Detection of Anastomotic Leakage Following Elective Colonic Surgery: Results of the Prospective Biomarkers and Anastomotic Leakage (BALL) Study.

BACKGROUND: Anastomotic leakage (AL) is an infrequent but life-threatening surgical complication following colorectal surgery. Early diagnosis remains clinically difficult but is a necessity to reduce associated morbidity and mortality. Clinical review and radiological modalities for the diagnosis of leakage remain non-specific and often only detect AL once it is well developed. Inflammatory biomarkers however have shown promise in early pre-clinical detection of leakage following colorectal surgery. METHODS: A multi-center, prospective observational study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were initially recruited over a 3-y period. Perioperative blood samples were collected to measure interleukin (IL)-6, IL-1ß, tumor necrosis factor α, IL-10, C-reactive protein (CRP), leukocyte and neutrophil counts. Statistical analysis was performed to compare patients with an uncomplicated recovery with patients with AL. RESULTS: Sixteen patients developed AL (5.7%), diagnosed at a median post-operative (POD) day 7. CRP and IL-6 were consistently elevated in the early post-operative period in patients with AL, and had the best diagnostic accuracy on POD 3 (area under the curve 0.70; P = 0.02) and POD 1 (area under the curve 0.69; P = 0.02), respectively. IL-10, once adjusted for body mass index and surgical approach, was the sole biomarker significantly elevated in patients with AL on POD 4. CONCLUSIONS: Early post-operative elevations of CRP and IL-6 provide utility for early detection of AL after elective colectomy. Application of these inflammatory biomarkers and their combinations in daily practice warrants further investigation.

Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial.

BACKGROUND & AIMS: Antibiotic treatment is the standard care for patients with uncomplicated acute diverticulitis. However, this practice is based on low-level evidence and has been challenged by findings from 2 randomized trials, which did not include a placebo group. We investigated the non-inferiority of placebo vs antibiotic treatment for the management of uncomplicated acute diverticulitis. METHODS: In the selective treatment with antibiotics for non-complicated diverticulitis study, 180 patients hospitalized for uncomplicated acute diverticulitis (determined by computed tomography, Hinchey 1a grade) from New Zealand and Australia were randomly assigned to groups given antibiotics (n = 85) or placebo (n = 95) for 7 days. We collected demographic, clinical, and laboratory data and answers to questionnaires completed every 12 hrs for the first 48 hrs and then daily until hospital discharge. The primary endpoint was length of hospital stay; secondary endpoints included occurrence of adverse events, readmission to the hospital, procedural intervention, change in serum markers of inflammation, and patient-reported pain scores at 12 and 24 hrs. RESULTS: There was no significant difference in median time of hospital stay between the antibiotic group (40.0 hrs; 95% CI, 24.4-57.6 hrs) and the placebo group (45.8 hrs; 95% CI, 26.5-60.2 hrs) (P = .2). There were no significant differences between groups in adverse events (12% for both groups; P = 1.0), readmission to the hospital within 1 week (1% for the placebo group vs 6% for the antibiotic group; P = .1), and readmission to the hospital within 30 days (11% for the placebo group vs 6% for the antibiotic group; P = .3). CONCLUSIONS: Foregoing antibiotic treatment did not prolong length of hospital admission. This result provides strong evidence for omission of antibiotics for selected patients with uncomplicated acute diverticulitis. ACTRN: 12615000249550.

High-Resolution Colonic Manometry Pressure Profiles Are Similar in Asymptomatic Diverticulosis and Controls.

BACKGROUND: Elevated colonic pressures and increased colonic activity have been thought to contribute to the pathophysiology of diverticulosis. However, evidence for this has been limited to low-resolution manometry, which is of limited accuracy. AIMS: This study aimed to evaluate the contraction pressures, counts, and distance of propagation recorded by high-resolution colonic manometry in diverticulosis vs control patients. METHODS: High-resolution colonic manometry was used to record descending and sigmoid colon activity pre- and post-meal in patients with established, asymptomatic diverticulosis and in healthy controls. Antegrade and retrograde propagating contractions, distance of propagation (mm), and mean contraction pressures (mmHg) in the descending and sigmoid colon were compared between patients and controls for all isolated propagating contractions, the cyclic motor pattern, and high-amplitude propagating contractions independently. RESULTS: Mean manometry pressures were not different between controls and diverticulosis patients (p > 0.05 for all comparisons). In the descending colon, diverticulosis patients had lower post-meal mean distance of propagation for all propagating contractions [10.8 (SE1.5) mm vs 20.0 (2.0) mm, p = 0.003] and the cyclic motor pattern [6.0 (2.5) mm vs 17.1 (2.8) mm, p = 0.01]. In the sigmoid colon, diverticulosis patients showed lower post-meal mean distance of propagation for all propagating contractions [10.8 (1.5) mm vs 20.2 (5.9) mm, p = 0.01] and a lower post-meal increase in retrograde propagating contractions (p = 0.04). CONCLUSIONS: In this first high-resolution colonic manometry study of patients with diverticular disease, we did not find evidence for increased manometric pressures or increased colonic activity in patients with diverticular disease.

