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Background: Colorectal cancer is the third most common cancer and the second highest cause of cancer mortality in Australia. Despite advances in colorectal surgery, anastomotic leak still occurs in low‐risk patients and is a substantial cause of morbidity and mortality. Many operative strategies are used to assess anastomotic integrity such as an air leak test or intraoperative flexible sigmoidoscopy, however an objective anastomotic checklist is yet to be developed and studied. This study aims to develop a photodocumentary anastomotic specific checklist and determine its feasibility for implementation. Methods: Patients undergoing left sided colorectal resections with primary anastomosis without a de‐functioning ileostomy were prospectively included between May 2021 and December 2022. A photographic checklist assessing anastomotic perfusion, integrity via either air test or endoscopic image, evidence of complete operative doughnut specimens and the assessment of tension was implemented. The feasibility of an anastomotic checklist was externally validated by four independent colorectal surgeons from Australia, New Zealand and United States of America. Results: The anastomotic checklist was completed in 44 patients. Mean age was 62 years, with 43% male and mean BMI 28. Operations included high anterior resection (45%), low anterior resection (18%), ultra‐low anterior resection (20%), reversal of Hartmann's (11%). Median length of stay was 4 days. Complications post operatively were documented in six patients with anastomotic leak in 2% and wound infection in 6.8%. Intraclass correlation coefficients were poor amongst all reviewers with air leak and tension having no inter‐reviewer correlation. Conclusion: The introduction of an anastomotic checklist was a feasible tool to systematically assess and document anastomotic integrity. Unfortunately, with the small sample size there was significant discrepancy in inter‐observer variability, and this led to poor correlation regarding which patients were typically high risk requiring a temporary ileostomy. Larger studies on the implementation of an anastomotic checklist will be needed to evaluate if it is an inherently feasible approach and if there is an effect on anastomotic leak. [ABSTRACT FROM AUTHOR]

Background: Over 42 000 Australians live with a stoma, and this number increases annually. Pregnancy in stoma patients is a rare but complex condition and there is limited published literature regarding surgical and obstetric complications in pregnant stoma patients. The aim of this paper was to review stoma outcomes, perinatal morbidity and mortality, and early postpartum period in pregnant stoma patients. Methods: Data was retrospectively obtained on women of childbearing age, with a stoma, who had been pregnant and birthed in the last nine years at the Royal Brisbane and Women's Hospital between January 2014 to December 2022. Data recorded included patient demographics, type of stoma, indication for stoma, need for additional abdominal surgeries, method of conception, pregnancy complications, length of stay, neonatal outcomes and post pregnancy stomal complications. Results: In total, there were 16 births from 13 mothers with stomas. Of 10 births to IBD patients, 40% experienced a serious stomal complication. Caesarean section (CS) rate was 90% for IBD and 83% for non‐IBD. In‐vitro fertilisation rates were 40% in IBD patients and 0% in non‐IBD patients. The average gestational age at delivery was 36 weeks in IBD and 35 weeks in non‐IBD patients. Neonates delivered to IBD mothers had a birth weight under 2500g in 40% of cases and in non IBD mothers at 33.3% (p = 0.62). Of the sixteen births there was five complications (31.25%) associated with the stoma either during pregnancy or during the sixty‐day postpartum period. Conclusion: Pregnancy in stoma patients is a rare occurrence and appears to be associated with high rates of CS, preterm delivery, low birth weight and stomal complication. [ABSTRACT FROM AUTHOR]

Rectal cancer surgery is complex and more technically challenging than colonic surgery. Over the last 30 years internationally, there has been a growing impetus for centralizing care to improve outcomes for rectal cancer. Centralizing care may potentially reduce variations of care, increase standardization and compliance with clinical practice guidelines. However, there are barriers to implementation at a professional, political, governance and resource allocation level. Centralization may increase inequalities to accessing healthcare, particularly impacting socioeconomically disadvantaged and rural populations with difficulties to commuting longer distances to "centres of excellence". Furthermore, it is unclear if centralization actually improves outcomes. Recent studies demonstrate that individual surgeon volume rather than hospital volume may be more important in achieving optimal outcomes. In this review, we examine the literature to assess the value of centralization for rectal cancer surgery. [ABSTRACT FROM AUTHOR]

