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.

How to do it: Splenic flexure mobilisation via medial trans-mesocolic approach

Complete splenic flexure mobilization is a critical step in left-sided colorectal resections. Surgeons use three approaches-anterior, medial, and lateral-to divide peritoneal ligaments connecting the left colon. The decision to perform mobilization varies, with minimal impact on post-operative outcomes but longer surgery times and rare complications. Pancreatic injury risk is low, though other structures, like arteries and the duodenum, may be at risk. Our video outlines the medial trans-mesocolic approach, with the patient positioned in lithotomy. We expose the duodenal-jejunal flexure, ligate the inferior mesenteric vein, and perform medial to lateral dissection, completing splenic flexure mobilization. This video vignette outlines how to perform this technique for left sided colorectal resections.

Mechanical bowel preparation with pre-operative oral antibiotics in elective colorectal resections: an Australian single institution experience

BACKGROUND

Anastomotic leaks (AL) and surgical site infections (SSI) are serious complications after colorectal resection. Studies have shown the benefits of pre-operative oral antibiotics (OAB) with mechanical bowel preparation (MBP) in reducing AL and SSI rates. We aim to investigate our experience with the short-term outcomes of AL and SSI following elective colorectal resections in patients receiving OAB with MBP versus MBP only.

METHODS

A retrospective analysis was performed from our database for patients who underwent elective colorectal resection between January 2019 and November 2021. Prior to August 2020, OAB was not used as part of MBP. After 2020, Neomycin and Metronidazole were used in conjunction with MBP. We evaluated differences in AL and SSI between both groups.

RESULTS

Five hundred and seventeen patients were included from our database with 247 having MBP while 270 had OAB and MBP. There was a significantly lower rate of AL in patients receiving MBP and OAB as compared to MBP alone (0.4% versus 3.0%, P-value = 0.03). The SSI rate at our institution was 4.4%. It was lower in patients with MBP and OAB as compared to MBP alone, but this was not clinically significant (3.3% versus 5.7%, P-value = 0.19).

CONCLUSION

The association in the reduction of AL with the addition of OAB to the MBP protocol seen here reinforces the need for future randomized controlled trials in the Australasian context. We recommend colorectal institutions in Australian and New Zealand consider OAB with MBP as part of their elective colorectal resection protocol.

First Reported Case of Lesser Sac Empyema Secondary to Foreign Body Perforation

This is the first reported case of lesser sac empyema secondary to a foreign body perforation in the posterior stomach. Although PubMed and Google Scholar search reports cases of lesser sac empyema alone and foreign body penetrations, there are currently no reported cases of a lesser sac abscess secondary to a foreign body. Patients with a lesser sac empyema present atypically with an insidious onset. The lesser sac should be examined in patients with peritonitis without a clear source. A 48-year-old female presented to the emergency department with acute onset epigastric pain. The patient was tender in the epigastrium and left upper quadrant with associated guarding. The patient had elevated white cell count and C-reactive protein, with a computed tomography scan identifying a foreign body posterior gastric wall perforation. The patient was managed with endoscopic drainage of the lesser sac empyema and surgical washout of the abdomen. Foreign bodies are investigated using different imaging modalities, with computed tomography being able to further evaluate the size, shape, and complications. Intra-abdominal collections can be managed through three different methods: percutaneous drainage, endoscopic drainage, and surgery. Patients with peritonitis would require a laparoscopic or open surgical washout of the abdomen and inspection of the lesser sac would be necessary if no obvious source is identified. Foreign body ingestion requires careful history taking and assessment. Patients with lesser sac empyema present atypically, and this can lead to delayed surgical referral and management. Contained intra-abdominal collections can be drained percutaneously or endoscopically.

A rare presentation of large bowel obstruction post haemorrhoidectomy: a case report

BACKGROUND

Hemorrhoidal disease is a common anorectal pathology. Complications post hemorrhoidectomy are rare. Postoperative complications following hemorrhoidectomy include bleeding (2%), infection (0.4-8%), urinary retention (15%), and constipation (15-30%).

