Annals of Coloproctology

Original Articles

Colorectal cancer

Obstructing colorectal cancer: a population-based review of colonic stenting in Queensland, Australia: Cian Keogh, Julie Moore, Danica Cossio, Nick Smith, David A. Clark; Ann Coloproctol. 2024;40(3):268-275. Published online June 25, 2024; DOI: https://doi.org/10.3393/ac.2023.00640.0091

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Abstract PDF: Purpose
Stenting is a useful treatment option for malignant colonic obstruction, but its role remains unclear. This study was designed to establish how stents have been used in Queensland, Australia, and to review outcomes.
Methods
Patients diagnosed with colorectal cancer in Queensland from January 1, 2008, to December 31, 2014, who underwent colonic stent insertion were reviewed. Primary outcomes of 5-year survival, 30-day mortality, and overall length of survival were calculated. The secondary outcomes included patient and tumor factors, and stoma rates.
Results
In total, 319 patients were included, and distant metastases were identified in 183 patients (57.4%). The 30-day mortality rate was 6.6% (n=21), and the 5-year survival was 11.9% (n=38). Median survival was 11 months (interquartile range, 4–27 months). A further operation (hazard ratio [HR], 0.19; P<0.001) and chemotherapy and/or radiotherapy (HR, 0.718; P=0.046) reduced the risk of 5-year mortality. The presence of distant metastases (HR, 2.052; P<0.001) and a comorbidity score of 3 or more (HR, 1.572; P=0.20) increased mortality. Surgery was associated with a reduced risk of mortality even in patients with metastatic disease (HR, 0.14; P<0.001). Twenty-two patients (6.9%) ended the study period with a stoma.
Conclusion
Colorectal stenting was used in Queensland in several diverse scenarios, in both localized and metastatic disease. Surgery had a survival advantage, even in patients with metastatic disease. There was no survival difference according to whether patients were socioeconomically disadvantaged, diagnosed in a major city or not, or treated at private or public hospitals. Stenting proved a valid treatment option with low stoma rates.

Colorectal cancer

Estimation of risk posed by malignant polyps amongst colorectal surgeons in Australia and New Zealand: Andrew P. Zammit, Ian Brown, John D. Hooper, David A. Clark, Andrew D. Riddell; Ann Coloproctol. 2024;40(2):114-120. Published online March 25, 2024; DOI: https://doi.org/10.3393/ac.2023.00178.0025

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105 Download

Abstract PDF Supplementary Material: Purpose
The estimation of the risk posed by malignant polyps for residual or lymphatic disease plays a central role. This study investigated colorectal surgeons’ assessment of these risks associated with malignant polyps.
Methods
A cross-sectional questionnaire was electronically administered to colorectal surgeons in Australia and New Zealand in October 2022. The questionnaire contained 17 questions on demographics, when surgeons consider colorectal resection appropriate, and the risk assessment for 5 hypothetical malignant polyps.
Results
The mean risk of residual or lymphatic disease that would prompt surgeons to recommend colonic resection was 5%. However, this increased to a mean risk of 10% if the malignant polyp was located in the rectum, and the only resection option was abdominoperineal resection with end-colostomy. There was high concordance between the estimated risk of residual or lymphatic disease by colorectal surgeons and the Association of Coloproctology of Great Britain and Ireland (ACPGBI) guidelines for the 5 hypothetical malignant polyps, with the ACPGBI estimated risk lying within the 95% confidence interval for 4 of the 5 malignant polyps. Nonetheless, 96.6% of surgeons felt that an online risk calculator would improve clinical practice.
Conclusion
Colorectal surgeons in Australia and New Zealand accurately estimated the risk posed by malignant polyps. An online risk calculator may assist in better conveying risk to patients.

