The aetiology of pouchitis in patients with inflammatory bowel disease.

Restorative proctocolectomy with ileal pouch-anal anastomosis is a treatment option for patients with refractory ulcerative colitis. Pouchitis is the most common complication, representing a spectrum of diseases ranging from acute antibiotic-responsive type to chronic antibiotic-refractory. Early accurate diagnosis using a combined assessment of symptoms, endoscopy and histology is important for both treatment and prognostication. Most patients respond well to antibiotic therapy; however, management of chronic antibiotic-refractory pouchitis remains a challenge, and treatment options are based on small studies. Pouchitis is thought to be driven by the interaction between genetics, the immune system and the environment but as yet a causal relationship has yet to be identified. Further longitudinal assessment of the pouch integrating new technologies may help us understand the factors driving pouchitis. This review outlines the currently understood risk factors and aetiology of pouchitis.

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.

Impact of obesity on patients undergoing surgery for rectal cancer in Australia and New Zealand.

PURPOSE: Patients with obesity undergoing rectal cancer surgery may have an increased risk of developing complications, though evidence is inconclusive. The aim of this study was to determine the direct impact of obesity on postoperative outcomes using data from a large clinical registry. METHOD: The Binational Colorectal Cancer Audit registry was used to identify patients who underwent rectal cancer surgery in Australia and New Zealand from 2007-2021. Primary outcomes were inpatient surgical and medical complications. Logistic regression models were developed to describe the association between body-mass index (BMI) and outcomes. RESULTS: Among 3,708 patients (median age 66 years [IQR 56.75-75], 65.0% male), 2.0% had a BMI < 18.5 kg/m2, 35.4% had a BMI of 18.5-24.9 kg/m2, 37.6% had a BMI of 25.0-29.9 kg/m2, 16.7% had a BMI of 30.0-34.9 kg/m2, and 8.2% had a BMI ≥ 35.0 kg/m2. Surgical complications occurred in 27.7% of patients with a BMI of 18.5-24.9 kg/m2, 26.6% of patients with a BMI of 25.0-29.9 kg/m2 (OR 0.91, 95% CI 0.76-1.10), 28.5% with a BMI of 30.0-34.9 kg/m2 (OR 0.96, 95% CI 0.76-1.21), and 33.2% with a BMI ≥ 35.0 kg/m2 (OR 1.27, 95% CI 0.94-1.71). Modelling BMI as a continuous variable confirmed a J-shaped relationship. The association between BMI and medical complications was more linear. CONCLUSION: Risk of postoperative complications is increased in patients with obesity undergoing rectal cancer surgery.

Metastatic osteosarcoma bowel perforation secondary to chemotherapy-induced tumour necrosis.

Osteosarcoma is the most common paediatric and adolescent primary bone malignancy and is highly chemosensitive. Gastrointestinal metastases from osteosarcomas are rare. Bowel perforation secondary to chemotherapy is a potential serious complication reported in ovarian, colorectal and haematological malignancies. We report the first documented case of chemotherapy-mediated bowel perforation in an osteosarcoma patient with gastrointestinal metastases. A man in his 20s, with a history of resected osteosarcoma in remission, presented with abdominal pain. A computed tomography (CT) scan demonstrated a large calcified intrabdominal mass (15×13×9 cm) consistent with new peritoneal disease. After one cycle of palliative ifosfamide and etoposide chemotherapy, he developed a large bowel perforation and neutropenic sepsis consequently requiring resection of the perforated mass. Chemotherapy-induced bowel perforation is a rare but serious complication that should be considered in patients with osteosarcoma, and other chemosensitive malignancies, with intra-abdominal metastases. Recommencement of systemic therapies after bowel complications must be assessed cautiously on a case-by-case basis.

Impact of preoperative smoking on patients undergoing right hemicolectomies for colon cancer.

PURPOSE: The tobacco epidemic is one of the biggest global public health issues impacting quality of life and surgical outcomes. Although 30% of colon cancers warrant a right hemicolectomy (RH), there is no specific data on the influence of smoking on postoperative complications following RH for cancer. The aim of this study was to determine its effect on post-surgical outcomes. METHODS: Patients who underwent elective RH for colon cancer between 2016 and 2019 were identified from the ACS-NSQIP database. Propensity score matching (PSM) was used with a maximum absolute difference of 0.05 between propensity scores. Primary outcome was to assess the 30-day complication risk profile between smokers and non-smokers. Secondary outcomes included smoking impact on wound and major medico-surgical complication rates, as well as risk of anastomotic leak (AL) using multivariable logistic regression models. RESULTS: Following PSM, 5652 patients underwent RH for colon cancer with 1,884 (33.3%) identified as smokers. Smokers demonstrated a higher rate of organ space infection (4.1% vs 3.1%, p = 0.034), unplanned return to theatre (4.8% vs 3.7%, p = 0.045) and risk of AL (3.5% vs 2.1%, p = 0.005). Smoking was found to be an independent risk factor for wound complications (OR 1.32, 95% CI 1.03-1.71, p = 0.032), primary pulmonary complications (OR 1.50, 95% CI 1.06-2.13, p = 0.024) and AL (OR 1.66, 95% CI 1.19-2.31, p = 0.003). CONCLUSION: Smokers have increased risk of developing major post-operative complications compared to non-smokers. Clinicians and surgeons must inform smokers of these surgical risks and potential benefit of smoking cessation prior to undergoing major colonic resection.

