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Background: The COVID-19 pandemic has created challenges in the diagnosis and management of colorectal cancer (CRC). It was proposed in regional Northern Australia that the distance to services could further impact cancer outcomes, leading to delayed diagnosis. The authors compared the outcomes of patients prior and during the pandemic; with a focus on whether patients were presenting in the emergency setting with more advanced disease. The distance to treatment was also analysed to see if there was any impact to the management of patients with colorectal cancer. Methods: A retrospective analysis of 444 patients who underwent treatment for colorectal cancer over two time periods was examined. Time period 1 (prior to COVID-19); March 2017-July 2019 and time period 2 (during COVID-19); March 2020-July 2022. Only patients with colorectal adenocarcinoma were included if they were primarily treated at a hospital in northern Australia; those with benign pathologies or recurrent disease were also excluded. Data was collected in terms of treatment and outcomes and compared between the two groups. A separate analysis of whether locality affected outcomes and referral times was also performed. Results: In the time period prior to COVID-19, 174 patients' required invasive management, while in the second time period during COVID-19, there were 188 patients managed surgically or endoscopically. Of the patients managed prior to COVID-19 17/174 (9.8%) patients required emergency interventions, during COVID-19 this number increased to 37/188 (19.7%). This difference was deemed to be statistically significant (P =0.008). No substantial difference in cancer staging at presentation was found between the two groups. There was an increase in complication rate found during COVID-19 34.6 vs 25.5% prior to COVID-19 (P=0.046). During COVID-19, the median time between General Practitioner (primary care physician) referral and colonoscopy was actually lower than prior to covid 26.5 vs 36 days (P=0.047). When comparing local to distant patients, we found locally based patients had lower rates of neoadjuvant treatment 18.9 vs 30.4% (P=0.018) and higher rates of open surgery 39.1 vs 26.5%, P =0.012. An increase in time between colonoscopy and outpatient department review (OPD) was seen in patients not from the local area 13 vs 18 days (P =0.006). Conclusion: The authors found during the COVID-19 pandemic a greater proportion of patients were presenting with colorectal cancer that required emergency intervention. This may be due to decreased presentations to general practitioners due to lockdown causing potential delays in diagnosis. The authors did not see more advanced disease in these patients presenting emergently, between the two groups. Further assessment of local patients' vs patients from distant sites, showed difference in how patients were managed but similar outcomes. Our large catchment area with distance to treatment in Northern Australia may further impact the management of colorectal cancer in the future.
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Internal biliary fistula is a rare but well-known complication of cholelithiasis. It is a notoriously challenging entity to diagnose and manage. Gallstones are often the causative factor in the formation of a cholecystoenteric fistula, with the most common internal biliary fistula being a cholecystoduodenal fistula followed by a cholecystocolonic fistula. Rarely, do these fistulae exist simultaneously. Here, we present an uncommon case of cholecysto-duodenocolonic fistula.
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Metastatic melanoma is a significant public health issue in Australia and New Zealand. Although melanoma commonly metastasises to the liver, isolated hepatic metastases are rare, with isolated metastasis to portohepatic lymph nodes being scarce. As such, the optimal management strategy for this subset of patients remains unclear. Here, we present a case of a patient with isolated portohepatic metastases management with a combination neoadjuvant immunotherapy and surgical resection.
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A staple line leak is a feared complication of sleeve gastrectomy. Endoscopic methods have superseded surgical management of small leaks, however large collections often require surgical intervention. Here, we describe endoscopic management of large collection adjacent to the staple line with an 8Fr nasobiliary tube.
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Hyperammonaemia is a metabolic disorder with elevated blood ammonia levels. Here we describe a case of hyperammonaemia associated encephalopathy as an incredibly rare, potentially fatal and treatable complication associated with bariatric surgery. This case highlights the importance of longer-term follow-up after bariatric surgery.
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Protease-activated receptors (PARs) are a family of four G protein-coupled receptors that exhibit increasingly appreciated differences in signaling and regulation both within and between the receptor class. By nature of their proteolytic self-activation mechanism, PARs have unique processes of receptor activation, "ligand" binding, and desensitization/resensitization. These distinctive aspects have presented both challenges and opportunities in the targeting of PARs for therapeutic benefit-the most notable example of which is inhibition of PAR1 on platelets for the prevention of arterial thrombosis. However, more recent studies have uncovered further distinguishing features of PAR-mediated signaling, revealing mechanisms by which identical proteases elicit distinct effects in the same cell, as well as how distinct proteases produce different cellular consequences via the same receptor. Here we review this differential signaling by PARs, highlight how important distinctions between PAR1 and PAR4 are impacting on the progress of a new class of anti-thrombotic drugs, and discuss how these more recent insights into PAR signaling may present further opportunities for manipulating PAR activation and signaling in the development of novel therapies.
