Outcomes Following Intrasphincteric Injection of Botulinum Toxin for Treatment of Anal Fissures.

Background Intrasphincteric injection of botulinum toxin is an alternative treatment for anal fissures, which may present less risk of fecal incontinence than more invasive procedures, such as lateral internal sphincterotomy. The aim is to compare cure and complication rates between these two treatments. Methods We conducted a retrospective audit of patients who underwent treatment of anal fissures with intrasphincteric botulinum toxin or lateral internal sphincterotomy from 2016 to 2020 at the Colorectal Surgery Unit of Monash Health, Melbourne, Australia, excluding those who had previously had either procedure. Results Fifty-one patients received intrasphincteric botulinum toxin, and 40 patients underwent lateral internal sphincterotomy. Most patients in the botulinum group had a total dose of either 80 (53%; n=27) or 100 units (37%; n=19) and had the dose administered bilaterally at the 3 o'clock and 9 o'clock positions (n=41; 80%). Thirty-one patients in the botulinum group (61%) had complete resolution of symptoms, with a mean time to cure of two months, compared to 36 patients (90%) in the sphincterotomy group with a mean time to cure of 1.5 months. In most cases, postoperative incontinence was transient, although one patient in the botulinum group had persistent incontinence of flatus, and two patients in the sphincterotomy group had persistent fecal incontinence. Conclusion Intrasphincteric botulinum injection is an effective, less-invasive alternative to sphincterotomy for the treatment of anal fissures, with incontinence usually temporary when it occurs. Further research is needed to optimize the dose and location of injection and guide future recommendations.

Local fistula injection of allogeneic human amnion epithelial cells is safe and well tolerated in patients with refractory complex perianal Crohn's disease: a phase I open label study with long-term follow up.

BACKGROUND: Local fistula injection of mesenchymal stromal/stem cells (MSC) is effective for complex perianal Crohn's fistulas but is also expensive and requires specialised facilities for cell revival before administration. Human amnion epithelial cells (hAEC) are non-MSC cells with therapeutic properties. The primary aim of this study was safety of hAEC therapy. Secondary aims included hAEC efficacy, feasibility of the protocol and impact on quality of life. METHODS: A phase I open label study of ten adults with active complex Crohn's perianal fistulas refractory to conventional treatment, including anti-tumour necrosis factor alpha therapy, was undertaken. A single dose of hAEC was injected into the fistula tract(s) after surgical closure of the internal opening(s). Study outcomes were assessed at week 24 with follow up for at least 52 weeks. FINDINGS: Local injection of hAEC was safe, well tolerated and the injection procedure was feasible. Complete response occurred in 4 patients, and a partial response in an additional 4 patients. There was a mean reduction in the Perianal Disease Activity Index of 6.5 points (95% CI -9.0 to -4.0, p = 0.0002, paired t-test), modified Van Assche MRI Index of 2.3 points (95% CI -3.9 to -0.6, p = 0.012, paired t-test) and a mean improvement of 15.8 points (95% CI 4.9 to 26.8, p = 0.010, paired t-test) in quality of life using the Short IBD-Questionnaire in complete responders. INTERPRETATION: Local injection of hAEC therapy for refractory complex perianal fistulising Crohn's disease appears safe, well-tolerated, feasible and demonstrated improvement. Quality of life is improved in those who achieve complete fistula healing. FUNDING: This study was funded by competitive research grant funding from the Gastroenterological Society of Australia Seed Grant 2018.

Managing Recurrent Teratoma in Currarino Syndrome.

To the best of our knowledge, this is the first reported case of a recurrent presacral tumor in Currarino syndrome. Currarino syndrome is a rare disease usually found in childhood with a triad of sacral agenesis, anorectal malformation, and presacral tumor. However, it can often remain undiscovered until adulthood. Currarino syndrome is generally diagnosed during childhood in the setting of recurrent meningitis and is often suspected when there is a family history. Occasionally, it is diagnosed in adulthood through incidental imaging or due to investigations for back pain and chronic constipation. MRI is the recommended imaging modality in this disease process, as it can better help differentiate soft tissue. The tumor can be resected through either the transabdominal approach or the posterior approach (Kraske procedure). We present a 52-year-old female patient who was diagnosed with Currarino syndrome when she was one year old due to recurrent meningitis and surgical resection of a presacral mass and was asymptomatic until she developed back pain and constipation. Her symptoms were investigated with an MRI, revealing a recurrence of a presacral tumor, and she subsequently underwent a Kraske procedure. The patient is currently under annual surveillance, and the residual tumor has remained stable. There are currently no surveillance guidelines after resection of a presacral tumor in Currarino Syndrome. However, follow-up surveillance should be considered.

Right hemicolectomy for colon cancer: does the anastomotic configuration affect short-term outcomes?