CASE PRESENTATION

A 40-year-old of Asian background female presented to a tertiary colorectal service with large bowel obstruction post hemorrhoidectomy. This is the first case in the surgical literature describing large bowel obstruction secondary to extrinsic compression from urinary retention following hemorrhoidectomy. The patient developed urinary retention and obstructed defecation in setting of inadequate analgesia post hemorrhoidectomy. The patient required indwelling catheter insertion and aggressive constipation management to resolve symptoms. Histopathology from the hemorrhoidectomy did not reveal a malignancy.

CONCLUSION

Anesthetic choice and postoperative analgesia are important factors to avoid the development of complications. A missed malignancy diagnosis must always be excluded with patients presenting post hemorroidectomy with bowel obstruction.

Surgical management of splenic flexure cancer: is there an optimal technique? A bi-national registry analysis

BACKGROUND

Splenic flexure tumours (SFC) are uncommon and present at more advanced disease stages. The optimal surgical technique for SFC remains controversial. We sought to compare the short-term outcomes of a left hemicolectomy (LHC) versus an extended resection (subtotal colectomy, STC) for SFCs.

METHODS

A retrospective analysis using the Binational Colorectal Cancer Audit (BCCA) registry was performed. All patients with SFC who underwent elective or emergency surgery for a SFC between 2010 and 2021 were included. Primary outcomes included short-term inpatient complications. Secondary outcomes included survival outcomes.

RESULTS

Six hundred and ninety-nine patients underwent resections for SFCs. A LHC was more common, performed in 64.1%. Patients having a LHC were significantly older, with proportionally more LHCs done laparoscopically. Overall grade III/IV complications were similar between both operations. Prolonged ileus and return to theatre were significantly higher in patients undergoing a STC. On multivariate analysis, anastomotic leak and overall grade III/IV complications were not independently associated with the type of operation. There was no difference in medial survival based on type of operation. Higher tumour stage (Stage III/IV) were independently associated with worse survival.

CONCLUSION

Segmental and extended resections are both oncologically sound procedures for SFCs. Segmental resections are associated with lower rates of prolonged ileus.

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.

How to do it: perineal hernia repair

Perineal hernias are rare complications of surgeries like abdominoperineal resections. This submission is an educational piece outlining the steps to completing a posterior perineal hernia repair with mesh.

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.

Endoscopic Removal of a Fecalith or Fecomucolith in a Rectal Stump or Pouch

Fecaliths or fecomucoliths can form in rectal stumps after a Hartmann procedure or in a coloneovaginal conduit. They can cause significant distress to the patient by causing symptoms such as discharge and odor. We describe a novel and effective method of endoscopic obliteration and removal where other techniques such as removal during examination under anesthesia or serial enemas have failed. By using a combination of hydrodissection with a saline injector gun and biopsy forceps and a polypectomy snare to break down the fecomucolith or fecalith, this troublesome problem can be resolved endoscopically. Successful removal of the fecalith/fecomucolith and resolution of the symptoms for the patients were achieved. No complications are reported. We describe an effective and novel method for endoscopic removal of fecaliths and fecomucoliths.

Small bowel evisceration from vagina

Vaginal evisceration is a rare condition where abdominal contents herniate through a vaginal wall defect. The estimated incidence is 0.032–1.2% after hysterectomy, trachelectomy or upper vaginectomy. We present a 78-year-old lady who developed vaginal evisceration 2 years after radical cystectomy and hysterectomy for bladder cancer. It is rare surgical emergency that requires prompt recognition and damage control with bowel reduction and packing. We discuss the initial management and surgical options for definitive repair.

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.

A comparison of long-term healthcare utilization and costs in patients with acute severe ulcerative colitis receiving infliximab versus early colectomy

Background

Early intervention for acute severe ulcerative colitis (ASUC) improves outcomes. Outcomes and healthcare costs for an infliximab-first and colectomy-first approach were compared.

Methods

This single-center retrospective cohort study of inpatients with steroid-refractory ASUC who received infliximab 5 mg/kg (1-3 doses without maintenance) or initial colectomy between 2004 and 2014 assessed long-term healthcare utilization and direct costs following infliximab or colectomy, using admission coding data until 31 December 2016.

