Ian S. Reynolds

Background: Bowel obstruction in the setting of peritoneal metastases is a complex clinical situation. Evidence for operative intervention in this setting remains unclear. This study aimed to compare outcomes between patients with bowel obstruction and peritoneal metastases who underwent operative intervention vs those who underwent conservative management. Methods: This was a retrospective single center study of all patients that were consulted on by the Division of Colon and Rectal Surgery in the 6-year period between January 1st 2019 and December 31st 2024 for the management of bowel obstruction in the setting of peritoneal metastases. The study compared patients who underwent operative intervention vs those who underwent conservative management. The primary outcome measures were ability to tolerate solid food at discharge, median obstruction free survival, and median overall survival. Results: A total of 100 patients were diagnosed with bowel obstruction in the setting of peritoneal carcinomatosis. 47 patients underwent operative intervention and 53 underwent non-operative management. Those who underwent operative intervention were more likely to tolerate solid food at discharge (78.72% vs 47.17%, P < 0.01) and had a longer median obstruction free survival (593 days vs 147 days, P = 0.01). No difference was identified in overall survival (133 days vs 99 days, P = 0.49). Conclusions: Bowel obstruction in the setting of peritoneal metastases is a complex situation that requires a personalized and pragmatic approach for each patient. Selecting those who may benefit from operative intervention can be challenging, however, there are subsets of patients for whom surgical management may be offered with acceptable outcomes.

Background: The use of pressurized intraperitoneal aerosol chemotherapy (PIPAC) is becoming more frequent for patients with unresectable peritoneal metastases. This systematic review explores the indications, protocols, feasibility, safety, oncological outcomes, patient reported outcomes and quality of life outcomes for patients being treated with PIPAC.Methods: A review of PubMed, Embase and the Cochrane Library was undertaken to identify studies pertaining to patients undergoing treatment with PIPAC. Clinicopathological characteristics, treatment protocols, safety data, treatment response data and outcome data were extracted from relevant studies and included in the analysis.Results: Data from 1980 patients undergoing 4454 PIPAC procedures for peritoneal metastases from a range of primary cancers was extracted. The treatment protocols identified were relatively homogenous across all studies. Grade 3/4 complications, grade 3/4 toxicity and procedure related mortality occurred infrequently. At least partial histological response was seen in 61.8% of patients. Overall survival for studies presenting data for mixed primary tumors ranged from 8 to 25 months. Quality of life and function were relatively stable throughout treatment.Conclusions: PIPAC is a safe and feasible treatment option for patients with peritoneal metastases. Ongoing studies are required to evaluate how it compares to best option standard of care chemotherapy.

Background: Crohn’s disease (CD) is an inflammatory bowel disease (IBD) that is prevalent worldwide. It can affect any segment of the gastrointestinal tract, from the mouth to the anus. When CD affects the anus, perianal fistulizing disease develops. The management of perianal CD is challenging and may require morbid surgery when there is no response to medical therapy. The emergence of novel biologic therapies, namely tumor necrosis alpha (TNF-α) inhibitors, has proven to provide long-term relief and prevent disease-related complications. Perianal CD is, however, refractory or recurrent in up to 80% of patients. One of the reported options to manage perianal CD is hyperbaric oxygen therapy (HBOT), which aims at increasing tissue oxygen saturation in an attempt to promote repair and reverse local inflammation. Data on this approach is scant. Methods: A retrospective review was performed to identify patients with CD at the Mayo Clinic in Rochester who underwent HBOT for perianal disease between 2014 and 2023. Demographic and clinical data were reviewed, including the history of the disease, concomitant medical and surgical therapy and the need for fecal diversion. The HBOT regimen, including the number of sessions and clinical response, were reviewed. Results: Six patients aged from 19 to 60 years underwent HBOT for perianal CD. Two patients had a history of total proctocolectomy with ileal-anal pouch anastomosis (IPAA). All patients except one were on immunosuppressive medication including biologic agents. Four patients had fecal diversion with an ileostomy or colostomy. Patients received between 10 and 40 sessions of HBOT. Four patients reported symptomatic improvement. On physical examination and/or imaging assessment, improvement was noted in one patient. Progression of the perianal disease was noted in all other patients, with all except one requiring an operation in the following year. Conclusions: HBOT may provide symptomatic relief in some patients with refractory perianal CD, but data on its long-term efficacy remains limited.