Benign GI diease,Benign diesease & IBD,Complication,Biomarker & risk factor

A development study of drain fluid gastrografin as a biomarker of anastomotic leak: David A. Clark, Edward Yeoh, Aleksandra Edmundson, Craig Harris, Andrew Stevenson, Daniel Steffens, Michael Solomon; Ann Coloproctol. 2022;38(2):124-132. Published online January 11, 2021; DOI: https://doi.org/10.3393/ac.2020.12.24

3,794 View
175 Download
4 Web of Science
4 Citations

Abstract PDF

Purpose
Anastomotic leakage (AL) is the anathema of colorectal surgery. Its occurrence leads to increased morbidity and mortality and a prolonged hospital stay. Much work has gone into studying various biomarkers in drain fluid to facilitate early detection of AL. This stage 2a development study aims to assess the safety and feasibility of reliably detecting the iodine in Gastrografin (GG; Bayer Australia Ltd.) in drain fluid and stool samples by dual-energy computed tomography (DECT).
Methods
This is a prospective, observational, controlled, consecutive cohort study establishing the safety and feasibility of the detection of GG in surgical drain fluid and stool as a biomarker of AL when patients with a low pelvic colorectal anastomosis undergo luminal flushing of the rectal tube with GG.
Results
Ten consecutive patients were allocated to the saline flush group and the following 10 to the GG flush group. Three patients in the saline flush group developed an AL. One patient in the GG flush group developed an AL. An elevation in the drain fluid GG was detected using DECT on the day of clinical deterioration. None of the patients in the control group were found to have a positive result on DECT.
Conclusion
This study demonstrates the safety of a novel approach to the early detection of AL from extraperitoneal colorectal anastomoses. The technique requires validation in a larger cohort and a multicenter study is planned to investigate the efficacy of GG rectal tube flushes as an early biomarker of AL in low pelvic anastomoses.

Citations

Citations to this article as recorded by

Impact of Postoperative Naples Prognostic Score to Predict Survival in Patients with Stage II–III Colorectal Cancer
Su Hyeong Park, Hye Seung Woo, In Kyung Hong, Eun Jung Park
Cancers.2023; 15(20): 5098. CrossRef
Successful colorectal anastomotic leakage management: a two oncological centres' 12-year experience
Kiril G. KIROV, Tsvetomir M. IVANOV, Nadya S. IVANOVA
Chirurgia.2022;[Epub] CrossRef
Neoadjuvant chemoradiotherapy determines the prognostic impact of anastomotic leakage in advanced rectal cancer
Bo Young Oh, Yoon Ah Park, Jung Wook Huh, Yong Beom Cho, Seong Hyeon Yun, Hee Cheol Kim, Woo Yong Lee
Annals of Surgical Treatment and Research.2022; 103(4): 235. CrossRef
Does an ileostomy cover the surgeon or the anastomosis?
David A. Clark, Andrew Stevenson, John Lumley, Damien Petersen, Craig Harris, Daniel Steffens, Michael Solomon
ANZ Journal of Surgery.2022; 92(1-2): 19. CrossRef

Benign GI diease,Benign diesease & IBD,Rare disease & stoma

Geographical Variation in the Use of Diverting Loop Ileostomy in Australia and New Zealand Colorectal Surgeons: David A. Clark, Bree Stephensen, Aleksandra Edmundson, Daniel Steffens, Michael Solomon; Ann Coloproctol. 2021;37(5):337-345. Published online September 18, 2020; DOI: https://doi.org/10.3393/ac.2020.09.14.1

3,081 View
69 Download
6 Web of Science
7 Citations

Abstract PDF

Purpose
Anastomotic leak (AL) after a low pelvic anastomosis is a devastating complication, with short- and long-term morbidity and increased mortality. Surgeons may employ various adjuncts in an attempt to reduce AL rates or mitigate their impact. These include the use of temporary diverting ileostomy (TDI), transanal or rectal tubes and pelvic drains. This questionnaire evaluates the preferences and routine use of these adjuncts in Australasian colorectal surgeons.
Methods
A cross-sectional survey was administered to Australian and New Zealand colorectal surgeons on September 20, 2018. The study survey consisted of 15 questions exploring basic demographics and the number of rectal resections and ileal pouches performed in 12 months, along with the surgeon’s preference for the use of diverting stomas, rectal tubes, and pelvic drains.
Results
There were 90 respondents to the survey (31.6%). Surgeons in Western Australia (71.4%) were more likely to use a mandatory TDI in colorectal extraperitoneal anastomoses than surgeons in Queensland (14.3%). South Australian surgeons are more likely to employ a mandatory TDI (100%) for ileal pouches than Queensland surgeons (42.9%). Rectal tubes are not commonly utilized (40.0% never use them), and pelvic drains are (45.6% in all cases). Surgeons consider a median AL rate of 15% was felt to justify the use of a TDI in low pelvic anastomoses and a median AL rate of 10% for ileal pouches
Conclusion
There is considerable geographical variation in colorectal surgical practice throughout Australia and New Zealand. While surgeons interrogate the same literature, there are presumably other factors that see translation into variations in clinical practice.

