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Background: In elective and emergency general surgery, bowel anastomoses are common procedures. Although several stoma-related issues may arise following stoma creation, establishing a stoma is incredibly morbid. Aims and Objectives: The study compares patients with diversion ileostomies (stomas) to those who had to cover ileal loops without ostomies or delayed ostomies for large bowel anastomosis to compare the risks and advantages of each procedure. Materials and Methods: This prospective and comparative study was conducted on 50 patients undergoing large bowel anastomosis. Patients were divided into two groups: Group A: Those with covering ileal loop without or delayed ostomy, and Group B: Those undergoing diversion ileostomy. Results: Demographic data of the study indicated that most of the participants in both groups were male (72% in covering ileal loop and 64% in diversion ostomy). In both groups, most participants belonged to the >45 age group. We have seen a significant difference in the setting of surgery, Vitamin B 12 levels, early complications, late complications, and time of takedown comparing covering ileal loop to the diversion ostomy group. Conclusion: This study showed reduced postoperative morbidity and complications of stomas following covering ileal loop compared to diversion ileostomy. Hence, the technique should be considered.

Background: In elective and emergency general surgery, bowel anastomoses are common procedures. Although several stoma-related issues may arise following stoma creation, establishing a stoma is incredibly morbid. Aims and Objectives: The study compares patients with diversion ileostomies (stomas) to those who had to cover ileal loops without ostomies or delayed ostomies for large bowel anastomosis to compare the risks and advantages of each procedure. Materials and Methods: This prospective and comparative study was conducted on 50 patients undergoing large bowel anastomosis. Patients were divided into two groups: Group A: Those with covering ileal loop without or delayed ostomy, and Group B: Those undergoing diversion ileostomy. Results: Demographic data of the study indicated that most of the participants in both groups were male (72% in covering ileal loop and 64% in diversion ostomy). In both groups, most participants belonged to the >45 age group. We have seen a significant difference in the setting of surgery, Vitamin B 12 levels, early complications, late complications, and time of takedown comparing covering ileal loop to the diversion ostomy group. Conclusion: This study showed reduced postoperative morbidity and complications of stomas following covering ileal loop compared to diversion ileostomy. Hence, the technique should be considered. [ABSTRACT FROM AUTHOR]

Background: Early detection and treatment of a colorectal anastomotic leak reduces leak-associated morbidity. The primary objective of this study was to assess the role of C-reactive protein (CRP) as a tool to facilitate the early diagnosis of large bowel anastomotic leak. Patients and Methods: We conducted a prospective observational study at a specialized colorectal unit of a tertiary referral teaching center where we recorded CRP levels pre-operatively and on day three for 113 patients undergoing a large bowel anastomosis. The primary outcome measure was the occurrence of anastomotic leak and its association with post-operative day three CRP levels (day one considered as 24 hours after surgery). The area under the curve of the receiver operating characteristic (ROC) curve analysis for the day three CRP value with the anastomotic leak was calculated and optimal cutoffs derived. Definitions and diagnostic criteria for a leak were established before commencing the study. Demographic, operative, diagnostic, and interventional procedure data were also recorded. Results: Twenty-two patients had an anastomotic leak (19.4%), and 14 (12.3%) required re-exploration or drain placement. The cutoff value of day three CRP with the greatest area under the ROC curve in the ROC curve analysis was 166 mg/L (area under the curve [AUC], 0.853) for open and laparoscopic procedures (sensitivity and specificity of 81.81% and 82.42%, respectively) with a negative predictive value of 93.8%. There was no difference in mean day three CRP levels between open and laparoscopic surgery (116.57 mg/L vs. 108.94 mg/L) Conclusions: A CRP value of more than 166 mg/L on day three should raise suspicion of an anastomotic leak. [ABSTRACT FROM AUTHOR]

