Functional outcomes of bowel resection versus shaving or disc excision of colorectal endometriosis: a systematic review protocol.

INTRODUCTION: Endometriosis is a prevalent gynaecological condition for women of reproductive age worldwide. While endometriosis primarily involves the reproductive system, it can also infiltrate additional viscera such as the gastrointestinal tract. Patients with colorectal endometriosis can have severe symptoms that require surgical intervention. There are limited data available to guide the choice of resection technique based on the functional outcomes of bowel resection versus shaving or disc excision in treating colorectal endometriosis. This protocol aims to outline the methods that will be used in a systematic review of the literature comparing the functional outcomes of bowel resection to shaving and disc excision when surgically treating colorectal endometriosis. METHODS AND ANALYSIS: Papers will be identified through database searches, scanning reference lists of relevant studies and citation searching of key papers. Two independent reviewers will screen studies against eligibility criteria and extract data using standardised forms. Databases including MEDLINE, EMBASE and Cochrane will be searched from the beginning of each database until February 2024. The primary outcome is comparing the functional bowel outcomes between the different methods of surgical treatment. Secondary outcome will be quality of life, based on the Low Anterior Resection Syndrome score and the incidence of postoperative pain. A meta-analysis will be performed if the data are homogenous. ETHICS AND DISSEMINATION: This study does not require ethics approval. The results of the systematic review described within this protocol will be disseminated through presentations at relevant conferences and publication in a peer-reviewed journal. The methods will be used to inform future reviews. PROSPERO REGISTRATION NUMBER: CRD42023461711.

Clozapine-Induced Refractory Colonic Pseudo-Obstruction.

The management of treatment-resistant schizophrenia (TRS) is challenging as the medications involved, often atypical antipsychotics, have a host of associated adverse effects. While complications such as agranulocytosis are well established and necessitate close hematological monitoring, the gastrointestinal effects of particular atypical antipsychotics, such as clozapine, are recognized to a lesser extent. The following case of TRS leading to chronic treatment-resistant pseudo-obstruction, eventually requiring total colectomy, highlights the considerable sequelae of clozapine on the gastrointestinal tract. Beyond the effects of severe constipation, the possible implications of ischemic colitis, stercoral perforation, and intraabdominal sepsis warrant a degree of caution when prescribing such medication. This study sheds light on the importance of monitoring bowel motility when administering antipsychotics, particularly clozapine, to avoid these deleterious consequences.

Postoperative superior mesenteric artery syndrome following appendicectomy: A case report.

INTRODUCTION: Superior mesenteric artery syndrome is a rare cause of proximal intestinal obstruction. It is caused by a narrow aortomesenteric angle resulting in external compression of the duodenum as it traverses between the abdominal aorta and the superior mesenteric artery. Presenting symptoms tend to be non-specific and aetiological risk factors for this syndrome remain subjects to debate. The lack of awareness for this phenomenon often results in a delayed diagnosis, yet it can predispose to potentially life-threatening complications. CASE PRESENTATION: We describe an acquired case of SMA syndrome, in an 88-year old male who underwent an open appendicectomy 20 years prior. The patient presented with an 18-month history of progressive anorexia, weight loss, and intractable vomiting. After inconclusive initial investigations, an exploratory laparotomy demonstrated extensive postoperative adhesions, placing traction on the SMA through its ileocolic branch, resulting in acute angulation of the SMA and subsequent external duodenal compression. DISCUSSION: This case illustrates the acute evolving presentation of gastric and duodenal obstruction associated with SMA syndrome, and the need to raise the index of suspicion for its diagnosis. In this case, it is postulated that SMA syndrome presented as a late complication of an open appendicectomy - A rare presentation for a rare disease. CONCLUSION: SMA syndrome is an uncommon, but important differential for upper gastrointestinal obstruction. This case illustrates the challenges in the diagnosis of this rare clinical entity. Further study is warranted to understand the varied aetiology and optimal management for patients presenting with SMA syndrome.

Catastrophic intraoperative bleeding due to congenital extrahepatic porto-systemic shunt anomaly: A surgical case report of two rare anomalies.

INTRODUCTION: Abernethy malformations are extremely rare congenital anomalous portosystemic shunts. We report the case of a patient with a rare variant Abernethy malformation between the superior mesenteric vein and left renal vein, associated with a massive jejunal diverticulum. PRESENTATION OF CASE: A 37-year-old Caucasian female presented to our emergency department with severe abdominal pain and proceeded to laparotomy for a presumed small bowel obstruction. At laparotomy she was found to have a massive diverticulum at the duodeno-jejunal junction, which was intimately associated with a venous malformation and the anomalous portosystemic shunt. Whilst mobilising the diverticulum, the patient developed catastrophic haemorrhage from the malformation. The patient underwent a complicated post-operative course however was eventually stabilised. DISCUSSION: We discuss the anatomy and pathophysiology of anomalous portosystemic shunts and propose an embryological origin for our patients' anomalies. CONCLUSION: Abernethy malformations are rare however may be associated with other intra-abdominal pathology and extreme caution is required when operating on these patients.