Barriers to adopting intracorporeal anastomosis in colorectal procedures amongst Australian general surgeons.

INTRODUCTION: Minimally invasive colonic anastomosis can be performed intracorporeally or extracorporeally with laparoscopic or robotic assistance. In colorectal surgery, choosing the optimal approach is still controversial. Mainly, the debate involves balancing the potential benefits of intracorporeal anastomosis (ICA) with increased technical difficultly with the more straightforward and widely accepted extracorporeal anastomosis (ECA). Both techniques require different skill sets, and this study aims to identify barriers that prevent adoption of ICA. METHODS: A 31-point questionnaire survey was distributed through the General Surgeons Australia (GSA) platform of active general surgeon in Australia. It was open for 2 months between July and August 2023. Statistical analysis was completed using descriptive analysis and logistic regression. RESULTS: Forty-three general surgeons completed the survey. ECA was the most performed and preferred surgical technique. It was identified that increased operative time is the biggest barrier to completing ICA followed by lack of training and no perceived benefit with ICA. Patient comorbidities did not result in choosing ICA over ECA; however, surgeons with less experience and volume in colorectal surgery were more likely complete ECA in operations with increased technical difficulty. CONCLUSION: Although ECA is the go-to technique for many Australian general surgeons, it is evident that they may be overlooking the benefits offered by ICA. Further training is required to improve operative times and confidence in the technique. Ongoing research, audits of existing techniques, and updated training will assist surgeons becoming acquainted with the latest evidence and to offer the best care to their patients.

Patient Experiences after Intracorporeal Right Hemicolectomy: Evaluating Patient Reported Outcome Measures via Short Form-36.

OBJECTIVE: To identify the patient-reported outcome measures (PROMs) after intracorporal anastomosis (ICA) during laparoscopic right hemicolectomy. STUDY DESIGN: An observational study. Place and Duration of the Study: Department of General Surgery, Griffith Base Hospital, New South Wales, Australia, from August 2022 till February 2023. METHODOLOGY: Participants who underwent laparoscopic intracorporeal right hemicolectomy were included in this study. Patients requiring emergency procedures or with a history of psychiatric illness were excluded. The Short Form-36 (SF-36); a quality of life (QoL) questionnaire employed focusing on physical health-related domains post laparoscopic intracorporeal hemicolectomy. The relationship between QoL domains and operative outcomes specific to this anastomotic technique was also assessed. RESULTS: The SF-36 scores at six weeks and six months postoperation revealed shifts in the overall QoL following ICA. Notably, physical function showed significant improvement, while bodily pain remained a significant concern. The correlation analysis found operative blood loss and the length of the extraction site to be significantly correlated with postoperative physical role. CONCLUSION: The study determined that decreased operative blood loss and a shorter extraction site were associated with improved postoperative physical role. It showed the overall QoL improved within six months of the procedure, with the bodily pain domain still an area requiring attention. Understanding the impact of laparoscopic ICA on patient-reported outcomes may help in tailoring patient-cantred approaches and enhancing the overall quality of care. KEY WORDS: Intracorporeal, Right hemicolectomy, Patient-reported outcome measures, Colorectal anastomosis.

Procedure-based assessment implementation in colorectal surgery: a scoping review.

BACKGROUND: Competency-based training (CBT) programs use procedure-based assessments (PBAs) to evaluate trainees' abilities to perform specific procedures in clinical settings, similar to Entrustable Professional Activities (EPAs). PBAs help determine trainees' readiness for advanced training levels. However, there is limited evidence on implementing colorectal-specific PBAs in surgical training schemes. This review aims to identify observed and perceived challenges to implementing PBAs in workplace settings. METHODS: A scoping review following the Joanna Briggs Institute Protocol for Scoping Reviews (JBI-ScR) was conducted. Eligible studies provided evidence on the implementation, feasibility, and challenges of PBAs in colorectal surgery, including various study designs from retrospective to prospective. RESULTS: Of the 80 screened studies, 75 were excluded based on exclusion criteria. Most of the included studies were conducted in national training institutions in the United Kingdom, assessing 778 colorectal procedures with specific PBAs. The main facilitators of implementing PBAs were structured assessments, focused assessors' training, and electronic forms usage. CONCLUSION: This review offers insight into the practicality and feasibility of implementing PBAs in colorectal surgery. Identified challenges include the need for adequate assessor training and the time-consuming nature of the assessment. These findings could improve PBA implementation in colorectal surgery and enhance surgical education quality. However, the limited number of studies and existing literature heterogeneity call for more research to identify other gaps.

