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Background: Total (procto)colectomy is indicated in 15%-20% of ulcerative colitis(UC) patients during their disease course. Reconstruction options to avoid a permanent ileostomy include an ileoanal pouch anastomosis (IPAA) or ileorectal anastomosis (IRA). This study aimed to investigate reconstruction rates using Australian-based population-level data, and factors influencing reconstruction., Methods: A retrospective data linkage study of the NSW population over a 19-year period was performed. Patients with UC who underwent total (procto)colectomy with a minimum of 1-year follow up were included. The main outcome was reconstruction with either IPAA or IRA. The influence of hospital and patient factors on reconstruction rates was assessed by Cox regression., Results: Overall, 1047 patients underwent a (procto)colectomy for UC (mean age 45.9 years [SD ± 18.3], 640 [61.1%] male). The 5-year reconstruction rate was 55% (IPAA 89%). Advanced age, emergent colectomy, higher comorbidity burden, and geographical remoteness were significantly associated with lower reconstruction rates. A lower reconstruction rate was also observed in the most recent time-period (2014-2019) (aHR 0.68[95% CI 0.54-0.86]), and where index (procto)colectomy was performed in low-volume (<1 pouch/year) pouch hospitals (aHR 0.60 [95% CI 0.43-0.82])., Conclusions: NSW Australia has the highest reported rate of reconstruction following UC (procto)colectomy globally. However, rates reduced in the most recent time-period. There was variation in reconstruction rates across centres, with primary and overall reconstruction rates proportionate to hospital pouch volume. Reconstruction rates were also lower for patients living outside major cities. To ensure equitable opportunities for reconstruction, patients being considered for IBD pouch surgery should be centralized to a limited number of specialist pouch centres., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Aim: Total (procto)colectomy for ulcerative colitis (UC) is associated with significant morbidity, which is increased in the emergency setting. This study aimed to evaluate the outcomes following total (procto)colectomies at a population level within New South Wales (NSW), Australia, and identify case mix and hospital factors associated with these outcomes., Methods: A retrospective data linkage study of patients undergoing total (procto)colectomy for UC in NSW over a 19-year period (2001-2020) was performed. The primary outcome was 90-day mortality. The influence of hospital level factors (including annual volume) and patient demographic variables on outcomes was assessed using logistic regression. Temporal trends in annual volume and evidence for centralization were assessed., Results: In all, 1418 patients (mean 47.0 years [SD 18.7], 58.7% male) underwent total (procto)colectomy during the study period. The overall 90-day mortality rate was 3.2% (emergency 8.6% and elective 0.8%). After adjusting for confounding, increasing age at total (procto)colectomy, higher comorbidity burden, public health insurance (Medicare) status, emergency operation and living outside a major city were significantly associated with increased mortality. Hospital volume was significantly associated with mortality at a univariate level, but this did not persist on multivariate modelling., Conclusions: Outcomes of UC patients undergoing total (procto)colectomy in NSW Australia are comparable to international experience. Whilst higher mortality rates are observed in low volume and public hospitals, this appears attributable to case mix and acuity rather than surgical volume alone. However, as inflammatory bowel disease surgery is not centralized in Australia, only one NSW hospital performed >10 UC total (procto)colectomies annually. Variation in mortality according to insurance status and across regional/remote areas may indicate inequality in the availability of specialist inflammatory bowel disease treatment, which warrants further research., (© 2024 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: This study aims to investigate the trends in UC surgery in New South Wales (NSW) at a population level., Methods: A retrospective data linkage study of the NSW population was performed. Patients of any age with a diagnosis of UC who underwent a total abdominal colectomy (TAC) ± proctectomy between Jul-2001 and Jun-2019 were included. The age adjusted population rate was calculated using Australian Bureau of Statistics data. Multivariable linear regression modelled the trend of TAC rates, and assessed the effect of infliximab (listed on the Pharmaceutical Benefits Scheme for UC in Apr-2014)., Results: A total of 1365 patients underwent a TAC ± proctectomy (mean age 47.0 years (±18.6), 59% Male). Controlling for differences between age groups, the annual rate of UC TACs decreased by 2.4% each year (95% CI 1.4%-3.4%) over the 18-year period from 1.30/100000 (2002) to 0.84/100000 (2019). An additional incremental decrease in the rate of TACs was observed after 2014 (OR 0.83, 95% CI 0.69-1.00). There was no change in the proportion of TACs performed emergently over the study period (OR 1.02, 95% CI 0.998-1.04). The odds of experiencing any perioperative surgical complication (aOR 1.54, 95% CI 1.01-2.33, P = 0.043), and requiring ICU admission (aOR 1.85, 95% CI 1.24-2.76, P = 0.003) significantly increased in 2014-2019 compared to 2002-2007., Conclusions: The rate of TACs for UC has declined over the past two decades. This rate decrease may have been further influenced by the introduction of biologics. Higher rates of complications and ICU admissions in the biologic era may indicate poorer patient physiological status at the time of surgery., (© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Ileal pouch-anal anastomosis (IPAA) is considered the gold standard