Identification and surgical management of acute severe ulcerative colitis: A guide for general practitioners.

BACKGROUND: Approximately 25% of patients with ulcerative colitis (UC) develop acute severe UC (ASUC), necessitating urgent care. General practitioners (GPs), whether based in rural or urban settings, are instrumental in detecting early warning signs, expediting emergency interventions, coordinating with medical teams, educating patients and overseeing outpatient care. This involvement ensures timely, appropriate surgical responses, especially if complications arise or medical treatments prove ineffective. OBJECTIVE: This review provides GPs with an understanding of ASUC evaluation and risk assessment, emphasising surgical management and complementing existing medical methods. The objective is to equip GPs, whether in rural or urban environments, with the knowledge and confidence to play an integral role in the treatment team. DISCUSSION: Identifying and diagnosing ASUC is crucial for timely emergency care. Moreover, effective ASUC management demands appropriate preoperative work-up. GPs should be adept at monitoring treatment efficacy and guiding patients through surgical aftercare. Thus, GPs should be well versed in diagnostic criteria and surgical approaches for ASUC, as well as their important role within a multidisciplinary team.

When you hear hoofbeats, think horses before zebras - a case of recurrent small bowel obstructions with a twist.

Mechanical small bowel obstructions (SBOs) account for a considerable proportion of hospital admissions for acute abdominal pain. SBOs are most frequently caused by adhesions; and very few SBOs are associated with intraperitoneal devices. An 84-year-old man was admitted to our tertiary institution with recurrent SBOs that were initially believed to be caused by his implantable cardioverter defibrillator which had undergone intraperitoneal migration. However, this was later found to be a misguided 'zebra'; as the cause was revealed to be a common 'horse' - adhesions. This article shares our key learnings from this diagnostic dilemma.

Splenic flexure cancer survival: a 25-year experience and implications for complete mesocolic excision (CME) and central vascular ligation (CVL).

BACKGROUND: The management of splenic flexure cancers (SFCs) in the era of complete mesocolic excision (CME) and central vascular ligation (CVL) is challenging because of its variable lymphatic drainage. This study aimed to compare survival outcomes for SFCs and non-SFCs, and better understand the clinicopathological characteristics which may define a distinct SFC phenotype. METHODS: An observational cohort study at Concord Hospital, Sydney was conducted with patients who underwent resection for colon adenocarcinoma (1995-2019). Clinicopathological data were extracted from a prospective database. Overall survival (OS) and disease-free survival (DFS) estimates and their associations to clinicopathological variables were investigated with Kaplan-Meier and Cox regression analyses. RESULTS: Of 2149 patients with colon cancer, 129 (6%) had an SFC. The overall 5-year OS and DFS rates were 63.6% (95% CI 62.5-64.7) and 59.4% (95% CI 58.3-60.5), respectively. SFCs were not associated with OS (P = 0.6) or DFS (P = 0.5). SFCs were more likely to present urgently (P < 0.001) with obstruction (P < 0.001) or perforation (P = 0.03), and more likely to require an open operation (P < 0.001). These characteristics were associated with poorer survival outcomes. No differences were noted between SFCs and non-SFCs with respect to tumour stage (P = 0.3). CONCLUSION: SFCs have a distinct phenotype, the individual characteristics of which are associated with poorer survival. However, the survivals of SFCs and non-SFCs are similar, possibly because the most important determinant of outcome, tumour stage, is no different between the groups. This may have implications for the surgical approach to SFCs with respect to standardization of CME and CVL surgery for these cancers.

Right hemicolectomy anastomotic leak study: a review of right hemicolectomy in the binational clinical outcomes registry (BCOR).

