Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies.

BACKGROUND: The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence. OBJECTIVE: To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction. DATA SOURCES: A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023. STUDY SELECTION: Randomized controlled trials and propensity score-matched studies. INTERVENTIONS: Emergency colonic resection, self-expanding metallic stent, and decompressing stoma. MAIN OUTCOME MEASURES: Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates. RESULTS: Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively. LIMITATIONS: There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction. CONCLUSIONS: This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Robotic beyond total mesorectal excision for locally advanced rectal cancers: Perioperative and oncological outcomes from a multicentre case series.

BACKGROUND: Around 20% of rectal tumors are locally advanced with invasion into adjacent structures at presentation. These may require surgical resections beyond boundaries of total mesorectal excision (bTME) for radicality. Robotic bTME is under investigation. This study reports perioperative and oncological outcomes of robotic bTME for locally advanced rectal cancers. MATERIALS AND METHODS: A multicentre, retrospective analysis of prospectively collected robotic bTME resections (July 2015-November 2020). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. RESULTS: One-hundred-sixty-eight patients (eight centres) were included. Median age and BMI were 60.0 (50.0-68.7) years and 24.0 (24.4-27.7) kg/m2. Female sex was prevalent (n = 95, 56.8%). Fifty patients (29.6%) were ASA III-IV. Neoadjuvant chemoradiotherapy was given to 125 (74.4%) patients. Median operative time was 314.0 (260.0-450.0) minutes. Median estimated blood loss was 150.0 (27.5-500.0) ml. Conversion to laparotomy was seen in 4.8%. Postoperative complications occurred in 77 (45.8%) patients; 27.3% and 3.9% were Clavien-Dindo III and IV, respectively. Thirty-day mortality was 1.2% (n = 2). R0 rate was 92.9%. Adjuvant chemotherapy was offered to 72 (42.9%) patients. Median follow-up was 34.0 (10.0-65.7) months. Distant and local recurrences were seen in 35 (20.8%) and 15 patients (8.9%), respectively. Overall survival (OS) at 1, 3, and 5-years was 91.7, 82.1, and 76.8%. Disease-free survival (DFS) at 1, 3, and 5-years was 84.0, 74.5, and 69.2%. CONCLUSION: Robotic bTME is technically safe with relatively low conversion rate, good OS, and acceptable DFS in the hands of experienced surgeons in high volume centres. In selected cases robotic approach allows for high R0 rates during bTME.

A 20-year population study of peripartum cardiomyopathy.

BACKGROUND AND AIMS: The epidemiology of peripartum cardiomyopathy (PPCM) in Europe is poorly understood and data on long-term outcomes are lacking. A retrospective, observational, population-level study of validated cases of PPCM in Scotland from 1998 to 2017 was conducted. METHODS: Women hospitalized with presumed de novo left ventricular systolic dysfunction around the time of pregnancy and no clear alternative cause were included. Each case was matched to 10 controls. Incidence and risk factors were identified. Morbidity and mortality were examined in mothers and children. RESULTS: The incidence of PPCM was 1 in 4950 deliveries. Among 225 women with PPCM, obesity, gestational hypertensive disorders, and multi-gestation were found to be associated with having the condition. Over a median of 8.3 years (9.7 years for echocardiographic outcomes), 8% of women with PPCM died and 75% were rehospitalized for any cause at least once. Mortality and rehospitalization rates in women with PPCM were ∼12- and ∼3-times that of controls, respectively. The composite of all-cause death, mechanical circulatory support, or cardiac transplantation occurred in 14%. LV recovery occurred in 76% and, of those who recovered, 13% went on to have a decline in LV systolic function despite initial recovery. The mortality rate for children born to women with PPCM was ∼5-times that of children born to controls and they had an ∼3-times greater incidence of cardiovascular disease over a median of 8.8 years. CONCLUSIONS: PPCM affected 1 in 4950 women around the time of pregnancy. The condition is associated with considerable morbidity and mortality for the mother and child. There should be a low threshold for investigating at-risk women. Long term follow-up, despite apparent recovery, should be considered.

