41 cystic lesions were identified, including 23 IPMN (22 branch-duct (BD)). The PDAC case occurred in the top 10% of risk, and the BD-IPMN cases were evenly distributed amongst risk categories: low (6/107), medium (10/107) and high (6/107) (P 5 0.63). CONCLUSIONS: The risk of finding BD-IPMN was independent of genetic predisposition and so they should be managed according to guidelines for incidental finding of IPMN.