The article discusses the unresolved debate on the optimal surgical approach for deep infiltrating endometriosis (DIE) of the rectum, focusing on whether bowel resection or a more conservative approach is preferable. Various surgical techniques, including rectal shaving, disc excision, and segmental resection, are compared in terms of symptom control, fertility outcomes, and complications. Studies highlight the importance of balancing the risks and benefits of each surgical option, with some advocating for less invasive approaches to minimize complications and improve quality of life for patients with rectal DIE. [Extracted from the article]

Background: Traditionally, international guidelines recommend patients with acute diverticulitis should be followed up with a colonoscopy 6–8 weeks after discharge. However, the need for an interval colonoscopy has been increasingly challenged in the setting of computed tomography (CT). Previous meta‐analyses have included studies which combined suspected rather than imaging confirmed diverticulitis and often without correlation with endoscopic findings. This meta‐analysis aims to investigate endoscopic findings of patients with CT confirmed diverticulitis. Methods: An electronic search of Medline, PubMed, Cochrane Library, Embase, CINAHL, Web of Science, Scopus, Clinicaltrials.gov and WHO ICTRP was performed up to October 18, 2021. Studies which reported CT confirmed acute diverticulitis in adults and who underwent endoscopic follow‐up with either a colonoscopy or flexible sigmoidoscopy were included. Studies were excluded if diverticulitis was diagnosed by clinical grounds alone, ultrasound, barium enema, or other non‐CT forms of imaging. Results: A total of 68 studies with 13 905 patients were included. Median age was 58 years and male to female ratio was 0.84. Cancer was detected in 2.0% and advanced adenoma in 3.8%. Complicated diverticulitis had 9.2 higher odds of cancer compared to uncomplicated diverticulitis (95% CI 4.42–19.08, P < 0.001). Adenomas were detected in 17%. Of those diagnosed with colorectal cancer, 85% were concordant with the site of the diverticulitis on CT while 15% were incidental findings. Conclusion: Routine colonoscopic follow up should be recommended in medically fit patients who have CT proven acute diverticulitis due to the higher than population prevalence of colorectal cancer and advanced adenomas. [ABSTRACT FROM AUTHOR]

Background: Traditional siting of stomas, in the lower abdomen, has been guided by surgical dogma lacking evidence. In the lower abdomen, the combination of a thick and pendulous abdominal apron, can create a challenging and suboptimal site for a stoma. The anatomical determinant limiting delivery of a stoma to the abdominal skin is the distance of the SMA from the lower border of the pancreas. The aim of this cross‐sectional study was to compare the distance between the traditional stoma site, and upper abdominal stoma sites, to both the superior mesenteric artery (SMA) origin and SMA at the inferior border of the pancreas on abdominal computed tomography (CT). Methods: A cross‐sectional study at a single academic university hospital of adult patients who underwent abdominal CT in Australia. Results: Two hundred and thirteen patients were included. Stoma sites in the upper abdomen were 57‐76 mm shorter to the origin of the SMA and inferior border of the pancreas than those positioned at the traditional stoma site (P < 0.001). The mean panniculus thickness in the upper abdomen was 10 mm thinner than in the lower abdomen and increased with increasing BMI (P < 0.001). The ratio between the distance from the xiphisternum to umbilicus, and the umbilicus to pubic symphysis, was 1.10; this ratio increased with increasing BMI. Conclusion: The distance of the SMA to the skin is always shorter in the upper abdomen compared to the traditional stoma site. Consideration should be given to placing stomas in the upper abdomen, particularly in overweight or obese patients. [ABSTRACT FROM AUTHOR]