Alleviation of adverse effects of nickel on growth and concentration of copper and manganese in wheat through foliar application of ascorbic acid.

We investigated the role of ascorbic acid (AsA) to alleviate nickel (Ni) induced adverse effects on growth and concentration of Ni, copper (Cu), and manganese (Mn) in hydroponically grown wheat varieties viz. Galaxy, Punjab-2011, and FSD-08. Plants were exposed to five levels of Ni viz. 0, 5, 10, 15, and 20 mg L-1. After 1 week, AsA (1 mM) was sprayed onto the Ni-stressed plants. FSD-08 produced the maximum SDW with and without AsA compared to other varieties. FSD-08, Galaxy, and Punjab-2011 witnessed 2.61-, 2.83-, and 7.5-fold increases in SDW with AsA, respectively. Wheat plants contained the maximum Ni in shoots and roots with a Ni level of 20 mg L-1 irrespective of varieties. Nickel in shoots decreased with AsA witnessing 13, 12, and 10% decrease in FSD-08, Punjab-2011, and Galaxy, respectively. Nickel in roots of FSD-08 decreased by 18% while increased by 3.34-fold and 3.50-fold in Galaxy and Punjab-2011, respectively with AsA. Nickel decreased Cu in shoot and Mn in shoot and root while Cu in roots of all wheat varieties increased. It was concluded that AsA improved the growth of Ni-stressed and FSD-08 performed better by maintaining good growth and less Ni in shoots compared to other varieties.

Exploiting plant internal mechanisms with foliar application of different organic substances have widely been investigated to decrease metal accumulation and their adverse effects on plants. However, the differential response of different varieties to metal accumulation in response to foliar application of ascorbic acid is not well documented. This study was conducted to investigate the effect of exogenous application of ascorbic acid on growth response, the concentration of Ni, Cu, and Mn in three wheat varieties.

Enhancing Cadmium Tolerance and Pea Plant Health through Enterobacter sp. MN17 Inoculation Together with Biochar and Gravel Sand.

Contamination of soils with heavy metals, particularly cadmium (Cd), is an increasingly alarming environmental issue around the world. Application of organic and inorganic immobilizing amendments such as biochar and gravel sand in combination with metal-tolerant microbes has the potential to minimize the bioavailability of Cd to plants. The present study was designed to identify the possible additive effects of the application of Enterobacter sp. MN17 as well as biochar and gravel sand on the reduction of Cd stress in plants and improvement of growth and nutritional quality of pea (Pisum sativum) plants through the reduction of Cd uptake. Pea seeds were surface sterilized then non-inoculated seeds and seeds inoculated with Enterobacter sp. MN17 were planted in artificially Cd-polluted soil, amended with the immobilizing agents biochar and gravel sand. Application of biochar and gravel sand alone and in combination not only improved the growth and nutritional quality of pea plants by in situ immobilization but also reduced the uptake of Cd by plant roots and its transport to shoots. However, microbial inoculation further enhanced the overall plant health as well as alleviated the toxic effects of Cd on the pea plants. These soil treatments also improved rates of photosynthesis and transpiration. The combined use of biochar and gravel sand with bacterial inoculation resulted in an increase in plant height (47%), shoot dry weight (42%), root dry weight (57%), and 100 seeds weight (49%) as compared to control plants in Cd contaminated soil. Likewise, biochemical constituents of pea seeds (protein, fat, fiber, and ash) were significantly increased up to 41%, 74%, 32%, and 72%, respectively, with the combined use of these immobilizing agents and bacterium. Overall, this study demonstrated that the combined application of biochar and gravel sand, particularly in combination with Enterobacter sp. MN17, could be an efficient strategy for the remediation of Cd contaminated soil. It could support better growth and nutritional quality of pea plants.