reconstructive option in ulcerative colitis (UC). Recent efforts to improve pouch outcomes have seen a push towards centralisation of surgery. This study aimed to document outcomes following pouch surgery at a population level within New South Wales (NSW), and identify factors associated with, and temporal trends of these outcomes., Methods: A retrospective data linkage study of the NSW population over a 19-year period was performed. The primary outcome was pouch failure in patients with UC who underwent IPAA. The influence of hospital level factors (including annual volume) and patient demographic variables on this outcome were assessed using Cox proportional hazards modelling. Temporal trends in annual volume and evidence for centralisation over the studied period were assessed using Poisson regression analysis., Results: The annual volume of UC pouches reduced over the study period. The pouch failure rates were 8.6% (95% CI 6.3-10.8%) and 10.6% (95% CI 8.0-13.1%) at 5- and 10-years, respectively. Increasing age and non-elective admission were associated with higher failure rates. One-third of UC pouches (31.6%) were performed in a single institution, which averaged 6.5 pouches/year throughout the study period. Three-quarters (19/25) of NSW public hospitals who performed pouches performed less than one UC pouch annually., Conclusions: The outcomes following UC pouch surgery in NSW are comparable with global standards. Concentrating IBD pouch surgery with the aim of producing specialist surgical teams may be a reasonable way forward in NSW and would ensure equity of access and facilitate research and training collaboration., (© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: There is a need for evidence of the effectiveness of pre-operative exercise for patients undergoing major cancer surgery; however, recruitment to such trials can be challenging. The PrE-operative Physical Activity (PEPA) Trial will establish the feasibility and acceptability of a pre-operative exercise programme aimed to improve patient outcomes after cytoreductive surgery and pelvic exenteration. The secondary aim is to obtain pilot data on the likely difference in key outcomes (post-operative complications, length of hospital stay, post-operative functional capacity and quality of life) to inform the sample size calculation for the substantive randomised clinical trial., Methods/design: Twenty patients undergoing cytoreductive surgery and pelvic exenteration at the Royal Prince Alfred Hospital, Sydney will be recruited and randomly allocated (1:1 ratio) to either 2 to 6 weeks' pre-operative exercise programme (intervention group) or usual care (control group). Those randomised to the intervention group will receive up to six individualised, 1-h physiotherapy sessions (including aerobic and endurance exercises, respiratory muscle exercises, stretching and flexibility exercises), home exercises (instruction and recommendations on how to progress the exercises at home) and encouragement to be more active by using an activity tracker to measure the number of steps walked daily. Patients allocated to the control group will not receive any specific advice about exercise training. Feasibility will be assessed with consent rates to the study, and for the intervention group, retention and adherence rates to the exercise programme. Acceptability of the exercise programme will be assessed with a semi-structured questionnaire. The following measures of the effectiveness of the intervention will be collected at baseline (2 to 6 weeks pre-operative), a week before surgery, during hospital stay and pre hospital discharge: post-operative complication rates (Clavien-Dindo), post-operative functional capacity (Six-minute Walk Test) and quality of life (SF-36v2®) and length of hospital stay. Functional status will be additionally measured using Cardiopulmonary Exercise Testing (CPET), at baseline and within a week before surgery., Discussion: The PEPA Trial will provide important information about the feasibility and acceptability of a pre-operative exercise programme for patients undergoing major cancer surgery. Data from the PEPA Trial will be used to inform the design, methodology and to calculate sample size required for a larger, definitive trial., Trial Registration: Australian New Zealand Clinical Trials Registry, ID: ACTRN12617001129370 . Registered on 1 August 2017.

Objective: To investigate a range of transient risk factors for an episode of sudden-onset, acute low back pain (LBP)., Methods: This case-crossover study recruited 999 subjects with a new episode of acute LBP between October 2011 and November 2012 from 300 primary care clinics in Sydney, Australia. Each participant was asked to report exposure to 12 putative triggers over the 96 hours preceding the onset of back pain. Conditional logistic regression was used to estimate odds ratios (ORs) expressing the magnitude of increased risk with exposure to each trigger., Results: Exposure to a range of physical and psychosocial triggers significantly increased the risk of a new onset of LBP; ORs ranged from 2.7 (moderate or vigorous physical activity) to 25.0 (distracted during an activity or task). Age moderated the effect of exposure to heavy loads and sexual activity. The ORs for heavy loads for people ages 20, 40, or 60 years were 13.6, 6.0, and 2.7, respectively. The risk of developing back pain was greatest between 7:00 AM and noon., Conclusion: Transient exposure to a number of modifiable physical and psychosocial triggers substantially increases risk for a new episode of LBP. Triggers previously evaluated in occupational injury studies, but never in LBP, have been shown to significantly increase risk. These results aid our understanding of the causes of LBP and can inform the development of new prevention approaches., (Copyright © 2015 by the American College of Rheumatology.)