Diverticulosis and nine connective tissue disorders: epidemiological support for an association.

Purpose: An underlying connective tissue disorder (CTD) may predispose to formation of intestinal diverticula. We assess the association of diverticulosis with nine selected CTDs, to inform the pathophysiology of diverticula. Methods: A population-based period-prevalence study. Individuals (3.5 million New Zealand residents born 1901-1986) with a health system record 1999-2016 were grouped into those with a hospital diagnosis of diverticulosis or diverticulitis (ICD-10-AM K57), and those without. Also recorded were any hospital diagnoses of nine selected CTDs. The association of exposure to diverticulosis and each CTD was assessed using logistic regressions adjusted for age, gender, ethnicity and region. Results: In all, 85,958 (2.4%) people had a hospital diagnosis of diverticulosis. Hospitalisation with diverticulosis was highly significantly associated with rectal prolapse (adjusted odds ratio [OR] = 3.9), polycystic kidney disease (OR = 3.8), heritable syndromes (Marfan or Ehlers-Danlos) (OR = 2.4), female genital prolapse (OR = 2.3), non-aortic aneurysm (OR = 2.3), aortic aneurysm (OR = 2.2), inguinal hernia (OR = 1.9) and dislocations of shoulder and other joints (OR = 1.7), but not subarachnoid haemorrhage (OR = 1.0). Conclusion: People with diverticulosis are more likely to have colonic extracellular matrix (ECM)/connective tissue alterations in anatomical areas other than the bowel, suggesting linked ECM/connective tissue pathology. Although biases may exist, the results indicate large-scale integrated studies are needed to investigate underlying genetic pathophysiology of colonic diverticula, together with fundamental biological studies to investigate cellular phenotypes and ECM changes.

Uncomplicated Acute Diverticulitis: Identifying Risk Factors for Severe Outcomes.

BACKGROUND: The management of uncomplicated (Modified Hinchey Classification Ia) acute diverticulitis (AD) has become increasingly conservative, with a focus on symptomatic relief and supportive management. Clear criteria for patient selection are required to implement this safely. This retrospective study aimed to identify risk factors for severe clinical course in patients with uncomplicated AD. MATERIALS AND METHODS: Patients admitted to General Surgery at two New Zealand tertiary centres over a period of 18 months were included. Univariate and multivariate analyses were carried out in order to identify factors associated with a more severe clinical course. This was defined by three endpoints: need for procedural intervention, admission >7 days and 30-day readmission; these were analysed separately and as a combined outcome. RESULTS: Uncomplicated AD was identified in 319 patients. Fifteen patients (5%) required procedural intervention; this was associated with SIRS (OR 3.92). Twenty-two (6.9%) patients were admitted for >7 days; this was associated with patient-reported pain score >8/10 (OR 5.67). Thirty-one patients (9.8%) required readmission within 30 days; this was associated with pain score >8/10 (OR 6.08) and first episode of AD (OR 2.47). Overall, 49 patients had a severe clinical course, and associated factors were regular steroid/immunomodulator use (OR 4.34), pain score >8/10 (OR 5.9) and higher temperature (OR 1.51) and CRP ≥200 (OR 4.1). CONCLUSION: SIRS, high pain score and CRP, first episode and regular steroid/immunomodulator use were identified as predictors of worse outcome in uncomplicated AD. These findings have the potential to inform prospective treatment decisions in this patient group.

Gastrografin in Prolonged Postoperative Ileus: A Double-blinded Randomized Controlled Trial.

