Caecal perforation from CT colonography: an unexpected complication.

Computer tomography colonography (CTC) is an increasingly utilized diagnostic modality in Australia. CTC aims to image the entire colon, and is often used in higher risk patient populations. Colonic perforation following CTC is a rare complication, with only 0.008% of patients undergoing CTC requiring surgical intervention. Most published cases of perforation following CTC are due to identifiable causes, often involving the left colon or rectum. We present a rare case of caecal perforation following CTC, requiring right hemicolectomy. This report highlights the need for high suspicion for CTC complications, despite their rarity, and the utility of diagnostic laparoscopy for diagnosis in atypical presentations.

Exploring variation in surgical practice: does surgeon personality influence anastomotic decision-making?

BACKGROUND: Decision-making under uncertainty may be influenced by an individual's personality. The primary aim was to explore associations between surgeon personality traits and colorectal anastomotic decision-making. METHODS: Colorectal surgeons worldwide participated in a two-part online survey. Part 1 evaluated surgeon characteristics using the Big Five Inventory to measure personality (five domains: agreeableness; conscientiousness; extraversion; emotional stability; openness) in response to scenarios presented in Part 2 involving anastomotic decisions (i.e. rejoining the bowel with/without temporary stomas, or permanent diversion with end colostomy). Anastomotic decisions were compared using repeated-measure ANOVA. Mean scores of traits domains were compared with normative data using two-tailed t tests. RESULTS: In total, 186 surgeons participated, with 127 surgeons completing both parts of the survey (68.3 per cent). One hundred and thirty-one surgeons were male (70.4 per cent) and 144 were based in Europe (77.4 per cent). Forty-one per cent (77 surgeons) had begun independent practice within the last 5 years. Surgeon personality differed from the general population, with statistically significantly higher levels of emotional stability (3.25 versus 2.97 respectively), lower levels of agreeableness (3.03 versus 3.74), extraversion (2.81 versus 3.38) and openness (3.19 versus 3.67), and similar levels of conscientiousness (3.42 versus 3.40 (all P <0.001)). Female surgeons had significantly lower levels of openness (P <0.001) than males (3.06 versus 3.25). Personality was associated with anastomotic decision-making in specific scenarios. CONCLUSION: Colorectal surgeons have different personality traits from the general population. Certain traits seem to be associated with anastomotic decision-making but only in specific scenarios. Further exploration of the association of personality, risk-taking, and decision-making in surgery is necessary.

The effect of socioeconomic deprivation on presentation stage and long-term outcomes in patients undergoing colorectal cancer resection in Western Sydney.

BACKGROUND: While socioeconomic deprivation has been shown to affect survival in colorectal cancer, other factors such as global region of birth and ethnicity also exert an effect. We wished to ascertain the influence of socioeconomic deprivation on stage of presentation and cancer survival in an ethnically diverse Australian population. METHODS: Cases from a database of resections in Western Sydney (n = 1596) were stratified into cohorts of socioeconomic quintiles. Univariate analysis was used to compare demographics, AJCC stage and histopathological details between the least and most socioeconomically deprived groups. Kaplan-Meier analysis and log-rank testing were used to compare cancer-specific and all-cause 5-year survival between the most deprived quintile and all others, after case-control matching for age and overseas birth. RESULTS: A total of 322 (20.2%) patients from the most socioeconomically deprived centile, and 275 (17.2%) from the least were compared. The most deprived were significantly more likely to be aged under 70 (54.1% vs. 44.4%, p = 0.019), born overseas (54.3% vs. 38.6%, p = 0.003), present with stage III disease (37.4% vs. 26.7%, p = 0.005), perforated (12.5% vs. 5.3%, p = 0.005) or circumferential tumours (37% vs. 24.3%, p = 0.043). There was no significant difference in proportions presenting with metastatic disease, or 5-year survival between the most deprived quintile and all others after correction for age and foreign birth. CONCLUSIONS: Socioeconomic deprivation is associated with unfavourable colorectal cancer presentation stage but not poorer 5-year survival in our Western Sydney population. The reasons for this are unclear and demand further attention.

Effect of rurality and socioeconomic deprivation on presentation stage and long-term outcomes in patients undergoing surgery for colorectal cancer.

BACKGROUND: Geographical remoteness and socioeconomic status (SES) are important factors affecting presentation stage and survival for colorectal cancer. A series of patients from a single institution in northern New South Wales was studied to determine if rural isolation or SES affected presentation and survival in patients undergoing resection. METHODS: Consecutive colorectal cancer resections performed at Lismore Base Hospital from 2011 to 2019 were identified. Patient residential addresses were categorized by the Modified Monash Model (MMM), an Australian Government definition of rural isolation, and Socioeconomic Index for Areas (SEIFA) quintiles, an Australian Bureau of Statistics index of socioeconomic deprivation. Univariate and Cox regression survival analysis was performed on data from histopathology and clinical notes matched with survival data. RESULTS: A total of 405 patients were included in MMM categories 3 (n = 207, 51.1%), 4 (n = 69, 17%) and 5 (n = 129, 31.9) corresponding to large, medium and small rural towns. MMM 3 was associated with emergency cases (25.6% versus 18.7%, P < 0.001), nodal disease (44.4% versus 38.4%, P = 0.018) and T3/4 tumours (82.1% versus 73.7%, P < 0.001) compared with isolated patients without difference in 5-year survival (P = 0.370). Disadvantaged SEIFA quintiles 1/2 demonstrated increased poor differentiation (23.0% versus 15.4%, P < 0.001) and vascular invasion (15.8% versus 9.1%, P < 0.001) with reduced 5-year survival (57.0% versus 70.4%, P = 0.039). Independent predictors of survival included age, emergency cases, group stage, lymphatic invasion and low lymph node yield. CONCLUSION: A 'rural reversal' may be present for patients in northern New South Wales; however, SES and established clinicopathological factors are the strongest predictors of survival in our population.