Obesity, Sarcopenia and Myosteatosis: Impact on Clinical Outcomes in the Operative Management of Crohn's Disease.

BACKGROUND: Obesity, sarcopenia, and myosteatosis in inflammatory bowel disease may confer negative outcomes, but their prevalence and impact among patients with Crohn's disease (CD) have not been systematically studied. The aim of this study was to assess nutritional status and body composition among patients undergoing resectional surgery for CD and determine impact on operative outcomes. METHODS: Consecutive patients with CD undergoing resection from 2000 to 2018 were studied. Total, subcutaneous, and visceral fat areas and lean tissue area (LTA) and intramuscular adipose tissue (IMAT) were determined preoperatively by computed tomography at L3 using SliceOmatic (Tomovision, Canada). Univariable and multivariable linear, logistic, and Cox proportional hazards regression were performed. RESULTS: One hundred twenty-four consecutive patients were studied (ileocolonic disease 53%, n = 62, biologic therapy 34.4% n = 43). Mean fat mass was 22.7 kg, with visceral obesity evident in 23.9% (n = 27). Increased fat stores were associated with reduced risk of emergency presentation but increased corticosteroid use (ß 9.09, standard error 3.49; P = .011). Mean LBM was 9.9 kg. Sarcopenia and myosteatosis were associated with impaired baseline nutritional markers. Myosteatosis markers IMAT (P = .002) and muscle attenuation (P = .0003) were associated with increased grade of complication. On multivariable analysis, IMAT was independently associated with increased postoperative morbidity (odds ratio [OR], 1.08; 95% confidence interval (CI), 1.01-1.16; P = .037) and comprehensive complications index (P = .029). Measures of adiposity were not associated with overall morbidity; however, increased visceral fat area independently predicted venous thromboembolism (OR, 1.02; 95% CI, 1.00-1.05; P = .028), and TFA was associated with increased wound infection (OR, 1.00; 95% CI, 1.00-1.01; P = .042) on multivariable analysis. CONCLUSION: Myosteatosis is associated with nutritional impairment and predicts increased overall postoperative morbidity following resection for CD. Despite its association with specific increased postoperative risks, increased adiposity does not increase overall morbidity, reflecting preservation of nutritional status and relatively more quiescent disease phenotype. Impaired muscle mass and function represent an appealing target for patient optimization to improve outcomes in the surgical management of CD.

Myosteatosis was predictive of postoperative morbidity following surgery for Crohn's Disease. Increased adiposity does not increase overall morbidity, reflecting a more quiescent disease phenotype. Obesity, myosteatosis, and sarcopenia represent appealing targets for patient optimization to improve outcomes surgical outcomes in Crohn's Disease.

Metformin is a metabolic modulator and radiosensitiser in rectal cancer.

Resistance to neoadjuvant chemoradiation therapy, is a major challenge in the management of rectal cancer. Increasing evidence supports a role for altered energy metabolism in the resistance of tumours to anti-cancer therapy, suggesting that targeting tumour metabolism may have potential as a novel therapeutic strategy to boost treatment response. In this study, the impact of metformin on the radiosensitivity of colorectal cancer cells, and the potential mechanisms of action of metformin-mediated radiosensitisation were investigated. Metformin treatment was demonstrated to significantly radiosensitise both radiosensitive and radioresistant colorectal cancer cells in vitro. Transcriptomic and functional analysis demonstrated metformin-mediated alterations to energy metabolism, mitochondrial function, cell cycle distribution and progression, cell death and antioxidant levels in colorectal cancer cells. Using ex vivo models, metformin treatment significantly inhibited oxidative phosphorylation and glycolysis in treatment naïve rectal cancer biopsies, without affecting the real-time metabolic profile of non-cancer rectal tissue. Importantly, metformin treatment differentially altered the protein secretome of rectal cancer tissue when compared to non-cancer rectal tissue. Together these data highlight the potential utility of metformin as an anti-metabolic radiosensitiser in rectal cancer.

Mechanical bowel preparation and antibiotics in elective colorectal surgery: network meta-analysis.