OBJECTIVE: To investigate the therapeutic value of Gastrografin in shortening duration of prolonged postoperative ileus (PPOI) after elective colorectal surgery. BACKGROUND: Gut wall edema is central to the pathogenesis of PPOI. Hyperosmotic, orally administered, water-soluble contrast media such as Gastrografin are theoretically capable of mitigating this edema. METHODS: A double-blinded, placebo-controlled, randomized trial was conducted. Participants were allocated to receive 100 mL of Gastrografin (Exposure Group) or flavored distilled water (Control Group) administered enterally. Other aspects of management were standardized. Resolution of PPOI was assessed 12-hourly. RESULTS: Eighty patients were randomized equally, with 5 in the Exposure Group and 4 in the Control Group excluded from analysis. Participants were evenly matched at baseline. Mean duration of PPOI did not differ between Exposure and Control Groups (83.7 vs 101.3 hours; P = 0.191). When considering individual markers of PPOI resolution, Gastrografin did not affect time to resolution of nausea and vomiting (64.5 vs 74.3 hours; P = 0.404) or consumption of oral diet (75.8 vs 90.0 hours; P = 0.297). However, it accelerated time to flatus or stool (18.9 vs 32.7 hours; P = 0.047) and time to resolution of abdominal distension (52.8 vs 77.7 hours; P = 0.013). There were no significant differences between groups in nasogastric output; analgesia, antiemetic, or fluid requirement; complications; or length of stay. CONCLUSIONS: Gastrografin is not clinically useful in shortening an episode of PPOI characterized by upper and lower gastrointestinal symptoms. It may however be of therapeutic benefit in the subset of PPOI patients who display lower gastrointestinal symptoms exclusively after surgery.

Cost analysis of early versus delayed loop ileostomy closure: a case-matched study.

BACKGROUND/AIMS: The optimal timing for the closure of loop ileostomies remains controversial. The aim of the current study was to investigate whether early ileostomy closure (EC) (<2 weeks post-formation) results in significant healthcare savings as against late closure (LC). METHODS: Patients with available cost data that underwent EC between January 2008 and December 2012 were compared against matched patients undergoing LC during the same period. Direct hospital costs for the two groups were compared. RESULTS: There were 42 EC patients and 61 LC patients. EC patients had significantly less ileostomy-related complications (p < 0.001) and hospital readmissions (p < 0.001). Operative time (p < 0.001) and operative cost (p = 0.002) were also both significantly less in the EC group. Community nursing costs favoured the LC group (p = 0.047). The EC group had an increased post-closure wound infection rate (p = 0.02). The mean total direct cost per patient was NZD 13,724 (SD NZD 3,736) for EC and NZD 16,728 (SD NZD 8,028) for LC. Representing an average costs saving of NZD 3,004 per patient favouring EC (p = 0.012). CONCLUSION: Although EC increases the post-closure wound infection rate, EC reduces ileostomy complications, hospital readmissions and operative costs resulting in significant healthcare savings. In order to improve patient outcomes and make EC even more cost effective, efforts should be taken to reduce wound infections.

Examining the impact of COVID-19 on Maori:non-Maori health inequities in Aotearoa, New Zealand: an observational study protocol.

INTRODUCTION: The COVID-19 pandemic has had both direct and indirect impacts on the health of populations worldwide. While racial/ethnic health inequities in COVID-19 infection are now well known (and ongoing), knowledge about the impact of COVID-19 pandemic management on non-COVID-19-related outcomes for Indigenous peoples is less well understood. This article presents the study protocol for the Health Research Council of New Zealand funded project 'Ma te Mohio ka Marama: Impact of COVID-19 on Maori:non-Maori inequities'. The study aims to explore changes in access to healthcare, quality of healthcare and health outcomes for Maori, the Indigenous peoples of Aotearoa New Zealand (NZ) and non-Maori during the COVID-19 outbreak period across NZ. METHODS AND ANALYSIS: This observational study is framed within a Kaupapa Maori research positioning that includes Kaupapa Maori epidemiology. National datasets will be used to report on access to healthcare, quality of healthcare and health outcomes between Maori and non-Maori during the COVID-19 pandemic in NZ. Study periods are defined as (a) prepandemic period (2015-2019), (b) first pandemic year without COVID-19 vaccines (2020) and (c) pandemic period with COVID-19 vaccines (2021 onwards). Regional and national differences between Maori and non-Maori will be explored in two phases focused on identified health priority areas for NZ including (1) mortality, cancer, long-term conditions, first 1000 days, mental health and (2) rheumatic fever. ETHICS AND DISSEMINATION: This study has ethical approval from the Auckland Health Research Ethics Committee (AHREC AH26253). An advisory group will work with the project team to disseminate the findings of this project via project-specific meetings, peer-reviewed publications and a project-specific website. The overall intention of the project is to highlight areas requiring health policy and practice interventions to address Indigenous inequities in health resulting from COVID-19 pandemic management (both historical and in the future).