Results

A total of 118 patients received either infliximab (n = 85, 72%) or colectomy (n = 33, 28%) as initial therapy, with 35(41%) patients eventually requiring colectomy post-infliximab (median 213 days, range [6, 3739]). Median follow up was 7 years [0, 14]. Following infliximab for ASUC, 44% of patients then received antitumor necrosis factor maintenance. After ASUC therapy, length of stay and number of admissions did not significantly differ between groups but higher numbers of complications prompting readmission occurred in the colectomy group (median 4 versus 1, p < 0.001). There were no differences in admissions or total length of stay for patients who had received infliximab first then colectomy versus those treated with colectomy first (median 7.0 versus 4.0, 41.5 days versus 29 days, respectively, each p > 0.05). Total costs were lower at 6 months (mean AUD17,662 versus AUD24,852, p = 0.003), yet were similar at 7 years following an infliximab compared with colectomy approach (AUD72,834 versus AUD59,557, p = 0.23). After infliximab, costs were significantly higher at 7 years with biologic rather than immunomodulator-only maintenance therapy (AUD109,365 versus AUD47,842, p < 0.01).

Conclusions

In support of current practice, infliximab salvage in steroid-refractory ASUC achieved reduced short-term healthcare costs compared with initial colectomy, though long-term costs were not significantly different.

Toothpick impaction in a sigmoid diverticulum

A 70-year-old woman presented to our emergency department with recurrent episodes of left lower quadrant pain. She subsequently underwent high anterior resection with working diagnosis of acute diverticulitis, but intraoperatively was found to have perforated sigmoid diverticulum due to toothpick impaction. A high index of suspicion is required for diagnosis of toothpick ingestion. Appropriate preoperative investigations such as endoscopy and CT, despite their fairly low sensitivity, should be performed to increase the ability to accurately diagnose this condition and therefore optimise subsequent management.

A rare case of concurrent penile and spinal schwannomas

Schwannoma of the penis is extremely rare. This is the case of a young male who presented with pain on sexual intercourse, multiple lumps on the dorsal shaft of his penis, as well as a temporal headache. He was subsequently diagnosed with schwannoma affecting both his penile region and cauda equina. This clinical finding has not been previously described in the literature. Hence, its presentation is unique to our specialty.

Assessing patient satisfaction in inflammatory bowel disease using the QUOTE-IBD survey: a small step for clinicians, a potentially large step for improving quality of care

BACKGROUND

Patient satisfaction is thought integral to high quality of care (QoC) in chronic disease models, including inflammatory bowel disease (IBD). Here we utilized the QUOTE-IBD survey in IBD clinic patients, in order to examine potential deficiencies in QoC from the patients' perspective, thus possibly amenable to change.

METHODS

Consecutive patients attending a single clinic were asked to complete the QUOTE-IBD survey, where 22 items (in seven domains) were rated for importance (I), and actual performance (P), and a quality index (QI) was derived. A QI <9.0 indicated suboptimal satisfaction. Other data were extracted from hospital records and CRP was measured. Factorial ANOVA examined effects of relevant clinical and demographic factors on satisfaction (QI) scores per domain.

RESULTS

Of 367 potential participants, 187 (51%) responded. 86 (46%) had Crohn's disease, 101 (54%) ulcerative colitis; 52% were females, and median age was 45y (range 18,82). The only QI score <9.0 was 'kept in waiting room >15min' (QI 8.73). In bivariate analyses, those with Crohn's, post-resection and longer IBD duration each had lower domain QI's than their respective counterparts, whereas those on concurrent anti-TNF therapy gave higher QI scores (each p<0.05). Factorial ANOVA showed female gender and IBD duration ≥ 5years were each associated with significantly lower mean QI scores in multiple domains.

CONCLUSIONS

Patients with adverse disease characteristics (e.g. longer duration, post-resection) and females reported lower satisfaction. Conversely, those on anti-TNF therapy reported higher satisfaction. Targeting these 'at-risk' groups and assessing satisfaction longitudinally may enhance QoC in IBD.