Citations

Citations to this article as recorded by

Feasibility of triple assessment of the anastomosis using an anastomotic checklist
Madeleine Louise Kelly, Amy Cao, Ruben Rajan, David A Clark
ANZ Journal of Surgery.2024; 94(10): 1812. CrossRef
Drain fluid amylase as a biomarker for the detection of anastomotic leakage after rectal resection without a diverting ileostomy
David A. Clark, Aleksandra Edmundson, Daniel Steffens, Craig Harris, Andrew Stevenson, Michael Solomon
ANZ Journal of Surgery.2022; 92(4): 813. CrossRef
Surgical management and long‐term functional outcomes after anastomotic leak in patients undergoing minimally invasive restorative rectal resection and without a diverting ileostomy
Tony McGiffin, David A. Clark, Aleks Edmundson, Daniel Steffens, Andrew Stevenson, Michael Solomon
ANZ Journal of Surgery.2022; 92(4): 806. CrossRef
Does an ileostomy cover the surgeon or the anastomosis?
David A. Clark, Andrew Stevenson, John Lumley, Damien Petersen, Craig Harris, Daniel Steffens, Michael Solomon
ANZ Journal of Surgery.2022; 92(1-2): 19. CrossRef
Risk taking propensity: Nurse, surgeon and patient preferences for diverting ileostomy
Ian Mackay, David A. Clark, James Nicholson, Aleks Edmundson, Daniel Steffens, Michael Solomon
Colorectal Disease.2022; 24(9): 1073. CrossRef
Multicenter Study of Drain Fluid Amylase as a Biomarker for the Detection of Anastomotic Leakage After Ileal Pouch Surgery Without a Diverting Ileostomy
David A. Clark, • Aleksandra Edmundson, Daniel Steffens, Graham Radford-Smith, Michael Solomon
Diseases of the Colon & Rectum.2022; 65(11): 1335. CrossRef
An umbrella systematic review of drain fluid analysis in colorectal surgery for the detection of anastomotic leak: Not yet ready to translate research studies into clinical practice
David A. Clark, Daniel Steffens, Michael Solomon
Colorectal Disease.2021; 23(11): 2795. CrossRef

Benign GI diease, IBD, Inflammatory bowel disease,Benign diesease & IBD

Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: An Australian Institution’s Experience: Ming Han Lim, Anton R. Lord, Lisa A. Simms, Katherine Hanigan, Aleksandra Edmundson, Matthew J.F.X. Rickard, Russell Stitz, David A. Clark, Graham L. Radford-Smith; Ann Coloproctol. 2021;37(5):318-325. Published online September 18, 2020; DOI: https://doi.org/10.3393/ac.2020.08.26

4,473 View
115 Download
12 Web of Science
11 Citations

Abstract PDF

Purpose
We report outcomes and evaluate patient factors and the impact of surgical evolution on outcomes in consecutive ulcerative colitis patients who had restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) at an Australian institution over 26 years.
Methods
Data including clinical characteristics, preoperative medical therapy, and surgical outcomes were collected. We divided eligible patients into 3 period arms (period 1, 1990 to 1999; period 2, 2000 to 2009; period 3, 2010 to 2016). Outcomes of interest were IPAA leak and pouch failure.
Results
A total of 212 patients were included. Median follow-up was 50 (interquartile range, 17 to 120) months. Rates of early and late complications were 34.9% and 52.0%, respectively. Early complications included wound infection (9.4%), pelvic sepsis (8.0%), and small bowel obstruction (6.6%) while late complications included small bowel obstruction (18.9%), anal stenosis (16.8%), and pouch fistula (13.3%). Overall, IPAA leak rate was 6.1% and pouch failure rate was 4.8%. Eighty-three patients (42.3%) experienced pouchitis. Over time, we observed an increase in patient exposure to thiopurine (P=0.0025), cyclosporin (P=0.0002), and anti-tumor necrosis factor (P<0.00001) coupled with a shift to laparoscopic technique (P<0.00001), stapled IPAA (P<0.00001), J pouch configuration (P<0.00001), a modified 2-stage procedure (P=0.00012), and a decline in defunctioning ileostomy rate at time of IPAA (P=0.00002). Apart from pouchitis, there was no significant difference in surgical and chronic inflammatory pouch outcomes with time.
Conclusion
Despite greater patient exposure to immunomodulatory and biologic therapy before surgery coupled with a significant change in surgical techniques, surgical and chronic inflammatory pouch outcome rates have remained stable.