Risk factors for readmission in patients with acute diverticulitis: a retrospective study at Auckland City Hospital.

AIM: Approximately one in five patients with acute diverticulitis (AD) will experience a recurrence. This study aimed to investigate the factors at AD admission that correlate with recurrence and test the proposed risk of recurrence-score according to Sallinen et al. method: This retrospective study followed patients for five years who were admitted with operatively or computed tomography (CT)-verified AD at Auckland City Hospital from January 2012-June 2013. Demographic, laboratory, radiological and patient-related factors at initial admission were analysed in relation to readmission with recurrent AD and to test a risk score presented by Sallinen et al. results: In the adjusted analyses, previous diagnosis of AD (OR, 7.3; 95% CI, 3.1-16.9), Maori ethnicity (OR, 5.7; 95% CI, 1.4-22.7) and complicated AD at index admission (OR, 2.5; 95% CI, 1.0-6.2), were all independent factors associated with readmission with recurrence. High-risk versus low-risk groups, according to the risk score, showed 71.4% and 18.6% recurrence rates, respectively. CONCLUSION: History of diverticulitis and complicated AD are risk factors for recurrence. The finding of higher recurrence rate in Maori requires further investigation utilising appropriate research methodologies. The risk score presented by Sallinen et al. may be a useful predictor of recurrent AD.

Asian New Zealanders' experiences of racism during the COVID-19 pandemic and its association with life satisfaction.

AIM: Racism is an important social determinant of wellbeing. This study describes New Zealand Asians' experience of racism and the association between their racism experiences and their impacts on life satisfaction during the COVID-19 pandemic. METHOD: This study collected 1,452 responses by the cross-sectional online survey conducted in 2021. Descriptive and logistic regression analyses yielded the prevalent types and settings of racism, identified subgroups exposed more to racism and its association with life satisfaction. RESULTS: Results show that nearly 40% (37.7-42.9%) of participants experienced racism, mainly in public places, social media and mainstream media. Verbal attacks and microaggressions were predominant types of racism. Younger, student, temporary visa holding, and rural area participants were more likely to experience racism. Associations between not experiencing racism and high life satisfaction were significant. CONCLUSION: This study identified two under-represented subgroups, students and migrants, who were disproportionately exposed to racism. It also revealed that experiences of COVID-era racism are associated with life satisfaction. These findings inform us where anti-racism interventions are most needed, and that such interventions are needed to ensure the wellbeing of Asian communities in a COVID-19 world.

Evaluation of the inflammatory profile following uncomplicated elective colectomy.

BACKGROUND: Attenuation of the inflammatory response in patients undergoing colectomy with modern perioperative care and laparoscopic surgery has been a focus of research in recent years. Despite reported benefits, significant heterogeneity remains with studies including patients undergoing both rectal and colon surgery and including surgery with postoperative complications. Therefore, the aim of the study was to evaluate the inflammatory response in patients undergoing elective colectomy without complications, specifically comparing open and laparoscopic approaches. METHODS: A multicenter prospective study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were included over a 3-year period. Perioperative blood samples were collected and analysed for the following inflammatory markers: IL-6, IL-1ß, TNFα, IL-10, CRP, leucocyte and neutrophil count. Statistical analysis was performed using SPSS statistical software. RESULTS: A total of 168 colectomy patients without complications were included in the analysis. Patients that underwent laparoscopy had significantly reduced IL-6, neutrophils and CRP on postoperative day (POD) 1 (p < 0.05) compared to an open approach. IL-10 and TNFα were significantly reduced on POD 2 (p < 0.05) in laparoscopic patients. Patients with a Body Mass Index (BMI) greater than 30 kg/m2 had significantly higher levels of CRP regardless of operative approach. Statins altered both preoperative and postoperative inflammatory markers. CONCLUSION: The postoperative inflammatory response is influenced by surgical approach, perioperative medications, and patient factors. These findings have important implications in the utility of biomarkers in the diagnosis of postoperative surgical complications, in particular in the early diagnosis of anastomotic leak.