Natural products derived from various sources, including plants, have garnered significant interest as alternative therapeutic options. Among these, Tualang honey, extracted from the nectar of Tualang trees (Koompassia excelsa (Becc.) Taub.), has a long history of traditional use due to its therapeutic properties. This review aims to examine the pharmacological activities of Tualang honey, encompassing both in vitro and in vivo studies. A systematic search was conducted in multiple databases, including PubMed, Springer, Scopus, Wiley, and Science Direct, up until December 2022 to identify relevant studies on the pharmacological activities of Tualang honey. Two independent reviewers were involved in article selection, followed by data extraction and assessment of methodological quality using Syrcle's risk of bias tool. 123 articles were included, collectively describing the pharmacological activities of Tualang honey, including antimicrobial, anticancer, anti-inflammatory, antioxidant, antinociceptive, neuroprotective effects, and others. Tualang honey has significant promise as an alternative treatment option for treating a wide range of pathological diseases due to its wide range of pharmacological properties. Tualang honey's diverse array of pharmacological actions indicates its potential for multiple medicinal uses. [ABSTRACT FROM AUTHOR]

Background: Gastrointestinal anastomosis surgery does not have standardized postoperative feeding practices. The majority of surgeons used to believe that early enteral feeding (EEF) after bowel resection and anastomosis could be harmful and cause stress on the anastomosis site, increasing the risk of leakage. This study compared EEF patients whose nutrition started for the first 24 hours with delayed enteral feedings (DEF) during bowel anastomosis surgery Case: This systematic review and meta-analysis used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. All extracted data was presented in the table, summarized narratively, and analyzed statistically using forest plots through a relative risk (RR) with a fixed effect model test. Results: This research included 444 participants from 6 studies, including 196 in the EEF group and 248 in the DEF group. From the analysis, the incidence of leakage, gastrointestinal symptoms of abdominal distention and vomiting, fever, and surgical site infection (SSI) were lower in the EEF group although not significant, with statistical values in order namely; leakage (RR 0.39, p=0.10); abdominal distention (RR 0.67, p=0.11), vomiting (RR 0.88, p=0.53); fever (RR 0.61, p=0.005) and SSI (RR 0.42; p=0.002). Length of stay (LOS) was found to be statistically significant shortened in the EEF group (Mean Difference 2.23 days; P < 0.00001). Conclusion: The EEF group had a statistically insignificant lower incidence of leakage, gastrointestinal symptoms, fever, and SSI and statistically significant shorter LOS. Twenty-four hours post-operation enteral feeding showed a satisfactory outcome, so we recommend it in either small or large bowel anastomosis surgery.

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Background: Emergency laparotomy is associated with a high morbidity and mortality rate. The decision on whether to perform an anastomosis or an enterostomy in emergency small bowel resection is guided by surgeon preference alone, and not evidence based. We examined the risks involved in small bowel resection and anastomosis in emergency surgery. Methods: A retrospective study from 2016 to 2019 in a university hospital in Denmark, including all emergency laparotomies, where small‐bowel resections, ileocecal resections, right hemicolectomies and extended right hemicolectomies where performed. Demographics, operative data, anastomosis or enterostomy, as well as postoperative complications were recorded. Primary outcome was the rate of bowel anastomosis. Secondary outcomes were the anastomotic leak rate, mortality and complication rates. Results: During the 3.5‐year period, 370 patients underwent emergency bowel resection. Of these 313 (84.6%) received an anastomosis and 57 (15.4%) an enterostomy. The 30‐day mortality rate was 12.7% (10.2% in patients with anastomosis and 26.3% in patients with enterostomy). The overall anastomotic leak rate was 1.6%, for small‐bowel to colon 3.0% and for small‐bowel to small‐bowel 0.6%. Conclusion: A primary anastomosis is performed in more than eight out of 10 patients in emergency small bowel resections and is associated with a very low rate of anastomotic leak. [ABSTRACT FROM AUTHOR]

Perianastomotic ulceration (PAU) is an uncommon but potentially devastating condition, with a wide range of presenting symptoms. However, treatment approaches differ between centres as they are well known to be difficult to treat, and recurrences are common. This is a case series with literature review on PAU. We report 2 cases under the care of a tertiary pediatric surgical centre in Hong Kong with a background of neonatal necrotizing enterocolitis who underwent massive bowel resection, followed by small bowel to large bowel anastomosis. The presentation of PAU was delayed for a median of 38 months, with varying severity of presentation from per rectal bleeding without need for transfusion to massive gastrointestinal bleeding requiring pediatric intensive care unit admission and immediate laparotomy. Recurrent bleeding was still evident in one of the patients after multiple courses of anti-inflammatory agents. PAU is a rare condition as a result of multiple factors and a consensus on management is lacking. Patients with short bowel syndrome with small to large bowel anastomoses appear to be more prone to PAU development. Due to its delayed presentation, long-term follow up and regular surveillance for PAU for patients with short bowel syndrome is recommended. • What is currently known about this topic?Perianastomotic ulceration is increasingly report in patients with small-to-large bowel anastomosis with different disease background, and most of the reports are from the West. • What new information is contained in this article?We report 2 cases of Chinese children with perianastomotic ulceration with a background of short bowel syndrome. We propose that enteral iron supplement may also contribute to the development of such condition.. [ABSTRACT FROM AUTHOR]

