Outcomes following anastomotic leak from rectal resections, including bowel function and quality of life.

PURPOSE: Anastomotic leak (AL) is an uncommon but potentially devastating complication after rectal resection. We aim to provide an updated assessment of bowel function and quality of life after AL, as well as associated short- and long-term outcomes. METHODS: A retrospective audit of all rectal resections performed at a colorectal unit and associated private hospitals over the past 10 years was performed. Relevant demographic, operative, and histopathological data were collected. A prospective survey was performed regarding patients' quality of life and fecal continence. These patients were matched with nonAL patients who completed the same survey. RESULTS: One hundred patients (out of 1,394 resections) were included. AL was contained in 66.0%, not contained in 10.0%, and only anastomotic stricture in 24.0%. Management was antibiotics only in 39.0%, percutaneous drainage in 9.0%, operative abdominal drainage in 19.0%, transrectal drainage in 6.0%, combination of percutaneous drainage and transrectal drainage in 2.0%, and combination abdominal/transrectal drainage in 1.0%. The 1-year stoma rate was 15.0%. Overall, mean Fecal Incontinence Severity Instrument scores were higher for AL patients than their matched counterparts (8.06±10.5 vs. 2.92±4.92, P=0.002). Patients with an AL had a mean EuroQol visual analogue scale (EQ-VAS) of 76.23±19.85; this was lower than the matched mean EQ-VAS for non-AL patients of 81.64±18.07, although not statistically significant (P=0.180). CONCLUSION: The majority of AL patients in this study were managed with antibiotics only. AL was associated with higher fecal incontinence scores in the long-term; however, this did not equate to lower quality of life scores.

Reviewing perianal abscess management and recurrence: lessons from a trainee perspective.

BACKGROUND: Perianal abscesses are a common surgical emergency. Due to their perceived ease, drainage is often delegated to junior trainees with varying levels of experience. The purpose of this study is to evaluate the current trend in perianal abscesses management at our institution, and identify factors that predict subsequent fistula formation or abscess recurrence. METHODS: All acute patients admitted to a major teaching hospital who required surgical drainage of a perianal abscess were analysed over a two-year period from January 2019 to December 2020. Patient demographics, clinical and laboratory findings were retrospectively reviewed. Proceduralist experience, operative management strategy and recurrence rates (fistula or abscess) were analysed. RESULTS: The mean age of patients was 43 years old, and 73% were male. Trainees performed 96% of the procedures. Re-presentation with a fistula or abscess recurrence requiring further surgery was 31%. Comorbidities of IBD, diabetes, or malignancy were present in one-third of patients and significantly increased the risk of recurrence (P = 0.01). Searching for a fistula tract was performed in 41% of cases but did not reduce recurrence (P = 0.9). Seton insertion occurred in 10%, and fistulotomy in 2%. CONCLUSION: Perianal abscess drainage at our institution is almost exclusively performed by trainees, the majority of which occurs after-hours. Patients who present with a fever, inflammatory bowel disease, diabetes mellitus or malignancy are at an increased risk of recurrent abscess or a subsequent fistula after drainage, and input from an experienced surgeon may be of value when considering seton insertion or fistulotomy.

Super-Selective Mesenteric Embolization Provides Effective Control of Lower GI Bleeding.

Introduction. We aimed to assess the efficacy and safety of digital subtraction angiography (DSA) and super-selective mesenteric artery embolization (SMAE) in managing lower GI bleeding (LGIB). Method. A retrospective case series of patients with LGIB treated with SMAE in our health service. Patients with confirmed active LGIB, on either radionuclide scintigraphy (RS) or contrast-enhanced multidetector CT angiography (CE-MDCT), were referred for DSA +/- SMAE. Data collected included patient characteristics, screening modality, bleeding territory, embolization technique, technical and clinical success, short-term to medium-term complications, 30-day mortality, and progression to surgery related to procedural failure or complications. Results. There were fifty-five hospital admissions with acute unstable lower gastrointestinal bleeding which were demonstrable on CE-MDCT or RS over a 31-month period. Eighteen patients proceed to embolization, with immediate success in all. Eight patients (44%) had clinical rebleeding after intervention, warranting repeated imaging. Only one case (5.6%) demonstrated radiological rebleeding and was reembolized. Complication rate was excellent: no bowel ischaemia, ischaemic stricture, progression to surgery, or 30-day mortality. Conclusion. SMAE is a viable, safe, and effective first-line management for localised LGIB. Our results overall compare favourably with the published experiences of other institutions. It is now accepted practice at our institution to manage localised LGIB with embolization.