A comparison of embalming fluids for use in surgical workshops.

There is a growing need to learn surgical skills without risk to patients. One of the major determining factors on the suitability of specimens for surgical workshops is the fluid used for embalming. This study sought to compare three different arterial embalming preparations to a single fresh cadaver. Eleven cadavers embalmed using Graz (single cadaver), Dodge (four cadavers) and Genelyn (five cadavers) preparations were compared using four criteria; joint flexibility measured with a goniometer, tissue pliability rated on standardized videos of instrument handling, tissue color analyzed on standardized photographs and resistance to fungal growth identified by inoculation and observation of tissue blocks. The cadaver embalmed according to the Graz method had joint flexibility comparable to fresh tissue while the Dodge and Genelyn cadavers were less flexible. Tissue pliability was significantly affected by the Dodge and Genelyn methods while the Graz method tissue remained most like fresh tissue. The Graz method cadaver had color that was most akin to fresh tissue and the Dodge method cadavers were relatively more like fresh than the Genelyn. The Dodge and Genelyn method had quite similar fungicidal properties (3/11 Dodge and 2/9 Genelyn embalmed cadavers susceptible) while the Graz method cadaver did not grow mould. Variation exists between cadavers; however, the Graz method produced a cadaver with more flexible joints, better tissue quality and muscle color closest to the fresh specimen. The Dodge and Genelyn methods are similar with the exception of tissue color where the Dodge method was more similar to fresh tissue.

Insulin use and new diabetes after acceptance for bariatric surgery: comparison of outcomes after completion of surgery or withdrawal from the program.

INTRODUCTION: In people accepted onto a bariatric surgery program we compared diabetes-related outcomes in those who completed surgery with those who withdrew before having surgery-examining rates of insulin use in people with type 2 diabetes (T2D), and rates of incident diabetes in people without pre-existing T2D. RESEARCH DESIGN AND METHODS: 771 people were accepted onto the program. 463 people (60%) had T2D at referral, of which 48% completed surgery and 52% withdrew. Of 308 people without T2D at referral, 49% completed surgery, and 51% withdrew. Rates of insulin use and incident diabetes were compared by Kaplan-Meier analyses. Among those with pre-existing T2D, we examined rates of remission and relapse after surgery. RESULTS: People without T2D who withdrew from the program had higher mean body mass index and glycated hemoglobin levels than those completing surgery (p<0.005). The rate of incident diabetes at 5 years was 19% in those who withdrew versus 0% in those completing surgery (p<0.001). 30% of people with T2D were taking insulin at referral and all stopped insulin after surgery. During follow-up, the rate of insulin (re)introduction was lower in those who completed surgery (8% vs 26% at 5 years, p<0.001). Of those with T2D who completed surgery, 80% had remission, but 34% had relapsed by 5 years. Diabetes relapse was associated with less weight loss after surgery, a longer duration of T2D and previous insulin use. CONCLUSIONS: Despite a high relapse rate, people with T2D who completed surgery had lower insulin use at 5 years than those withdrawing from the program. In people without T2D, bariatric surgery prevented incident diabetes. People without T2D who withdrew from the program were at greater risk of diabetes, suggesting those who could benefit the most in terms of T2D prevention are not completing bariatric surgery.

Diverticular disease management in primary care: How do estimates from community-dispensed antibiotics inform provision of care?

BACKGROUND: The literature regarding diverticular disease of the intestines (DDI) almost entirely concerns hospital-based care; DDI managed in primary care settings is rarely addressed. AIM: To estimate how often DDI is managed in primary care, using antibiotics dispensing data. DESIGN AND SETTING: Hospitalisation records of New Zealand residents aged 30+ years during 2007-2016 were individually linked to databases of community-dispensed oral antibiotics. METHOD: Patients with an index hospital admission 2007-2016 including a DDI diagnosis (ICD-10-AM = K57) were grouped by acute/non-acute hospitalisation. We compared use of guideline-recommended oral antibiotics for the period 2007-2016 for these people with ten individually-matched non-DDI residents, taking the case's index date. Multivariable negative binomial models were used to estimate rates of antibiotic use. RESULTS: From almost 3.5 million eligible residents, data were extracted for 51,059 index cases (20,880 acute, 30,179 non-acute) and 510,581 matched controls; mean follow-up = 8.9 years. Dispensing rates rose gradually over time among controls, from 47 per 100 person-years (/100py) prior to the index date, to 60/100py after 3 months. In comparison, dispensing was significantly higher for those with DDI: for those with acute DDI, rates were 84/100py prior to the index date, 325/100py near the index date, and 141/100py after 3 months, while for those with non-acute DDI 75/100py, 108/100py and 99/100py respectively. Following an acute DDI admission, community-dispensed antibiotics were dispensed at more than twice the rate of their non-DDI counterparts for years, and were elevated even before the index DDI hospitalisation. CONCLUSION: DDI patients experience high use of antibiotics. Evidence is needed that covers primary-care and informs self-management of recurrent, chronic or persistent DDI.