BACKGROUND: The use of intravenous antibiotics at anaesthetic induction in colorectal surgery is the standard of care. However, the role of mechanical bowel preparation, enemas, and oral antibiotics in surgical site infection, anastomotic leak, and other perioperative outcomes remains controversial. The aim of this study was to determine the optimal preoperative bowel preparation strategy in elective colorectal surgery. METHODS: A systematic review and network meta-analysis of RCTs was performed with searches from PubMed/MEDLINE, Scopus, Embase, and the Cochrane Central Register of Controlled Trials from inception to December 2022. Primary outcomes included surgical site infection and anastomotic leak. Secondary outcomes included 30-day mortality rate, ileus, length of stay, return to theatre, other infections, and side effects of antibiotic therapy or bowel preparation. RESULTS: Sixty RCTs involving 16 314 patients were included in the final analysis: 3465 (21.2 per cent) had intravenous antibiotics alone, 5268 (32.3 per cent) had intravenous antibiotics + mechanical bowel preparation, 1710 (10.5 per cent) had intravenous antibiotics + oral antibiotics, 4183 (25.6 per cent) had intravenous antibiotics + oral antibiotics + mechanical bowel preparation, 262 (1.6 per cent) had intravenous antibiotics + enemas, and 1426 (8.7 per cent) had oral antibiotics + mechanical bowel preparation. With intravenous antibiotics as a baseline comparator, network meta-analysis demonstrated a significant reduction in total surgical site infection risk with intravenous antibiotics + oral antibiotics (OR 0.47 (95 per cent c.i. 0.32 to 0.68)) and intravenous antibiotics + oral antibiotics + mechanical bowel preparation (OR 0.55 (95 per cent c.i. 0.40 to 0.76)), whereas oral antibiotics + mechanical bowel preparation resulted in a higher surgical site infection rate compared with intravenous antibiotics alone (OR 1.84 (95 per cent c.i. 1.20 to 2.81)). Anastomotic leak rates were lower with intravenous antibiotics + oral antibiotics (OR 0.63 (95 per cent c.i. 0.44 to 0.90)) and intravenous antibiotics + oral antibiotics + mechanical bowel preparation (OR 0.62 (95 per cent c.i. 0.41 to 0.94)) compared with intravenous antibiotics alone. There was no significant difference in outcomes with mechanical bowel preparation in the absence of intravenous antibiotics and oral antibiotics in the main analysis. CONCLUSION: A bowel preparation strategy with intravenous antibiotics + oral antibiotics, with or without mechanical bowel preparation, should represent the standard of care for patients undergoing elective colorectal surgery.

Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes.

PURPOSE: The optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection. METHODS: The study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes. RESULTS: Seventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n = 1389), shaving (n = 703) and discoid excision (n = 742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p = 0.002), comparable functional outcomes (minor LARS, p = 0.30, major LARS, p = 0.54), similar rates of postoperative leaks (p = 0.22), pelvic abscesses (p = 0.18) and rectovaginal fistula (p = 0.92). On subgroup analysis, shaving had the highest recurrence rate (p = 0.0007), however a lower rate of stoma formation (p < 0.00001) and rectal stenosis (p = 0.01). Discoid excision and formal resection were comparable. CONCLUSION: Colorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates.

Comparison of Restorative Proctocolectomy with and Without Defunctioning Loop Ileostomy in Patients with Ulcerative Colitis: A Systematic Review and Meta-analysis.