OBJECTIVES: Right hemicolectomy is a common colorectal operation for resection of cancers of the right colon. The ileocolic anastomosis may be created using a stapled end-to-side, stapled side-to-side or handsewn technique. Anastomotic leak and post-operative bleeding are uncommon but serious causes of morbidity and mortality, while post-operative ileus contributes to prolonged length of stay. The aim of this study was to evaluate differences in short-term outcomes between different anastomotic configurations following right hemicolectomy for colon cancer. METHODS: We conducted a retrospective study using data from the Bowel Cancer Outcomes Registry (BCOR), including 94 hospitals across Australia and New Zealand, of all patients who underwent right hemicolectomy or extended right hemicolectomy for colon cancer with formation of a primary anastomosis between 2007 and 2021. RESULTS: We included 8164 patients in the analysis. There was no significant difference in rates of anastomotic leak and anastomotic bleeding based on anastomotic technique. A stapled end-to-side anastomosis was associated with a lower rate of post-operative ileus than stapled side-to-side anastomosis (6.5% vs. 7.2%; P = 0.03). CONCLUSION: Both handsewn and stapled anastomosis techniques may be utilized for oncologic right hemicolectomy, with comparable rates of anastomotic leak and post-operative bleeding. Stapled end-to-side anastomosis resulted in lower rates of prolonged ileus compared to stapled side-to-side anastomoses.

Does intra-operative humidification with warmed CO2 reduce surgical site infection in open colorectal surgery? A randomized control trial.

BACKGROUNDS: Surgical site infections (SSI) are a significant cause of postoperative morbidity and mortality, contributing to a considerable financial burden on the healthcare system. Insufflation of the open surgical wound with warm, humidified carbon dioxide (CO2 ) is a novel measure aimed to reduce SSI. The local atmosphere of warm, humidified CO2 within the open surgical wound is proposed to decrease airborne contamination, bacterial growth, desiccation, and heat loss while improving tissue oxygenation and perfusion. This randomized controlled trial evaluates the impact of the HumiGard™ surgical humidification system on the incidence of SSI in patients undergoing open colorectal surgery. METHODS: We conducted a multi-site single-blinded randomized control trial on patients undergoing elective or emergency laparotomy at a single tertiary Colorectal Surgery service. The primary outcome measure was the incidence of SSI, with secondary outcomes including ICU length of stay (LOS), total LOS and mean core temperature. RESULTS: Patients who received HumiGard™ had a lower incidence of SSI, although this did not reach statistical significance (4.5% for treatment group versus 13.0% for control group; P = 0.092). There was no significant difference in ICU LOS or total LOS between cohorts. The HumiGard™ group had a higher mean core temperature than the control at the end of surgery (P < 0.001). CONCLUSION: The present study could not confirm that utilization of warm, humidified CO2 with HumiGard™ reduces SSI in open colorectal surgery. Further research is indicated to validate and extend these findings.

Ileocolic anastomosis after right hemicolectomy: stapled end-to-side, stapled side-to-side, or handsewn?

PURPOSE: Anastomotic leak (AL) following ileocolic anastomosis is a cause of significant morbidity and mortality. Stapled end-to-side (ESA), stapled side-to-side (SSA), and handsewn anastomoses (HSA) are commonly performed techniques. There is however conflicting data on the superiority of one technique over the other. The aim of this study was to compare the outcomes of ESA against SSA and HSA. METHODS: This retrospective cohort study was conducted at a tertiary colorectal unit. All patients who underwent an ileocolic anastomosis from October 2008 to May 2020 were included. Exclusion criteria were missing data on anastomotic technique or clinicopathological variables. Primary outcomes were AL and anastomotic bleeding (AB). Secondary outcomes were length of stay (LoS) and return of gut function. RESULTS: A total of 1390 patients met the inclusion criteria. A total of 976 (70%) ESA, 308 (22%) SSA, and 108 (8%) HSA were performed. AL occurred in 17/1390 (1.2%) patients, and 54/1390 (3.9%) had AB. On adjusted analysis, ESA experienced a lower AL when compared with SSA (OR 4.93, p = 0.005), with a trend towards a lower AL when compared to HSA (OR 2.6, p = 0.27). There was no difference in AB between all techniques: ESA vs. SSA (OR 1.07 p = 0.84), and ESA vs. HSA (OR 0.24 p = 0.76). Both stapled techniques were associated with a shorter return to gut function compared to HSA; 3.3 vs. 4.2 days (p < 0.001). There was no difference in LoS. CONCLUSION: ESA has the lowest leak rate when compared to other anastomotic techniques without any increased risk of anastomotic bleeding.

Is colorectal cancer associated with altered bowel habits in young patients?