Citations

Citations to this article as recorded by

Patient-reported Outcome Measures in Ileoanal Pouch Surgery: a Systematic Review
Zakary Ismail Warsop, Carlo Alberto Manzo, Natalie Yu, Bilal Yusuf, Christos Kontovounisios, Valerio Celentano
Journal of Crohn's and Colitis.2024; 18(3): 479. CrossRef
Surgical outcomes in ileal Crohn's disease complicated by ileosigmoid fistula
Ashley Jenkin, Aleksandra Edmundson, David Clark
ANZ Journal of Surgery.2024; 94(9): 1563. CrossRef
The Role of Minimally Invasive Surgery in the Management of Inflammatory Bowel Disease: Current Trends and Future Directions
Sanskruti Rathod , Nishant Kumar, German D Matiz, Sheryl Biju, Peter Girgis, Nagma Sabu, Hassan Mumtaz, Ali Haider
Cureus.2024;[Epub] CrossRef
Management and Outcomes of Ileal Pouch-Urethral Fistulas
João Pedro Emrich Accioly, Mariana Maspero, Hanson Zhao, Roger K. Khouri Jr., Olga Lavryk, Kenneth W. Angermeier, Tracy Hull, Hadley M. Wood
Urology.2023; 172: 213. CrossRef
Ileo-Anal Pouch Anastomosis and New Remedial Approaches for Ulcerative Colitis: A Review Article
Abhijeet Jankar, Tripti Shrivastava
Cureus.2023;[Epub] CrossRef
Review of long‐term complications and functional outcomes of ileoanal pouch procedures in patients with inflammatory bowel disease
Yusuf Hassan, William R. Connell, Alisha Rawal, Emily K. Wright
ANZ Journal of Surgery.2023; 93(6): 1503. CrossRef
Population outcomes, trends and the future of pouch surgery for ulcerative colitis: a 19‐year New South Wales data linkage study
Hugh L. Giddings, Kheng‐Seong Ng, Michael J. Solomon, Daniel Steffens, Joe Van Buskirk, Jane Young
ANZ Journal of Surgery.2023; 93(11): 2686. CrossRef
Ileoanal pouch cancers in ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis
Danujan Sriranganathan, Danilo Vinci, Gianluca Pellino, Jonathan P. Segal
Digestive and Liver Disease.2022; 54(10): 1328. CrossRef
Evolving Experimental Platforms to Evaluate Ulcerative Colitis
Tiffany T. Sharma, Rebecca R. Rabizadeh, Vibhav S. Prabhakar, Matthew I. Bury, Arun K. Sharma
Advanced Biology.2022;[Epub] CrossRef
Multicenter Study of Drain Fluid Amylase as a Biomarker for the Detection of Anastomotic Leakage After Ileal Pouch Surgery Without a Diverting Ileostomy
David A. Clark, • Aleksandra Edmundson, Daniel Steffens, Graham Radford-Smith, Michael Solomon
Diseases of the Colon & Rectum.2022; 65(11): 1335. CrossRef
Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: An Australian Institution’s Experience
Ming Han Lim, Anton R. Lord, Lisa A. Simms, Katherine Hanigan, Aleksandra Edmundson, Matthew J.F.X. Rickard, Russell Stitz, David A. Clark, Graham L. Radford-Smith
Annals of Coloproctology.2021; 37(5): 318. CrossRef

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