A Rare Presentation of Recurrent Diverticulitis in a Patient with Ulcerative Colitis.

Diverticulitis and ulcerative colitis (UC) are two separate colonic pathologies with different underlying mechanisms. Diverticulosis involves herniation of mucosal and submucosal tissue through muscular tissue in response to increased intraluminal pressure. In contrast, it is believed that the muscular tone in patients with UC is reduced due to chronic inflammatory changes. Thus, it has been reported that there may be an inverse relationship between the presence of diverticulosis in patients with UC, in that UC may possibly be protective against developing diverticular disease. Consequently, the co-presence of both pathologies is uncommon. Here we present a case in which a woman with a history of UC and recurrent diverticulitis after elective partial colectomy was admitted for recurrent acute diverticulitis. It is quite challenging to diagnose diverticulitis in ulcerative colitis patients given the usually similar presentation with abdominal pain, diarrhoea and hematochezia. A level of high suspicion is required for diagnosis. LEARNING POINTS: Colonic diverticulitis is not commonly associated with ulcerative colitis.The diagnosis of colonic diverticulitis in the setting of ulcerative colitis is challenging and requires a high level of suspicion.

Omentoplasty to reduce anastomotic leak in colorectal surgery: a meta-analysis.

BACKGROUND: Anastomotic leaks (AL) remain a devastating complication following intestinal anastomoses resulting in increased morbidity and mortality. Wrapping the anastomosis with omentum may be protective although data are conflicting. We performed a meta-analysis to assess the effect of omentoplasty on colorectal anastomoses. METHODS: PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until August 2021. All randomized controlled trials (RCT) that reported on the use of omentoplasty in colon and rectal surgery were included. The primary outcome was rate of overall AL while secondary outcomes included clinical and radiological AL, overall reoperation and mortality. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS: Four RCTs were included capturing 1067 patients. The mean (SD) age of the cohort was 61.5 (±14.8) years. On random effects analysis, omentoplasty reduced rate of overall (OR 0.43, 95% CI = 0.21-0.87, p = 0.02) and clinical AL (OR = 0.35, 95% CI = 0.15-0.81, p = 0.01). However, there was no difference in radiological AL (OR = 0.77, 95% CI = 0.40-1.47, p = 0.42), overall reoperations (OR 0.48, 95% CI = 0.18-1.32, p = 0.16) or mortality (OR 0.52, 95% CI = 0.12 to-2.18, p = 0.37). On sensitivity analysis, assessing rectal anastomoses only, the results for overall AL remained similar (OR 0.28, 95% CI = 0.12-0.61, p = 0.002). CONCLUSION: Although omentoplasty appears to reduce the rate of overall and clinical AL, the heterogeneity in the data prevents definitive recommendations from being made. Further well-designed trials are needed to investigate this technique.

Mirizzi Syndrome: An Unusual Complication of Cholelithiasis.

Mirizzi syndrome is a rare condition caused by the obstruction of the common bile duct or common hepatic duct by external compression from multiple impacted gallstones or a single large impacted gallstone in Hartman's pouch. The condition can easily be confused with choledocholithiasis, bile duct stricture or cholangiocarcinoma due to the presence of obstructive jaundice hence may be overlooked due to the rarity of the condition. The incidence of Mirizzi syndrome among patients with gallstones is reported to range from 0.63 to 5.7%. Furthermore, it poses a differential diagnosis dilemma for the physician as well as radiologists because there are no clinical features or diagnostic procedures that have a 100% specificity and sensitivity. Laparotomy is the preferred surgical technique of choice. For the patients who are poor surgical candidate, mainstay of treatment is biliary stent placement for the restoration of normal biliary drainage. Due to low incidence of the Mirizzi syndrome, an elevated index of suspicion is required to diagnose this condition. At present, there are no well-developed, internationally recognized clinical guidelines for the management of this syndrome. Furthermore, the diagnostic procedures available still pose a barrier in the ability to confirm the diagnosis prior to surgical treatment, even though the diagnostic rate has increased dramatically.

Incidence of Clostridioides difficile in patients post loop ileostomy reversal in an Australian tertiary hospital: a retrospective study.