BACKGROUND: Restorative proctocolectomy [RPC] without a defunctioning loop ileostomy [DLI] in patients with ulcerative colitis [UC] remains controversial. AIM: To compare safety and efficacy of RPC with and without DLI in patients exclusively with UC. METHODS: A systematic review was performed according to PRISMA/MOOSE guidelines. Dichotomous variables were pooled as odds ratios [OR]. Continuous variables were pooled as weighted mean differences [WMD]. Quality assessment was performed using the Newcastle-Ottawa score [NOS]. RESULTS: A total of 20 studies [five paediatric and 15 adult] with 4550 UC patients [without DLI, n = 2370, 52.09%; with DLI, n = 2180, 47.91%] were eligible for inclusion. The median NOS was 8 [range 6-9]. There was no increased risk of anastomotic leak [AL] (OR 1.13, 95% confidence interval [CI]: 0.92, 1.39; p = 0.25), pouch excision [OR 1.01, 95% CI: 0.68, 1.50; p = 0.97], or overall major morbidity [OR 1.44, 95% CI, 0.91, 2.29; p = 0.12] for RPC without DLI, and this technique was associated with fewer anastomotic strictures [OR 0.45, 95% CI: 0.29, 0.68; p = 0.0002] and less bowel obstruction [OR 0.73, 95% CI: 0.57, 0.93; p = 0.01]. However, RPC without DLI increased the likelihood of pelvic sepsis [OR 1.68, 95% CI: 1.03, 2.75; p = 0.04] and emergency reoperation [OR 1.74, 95% CI: 1.22, 2.50; p = 0.002]. CONCLUSION: RPC without DLI is not associated with increased clinically overt AL or pouch excision rates. However, it is associated with increased risk of pelvic sepsis and emergency reoperation. RPC without DLI is feasible, but should only be performed judiciously in select UC patient cohorts in high-volume, specialist, tertiary centres.

A contemporary series of surgical outcomes following subtotal colectomy and/or completion proctectomy for management of inflammatory bowel disease.

BACKGROUND: The main indications for emergency subtotal colectomy (SC) include management of toxic colitis, refractory haemorrhage and/or perforation. Alternatively, elective surgery is performed for those refractory to medical therapy or with evidence of multifocal dysplasia. Overall, the annual incidence of SC has fallen since the introduction of biologic therapies and we aimed to review our current practices. METHODS: A retrospective review of inflammatory bowel disease (IBD) patients undergoing subtotal colectomy between 2013 and 2020 was performed. Medical records, operative notes, discharge summaries, histopathology reports and other supporting documents were reviewed. Indication for surgery, management of the rectum (i.e. maintenance of rectal stump, progression to completion proctectomy or IPAA formation) associated morbidity (Clavien-Dindo classification) and length of hospital stay were examined. RESULTS: Fifty-six IBD patients underwent a subtotal colectomy. Twenty-five patients (UC 14, Crohn's 11) had an elective procedure, and 31 patients (UC 19 Crohn's 12) had an emergency/semi-urgent procedure. Interestingly, 80% (n = 25) of the emergency cohort and 68% (n = 17) of the elective cohort had a laparoscopic resection. Major morbidity (Clavien-Dindo > 2) was higher among the emergency group (39% vs. 24%). Deep surgical site infection was the commonest morbidity (13%) in the emergency group, while superficial surgical site infection was commonest in the elective cohort (20%). Overall, there was no difference in surgical re-intervention rate (13% vs 12%), and there were no perioperative mortalities. Median post-operative length of stay was shorter in the elective cohort (9 versus 13 days). CONCLUSION: A significant proportion of IBD patients still require semi-urgent/emergency colectomy, which is associated with considerable length of stay and morbidity. The results of our study provide real-world outcomes to help counsel patients on expected outcomes.

Robotic versus laparoscopic anterior resections for rectal and rectosigmoid cancer: an institutional experience.

INTRODUCTION: Colorectal surgery has evolved with the advent of laparoscopic techniques and now robotic-assisted surgery. There is significant literature supporting the use of laparoscopic techniques over open surgery with evidence of enhanced post-operative recovery, reduced use of opioids, smaller incisions and equivalent oncological outcomes. Robotic minimally invasive surgery addresses some of the limitations of laparoscopic surgery, providing surgical precision and improvements in perception and dexterity with a resulting decrease in tissue damage. METHODS: We retrospectively reviewed the medical records of patients who underwent robotic-assisted anterior resection for cancer of the rectum or rectosigmoid junction in our institution since our robotic programme began in 2017. Patient demographics were identified via electronic databases and patient charts. A matched cohort of laparoscopic cases was identified. RESULTS: A total of 51 consecutive robotic-assisted anterior resections were identified and case matched with laparoscopic resections for comparison. Robotic-assisted surgery was associated with a shorter length of stay (p = 0.04), reduced initial post-operative analgesia requirements (p < 0.01) and no significant difference in time to bowel movement or stoma functioning (p = 0.84). All patients had an R0 resection, and there was no statistical difference in lymph node yield between the groups (p = 0.14). Robotic surgery was associated with a longer operative duration (p < 0.001). CONCLUSION: In this early experience, robotic surgery has proven feasible and safe and is comparable to laparoscopic surgery in terms of completeness of resection and recovery. As costs and operating times decline and as technology progresses, robotic surgery may one day replace traditional laparoscopic techniques.