Introduction: Multiple factors have been linked with increased risk of anastomotic leak in bowel surgery, including infections, inflammatory bowel disease, patient comorbidities and poor surgical technique. The aim of this study was to investigate the positive effect, if any, of adipose derived mesenchymal stem cells (MSCs) mixed with platelet-rich plasma (PRP) in the healing of bowel anastomoses, in an inflammatory environment after establishment of experimental colitis. Materials and Methods: Thirty-five male Wistar rats were divided into five groups of seven animals: normal controls, colitis controls, PRP, MSCs, and PRP+MSCs. All groups underwent laparotomy, one-cm segmental colectomy and anastomosis in situ. In the colitis group, colectomy was performed at the affected area. Colitis was previously established by transrectal administration of 2,4,6-trinitrobenzene sulfonic acid (TNBS) except for the normal controls. Post-mortem histopathological, tissue hydroxyproline and anastomotic bursting pressure (ABP) assessments were performed. The Mann–Whitney U test was used to assess statistical significance differences between groups. Results: No perioperative mortality was noted. Tissue hydroxyproline and ABP were significantly increased in the group of PRP+MSCs compared to colitis controls (p = 0.0151 and p = 0.0104, respectively). Inflammatory cell infiltration was lower and fibroblast activity higher in PRP+MSCs group, but not statistically significant (p > 0.05). Neoangiogenesis (p = 0.0073) and anastomotic area epithelialization (p = 0.0182) were significantly higher in PRP + MSCs group compared to colitis controls. Discussion: The synergistic effect of the PRP and MSCs is apparently responsible for the improved healing markers in bowel anastomoses even on inflammatory bowel. This gives hope for primary anastomoses and stoma saving in many emergency and/or elective circumstances, especially in immunocompromised or malnourished patients, even in cases with inflammation or peritonitis. Clinical studies should follow in order to support the clinical application of PRP+MSCs in gastrointestinal anastomoses. [ABSTRACT FROM AUTHOR]

Introduction: The restoration of bowel continuity is associated with significant postoperative morbidity. Aim: The aim of the study was to report the outcomes of restoring intestinal continuity in a large patient cohort. Material and methods: A retrospective analysis was conducted on 91 patients with terminal stoma who were qualified for restoration of GI tract continuity between January 2015 and March 2020. The following demographic and clinical characteristics were analyzed: age, gender, BMI, comorbidities, indication for stoma creation, operative time, the need for blood replacement, the site and type of the anastomosis, and complication and mortality rates. Results: The study group was comprised of 40 women (44%) and 51 men (56%). The mean BMI was 26.8 ±4.9 kg/m². Only 29.7% of the patients (n = 27) were at normal weight (BMI: 18.5–24.9) and only 11% (n = 10) did not suffer from any comorbidities. The most common indications for index surgery were complicated diverticulitis (37.4%) and colorectal cancer (21.9%). The stapled technique was used in the majority of patients (n = 79, 87%). The mean operative time was 191.7 ±71.4 min. Nine patients (9.9%) required blood replacement peri- or postoperatively, whereas 3 patients (3.3%) required intensive care unit admission. The overall surgical complication rate was 36.2% (n = 33) and the mortality rate was 1.1% (n = 1). Discussion: Restoration of bowel continuity is quite a demanding and complex procedure and thus should be performed by an experienced surgical team. In the majority of patients, the complication rate represents only minor complications. The morbidity and mortality rates are acceptable and comparable to other publications. [ABSTRACT FROM AUTHOR]