BACKGROUNDS: Surgery remains mainstay management for colon cancer. Post-operative anastomotic leak (AL) carries significant morbidity and mortality. Rates of, and risk factors associated with AL following right hemicolectomy remain poorly documented across Australia and New Zealand. This study examines the Bowel Cancer Outcomes Registry (BCOR) to address this. METHODS: A retrospective cohort study was undertaken of consecutive BCOR-registered right hemicolectomy patients undergoing resection for colon cancer (2007-2021). The primary outcome measure was AL incidence. Clinicopathological data were extracted from the BCOR. Factors associated with AL and primary anastomosis were identified using logistic regression. AL-rate trends were assessed by linear regression. RESULTS: Of 13 512 patients who had a right hemicolectomy (45.2% male, mean age 72.5 years, SD 12.1), 258 (2.0%) had an AL. On multivariate analysis, male sex (OR 1.33; 95% CI 1.03-1.71) and emergency surgery (OR 1.41; 95% CI 1.04-1.92) were associated with AL. Private health insurance status (OR 0.66; 95% CI 0.50-0.88) and minimally-invasive surgery (OR 0.61; 95% CI 0.47-0.79) were protective for AL. Anastomotic technique (handsewn versus stapled) was not associated with AL (P = 0.84). Patients with higher ASA status (OR 0.47; 95% CI 0.39-0.58), advanced tumour stage (OR 0.56; 95% CI 0.50-0.63), and emergency surgery (OR 0.16; 95% CI 0.13-0.20) were less likely to have a primary anastomosis. AL-rate and year of surgery showed no association (P = 0.521). CONCLUSION: The AL rate in Australia and New Zealand following right hemicolectomy is consistent with the published literature and was stable throughout the study period. Sex, emergency surgery, insurance status, and minimally invasive surgery are associated with AL incidence.

Bouveret syndrome-a rare form of gastric outlet obstruction.

Bouveret syndrome is a rare form of gastric outlet obstruction. It is typically diagnosed in frail elderly patients with protracted biliary disease. Thus, it has disproportionally high rates of morbidity and mortality. A 90-year-old man presented to our tertiary hospital with acute abdominal pain and symptoms of bowel obstruction. He was diagnosed with Bouveret syndrome on abdominal computed tomography and required judicious resuscitation and an emergency laparotomy. This article highlights the key features of Bouveret syndrome, and reviews the current diagnostic modalities as well as the contemporary treatment paradigm.

An uncommon presentation of a sinister entity.

A case of a female patient presenting with clinical findings ominous for a neoplastic bowel obstruction is reported. Abdominal computed tomography demonstrated a bowel obstruction with evidence of intussusception. Laparotomy revealed an irreducible ileoileal intussusception and segments of the jejunum infiltrated with pigmented deposits. There was no perforation and no evidence of an ulcerating or fungating mass. Intestinal melanoma is not an uncommon sequela of cutaneous melanoma, yet the disease can occur as a primary intestinal process, albeit this is a rarity. Surgical resection is the primary treatment modality and may offer the hope of increased symptom-free survival and overall survival for those patients suffering from metastatic or primary melanoma of the small intestine.

An unusual urethral foreign body.

INTRODUCTION: Lower urinary tract foreign body insertions have a low incidence. The motives for insertion of a variety of objects are difficult to comprehend. This case warrants discussion given the great management challenge faced by the oddity and infrequency with which a fork is encountered in the penile urethra. PRESENTATION OF CASE: A 70-year-old man presents to the Emergency Department with a bleeding urethral meatus following self-insertion of a fork into the urethra to achieve sexual gratification. Multiple retrieval methods were contemplated with success achieved via forceps traction and copious lubrication. DISCUSSION: The presentation of urethral foreign bodies can vary widely, as can the type of object inserted. The most prevalent motivation for self-insertion of urethral foreign bodies is autoerotism. Motivations ought to be explored in light of possible underlying psychological or psychiatric conditions. The most appropriate surgical extraction technique can be guided by physical examination and imaging. Endoscopic removal is often successful, depending on the object's physical attributes and morphology. It is important to arrange appropriate follow-up, as late complications can occur such as urethral strictures. CONCLUSION: Psychological and surgical arms encompass the management plan. Foreign body retrieval is determined by its physical attributes and morphology with the aim to minimise urothelial trauma and preserve erectile function. Essentially, endourological extraction serves the primary means of retrieval. Cystourethoscopy is important to diagnose urothelial injuries and to ensure complete removal of foreign bodies following extraction.