Anal squamous cell carcinoma: a retrospective case series.

BACKGROUND: Anal cancer is a relatively rare cancer with 660 cases diagnosed in 2000-2015 in Ireland (1). The current standard treatment is radical chemoradiotherapy (CRT). The aim of our study was to review the treatment and outcomes of patients with localised anal squamous cell carcinoma (SCC), who received radical treatment in our radiation oncology network between 2008 and 2014 inclusive. METHODS: Data were collected retrospectively from ARIA® oncology information system and patient charts. Statistical analyses were performed using IBM® SPSS® statistical software version 25.0. RESULTS: Seventy-nine cases of anal SCC were identified. Mean age of patients at commencement of radiotherapy (RT) was 60.2 years (standard deviation: 13.1 years). The most common total RT dose was 50.4 Gy in 28 fractions (N = 58; 73.4%). Median follow-up was 5.6 years. Two (2.6%) patients had persistent disease, seventeen (21.8%) patients developed loco-regional recurrence and nine (11.5%) patients developed solid organ metastases, four of whom had complete treatment response at the primary site. Eight patients underwent salvage anal surgery following completion of RT. Median overall survival was 10.5 years (95% confidence interval (CI) 5.1-15.8 years), median loco-regional relapse-free survival was 10.4 years (95% CI 4.4-16.3 years) and median disease-free survival was 9.3 years (95% CI 6.3-12.2 years). CONCLUSION: Our study demonstrates that treatment for anal SCC and outcomes following definitive CRT in Ireland during the study period were comparable to international standards.

Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis.

BACKGROUND: Both endoscopic techniques and transanal surgery are viable options that allow organ preservation for early rectal neoplasms. Whilst endoscopic approaches are less invasive and carry less morbidity, it is unclear whether they are as oncologically effective. AIM: To compare endoscopic techniques with transanal surgery in the management of early rectal neoplasms. METHODS: A systematic literature search was performed for randomised and observational studies comparing these techniques. The pre-specified main outcomes measured were en bloc and R0 resection rates and recurrence. Pair-wise meta-analysis was performed. RESULTS: This review included 1044 patients. Transanal surgery had increased R0 resection rates (odds ratio (OR) 2.66; 95% CI 1.64; 4.31; p < 0.001) versus endoscopic management. The latter was associated with higher rates of incomplete resection (OR 2.25; 95% CI 1.14, 4.46; p = 0.02) and further intervention (OR 1.78; 95% CI 1.09, 2.88; p = 0.02). There was no difference in the rates of late recurrence (OR 1.01; 95% CI 0.53, 1.91; p = 0.99) or further major surgery (OR 0.87; 95% CI 0.39, 1.94; p = 0.73) between the groups. Endoscopic treatment was associated with a shorter operating time (weighted mean difference (WMD) - 12.08; 95% CI - 18.97, - 5.19; p < 0.001) and LOS (WMD - 1.94; 95% CI - 2.43, - 1.44; p < 0.001), as well as lower rates of urinary retention post-operatively (OR 0.12; 95% CI 0.02, 0.63; p = 0.01). CONCLUSION: Endoscopic techniques should be favoured in the setting of benign early rectal neoplasms given their decreased morbidity and increased cost-effectiveness. However, where malignancy is suspected transanal surgery should be the preferred option given the superior R0 resection rate.

Strictureplasty versus bowel resection for the surgical management of fibrostenotic Crohn's disease: a systematic review and meta-analysis.