Prospective comparison of return of bowel function after left versus right colectomy.

BACKGROUND: Passage of flatus and stool represents a key milestone in recovery after colonic resections. Colorectal surgeons may hold varied expectations regarding recovery rates after left- versus right-sided colectomies, but there is currently little evidence to inform post-operative care. This study prospectively compared gut function recovery after left- versus right-sided resections. METHODS: Prospective data were analysed from 94 consecutive patients undergoing elective colorectal resections with primary anastomosis at Auckland City Hospital. Patients having ileostomies were excluded. Primary analysis compared time to first bowel motion between left- versus right-sided resections, excluding patients who developed prolonged post-operative ileus, while secondary analyses compared length of stay, rates of prolonged ileus and other complications. RESULTS: Analysis included 42 patients with left-sided and 52 with right-sided resections. No significant differences were observed for complications (P = 0.1), length of stay (P = 0.9) or development of prolonged ileus (P = 0.2). Rate of return of bowel function was faster in patients after left-sided resections (median 2.5 versus 4 days; P = 0.03 by Log-rank (Mantel-Cox) test), when patients with prolonged post-operative ileus were excluded. An association was also identified between length of bowel resected and time to recovery of bowel function for right-sided (P = 0.02) but not left-sided resections (P = 0.9). CONCLUSION: This study shows that for patients who do not progress to prolonged ileus, those with left-sided resections experience faster return of bowel function when compared with those having right-sided resections. The reason for this finding is currently unknown and deserves further attention.

Current management of acute diverticulitis: a survey of Australasian surgeons.

AIMS: To evaluate the current practice and degree of consensus amongst Australasian surgeons regarding non-surgical management of acute diverticulitis (AD) and to determine whether newer approaches to management are being translated into practice. METHODS: An online survey was distributed to all Australasian colorectal surgeons and all general surgeons in the Auckland region. Responses were collected over two months and analysed to identify points of consensus and areas of significant difference in opinion between these groups. RESULTS: Responses were received from a total of 99 of 200 (49.5%) colorectal surgeons, and 19 of 36 (52.7%) general surgeons. The Hinchey Classification was the most commonly used measure of disease severity, used by 67 (95.7%) colorectal surgeons and 12 (92.3%) general surgeons. There was lack of consensus around important aspects of AD management, including antibiotic therapy, and use and modality of follow-up imaging. Selective antibiotic therapy and use of anti-inflammatory medication as adjuncts to treatment were practised by a minority of those surveyed. CONCLUSIONS: Newer approaches to management were being utilised by some respondents. The lack of consensus regarding management of AD may be a consequence of a paucity of high-level evidence to support specific management approaches, particularly in patients with uncomplicated AD.

Changes in the approach to acute diverticulitis.

Acute diverticulitis (AD) is one of the most common acute admission diagnoses for general surgery, and its prevalence is increasing, in part due to the ageing population. Currently, most patients who present to a tertiary hospital are admitted for a period of treatment and observation. Simple, safe and cost-effective strategies for improving our current treatment of this condition will be invaluable in providing the most appropriate management for individual patients and for reducing the health resources expended on hospital admissions and parenteral antibiotics. AD can be categorized as uncomplicated or complicated, these two subtypes have a very different clinical course. The management of uncomplicated AD has become increasingly conservative, with a focus on symptomatic relief and supportive management. Recent research has brought into question the need for extended hospital admission and questioned the current use of antibiotics. Anti-inflammatory agents that reduce local inflammation in uncomplicated AD may be a useful means of reducing damage caused by inflammation and aiding earlier resolution of the inflammatory response and associated symptoms. Mesalazine is an anti-inflammatory agent that has been trialled in uncomplicated AD. Mesalazine has been shown to improve time to resolution of endoscopic and histological evidence of inflammation following an episode of AD and also reduce the rate of recurrence. In this literature review, we provide an overview of recent advances in AD classification, pathophysiology and management, and examine the possibility of introducing the use of anti-inflammatory agents in the management of uncomplicated AD.

