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Crohn's disease is a chronic inflammatory bowel disease that most commonly affects the ileum. As a result, it is associated with a high lifetime risk of one or more surgical resections. The surgical paradigm is to preserve intestinal length. This study aims to assess the length of ileum resected at the index operation and at subsequent ileocolic resections for Crohn's disease.This is a retrospective study assessing the clinical and pathological data of patients undergoing ileocolic resection for the management of Crohn's disease over the period 01/01/2002 to 31/07/2020 in two metropolitan Australian hospitals.One hundred and seventy-six patients were analysed: 130 underwent a single resection; 31 underwent two resections; and 15 underwent three resections. The median age at the first operation was 37.2 years (range 18-69) with 60% of patients female. The median length resected at the first surgery was 17.8 cm (IQR 12.0) for small bowel, and 5.0 cm (IQR 1.0) for large bowel. The length of ileum resected at the first surgery was significantly greater than that of the second (P = 0.0001), without significant differences between the second and third resections (P = 0.49). The time interval from diagnosis to the first surgery had no significant impact on the length of intestine resected at the index ileocolic resection.In Crohn's disease, the length of ileum removed at first resection is the greatest, with subsequent resection lengths less than the first.

Anastomotic leak (AL) is the anathema of colorectal surgery. Early diagnosis is an essential segue to early intervention. A temporary diverting ileostomy (TDI) does not prevent an AL and presents inherent complications of its own. Numerous drain fluid biomarkers (BM) have been studied in colorectal surgery and extravasated intraluminal substances (EILS) such as amylase have shown promise. The aim of this study was to assess drain fluid amylase (DFA) as a BM of AL after minimally invasive rectal resection without a TDI.A single centre prospective cohort study performed from 2018 to 2021. The primary outcome was DFA measured daily whilst the drain was in situ. Rectal tube amylase was also measured for the first two post-operative days to quantitate the intra-luminal levels of the enzyme. DFA was compared between patients who experienced AL and those who did not.Of the 62 patients studied, six (9.7%) experienced AL. There was a statistically significant difference in DFA between patients who experienced AL (Median:1373.5 U/L; IQR: 306-7953) and patients who did not experience an AL (Median: 27.0 U/L; IQR: 16-38); p 0.0001.The measurement of drain fluid amylase is a highly sensitive BM of early clinical anastomotic leak in patients undergoing a rectal resection with an extraperitoneal anastomosis and when a TDI is not incorporated. This simple, inexpensive and non-invasive test should be considered in all patients as an adjunct to the clinical diagnosis and differentiation of AL from other postoperative complications.