INTRODUCTION: The purpose of a loop ileostomy is to temporarily divert faeces away from a distal anastomosis, to reduce the consequences of anastomotic leak. This ultimately requires a second procedure to restore bowel continuity, which confers risk of complications including the development of Clostridioides difficile infection (CDI). It is hypothesized that patients who undergo loop ileostomy reversal are at increased risk of CDI when compared with other patients undergoing elective colorectal surgical procedures, and that these patients also experience an increased length of stay (LOS). METHODS: A retrospective cohort study was performed on all patients who underwent loop ileostomy reversal at the Gold Coast Hospital and Health Service between 1 January 2012 and 31 December 2019. RESULTS: Two hundred and twenty-eight patients were identified. Eight tested positive for CDI on faecal PCR (3.51%), a higher incidence than that in patients who underwent an elective colorectal surgical procedure during the same period (0.83%) (RR = 4.23). Additionally, median LOS for ileostomy reversal patients was significantly increased in those who also had CDI when compared with those without CDI (11 versus 4 days; P = 0.0003). CONCLUSION: The study confirmed that the incidence of CDI was higher in those who underwent ileostomy reversal when compared with an otherwise comparable hospital population (elective colorectal surgery patients). Additionally, those patients who underwent ileostomy reversal and had CDI experienced an increased LOS which translates to increased cost to the healthcare system. Further investigation into pre-operative screening and prophylactic antibiotics should be considered as a measure to mitigate this post-operative complication.

Acute Pancreatitis Induced Splenic Vein Thrombosis.

Acute inflammation of the pancreas, known as pancreatitis, can result in many complications ranging from acute distress respiratory syndrome to pancreatic necrosis. A relatively common vascular complication of pancreatitis is splenic vein thrombosis (SVT) due to intimal inflammation leading to platelet aggregation and thrombosis. The management of SVT with regard to anticoagulation (AC) might appear to be perplexing at first given the recommendation to withhold any sort of AC. Research studies have shown that these patients have an increased risk of gastrointestinal bleeding without AC. In this report, we discuss a case of hypertriglyceridemia-induced pancreatitis. During hospitalization, our patient complained of worsening abdominal pain with objective fevers and leukocytosis in which CT scan of the abdomen was significant for hemorrhagic pancreatitis with necrosis, acute SVT, and splenomegaly. The patient was managed conservatively with IV fluids, pain relief medications, and antibiotics.

Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis.

BACKGROUND: Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention. METHODS: PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS: Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20). CONCLUSION: PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.

Delay to Adjuvant Chemotherapy: Survival and Recurrence in Patients of Rectal Cancer Treated with Neo-adjuvant Chemoradiotherapy and Surgery.

PURPOSE: This aim of the study is to evaluate the survival function and hazard risks of delayed adjuvant chemotherapy (ChT) to distant recurrence risk in patients with non-metastatic rectal cancer treated with neoadjuvant chemoradiotherapy (CRT) and surgery. METHODS: A single tertiary hospital retrospective cohort study of a duration of 5 years between January 2012 and December 2016 was performed. As no previous study shown a temporal relationship of delay to adjuvant/systemic ChT leading to increased risk of metastatic disease, we compared between our proposed cut-off with the median and mean value determined by our dataset. Time to event analysis and log rank tests were conducted. RESULTS: A total of 269 patients with rectal cancer were identified. Two hundred eighteen patients were ineligible, leaving 51 patients for final analysis. Patients in the non-delayed group at 23 (proposed) and 25 (median) weeks' cut-off reported better 5 years' disease free survival (DFS) compared with the delayed group by 4.1% and 0.8%. Inversely, at the cut-off 28 (mean) weeks, the delayed group had a better DFS by 4.4%. Females and patients less than 60 years old had better 5-year DFS by 22.8% and 24%. Delayed group has a higher hazard risk ratio (HR) of 1.28 of distant recurrence compared with non-delayed at 23 weeks' cut-off. CONCLUSION: This study has demonstrated delaying a patient to adjuvant ChT will lower their DFS and increase their HR compared with those whose treatment is not delayed. We have long been too focused on local control; hence, priority needs to be shifted to efforts in managing potential distant disease in a timely manner.

Evolution of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Metastases: 8-Year Single-Institutional Experience.