BACKGROUND: There is a rising incidence in young-onset colorectal cancer, with these patients falling outside of routine screening programmes. The aim of the study is to characterize the nature of altered bowel habits in young patients who are diagnosed with colorectal cancer. METHODS: A retrospective audit was conducted of adult patients younger than 45 years admitted under a Colorectal Surgery unit (Dandenong Hospital, Victoria) from 2011 to 2019 for the resection of colorectal cancer. We compared the patients' self-characterization of their bowel habits (from the medical record) with clinical and pathological data. RESULTS: A total of 75 patients were identified, aged between 18 and 45 years, who had surgical resection of colonic or rectal adenocarcinoma between 2011 and 2019. Forty-two (56%) presented with altered bowel habit (irregular bowel habit n = 13, 17%; constipation n = 13, 17%; diarrhoea n = 23, 31%). Constipation approached significance in association with left-sided colonic cancer. Fatigue approached significance in association with right-sided colonic cancers, which were less likely to present with bleeding or constipation, and approached significance in being less likely to present with diarrhoea. Rectal cancers were more likely to present with bleeding. CONCLUSION: Constipation was associated with left-sided colonic cancers, while right-sided colonic cancers were less likely to present with either constipation or diarrhoea. Our findings reinforce the need for clinicians to consider colorectal cancer as a differential diagnosis in young patients with altered bowel habits, or in patients with fatigue in the absence of specific bowel symptoms. Further prospective research is needed to further define bowel habits in this cohort.

Management options for rectal variceal bleeding in the setting of hepatic encephalopathy.

Bleeding related to rectal varices associated with portal hypertension is rare but life-threatening, and requires prompt treatment. We reviewed the literature for patients with this complex presentation and current recommendations, and commented on a case at our institution of a 68-year-old man with Child-Pugh B alcoholic liver cirrhosis and hepatic encephalopathy who presented with profuse life-threatening rectal variceal bleeding. Treatment options for rectal varices in patients with hepatic encephalopathy were reviewed and a management algorithm was devised from current knowledge in the literature. We suggest endoscopic management, and if unsuccessful then to proceed to angioembolization and/or balloon-occluded retrograde transvenous obliteration, which may be used in conjunction with surgical management. The chosen therapeutic option may depend on the clinical condition of the patient, the cause of portal hypertension and clinical expertise or facilities available. Given that transjugular intra-hepatic portosystemic shunting is contraindicated in patients with hepatic encephalopathy, management of life-threatening rectal variceal bleeding should be multimodal.

Preoperative anaemia and thrombocytopenia are associated with venous thromboembolism complications after colorectal resection.

BACKGROUND: Earlier studies have shown that abnormal levels of haemoglobin and platelets may be associated with worse post-operative outcomes. We aim to compare the rates of venous thromboembolism (VTE), anastomotic leak and other complications in patients post-colorectal resection with normal and abnormal levels of haemoglobin and platelets. METHODS: We performed a retrospective review of 1610 patients from July 2010 to June 2015 in a single colorectal unit. Our primary outcome was the rate of VTE and anastomotic leak in anaemic and thrombocytopenic patients. Secondary outcomes included length of stay, 30-day mortality, return to theatre, transfusion rates and Clavien-Dindo classification complications. RESULTS: VTE complications were more common in anaemic patients, and this difference became more pronounced with the severity of anaemia. Other complications such as length of stay >2 weeks occurred more frequently in anaemic and thrombocytopenic patients. A trend towards higher rates of 30-day mortality and anastomotic leak was noted in patients with anaemia and thrombocytopenia. CONCLUSION: Anaemia and thrombocytopenia are associated with worse outcomes including length of stay, anastomotic leak, VTE and 30-day mortality.

Neuroendocrine tumour developing within a long-standing tailgut cyst: case report and review of the literature.

A tailgut cyst is a rare congenital lesion that can develop in the presacral space from the remnants of an embryonic hindgut. It is unusual for malignant change to occur in a tailgut cyst. We report a case of a large long-standing tailgut cyst, which was removed during a laparotomy. Histopathology showed a well-differentiated neuroendocrine tumour (primary carcinoid tumour) arising in a tailgut cyst. We reviewed the English literature for all adult cases with this condition. All original articles were reviewed, and data were compiled and tabulated. Including this report, 29 cases of NET developing in a tailgut cyst were found in the English literature. Tailgut cysts have been reported as more common in females, with a mean age of presentation in the fifth decade (Devine, in: Zbar A, Wexner S (eds) Coloproctology. Springer specialist surgery series, Springer, London, 2010; Hjermstad and Helwig in Am J Clin Pathol 89:139-147, 1988). Tailgut cysts may undergo malignant change including adenocarcinoma, sarcoma, and NET (Mathis et al. Br J Surg 97:575-579, 2010; Messick in Dis Colon Rectum 61:151-153, 2018; Patsouras et al. in Colorectal Dis 17:724-729, 2015; Chereau et al in Colorectal Dis 15:e476-e482, 2013). It is difficult to estimate the true incidence of malignant change in a tailgut cyst, with the literature reports only limited to case reports and small-case series. Although rare, our case confirms need to consider the possibility of a malignant component, even in a benign process such as a tailgut cyst. This prompts consideration for upfront definitive management.

Correction: Improving Pharmacy Staff Knowledge and Practice on Childhood Diarrhea Management in Vietnam: Are Educational Interventions Effective?

[This corrects the article DOI: 10.1371/journal.pone.0074882.].