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

Anastomotic leak is the anathema of colorectal surgery. Early diagnosis is an essential segue to early intervention. A temporary defunctioning ileostomy does not prevent an anastomotic leak and presents inherent complications of its own. Drain fluid biomarkers have been studied in colorectal surgery but not in ileal pouch surgery.This study aimed to assess drain fluid amylase as a biomarker of anastomotic leak after ileal pouch surgery and without a diverting ileostomy.This was a multicenter prospective observational cohort study.The study was conducted at 4 tertiary hospitals in Queensland, Australia.This study included elective patients undergoing restorative proctectomy and ileal pouch surgery.Measurement of rectal tube amylase and drain fluid amylase.The primary measure was observation of increased drain fluid amylase on the day of anastomotic leak.Fifty-three patients were studied. On the day of anastomotic leak, 4 patients in the anastomotic leak group who experienced an early anastomotic leak recorded a median drain fluid amylase of 21,897 U/L compared with a median drain fluid amylase of 25 U/L for those in the no anastomotic leak group ( p0.0001).This study relies on the anastomotic leak occurring while the pelvic drain is in situ.The measurement of drain fluid amylase is a sensitive biomarker of early clinical anastomotic leak in patients undergoing restorative proctectomy with an ileal pouch and when a diverting ileostomy is not incorporated. This simple, inexpensive, and noninvasive test should be considered in all patients with ileal pouches as an adjunct to the clinical diagnosis and differentiation of anastomotic leak from other postoperative complications. See Video Abstract at http://links.lww.com/DCR/B958 .Estudio multicéntrico de la amilasa del líquido de drenaje como biomarcador para la detección de fugas anastomóticas después de una cirugía de reservorio ileal sin ileostomía de derivación.La fuga anastomótica es el anatema de la cirugía colorrectal. El diagnóstico precoz es una transición esencial a la intervención temprana. Una ileostomía desfuncionalizante temporal no evita una fuga anastomótica y presenta sus propias complicaciones inherentes. Los biomarcadores del líquido de drenaje se han estudiado en la cirugía colorrectal, pero no en la cirugía del reservorio ileal.El objetivo fue evaluar la amilasa del líquido de drenaje como biomarcador de fuga anastomótica después de cirugía de reservorio ileal y sin ileostomía de derivación.Este fue un estudio de cohorte observacional prospectivo multicéntrico.El estudio se realizó en 4 hospitales terciarios en Queensland, Australia.Se incluyeron pacientes electivos sometidos a proctectomía restauradora y cirugía de reservorio ileal.Medición de la amilasa del tubo rectal y amilasa del líquido de drenaje.La medida principal fue la observación del aumento de la amilasa en el líquido de drenaje el día de la fuga anastomótica.Cincuenta y tres pacientes fueron estudiados. Los 4 pacientes que experimentaron una fuga anastomótica temprana registraron una mediana de amilasa en el líquido de drenaje de 21 897 U/L el día de la fuga anastomótica en comparación con una mediana de amilasa en el líquido de drenaje de 25 U/L para aquellos en el grupo sin fuga anastomótica (p0,0001).Este estudio se basa en que la anastomosis ocurre mientras el drenaje pélvico está in situ.La medición de amilasa en el líquido de drenaje es un biomarcador sensible de fuga anastomótica clínica temprana en pacientes sometidos a proctectomía restauradora con reservorio ileal y cuando no se incorpora ileostomía derivativa. Esta prueba simple, económica y no invasiva se debe considerar en todos los pacientes con reservorio ileal como complemento del diagnóstico clínico y la diferenciación de la fuga anastomótica de otras complicaciones posoperatorias. Consulte Video Resumen en http://links.lww.com/DCR/B958 . (Traducción-Dr Yolanda Colorado ).

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 pouchesConclusion: 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.

Importance: The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer.Observations: Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts.Conclusions and Relevance: The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.

Amylase is elevated in the foregut and has been used to confirm anastomotic integrity after pancreatic surgery. The physiological activity of pancreatic enzymes in the ileum has been studied in healthy volunteers but not quantitated with the simple and readily available amylase measurements employed with serum tests. We aim to quantitate the levels of amylase in the terminal ileum. This was a prospective, non-randomised, non-blinded, consecutive cohort study conducted at the Royal Brisbane and Women’s Hospital. Consecutive patients undergoing routine surgery with an ileostomy were invited to participate in the study. Ileostomy effluent was collected and analysed daily for the first 5 post-operative days. This validation cohort included 8 males and 3 females, with a mean age of 49 years. Median daily amylase levels ranged from 4470 U/L to 23,000 U/L, with no specimens falling within the laboratory serum reference range of 40 to 130 U/L. Two specimens were not available on day one post-operative due to complete ileus. The sample size of 11 patients is small but was considered sufficient given that 55 effluent specimens were anticipated for analysis. Amylase levels remain highly elevated as the enzyme transits through the length of the small intestine and measured in the terminal ileum, and can be readily quantitated by the existing testing methodology routinely available.

Purpose Anastomotic leakage 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 anastomotic leak (AL). This 2a development study aims to assess the safety and feasibility of reliably detecting the iodine in Gastrografin (GG) 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 anastomotic leak 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 ten 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. Conclusions This observational 2a development 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 multicentre study is planned to investigate the efficacy of GG rectal tube flushes as an early biomarker of AL in low pelvic anastomoses.