Abstract Background Regardless of the availability of therapeutic options, the overall 5-year survival for patients diagnosed with pancreatic cancer remains less than 5%. Gum resins from Boswellia species, also known as frankincense, have been used as a major ingredient in Ayurvedic and Chinese medicine to treat a variety of health-related conditions. Both frankincense chemical extracts and essential oil prepared from Boswellia species gum resins exhibit anti-neoplastic activity, and have been investigated as potential anti-cancer agents. The goals of this study are to identify optimal condition for preparing frankincense essential oil that possesses potent anti-tumor activity, and to evaluate the activity in both cultured human pancreatic cancer cells and a xenograft mouse cancer model. Methods Boswellia sacra gum resins were hydrodistilled at 78°C; and essential oil distillate fractions were collected at different durations (Fraction I at 0–2 h, Fraction II at 8–10 h, and Fraction III at 11–12 h). Hydrodistillation of the second half of gum resins was performed at 100°C; and distillate was collected at 11–12 h (Fraction IV). Chemical compositions were identified by gas chromatography–mass spectrometry (GC-MS); and total boswellic acids contents were quantified by high-performance liquid chromatography (HPLC). Frankincense essential oil-modulated pancreatic tumor cell viability and cytotoxicity were determined by colorimetric assays. Levels of apoptotic markers, signaling molecules, and cell cycle regulators expression were characterized by Western blot analysis. A heterotopic (subcutaneous) human pancreatic cancer xenograft nude mouse model was used to evaluate anti-tumor capability of Fraction IV frankincense essential oil in vivo. Frankincense essential oil-induced tumor cytostatic and cytotoxic activities in animals were assessed by immunohistochemistry. Results Longer duration and higher temperature hydrodistillation produced more abundant high molecular weight compounds, including boswellic acids, in frankincense essential oil fraactions. Human pancreatic cancer cells were sensitive to Fractions III and IV (containing higher molecular weight compounds) treatment with suppressed cell viability and increased cell death. Essential oil activated the caspase-dependent apoptotic pathway, induced a rapid and transient activation of Akt and Erk1/2, and suppressed levels of cyclin D1 cdk4 expression in cultured pancreatic cancer cells. In addition, Boswellia sacra essential oil Fraction IV exhibited anti-proliferative and pro-apoptotic activities against pancreatic tumors in the heterotopic xenograft mouse model. Conclusion All fractions of frankincense essential oil from Boswellia sacra are capable of suppressing viability and inducing apoptosis of a panel of human pancreatic cancer cell lines. Potency of essential oil-suppressed tumor cell viability may be associated with the greater abundance of high molecular weight compounds in Fractions III and IV. Although chemical component(s) responsible for tumor cell cytotoxicity remains undefined, crude essential oil prepared from hydrodistillation of Boswellia sacra gum resins might be a useful alternative therapeutic agent for treating patients with pancreatic adenocarcinoma, an aggressive cancer with poor prognosis.

Abstract Background Gum resins obtained from trees of the Burseraceae family (Boswellia sp.) are important ingredients in incense and perfumes. Extracts prepared from Boswellia sp. gum resins have been shown to possess anti-inflammatory and anti-neoplastic effects. Essential oil prepared by distillation of the gum resin traditionally used for aromatic therapy has also been shown to have tumor cell-specific anti-proliferative and pro-apoptotic activities. The objective of this study was to optimize conditions for preparing Boswellea sacra essential oil with the highest biological activity in inducing tumor cell-specific cytotoxicity and suppressing aggressive tumor phenotypes in human breast cancer cells. Methods Boswellia sacra essential oil was prepared from Omani Hougari grade resins through hydrodistillation at 78 or 100 oC for 12 hours. Chemical compositions were identified by gas chromatography-mass spectrometry; and total boswellic acids contents were quantified by high-performance liquid chromatography. Boswellia sacra essential oil-mediated cell viability and death were studied in established human breast cancer cell lines (T47D, MCF7, MDA-MB-231) and an immortalized normal human breast cell line (MCF10-2A). Apoptosis was assayed by genomic DNA fragmentation. Anti-invasive and anti-multicellular tumor properties were evaluated by cellular network and spheroid formation models, respectively. Western blot analysis was performed to study Boswellia sacra essential oil-regulated proteins involved in apoptosis, signaling pathways, and cell cycle regulation. Results More abundant high molecular weight compounds, including boswellic acids, were present in Boswellia sacra essential oil prepared at 100 oC hydrodistillation. All three human breast cancer cell lines were sensitive to essential oil treatment with reduced cell viability and elevated cell death, whereas the immortalized normal human breast cell line was more resistant to essential oil treatment. Boswellia sacra essential oil hydrodistilled at 100 oC was more potent than the essential oil prepared at 78 oC in inducing cancer cell death, preventing the cellular network formation (MDA-MB-231) cells on Matrigel, causing the breakdown of multicellular tumor spheroids (T47D cells), and regulating molecules involved in apoptosis, signal transduction, and cell cycle progression. Conclusions Similar to our previous observations in human bladder cancer cells, Boswellia sacra essential oil induces breast cancer cell-specific cytotoxicity. Suppression of cellular network formation and disruption of spheroid development of breast cancer cells by Boswellia sacra essential oil suggest that the essential oil may be effective for advanced breast cancer. Consistently, the essential oil represses signaling pathways and cell cycle regulators that have been proposed as therapeutic targets for breast cancer. Future pre-clinical and clinical studies are urgently needed to evaluate the safety and efficacy of Boswellia sacra essential oil as a therapeutic agent for treating breast cancer.