Vesicocutaneous Fistula Following Radiation and Surgery for the Treatment of Rectal Cancer.

Vesicocutaneous fistulas (VCF) are abnormal tracts formed between the bladder and the cutaneous surfaces of the body. Although rare, it has been reported following radiotherapy to the pelvic region, surgery and trauma. We present a case of a 70-year-old male who underwent neoadjuvant chemoradiotherapy for the treatment of rectal cancer metastatic to the perineum prior to definitive abdominoperineal resection (APR). Six months later, he developed urinary retention secondary to bladder obstructive outlet disease. This was managed with urinary catheterisation and a month later with transurethral resection of the prostate (TURP). At outpatient follow-up, he complained of urinary leakage in the perineal region approximately 10 months post-chemoradiotherapy. He underwent a computer tomography (CT) cystogram which confirmed the findings of a VCF extending to his perineum scar. He was managed conservatively with successful outcomes using a multidisciplinary team approach. This is the first case of delayed VCF reported arising after chemoradiotherapy for locally advanced rectal colorectal cancer.

Occult Para-Psoas Hernia during Routine Endoscopic Totally Extraperitoneal Inguinal Hernia Repair.

BACKGROUND AND OBJECTIVES: Advantage of the total extraperitoneal (TEP) technique over open inguinal hernia repair allows for exploration of other anatomical regions in search for occult hernias (OH). METHODS: Our institutional practice is to routinely explore the obturator and femoral regions for occult hernias. In addition to this technique, we routinely expose the psoas muscle extensively to perfect mesh placement followed by fibrin glue fixation on both 'triangles of doom and pain'. The use of this technique has led to the identification of three incidental occult para-psoas hernias (PPH) out of a total of 800 TEP repairs performed in a high-volume specialist hernia center. CONCLUSIONS: The purpose of this article is to demonstrate that occult parapsoas hernias (PPH) can be easily identified and safely repaired with mesh glue fixation, using the standard TEP technique during inguinal hernia repair.

A decade review of emergency obturator hernia repairs.

BACKGROUND: Obturator hernia is a rare pelvic hernia associated with a high morbidity and mortality. It most commonly occurs in elderly, multiparous females with symptoms and signs of small bowel obstruction. We present an Australian hospital network experience on emergency presentations of obturator hernias highlighting differences between clinical profile and surgical management. METHODS: A retrospective review of adult patients diagnosed with acute obturator hernia during a 10 year period (2010-2020) was conducted across 10 major Sydney hospitals in New South Wales, Australia. RESULTS: Obturator hernia was diagnosed in 18 patients (mean 82.7 years, range: 60-96 years old), all confirmed on pre-operative computed tomography imaging. The most common presentations were elderly women demonstrating clinical features of a small bowel obstruction. The mean onset of symptoms from home to hospital admission was 49.4 h. Non-survivors had a significantly elevated urea level (15.6 vs. 7.8 mmol/L, p = 0.036) at presentation and a longer delay from onset of presenting symptoms to diagnosis (84.0 vs. 36.2 h, p = 0.028). Eleven patients underwent urgent laparotomy and six laparoscopic repairs. The mean operative time was 101.0 min. The average hospital length of stay was 16.2 days with a mortality rate of 27.8%. CONCLUSION: Timely diagnosis and operative intervention for obturator hernia is the cornerstone of management.

How to do a combined endoscopic and tailored open extraperitoneal approach for large congenital inguinoscrotal hernia.

Large inguinoscrotal hernias require experienced and skilful laparoscopic hernia surgeons to reap the benefits of laparoscopic versus open surgery. We advocate for an alternative hybrid TEP-open technique that allows tissue extraction away from the groin area, whenever necessary, thus avoiding more painful conventional open herniorrhaphy incision.

Diagnosis and Management of Adult Omental Infarction: 10-Year Case Series.

BACKGROUND: Omental infarction is a rare cause of an acute abdomen with nonspecific signs that can be easily mistaken with other more common intra-abdominal pathologies. The increased use of radiological imaging has brought this diagnosis to attention with respect to management plan. We present the experience of an Australian hospital network with the diagnosis and management of omental infarction to raise awareness of this uncommon pathology. METHODS: A retrospective review of medical records of adult patients diagnosed with omental infarction from 2010 to 2020 was conducted across four major hospitals in South Western Sydney. Data relating to clinical presentation, investigations, management and outcomes were obtained. RESULTS: Omental infarction was diagnosed in 61 patients (mean 51.1 years, range: 19-76 years old). All patients presented with nonspecific abdominal pain with the most common sites being the right iliac fossa followed by the right upper quadrant, respectively, over an average period of 2.7 days. Computed tomography and/or diagnostic laparoscopy identified omental infarction in all cases. Forty-two patients (68.9%) had successful conservative management, six failed conservative management and 19 patients had emergency laparoscopic omentectomy. The average hospital length of stay was 3.4 days with no significant morbidity or mortality. CONCLUSION: Omental infarction generally presents with nonspecific clinical signs often masquerading as other more common abdominal diagnosis like cholecystitis or appendicitis. A trial of conservative management initially coupled with appropriate imaging should be recommended within the first 24-48 h before considering surgical treatment in refractory cases.