Ileal pouch-anal anastomosis (IPAA) is an effective surgical alternative to a permanent ileostomy following proctocolectomy in patients with ulcerative colitis (UC). Anastomotic leakage (AL) is a serious postoperative complication of an intestinal anastomosis that is associated with increased morbidity and mortality. The aim of this study was to evaluate the longitudinal long-term functional outcomes of patients who had IPAA that was complicated by AL. A retrospective longitudinal cohort study was performed of patients who had an IPAA procedure at a tertiary referral centre and a metropolitan private centre in Australia, over a 14-year period (October 2003–October 2017). The long-term functional outcome was assessed using objective clinical measures such as the number of bowel motions during the day and overnight, ability to defer defaecation and the presence of faecal incontinence, and repeated at annual intervals. A total of 138 patients [mean age 38.5 (± 16.9) years, 72 males] satisfied the inclusion criteria. AL was diagnosed in 14 (10%) patients [mean age 38.8 (± 17) years, 10 males], 11 (79%) of which were managed with surgery. The median bowel motion frequency during the day and overnight remained stable over a median of 62 (28–91) months follow-up, with no significant difference between those who had AL or not (p = 0.6, p = 0.1 respectively). The incidence of faecal incontinence remained low, and the majority of patients in both groups were able to defer defaecation for more than 60 min. Six patients (4.3%) had their pouch excised. There is no statistical difference in longitudinal function between patients who experienced AL after IPAA surgery for UC compared with those who did not. Therefore, an acute AL does not negatively impact long-term functional outcomes in IPAA patients.

Background: Dual‐energy CT is able to distinguish between materials based on differences in X‐ray absorption at different X‐ray beam energies. The strong k‐edge photoelectric effect of materials with a high atomic number makes this modality ideal for identifying iodine‐containing compounds. We aim to evaluate dual‐energy CT for the detection of Gastrografin (GG) (diatrizoate, Bayer PLC, Reading, UK) enteric contrast medium and validate the conditions for the measurement in ex vivo samples. Methods: Dual‐energy CT acquisitions were performed to detect Gastrografin in serial dilutions of water, saline and body fluids. We also evaluated the stability of Gastrografin solutions over time at room temperature. Stool specimens were examined to validate the proposed study protocol for clinical applications. Results: Concentrations as low as 0.2% of Gastrografin were reproducibly detected in vitro and ex vivo samples by DECT, with linear readings ranging from 0.2% to 25% Gastrografin. Gastrografin was shown to be stable in ex vivo biological samples, and there was no difference in detection over time. Gastrografin was detected in stool specimens when administered orally. The detection curves followed the expected saturation effect at high concentrations of iodine. Conclusions: Dual‐energy CT offers a convenient, quick, reliable and reproducible method for detecting and quantifying the presence of Gastrografin in ex vivo clinical specimens. Biological solutions containing Gastrografin are stable over time. A minimum dilution level of 25% is suggested to avoid beam saturation and inaccurate results.

Objective Crohn's disease (CD) is characterised by inflammation, predominantly associated with ilea. To investigate the basis for this inflammation in patients with CD, we examined dendritic cells (DC) which are pivotal for maintenance of immunological tolerance in the gut. Methods Ileal biopsies and blood DCs from CD patients and controls were examined by microscopy and flow cytometry for PD‐L1 and PD‐L2 expression, as PD‐L1 has been implicated in colitis but the contribution of PD‐L2 is less clear. In vitro studies, of blood samples from CD patients, were used to demonstrate a functional role for PD‐L2 in disease pathogenesis. Results Quantitative microscopy of CD11c+ DCs in inflamed and noninflamed ilea from CD patient showed > 75% loss of these cells from the villi, lamina propria and Peyer's patches compared with non‐CD controls. Given this loss of DCs from ilia of CD patients, we hypothesised DCs may have migrated to the blood as these patients can have extra‐intestinal symptoms. We thus examined blood DCs from CD patients by flow cytometry and found significant increases in PD‐L1 and PD‐L2 expression compared with control samples. Microscopy revealed an aggregated form of PD‐L2 expression, known to drive Th1 immunity, in CD patients but not in controls. In vitro functional studies with PD‐L2 blockade confirmed PD‐L2 contributes significantly to the secretion of pro‐inflammatory cytokines known to cause disease pathogenesis. Conclusion Taken together, this study shows that PD‐L2 can influence the progression of CD and blockade of PD‐L2 may have therapeutic potential.