Case Diagnosis: Rasmussen's encephalitis (RE) is a rare neurological disease characterized by frequent and severe seizures, hemiparesis, inflammation of the brain and mental deterioration. While the etiology of this disease is unclear, it is believed to be immune mediated. Seizures may be difficult to manage with antiepileptic medication alone and treatment may include surgical hemispherectomy. We present a case of RE in a patient with worsening subclinical seizures, spasticity, dystonia and chronic pain syndrome. He had an intrathecal baclofen pump and underwent right-sided frontal, temporal and parietal lobectomy followed by intensive inpatient rehabilitation with decreased need for medication, incidence of seizure, spasticity and resolution of chronic pain. Case Description: A 26 year-old male diagnosed with RE at age 5 presented with worsening seizures affecting the left side of his body. This was accompanied by severe left-sided spasticity, dystonia and left upper extremity (LUE) burning pain. Antiepileptic medications including divalproex, lacosamide, valium, and zonisamide were insufficient. Methadone, codeine and dilaudid provided limited analgesia with impaired arousal and cognition. Neurologic examination revealed attention deficits, slow psychomotor processing speed, poor manual dexterity and left visual neglect. Musculoskeletal examination demonstrated Modified Ashworth Scale (MAS) grade 2 of the left biceps, brachioradialis, brachialis and pronator teres. Hyperactive reflexes were present with decreased range of motion. Additional findings included LUE edema, sudomotor abnormality and allodynia. Video electroencephalogram monitoring demonstrated unihemispheric findings of impaired background activity and sleep spindles, focal slow activity and multifocal ictal discharges affecting right parieto-temoporal areas. Magnetic resonance imaging revealed an atrophic encephalomalacic right frontal lobe. Discussions: The patient underwent right frontotemporoparietal lobectomy. Following surgical recovery, he received intensive comprehensive rehabilitation including speech therapy, physical therapy, occupational therapy, neuropsychological evaluation and aggressive spasticity management. He received a combination of botulinum toxin A injections and intrathecal baclofen therapy. These led to decrease in overall seizure frequency, muscle spasticity and significant pain relief. Subsequently, all pain medications were eventually discontinued. Two months following inpatient rehabilitation he demonstrated enhanced baseline arousal and cognition, increased mental capacity and exhibited more independence with ability to ambulate 150 feet. This case highlights the importance of a multidisciplinary approach to patients with neurologic disease, brain injury, and pain. The combination of surgical intervention and comprehensive rehabilitation allowed this patient to come off multiple sedatives and pain medications. All of these resulted in increased arousal, cognition, function and substantial improvement in quality of life. Conclusions: For patients with RE, comprehensive neurorehabilitation in combination with surgical resection may increase a patient's independence and function while decreasing caregiver burden and decreasing a patient's reliance on medication for treatment of pain and seizures. [ABSTRACT FROM AUTHOR]