BACKGROUND: Strictureplasty (SPX) conserves bowel length and minimizes the risk of developing short bowel syndrome in patients undergoing surgery for Crohn's disease (CD). However, SPX may be associated with a higher risk of recurrence compared with bowel resection (BR). AIM: We sought to compare morbidity and recurrence following SPX and BR in patients with fibrostenotic CD. METHODS: A systematic review was performed according to PRISMA and MOOSE guidelines. Observational studies that compared outcomes of CD patients undergoing either SPX or BR were identified. Log hazard ratios (InHR) for recurrence-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots or Cox regression models and pooled using the inverse variance method. Dichotomous variables were pooled as odds ratios (OR) using the Mantel-Haenszel method. Continuous variables were pooled as weighted mean differences. RESULTS: Twelve studies of 1026 CD patients (SPX n = 444, 43.27%; BR with or without SPX n = 582, 56.72%) were eligible for inclusion. There was an increased likelihood of disease recurrence with SPX than with BR (OR 1.61; 95% CI, 1.03, 2.52; p = 0.04; I2 = 0%). Patients who had a SPX alone had a significantly reduced RFS than those who underwent BR (HR 1.47; 95% CI, 1.08, 2.01; p = 0.02; I2 = 0%). There was no difference in morbidity between the groups (OR 0.58; 95% CI, 0.26, 1.28; p = 0.18; I2 = 0%). CONCLUSION: SPX should only be performed in those patients with Crohn's strictures that are at high risk for short bowel syndrome and intestinal failure; otherwise, BR is the favored surgical technique for the management of fibrostenotic CD.

Meta-analysis of early bowel resection versus initial medical therapy in patient's with ileocolonic Crohn's disease.

BACKGROUND: Early bowel resection (EBR) in ileocolonic Crohn's disease (CD) may be associated with more durable remission compared with initial medical therapy (IMT) even when biologic therapy is included. AIM: To compare the efficacy of EBR versus IMT for ileocolonic CD METHODS: A systematic search was performed to identify studies that compared EBR (performed < 1 year from initial diagnosis) or IMT for the management of ileocolonic CD. Log hazard ratios (InHR) for relapse-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots and pooled using the inverse-variance method. Dichotomous variables were pooled as odds ratios (OR). Quality assessment of the included studies was performed using the Newcastle-Ottawa (NOS) and Jadad scales. RESULTS: A total of 7 studies with 1863 CD patients (EBR n = 581, 31.2%; IMT n = 1282, 68.8%) were eligible for inclusion. There was a moderate-to-high risk of bias. The median NOS was 8 (range 7-9). There was a reduced likelihood of overall (OR, 0.53; 95% confidence interval (95% CI), 0.34, 0.83; p = 0.005) and surgical (OR, 0.47; 95% CI, 0.24, 0.91; p = 0.03) relapse with EBR. There was also a less requirement for maintenance biologic therapy (OR, 0.24; 95% CI, 0.14, 0.42; p < 0.0001). Patients who underwent EBR had a significantly improved RFS than those who underwent IMT (HR, 0.62; 95% CI, 0.52, 0.73; p < 0.001). There was no difference in morbidity (OR, 1.67; 95% CI, 0.44, 6.36; p = 0.45) between the groups. CONCLUSION: EBR may be associated with less relapse and need for maintenance biologic therapy than IMT. 'Upfront' or early resection may represent a reasonable and cost-effective alternative to biologic therapy, especially in biologic-resistant subpopulations.

An unusual cause of bowel ischemia in an intensive care unit patient with herpes simplex virus encephalitis.

We present a case of an unexpected cause of bowel ischemia in an intensive care unit patient with herpes simplex virus encephalitis who required an operation. A 79-year-old lady was being worked up and treated for encephalitis with antibiotics and an antiviral. On Day 13, she developed abdominal pain, and an ultrasound showed cholelithiasis but no cholecystitis; thus conservative treatment was advocated. By Day 18, pain localized to the right iliac fossa, and she had an emergency laparotomy that showed bowel ischemia and perforation of the caecum with the cause being a terminal ileal adhesional band. An extended right hemicolectomy and ileostomy was performed. Patients with significant comorbidities who are intensive care unit-dependent may still have unexpected clinical challenges. We advocate an increased clinical vigilance in this cohort for unexpected life-threatening presentations such as bowel ischemia and more specifically the cause of the bowel ischemia.