Early closure of temporary loop ileostomies: a systematic review.

A temporary loop ileostomy is a common surgical procedure to protect colorectal anastomoses. The aim of this systematic review was to determine whether early closure of a defunctioning loop ileostomy (<2 weeks from index operation) is safe and reduces stoma-related morbidity. A systematic literature search was conducted using Ovid MEDLINE, EMBASE, Cochrane Collaboration, and the Cumulative Index to Nursing and Allied Health (CINAHL®) databases to identify all publications from January 1996 to March 2014 that reported the outcomes of early ileostomy closure. The following search terms (and their variations) were used as both medical subject headings (MeSH terms) and text words: ileostomy, surgical stoma, stoma, early, reversal, closure. No language restrictions were applied. The main outcomes of interest were stoma-related complications and postclosure complications. Studies that included pediatric patients (<18 years of age), small cohorts (<10 participants), case reports, conference abstracts, reviews, and letters; studies involving defunctioning colostomies or other types of small bowel stomas; and studies where results from closure of an ileostomy at >14 days could not be separated from early closure results were excluded. Where multiple studies were reported by the same institution and/or authors, only the most recent was included. This search strategy identified 4 studies (2 retrospective case series, 1 prospective nonrandomized study, and 1 randomized controlled trial), yielding a pooled population of 142 patients, ages 18-89 years old. Three studies reported indication for ileostomy; colorectal cancer accounted for 96 patients (78%). Time to ileostomy closure ranged from 8-14 days. No reported deaths were related to ileostomy closure. Wound infections were reported in 3 studies and were the most common complications, affecting 24 patients (19.8%). Of the 2 studies that reported ileostomy-related complications, 4 patients (3.6%) experienced a stoma-related complication before closure. Ileus or small bowel obstruction (SBO) occurred in 7 patients (4.9%). Compared to traditionally timed closure (8-12 weeks), reported stoma-related complication rates were lower in patients undergoing early closure. Both mortality and ileus/SBO rates also compare favorably with traditionally timed closure; however, wound infection rates appear to be increased. Additional studies to accurately define which individuals stand to benefit from early closure, as well as to further evaluate the impact of early ileostomy closure on quality of life and health care costs, are warranted.

Development of a risk stratification system for the occurrence of prolonged postoperative ileus after colorectal surgery: a prospective risk factor analysis.

BACKGROUND: Management strategies for prolonged postoperative ileus (PPOI) are principally conservative and it is therefore valuable to shift attention to prevention. This study aimed to identify prospectively the perioperative risk factors for the development of PPOI and create a tool to predict its occurrence. METHODS: Patients undergoing elective colorectal surgery at Auckland District Health Board between September 2012 and June 2014 were enrolled. In total, 92 variables were investigated prospectively with uniform application of a standardized definition of PPOI. Logistic regression and area under receiver operating characteristic curves (AUC) were used to generate risk stratification models. RESULTS: PPOI occurred in 88 of 327 patients (26.9%). Independent predictors of PPOI were male gender (odds ratio [OR], 3.01), decreasing preoperative albumin (OR, 1.11 per g/L unit), open or converted technique (OR, 6.37 [vs laparoscopic]), increasing wound size (OR, 1.09 [per cm]), operative difficulty (OR, 1.28 [per unit on 10-point Likert scale]), operative bowel handling (OR, 1.38 [per unit on 10-point Likert scale]), red cell transfusion (OR, 1.84 [per unit]), intravenous crystalloid administration (OR, 1.55 [per liter]), and delayed first mobilization (OR, 1.39 [per day]). The I-Score assimilated preoperative and intraoperative variables to generate a score out of 6 with a 7-fold increase in risk from low-risk to high-risk strata and fair predictive capacity (AUC, 0.742; 95% CI, 0.684-0.799). CONCLUSION: Independent predictors for the development of PPOI have been identified prospectively and used to construct a novel risk stratification model.