BACKGROUND: Colorectal cancer is the second leading cause of cancer-related mortality worldwide. Peritoneal metastases carry the worst prognosis among all sites of colorectal cancer metastases. In recent years, the advent and acceptance of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy have greatly improved survival for selected patients with low-volume peritoneal metastases. OBJECTIVE: Here, we report the evolution of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases at a statewide tertiary referral center over an 8-year period. DESIGN: This is a retrospective study from 2009 to 2017. SETTING: The study was conducted at a single center over 8 years. PATIENTS: Patients with colorectal peritoneal metastases undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were included. MAIN OUTCOMES: Main outcomes included evaluation of grade III/IV morbidity rate, mortality rate, overall and relapse-free survival, and prognostic factors influencing survival on a Cox multivariate analysis model. RESULTS: One hundred one cytoreductive surgeries were undertaken on 96 patients during this time for colorectal peritoneal metastases. The median patient age was 60 years with 55.2% being female. The median Peritoneal Carcinomatosis Index was 9, with complete cytoreduction achieved in 76 (75.2%) cases. Grade III or IV complications occurred in 26 cases (25.7%) with 2 (2%) perioperative mortalities. Median overall survival for the entire cohort was 32 months, with a 3-year survival of 38%. For patients who achieved a complete cytoreduction, median overall survival was 37 months, with a relapse-free survival of 13 months and a 3-year survival of 54%. Complete cytoreduction and nonmucinous histology were key factors independently associated with improved overall survival. LIMITATIONS: The main limitation this study is its retrospective nature. CONCLUSION: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for isolated low-volume colorectal peritoneal metastases is safe and effective, with low morbidity. It offers selected patients a highly favorable overall and relapse-free survival. See Video Abstract at http://links.lww.com/DCR/B2. EVOLUCIÓN DE LA CIRUGÍA CITORREDUCTIVA Y QUIMIOTERAPIA INTRAPERITONEAL HIPERTÉRMICA (HIPEC) PARA METÁSTASIS PERITONEALES COLORRECTALES: EXPERIENCIA INSTITUCIONAL DE 8 AÑOS: El cáncer colorrectal es la segunda causa de mortalidad relacionada con el cáncer en todo el mundo. Las metástasis peritoneales tienen el peor pronóstico entre todos los sitios de metástasis del cáncer colorrectal. En los últimos años, el advenimiento y la aceptación de la cirugía citorreductiva y la quimioterapia intraperitoneal hipertérmica ha mejorado enormemente la supervivencia de pacientes seleccionados con metástasis peritoneales de bajo volumen. OBJETIVO: Aquí, informamos sobre la evolución de la cirugía citorreductiva y la quimioterapia intraperitoneal hipertérmica para las metástasis peritoneales colorrectales en un centro de referencia terciario para todo el estado durante un período de ocho años. DISEÑO:: Estudio retrospectivo del 2009 a 2017. CONFIGURACIÓN:: Centro único a lo largo de ocho años. PACIENTES: Pacientes con metástasis peritoneales colorrectales sometidos a cirugía citorreductiva y quimioterapia intraperitoneal hipertérmica. RESULTADOS PRINCIPALES: Los resultados principales incluyeron la evaluación de la tasa de morbilidad de grado III / IV, la tasa de mortalidad, la supervivencia general y libre de recaída y los factores pronósticos que influyen en la supervivencia en el modelo de análisis multivariado Cox. RESULTADOS: Se realizaron el ciento uno cirugías citorreductivas en noventa y seis pacientes durante este tiempo por metástasis peritoneales colorrectales. La edad media de los pacientes fue de 60 años, con un 55.2% de mujeres. El Índice de Carcinomatosis Peritoneal mediano fue de 9, con una citorreducción completa lograda en 76 (75.2%) casos. Las complicaciones de grado III o IV ocurrieron en 26 casos (25.7%) con dos (2%) de mortalidad perioperatoria. La supervivencia mediana general para toda la cohorte fue de 32 meses, con una supervivencia de 3 años del 38%. Para los pacientes que lograron una citorreducción completa, la supervivencia global media fue de 37 meses, con una supervivencia sin recaída de 13 meses y una supervivencia de 3 años del 54%. La citorreducción completa y la histología no mucinosa fueron factores clave asociados de forma independiente con una mejor supervivencia general. LIMITACIONES: La principal limitación es la naturaleza retrospectiva del estudio. CONCLUSIÓN:: La cirugía citorreductiva y la quimioterapia intraperitoneal hipertérmica para las metástasis peritoneales colorrectales aisladas de bajo volumen son seguras y eficaces, con baja morbilidad. Ofrece a los pacientes seleccionados una supervivencia global altamente favorable y libre de recaída. Vea el Resumen del video en http://links.lww.com/DCR/B2.