Stage IV jejunal adenocarcinoma: a multimodal therapeutic success story.

Small bowel adenocarcinoma is rare with an incidence of 2.6 in 100 000 patients. Diagnosis is often fortuitous and usually presents late. We present the case of a 36-year-old male who attended the emergency department with worsening abdominal discomfort. A computed tomography scan showed high-grade jejunal obstruction secondary to a jejunal mass suspicious for carcinoma with disseminated peritoneal carcinomatosis and hepatic metastases. Following a conservative approach, his obstruction settled. He commenced on a total of 12 cycles of FOLFOX (folinic acid, fluorouracil and oxaliplatin) and bevacizumab. After re-presenting with intermittent intussusception, a decision for surgical resection was made. On laparoscopy, there was no evidence of hepatic metastases or peritoneal carcinomatosis. A jejunal resection was carried out with an uneventful postoperative period. The patient remains disease free. Despite presenting with an advanced stage, a multimodal approach to these rare tumors may yield surprising and optimistic outcomes.

Factors Associated With Margin Positivity and Incidental Carcinoma in Patients Undergoing Transanal Endoscopic Microsurgery (TEMS) for the Management of Adenomatous and Dysplastic Rectal Lesions.

PURPOSE: Colorectal cancer screening has resulted in an increased detection of early premalignant rectal lesions. Transanal endoscopic microsurgery (TEMS) is a minimally invasive procedure for the resection of dysplastic and selected early malignant lesions with organ and functional preservation. The aim of this study was to assess factors associated with positive resection margin and the underlying invasive component. METHODS: This was an analysis of a prospective consecutive series of all TEMS procedures performed over the last 10-year period. Data was collated from hospital databases and operative theater registers. Statistical analysis was performed using Minitab-V18 with a P<0.05 regarded as significant. RESULTS: In total, 328 procedures were performed on 292 patients. The cohort included 165 male patients and 127 female patients with a mean age of 66.3 years (19 to 95 years). A total of 274 procedures performed were en bloc excisions and 54 procedures were piecemeal debulking excisions for larger lesions follow by formal TEMs at an interval. The mean tumor size was 41.9 mm (10 to 150 mm), and the mean distance from anal verge was 9.3 cm (2 to 20 cm). Clear margins were achieved in 85% of cases. An overall 10.6% of patients had pathologic upgrading to invasive disease after TEMS. Lesion volume was found to influence the completeness of excision, and the widest diameter of the lesions was related to the presence of an invasive component on histology (P=0.002, 0.008, respectively). CONCLUSIONS: TEMS is a minimally invasive technique for the resection of rectal lesions that are not amenable to endoscopic removal. Lesion size and endoscopic diameter were associated with invasive component and margin positivity, respectively. These factors should be taken into consideration when considering TEMS.

Coloproctology procedure clinic: a novel service developed to reduce suffering of patients with bleeding per rectum.

AIMS: Evaluation of the role and impact of introducing a dedicated coloproctology procedure clinic in tertiary referral colorectal unit. METHODS: A retrospective analysis of 126 consecutive patients managed in the coloproctology clinic between March2015 and September 2016 was carried out. All patients were preselected for attendance based on symptom-based protocol. RESULTS: Based on the information available in GP referrals, 126 patients with bleeding per rectum with low risk of cancer were re-triaged from the general outpatient to dedicated coloproctology procedure clinic. Those patients accounted for 14% of waiting list. The average waiting time to attend clinic was 27 months from referral to undergoing definitive procedure. A proctoscopy or/and rigid sigmoidoscopy was performed in patients. Seventy-nine (89.7%) patients were completely managed and discharged after attending their first visit. Sixty-seven (76%) patients had 2nd- or 3rd-degree haemorrhoids and were treated with rubber band ligation (RBL) or phenol injection in outpatient setting. Two patients had an anal fissure and were managed conservatively with medication. After clinic, follow-up was through telephone clinic. This avoids attendance physically in the hospital. Symptoms persisted in nine patients and were subsequently scheduled for colonoscopy, three had benign polyps. With the introduction of the procedure clinic, the waiting time from referral to treatment was reduced from 27 to 6 months (p < 0.05). CONCLUSIONS: Establishing a dedicated "Coloproctology procedure clinic" is an effective strategy in reducing number of hospital visits per patient and hospital waiting list. This innovative clinic reduces utilisation of precious endoscopy unit resources. This ultimately will improve endoscopy efficiency.

