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.

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.

Preceptorship in robotic colorectal surgery: experience from the Australian private sector.

This article describes a post-fellowship preceptorship training program to train sub-specialty colorectal surgeons in gaining proficiency in robotic colorectal surgery using a dual-surgeon model in the Australian private sector. The Australian colorectal surgeon faces challenges in gaining robotic colorectal surgery proficiency with limited exposure and experience in the public setting where the majority of general and colorectal surgery training is currently conducted. This training model uses graded exposure with a range of simulation training, wet lab training, and clinical operative cases to progress through both competency and proficiency in robotic colorectal surgery which is mutually beneficial to surgeons and patients alike. Ongoing audit of practice has shown no adverse impacts.

Appendiceal Abscess Within a Giant Amyand's Hernia: A Case Report.

Amyand's hernia is a rare clinical entity, defined as an inguinal hernia containing the appendix. Giant inguinoscrotal hernia is also a rare clinical finding that presents major operative dilemmas due to the loss of abdominal domain. Here, we report a case of a 57-year-old male who presented with a giant irreducible right inguinoscrotal hernia and obstructive symptoms. The patient underwent an emergency open right inguinal hernia repair, where an Amyand's hernia was identified. The hernia contained an inflamed appendix and associated abscess, caecum, terminal ileum, and descending colon. Using the giant sac to isolate the contamination, an appendicectomy was performed, the hernial contents reduced and the hernia repair reinforced with partially absorbable mesh. The patient recovered post-operatively and was discharged home with no recurrence on four-week follow-up. This case provides learning points on decision-making and surgical management of a giant inguinoscrotal hernia containing an appendiceal abscess, also known as Amyand's.

Accuracy of pre-operative 18-fluoride fluorodeoxyglucose positron emission tomography (FDG-PET) in predicting lymph node involvement in colon cancer.

BACKGROUND: Accurate staging of colon cancer is imperative in directing treatment and prognostication. Existing literature on pre-operative accuracy of FDG-PET/CT in detecting lymph node disease often combines colon and rectal cancer, examines rectal cancers alone, and rarely assesses colon cancer in isolation. Our aim was to assess pre-operative utility of FDG-PET/CT in detecting lymph node disease in colon cancer. METHODS: A retrospective cohort analysis was performed at a single Australian institution between 2017 and 2022 to identify treatment naive primary colonic tumours. Primary outcome was sensitivity and specificity using formal surgical histopathology as gold standard. Secondary outcomes were patient and tumour factors predictive of FDG-PET/CT positive disease including pre-operative CEA, mismatch repair status, duration to surgery, and tumour T-stage. RESULTS: Three hundred and thirty-nine patients were identified. Thirty-four had pre-operative FDG-PET/CT without neoadjuvant therapy. The mean surgical lymph node harvest was 18 nodes. Twenty-five patients had moderately differentiated tumours. The median duration between FDG-PET/CT and operation was 17 days. Pre-operative FDG-PET/CT suggested positive lymph node involvement in 12 patients. Compared to final lymph node histopathology, FDG-PET/CT had a sensitivity of 53%, specificity of 82%, positive predictive value of 75%, negative predictive value of 64% and accuracy of 68%. There was no significant difference between groups for secondary outcomes. CONCLUSION: FDG-PET/CT has moderate specificity but poor sensitivity in the detection of lymph node involvement in colon cancer. Its utility should likely remain isolated to investigating equivocal lesions or follow up of known PET avid disease.

Postoperative Pancreatic Fistula After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: An Update on Incidence, Risk Factors, Management, and Clinical Sequelae in 1,141 Patients.

BACKGROUND/AIM: An update on the incidence, risk factors, clinical sequalae, and management of postoperative pancreatic fistula (POPF) following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). PATIENTS AND METHODS: Retrospective analysis of prospectively collected data from the St George CRS/HIPEC database. RESULTS: Sixty-five (5.7%) out of 1,141 patients developed a POPF. Patients with POPFs were older, had a higher peritoneal cancer index, longer operation time, and required more units of blood intraoperatively. Splenectomy and distal pancreatectomy were significant risk factors for developing POPFs. While there was no effect on overall long-term survival in POPF patients, they did suffer higher rates of Clavien-Dindo grade 3/4 complications, in-hospital deaths, and longer hospital length of stay. Of the 65 POPF patients, 23 were taken back to theatre, 48 required radiological drains and 7 underwent endoscopic retrograde cholangiopancreatography. CONCLUSION: There are multiple risk factors for developing POPFs that are non-modifiable. While POPFs are associated with increased postoperative morbidity, long-term survival does not appear to be affected.

Patient compliance with surveillance colonoscopy: patient factors and the use of a graded recall system.

BACKGROUND: Surveillance colonoscopy allows for the early detection and improved treatment outcomes in colorectal neoplasms but compliance rates and factors require further investigation. METHODS: This is a retrospective cohort study examining 816 patients recalled for surveillance colonoscopy at an Australian colorectal practice over a 6-month period. Primary outcome was compliance with colonoscopy within 12 months of recall. The secondary outcome of this study was to identify factors affecting compliance including patient factors and the practices' graded recall system. RESULTS: A total of 715 patients (87.6%) were compliant with recall requests for repeat colonoscopy. Significantly higher compliance rates were noted with a personal history of adenomatous polyps (90.9% versus 85.6%, P = 0.025). Those with private insurance or Department of Veterans Affairs were more likely to be compliant than those publicly funded (89.0% versus 93.3% versus 79.0%, P = 0.007). No statistically significant difference in compliance was shown with a personal history of colorectal cancer, diverticular disease, perianal disease, National Health and Medical Research Council risk category, gender, time associated with the practice or the clinician. There was a significant positive correlation between the number of letters sent and compliance with recall, with 61.8% being compliant after a single letter, and a final cumulative compliance after five letters of 87.6% (R = 0.882, P = 0.048). CONCLUSION: A graded recall system can achieve compliance rates as high as 87.6% compared to a single letter only achieving 61.8% compliance. A history of adenomatous polyps and insurance status were the only factors shown to result in higher recall compliance.