Risk Factors Associated With Circumferential Resection Margin Positivity in Rectal Cancer: A Binational Registry Study.

BACKGROUND: Rectal cancer outcomes have improved with the adoption of a multidisciplinary model of care. However, there is a spectrum of quality when viewed from a national perspective, as highlighted by the Consortium for Optimizing the Treatment of Rectal Cancer data on rectal cancer care in the United States. OBJECTIVE: The aim of this study was to assess and identify predictors of circumferential resection margin involvement for rectal cancer across Australasia. DESIGN: A retrospective study from a prospectively maintained binational colorectal cancer database was interrogated. SETTINGS: This study is based on a binational colorectal cancer audit database. PATIENTS: Clinical information on all consecutive resected rectal cancer cases recorded in the registry from 2007 to 2016 was retrieved, collated, and analyzed. MAIN OUTCOME MEASURES: The primary outcome measure was positive circumferential resection margin, measured as a resection margin ≤1 mm. RESULTS: A total of 3367 patients were included, with 261 (7.5%) having a positive circumferential resection margin. After adjusting for hospital and surgeon volume, hierarchical logistic regression analysis identified a 6-variable model encompassing the independent predictors, including urgent operation, abdominoperineal resection, open technique, low rectal cancer, T3 to T4, and N1 to N2. The accuracy of the model was 92.3%, with an receiver operating characteristic of 0.783 (p < 0.0001). The quantitative risk associated with circumferential resection margin positivity ranged from <1% (no risk factors) to 43% (6 risk factors). LIMITATIONS: This study was limited by the lack of recorded long-term outcomes associated with circumferential resection margin positivity. CONCLUSIONS: The rate of circumferential resection margin involvement in patients undergoing rectal cancer resection in Australasia is low and is influenced by a number of factors. Risk stratification of outcome is important with the increasing demand for publicly accessible quality data. See Video Abstract at http://links.lww.com/DCR/A512.

The acceptability and efficacy of a group cognitive behavioural therapy programme in a community mental health setting.

This paper presents data on a patient evaluation of a group cognitive behavioural therapy programme in an applied setting and its efficacy for reducing generalised anxiety and or depression, and distress. Patients (n=14) participated in one of two 8-week group cognitive behavioural therapy programmes for generalised anxiety or depression, within a mental health service. Patients' perceptions of the programme were collected via an evaluation questionnaire, and data on clinical outcomes were sourced from patients' case notes. Most patients who were invited to participate in the programme (n=14 of 17), and their evaluations were generally favourable. Almost all participants (93%) indicated that the programme either met or exceeded their expectations. The clinical outcomes of the intervention were similar to those found in efficacy studies reported in the published literature (approximately half to threequarters of one standard deviation improvement in anxiety, depression, and distress scores).

Innovative approach for prevention and treatment of post subarachnoid hemorrhage vasospasm: A preliminary report.

More than one third of patients with subarachnoid hemorrhage (SAH) develop clinically significant vasospasm, as a leading morbidity and mortality factor for these patients. It is widely accepted that a) Degradation products of blood are the causative factors of vasospasm b) The amount of subarachnoid blood seen on admission CT is correlated to the risk of vasospasm c) Reducing the subarachnoid clot burden at the time of surgery reduces the risk of vasospasm. But there is no existing method to clear the blood from subarachnoid spaces satisfactorily. We have evaluated safety and feasibility of fluid exchange catheter system in SAH, to achieve this goal. We were successful in clearing cisternal blood in three patients with aneurysmal rupture with fluid exchange catheter system. Baseline CT scan of brain was performed immediately after the surgery and then at the end of irrigation. The amount of subarachnoid blood was evaluated. This innovative, fluid exchange catheter system infuses and aspirates micro volumes of drug solution in a cyclic mode, ensuring isobaric exchange of fluids. The result is good clearance of blood in subarachnoid spaces were seen in all the patients. Also, significant improvement in neurological deficits secondary to vasospasm was seen. We conclude that the fluid exchange catheter system is safe and adoptable in neurosurgical practice.

Bilateral transplantation of allogenic adult human bone marrow-derived mesenchymal stem cells into the subventricular zone of Parkinson's disease: a pilot clinical study.