Use of a Novel Measure of Nontechnical Skills in Surgical Trainees: Is There an Association With Technical Skills Performance?

OBJECTIVE: To investigate whether scores on a psychological measure of concentration and interpersonal characteristics, The Attentional and Interpersonal Style Inventory (TAIS), are associated with performance of surgical skills. DESIGN: Postgraduate surgical trainees completed an operative surgical skills assessment in the simulation laboratory and the psychological measure (TAIS). The surgical skills assessment consisted of 6 tasks (3 per trainee): laceration suturing; lipoma excision; incision and closure of a laparotomy wound; bowel anastomosis; saphenofemoral junction ligation and basic laparoscopic skills. The association between operative surgical skill performance and TAIS factors was investigated. SETTING: The TAIS assessments and surgical skills assessments were conducted at the National Surgical Training Centre at the Royal College of Surgeons in Ireland (RCSI). PARTICIPANTS: One hundred and two surgical trainees in years one and two (PGY 2-3 equivalent) participated in the study. RESULTS: Performance on 2 of the 6 tasks assessed (bowel anastomosis and lipoma excision) were positively associated with multiple TAIS factors (energy, confidence, competitiveness, extroversion, self-criticism and performing under pressure). Another factor, focus over time, was significantly associated with scores on the lipoma excision task. CONCLUSIONS: Trainees with high levels of energy, confidence, competitiveness, extroversion, and focus over time and low levels of self-criticism demonstrated better performance on specific technical skills tasks.

Safe adoption of robotic colorectal surgery using structured training: early Irish experience.

Robotic surgery enhances the precision of minimally invasive surgery through improved three-dimensional views and articulated instruments. There has been increasing interest in adopting this technology to colorectal surgery and this has recently been introduced to the Irish health system. This paper gives an account of our early institutional experience with adoption of robotic colorectal surgery using structured training. Analysis was conducted of a prospectively maintained database of our first 55 consecutive robotic colorectal cases, performed by four colorectal surgeons, each at the beginning of his robotic surgery experience, using the Da Vinci Si® system and undergoing training as per the European Academy of Robotic Colorectal Surgery (EARCS) programme. Overall surgical and oncological outcomes were interrogated. Fifty-five patients underwent robotic surgery between January 2017 and January 2018, M:F 34:21, median age (range) 60 (35-87) years. Thirty-three patients had colorectal cancer and 22 had benign pathologies. Eleven rectal cancer patients had neoadjuvant chemoradiotherapy. BMI was > 30 in 21.8% of patients and 56.4% of patients had previous abdominal surgery. Operative procedures performed were low anterior resection (n = 19), sigmoid colectomy (n = 9), right colectomy (n = 22), ventral mesh rectopexy (n = 3), abdominoperineal resection (n = 1) and reversal of Hartmann's procedure (n = 1). Median blood loss was 40 ml (range 0-400). Mean operative time (minutes) was 233 (SD 79) for right colectomy and 368 (SD 105) for anterior resection. Median length of hospital stay was 6 days (IQR 5-7). There was no 30-day mortality, intraoperative complications, conversion to laparoscopic or open, or anastomotic leakage. Median lymph nodes harvest was 15 in non-neoadjuvant cases (range 7-23) and 8 in neoadjuvant cases (2-14). Our early results demonstrate that colorectal robotic surgery can be adopted safely for both benign and neoplastic conditions using a structured training programme without compromising clinical or oncological outcomes. The early learning curve can be time intensive.