Surgical oncology issues in locally advanced rectal cancer.

The management of locally advanced (T3/4) rectal cancer is evolving. Randomized trials have shaped the current adjuvant treatment options, but yet there remain many unanswered questions. These include how best to define which patients to treat and choosing between short-course radiotherapy and long-course chemoradiotherapy. With respect to surgery, the optimal timing, the surgical approach in abdominoperineal resections and the role of laparoscopic surgery remain active areas of research. The possibility of avoiding surgery in selected patients is also a topic of great interest. A multidisciplinary team approach in managing rectal cancer patients is popular where possible and recommended in some guidelines.

Management of symptomatic colonic diverticular disease.

There are controversies surrounding the indications, time and place for elective surgery, and role of multistage operations in the treatment of complicated diverticular disease. Most patients with uncomplicated diverticulitis can be managed non-operatively. Previous indications for elective surgery after two attacks of diverticulitis have been questioned. Evidence that patients are less likely to respond to medical therapy in subsequent attacks of diverticulitis is lacking. Decisions should be based on individual circumstances. The Hartmann procedure remains a safe option for patients with free perforation and generalised peritonitis. In experienced hands, a one-stage procedure can be as successful as a two-stage procedure in an emergency setting in selected patients. When possible, an operation should be converted from an emergency to a semi-elective one using techniques such as radiologically or laparoscopically guided drainage of collections.

Cure, continence and quality of life after treatment for fistula-in-ano.

BACKGROUND: The best operation for high anal fistulas is difficult to nominate because they have varying cure and incontinence rates. The objective of this study was to quantify the relative importance of the outcomes of cure, continence and other quality-of-life (QOL) factors. METHODS: A questionnaire was sent in October 2006 to patients with anal fistulas and to colorectal surgeons. Participants were asked to nominate up to five QOL domains. They were also asked to choose between two treatment options (with different cure and continence rates). RESULTS: Seventy-five of 134 (56%) surgeons and 28 of 199 (14%) patients replied. Comparing draining and cutting setons, surgeons (57 of 71, six neutral) favoured the former and patients (15 of 27, four neutral) preferred the latter. Comparing mucosal advancement flap with cutting seton, both surgeons (71 of 75, four neutral) and patients (13 of 26, two neutral) preferred the former. There was greater uncertainty among surgeons when comparing draining seton (23) and mucosal advancement flap (33), with 18 neutral. Patients preferred the mucosal advancement flap (19) to draining seton (three) and four were neutral. In direct questioning of objectives, surgeons nominated continence, leakage, pain, cure and sepsis as the five most important QOL factors. Patients nominated independent activity, pain, continence, psychological health and leakage as their five factors. CONCLUSION: Functional impairment and QOL do not necessarily correlate. The development of a validated specific QOL scale for patients with anal fistulas would be important to compare the results of different treatment options. This scale should include social and psychological factors in addition to the physical outcomes.

Discrepancies in Gleason scoring of prostate biopsies and radical prostatectomy specimens and the effects of multiple needle biopsies on scoring accuracy. A regional experience in Tamworth, Australia.

BACKGROUND: The aim of this study was to review the discrepancies in Gleason scores (GS) of prostate biopsies and radical prostatectomy specimens and the effects of multiple-needle biopsies on scoring accuracy. METHODS: One hundred patients who had undergone consecutive radical prostatectomies (RP) between January 2004 and May 2006 were reviewed retrospectively. Patient information including age, prebiopsy prostate-specific antigen levels, biopsy GS, RP GS and pathology details were recorded and compared. RESULTS: The concordance rate of biopsy GS and RP GS was found to be at 43%, with 46% of biopsy specimens being undergraded. Eleven per cent of the specimens were overgraded. The accuracy was fairly similar when specimens were reported by the same or different pathologists, at 42 and 44%, respectively. The accuracy of biopsy GS improved with increasing number of biopsies taken. CONCLUSION: There are significant discrepancies in Gleason scoring of biopsy and RP specimens, with a concordance rate of 43% and undergrading rate of 46%. Increasing the number of biopsies helps improve scoring accuracy. Clinicians and patients need to be mindful when deciding cancer treatment options, in view of these discrepancies.

Autoimmune pancreatitis in a patient presenting with obstructive jaundice and pancreatic mass.

BACKGROUND: Autoimmune pancreatitis (AIP) is a rare cause of chronic pancreatitis. CASE OUTLINE: A case of obstructive jaundice with pancreatic mass mimicking malignancy is described. DISCUSSION: Recognition of the disease by its typical radiological and serological findings permits trial of steroid therapy and may avoid resection.