The progress of PD and its related disorders cannot be prevented with the medications available. In this study, we recruited 8 PD and 4 PD plus patients between 5 to 15 years after diagnosis. All patients received BM-MSCs bilaterally into the SVZ and were followed up for 12 months. PD patients after therapy reported a mean improvement of 17.92% during "on" and 31.21% during "off" period on the UPDRS scoring system. None of the patients increased their medication during the follow-up period. Subjectively, the patients reported clarity in speech, reduction in tremors, rigidity, and freezing attacks. The results correlated with the duration of the disease. Those patients transplanted in the early stages of the disease (less than 5 years) showed more improvement and no further disease progression than the later stages (11-15 years). However, the PD plus patients did not show any change in their clinical status after stem cell transplantation. This study demonstrates the safety of adult allogenic human BM-MSCs transplanted into the SVZ of the brain and its efficacy in early-stage PD patients.

Diffusion tensor imaging in spinal cord injury.

BACKGROUND AND PURPOSE: To assess the feasibility of spinal tractography in patients of spinal cord injury vs a control group and to compare fractional anisotropy (FA) values between the groups. MATERIALS AND METHODS: Diffusion tensor imaging (DTI) was performed in the spinal cord of 29 patients (18 patients and 11 controls). DTI was done in the cervical region if the cord injury was at the dorsal or lumbar region and in the conus region if cord injury was in the cervical or dorsal region. FA was calculated for the patients and the controls and the values were compared. RESULTS: The mean FA value was 0.550±0.09 in the control group and 0.367±0.14 in the patients; this difference was statistically significant (P=0.001). CONCLUSION: Spinal tractography is a feasible technique to assess the extent of spinal cord injury by FA, which is reduced in patients of spinal cord injury, suggesting possible Wallerian degeneration. In future, this technique may become a useful tool for assessing cord injury patients after stem cell therapy, with improvement in FA values indicating axonal regeneration.

Fulminant hepatic failure after repeated exposure to isoflurane.

Inhalational agents are used routinely for maintenance of anaesthesia. Post anaesthesia hepatic failure has been documented following exposure to halothane. However, there are very few reports of such complications following isoflurane anaesthesia. A 6-year-old child developed fulminant hepatic failure 2 days following craniotomy under general anaesthesia. There was no evidence of viral, autoimmune, or metabolic causes of hepatitis. No other medications known to cause hepatitis, except low dose paracetamol, were administered. The clinical and histological picture of our case is similar to that of halothane hepatitis, which has a significant mortality rate. We report this as a possible fulminant hepatic failure resulting from exposure to isoflurane anaesthesia.

Establishment of a brain tumor tissue repository in India: maintaining quality standards.

Tumor tissue repositories (TTRs) play a pivotal role in both basic and translational research by acting as a conduit to facilitate innovative research, thereby providing solutions to treat the incurable disease--'Cancer'. One of the fundamental requirements to achieve this goal would be the acquisition of high quality tumor tissue specimens that are stored in such a manner that its integrity is preserved. Further, a quality system should be in place that assures the compliance of procedures that are the key to a smooth functioning of all the inter-related departments that play a key role in the entire operations. To address this, we have initiated an effort to build a tumor tissue repository of brain tumor tissues in the Southern part of the Indian sub-continent. One of the cardinal features of brain tumors is the heterogeneity, both phenotypically and genotypically. Moreover, significant gaps exist in current understanding of the molecular pathways involved in the genesis, progression, and biological and clinical behavior of brain tumors. We hope that our initiative will provide researchers accessibility to a reserve of high quality tissues in this part of the globe. We have created and validated a complete histology service including tissue processing, embedding, sectioning and H&E staining for fixed tissues, in addition to creating and staining frozen sections. To our knowledge, such a structured initiative to store brain tumor samples is the first of its kind in the India.

Recurrent cerebral larva migrans: A case report and review of literature.

Cerebral larva migrans (CLM) is an uncommon and rarely diagnosed entity. We report here a histopathologically proven case of CLM in a 13 year-old girl, who presented with bilateral focal seizures, right hemiparesis, and lapsed into altered sensorium prior to admission. Her CT scan was suggestive of a granulomatous lesion which eventually turned out to be CLM (toxocariasis). Interestingly, the lesion recurred after excision, with a confusing clinical picture. Following the second surgery, the pathology was reconfirmed and cure was provided for the disease. There has been no further intracranial recurrence during the past ten years although she developed cutaneous lesions.