Burkitt Leukemia Presenting as Acute Appendicitis: A Case Report and Literature Review.

BACKGROUND Appendicitis is the most common cause of an acute abdomen. Approximately 1% of appendicectomies will have an incidental finding of an appendiceal neoplasm. A primary appendiceal lymphoma is extremely rare, and is found in 0.015% of all appendiceal specimens. Burkitt lymphoma is an aggressive B cell lymphoma characterized by translocation and dysregulation of the c-Myc gene. Burkitt leukemia is considered to be an alternative manifestation of the same pathology, and is defined by the presence of >25% Burkitt blasts within the bone marrow. The treatment approaches for Burkitt leukemia/lymphoma are similar. CASE REPORT A 6-year old girl presented with a history, examination, and radiological imaging consistent with acute appendicitis. An inflamed, edematous appendix was identified intraoperatively, and a cecectomy was performed. Histopathological investigations demonstrated Burkitt leukemia with isolated extra-nodal involvement of the appendix. The patient was subsequently started on a multi-agent steroid and chemotherapy regimen. A literature review was performed, identifying cases of Burkitt leukemia/lymphoma presenting as appendicitis. CONCLUSIONS This case highlights the importance of clinical vigilance and routine specimen histopathology review, and explores key management considerations associated with the incidental diagnosis of Burkitt leukemia/lymphoma.

Clinicopathological factors associated with positive circumferential margins in rectal cancers.

BACKGROUND: Positive circumferential resections are associated with local disease recurrence and reduced survival in rectal cancer. We studied a cohort of consecutive rectal cancer resections to assess for clinicopathological differences and survival in patients with positive and negative circumferential margins. METHODS: Rectal cancers were identified from a retrospective histopathology database of colorectal resections performed at five western Sydney hospitals from 2010 to 2016. Univariate and multivariate analysis with binary logistic regression were performed on histopathology data matched with survival times from the New South Wales Registry of Births Deaths and Marriages. RESULTS: A total of 502 rectal cancer patients were identified including 66 (13.1%) with involved circumferential margins. Patients with positive and negative circumferential margins had a similar distribution of age, gender and use of neoadjuvant radiotherapy. Tumours with involved circumferential margin comprised 98.5% T3 and T4 disease of which 51.5% received neoadjuvant radiotherapy. These were significantly associated with metastatic disease, increasing tumour size, circumferential and perforated tumours on univariate analysis. Multivariate analysis identified abdomino-perineal resection (odds ratio (OR) 3.35; P = 0.003), en-bloc multivisceral resection (OR 2.56; P = 0.032), T4 stage (OR 6.99; P < 0.001), perineural (OR 5.61; P < 0.001) and vascular invasion (OR 2.46; P = 0.022) as independent risk factors. Five-year survival was significantly worse for patients with involved circumferential margins (26% versus 69%; P < 0.001). CONCLUSION: Circumferential margin status reflects not only technical success but also aggressive disease phenotypes which require adjuvant therapy. Further work is needed to determine whether omission of radiotherapy has had an effect on long-term outcomes in some of our at-risk patients.

Heuristics and bias in rectal surgery.

PURPOSE: Deciding to defunction after anterior resection can be difficult, requiring cognitive tools or heuristics. From our previous work, increasing age and risk-taking propensity were identified as heuristic biases for surgeons in Australia and New Zealand (CSSANZ), and inversely proportional to the likelihood of creating defunctioning stomas. We aimed to assess these factors for colorectal surgeons in the British Isles, and identify other potential biases. METHODS: The Association of Coloproctology of Great Britain and Ireland (ACPGBI) was invited to complete an online survey. Questions included demographics, risk-taking propensity, sensitivity to professional criticism, self-perception of anastomotic leak rate and propensity for creating defunctioning stomas. Chi-squared testing was used to assess differences between ACPGBI and CSSANZ respondents. Multiple regression analysis identified independent surgeon predictors of stoma formation. RESULTS: One hundred fifty (19.2%) eligible members of the ACPGBI replied. Demographics between ACPGBI and CSSANZ groups were well-matched. Significantly more ACPGBI surgeons admitted to anastomotic leak in the last year (p < 0.001). ACPGBI surgeon age over 50 (p = 0.02), higher risk-taking propensity across several domains (p = 0.044), self-belief in a lower-than-average anastomotic leak rate (p = 0.02) and belief that the average risk of leak after anterior resection is 8% or lower (p = 0.007) were all independent predictors of less frequent stoma formation. Sensitivity to criticism from colleagues was not a predictor of stoma formation. CONCLUSIONS: Unrecognised surgeon factors including age, everyday risk-taking, self-belief in surgical ability and lower probability bias of anastomotic leak appear to exert an effect on decision-making in rectal surgery.