Background and Objectives: Perineal wound complications and pelvic fluid collections or abscesses following proctectomy for Crohn’s disease are a common cause of morbidity and might be mitigated by filling the pelvis and occluding the pelvic inlet with a flap. Alternative flap options can be considered when inadequate omentum is available and when avoiding myofasciocutaneous flaps. Materials and Methods: A retrospective review of our Crohn’s proctectomy database was conducted to identify patients who underwent a non-omental or non-myofasciocutaneous local pedicle flap to their pelvis or pelvic exclusion using biological material during surgery. The techniques and outcomes of these alternative techniques are described in detail. Results: 228 patients underwent proctectomy for Crohn’s disease during the 10-year study period. However, only six patients had their pelvis filled or pelvic inlet occluded using a non-omental, non-myofasciocutaneous local pedicled flap or biological material. The techniques identified included two sigmoid mesocolic flaps, one peritoneal, preperitoneal fat and falciform ligament flap, one perivesical fat flap, one Gerota’s fat pad flap, and one bovine pericardial patch assisted pelvic exclusion. These flaps’ clinicopathological and operative characteristics, surgical outcomes, and technical aspects are described. Conclusions: When greater omentum is unavailable or inadequate and myofasciocutaneous flaps need to be avoided, local pedicled flaps using a range of intra-abdominal tissues or biological material can be used to fill the pelvis or occlude the pelvic inlet after proctectomy for Crohn’s disease. These techniques may help to prevent short and long-term complications associated with having a pelvic dead space.

International surgical fellowships offer senior trainees the opportunity to experience alternative health systems and learn novel cutting-edge techniques. They might also offer trainees exposure to a job market that they had not considered before. Obtaining a surgical fellowship in a reputable North American institution has been the chosen pathway for generations of Irish surgical trainees, yet it is not always a straightforward pathway. The following manuscript highlights the necessary preparation and key steps required to be a successful candidate in the search for a fellowship. It details some key pieces of advice surrounding the application and interview process and provides some guidance on how to choose a programme that will best suit your needs and meet your expectations.

Background There has been a noticeable change in Irish hospitals in the demographics of patients sustaining head injuries that now includes many older patients suffering head injuries from low impact trauma. Aims This study sought to define the demographic nature of patients admitted with head injuries over a 3-month period to Beaumont Hospital and to determine the mechanisms of head injuries sustained, resource utilisation during the inpatient admission and the outcomes for these patients. Methods All head injuries admitted between December 1, 2023, and February 29, 2024, were captured and data pertaining to patient demographics, mechanism of injury, resource utilisation and outcomes were assessed. A comparison between patients under the age of 70 and over the age of 70 was also undertaken. Results Thirty six patients were admitted in the 3-month period. 52.8% (n = 19) were over the age of 70. The mechanism of injury in the older cohort had a tendency to be low impact trauma, often with mechanical falls from standing height The median length of stay was 4.5 days. The older cohort was more likely to have a history of previous falls, to require input from allied health and social care professionals and were less likely to be discharged directly home. Conclusions Older patients requiring hospital admission for head injuries have significantly different care needs to younger patients admitted with head injuries. A national pathway for older patients who sustain head injuries needs to be implemented to ensure they get timely access to the investigations and specialists required.

Introduction Total mesorectal excision (TME) is the standard-of-care in early, clinical stage (cT2-3 N0 M0) rectal cancer. Local excision (LE) may be an alternative after adequate response to neoadjuvant therapy (NAT), with either long-course chemoradiotherapy (nCRT) or short-course radiotherapy (SCRT), as a means of preserving the rectum and potentially obviating the morbidity of TME. Methods A systematic review was performed according to PRISMA guidelines for studies that randomly assigned patients with cT2-3 N0 M0 rectal cancer to either NAT + LE or TME that reported radiologic, oncologic, surgical, and morbidity outcomes. Results A total of 4 RCTs comprise 462 patients (232 patients receiving NAT + LE; nCRT n = 205; SCRT n = 27) and 230 undergoing TME, respectively. NAT compliance was 98.86%. The rate of early completion TME in the NAT + LE group was 22.3%, while the proportion of patients achieving durable organ preservation was 75.4% at mean follow-up of 5.6 years. There was no difference in disease-free survival (DFS) (HR [hazard ratio] 1.19; 95% CI 0.95, 1.49; p = 0.13) or overall survival (OS) (HR 0.94; 95% CI 0.72, 1.23; p = 0.63]) according to the assigned treatment arm. The local recurrence rate (LRR) (HR 1.22; 95% CI 0.5–3.02; p = 0.66) and distant metastases (HR 0.92; 95% CI 0.45, 1.90; p = 0.82) were also comparable between the groups. There was a significant reduction in major (OR 0.45; 95% CI 0.21, 0.95; p = 0.04) and minor morbidity (OR 0.45; 95% CI 0.24, 0.85; p = 0.01) for patients undergoing NAT + LE. Overall stoma formation was decreased in the NAT + LE group (OR 0.03; 95% CI 0.0, 0.23; p ≤ 0.00001). Conclusion NAT + LE reduces adverse effects of TME, without any compromise in oncological outcomes, and the potential for an organ preserving strategy should be discussed with patients with T2-3N0 rectal cancers prior to treatment.