Eosinophilic cholecystitis with common bile duct stricture: a rare disease.

Although the most common cause of cholecystitis is gallstones, other conditions may present as acute cholecystitis. We describe a case of eosinophilic cholecystitis with common bile duct stricture. A 36-year-old woman initially had generalised abdominal pain and peripheral eosinophilia. Diagnostic laparoscopy showed eosinophilic ascites and necrotic nodules on the posterior abdominal wall. She was treated with anthelminthics on presumption of toxacara infection based on borderline positivity of serological tests. She later presented with acute cholecystitis and had a cholecystectomy and choledocotomy. Day 9 T-tube cholangiogram showed irregular narrowing of the distal common bile duct. The patient's symptoms were improved with steroids and the T-tube was subsequently removed.

Cytomegalovirus enteritis with ischemia in an immunocompetent patient: A rare case report.

INTRODUCTION: Cytomegalovirus (CMV) is predominantly an opportunistic infection in the immunocompromised patients. Though, there are few cases of CMV colitis being reported in the immunocompetent individuals, CMV enteritis is exceedingly rare and enteritis leading into small bowel ischemia has never been reported yet. PRESENTATION OF CASE: A-78-year-old male patient presented with distal small obstruction for 4 days duration. Clinical examination revealed a distended abdomen and localised peritonism in right iliac fossa. An initial computed tomography (CT) scan revealed distended small bowel loops up to the thickened inflammed terminal illeum with no free fluid or gas and a normal appendix. No immunosuppressive risk factors such as human immunodeficiency virus, transplant procedures, or steroid therapy were present. Hematologic investigations showed leucocytosis with neutrophilia. Diagnostic laparoscopy confirmed a thickened terminal ileum causing small bowel obstruction. Laparoscopy converted to laparotomy and right hemicolectomy was performed. Histology showed isolated small bowel ischemia with ulcerative changes and cytomegalovirus inclusions. The patient was started on ganciclovir therapy and subsequently had an uneventful recovery and discharged after 16 days. DISCUSSION: Cytomegalovirus enteritis was initially not suspected in our patient. In this case CMV caused ischemia of the small bowel without evidence of colonic involvement. Even in elderly patients, the small bowel remains resilient to the ischemic changes because of the copious blood supply. CONCLUSION: We report possibly the first case of isolated small bowel ischaemia caused by cytomegalovirus in immunocompetent individuals, needed surgical resection.

"Less is more": Non operative management of short term superior mesenteric artery syndrome.

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a relatively rare aetiology of proximal intestinal obstruction. This is caused by narrowing of vascular angle of SMA and aorta compressing the third part of the duodenum (D3). Predisposing factors may include precipitous weight loss, corrective spinal surgery or repair of an aortic aneurysm. PRESENTATION OF CASE: A 53 year old male presented to our department with worsening post-prandial vomiting and epigastric pain for last three months. One examination, epigastric region was distended with succussion splash on abdominal auscultation. History did not include any predisposing factor. CT scan showed narrow angle of 12.77° between SMA and aorta owing to the compression of D3. Since onset of vomiting and resultant poor oral intake, he had lost 11 kg of his usual body weight. After gastric decompression, nasojejunal enteral feeding was started. Diet was progressed to oral feedings gradually and following return to his baseline weight, he continued to be free of symptoms in follow-up visits. DISCUSSION: Although there are recognised predisposing factors but sometimes aetiology remains idiopathic. SMA syndrome should initially be managed non-operatively with gastric decompression, correction of water and electrolyte imbalance, and hemodynamic instability. Regaining weight helps increasing vascular space between SMA and D3 thus relieving obstruction. Persistence of symptoms beyond 3-4 weeks warrants surgical intervention. CONCLUSION: Non operative management with nutritional supplementation remains the first line of therapy.