Purpose: Anastomotic leakage after small bowel resection in emergency laparotomy is a severe complication. A consensus on the risk factors for anastomotic leakage has not been established, and it is still unclear if peritonitis is a risk factor. This systematic review aimed to evaluate if an entero-entero/entero-colonic anastomosis is safe in patients with peritonitis undergoing abdominal acute care surgery. Methods: A systematic literature review based on PRISMA guidelines was performed, searching the databases Pubmed/MEDLINE, Cochrane Library, and Science Direct for studies of anastomosis in peritonitis. Patients with an anastomosis after non-planned small bowel resection (ischemia, perforation, or strangulation), including secondary peritonitis, were included. Elective laparotomies and colo-colonic anastomoses were excluded. Due to the etiology, traumatic perforation, in-vitro, and animal studies were excluded. Results: This review identified 26 studies of small-bowel anastomosis in peritonitis with a total of 2807 patients. This population included a total of 889 small-bowel/right colonic resections with anastomoses, and 242 enterostomies. All studies, except two, were retrospective reviews or case series. The overall mortality rates were 0–20% and anastomotic leakage rates 0–36%. After performing a risk of bias evaluation there was no basis for conducting a meta-analysis. The quality of evidence was rated as low. Conclusion: There was no evidence to refute performing a primary small-bowel anastomosis in acute laparotomy with peritonitis. There is currently insufficient evidence to label peritonitis as a risk factor for anastomotic leakage in acute care laparotomy with small-bowel resection. Trial registration: The review was registered with the PROSPERO register of systematic reviews on 14/07/2020 with the ID: CRD42020168670. [ABSTRACT FROM AUTHOR]

Predictive factors for rectal cancer Y. Aliyarov* National Oncology Centre of Azerbaijan Republic, Baku, Azerbaijan B Aim: b To investigate the role of mutation in KRAS and BRAF genes as predictive marker of radioresistanse in patients with local advanced rectal cancer undergoing neoadjuvant radiochemotherapy. Twenty-four patients received optimisation before elective surgery, and thirty patients received emergency surgery, without optimisation. All patients with symptomatic AL and PD underwent surgery as a treatment for leak, whereas patients with symptomatic AL and without PD were treated with surgery (66.7%), endoscopic (19.0%) and percutaneous (14.3%) procedures. 15.9% (30 patients) of the patients had tumour out of rectosigmoid colon (7 patients transverse/6 patients ascending/17 patients descending) and 84.1% (158 patients). Among clinical groups the distribution of patients with KRAS mutation was: 1 group- 6 (37.5%) patients, 2 group- 8 (23.5%) patients, 3 group -3 (20%) patients ( I p i < 0.5). [Extracted from the article]

Introduction: Abdominal surgeries or laparotomies are standard procedures for the treatment of different acute gastrointestinal pathologies and gastric decompression is commonly used before the majority of such surgeries. Nasogastric tubes are commonly used in the normal routine of abdominal surgeries and to achieve normal bowel function it is kept post-operatively as well for at least a couple of days. Several surgeons prefer to employ gastric decompression as they consider that it can decrease the incidence of side effects of surgeries such as post-operative ileus, nausea, aspiration, vomiting, and anastomotic leakage. We recommend no nasogastric intubation after small bowel anastomosis as the mean hospital time and stay for passage of first flatus was less compared to the intubated group and also it does not affect the prevention of intestinal anastomotic leak. Objective: To compare mean hospital stay and mean time for passage of first flatus between post-operative nasogastric intubation with no intubation after small bowel anastomosis. Material and Methods: This Randomized controlled trial was conducted at departments of surgery in Lady Reading Hospital and Mercy Teaching Hospital Peshawar from 1st July 2020 to 30th June 2021 as part of an endeavor to do an RCT and included cases operated both in the government and private sector i.e., Lady Reading Hospital Peshawar and Mercy Teaching Hospital Peshawar. In this study, a total of 60 patients in each group were observed. All patients were randomly allocated into two groups by the Lottery method. Patients in group A were not subjected to post-operative nasogastric intubation while patients in group-B were subjected to post-operative nasogastric intubation for 24 hours. Results: Our study shows that in group-A (Non-nasogastric intubation) mean age was 42 years with SD±0.76, whereas in group-B (nasogastric intubation) mean age was 44 years with SD±9.11. In group-A (Non-nasogastric intubation) 55% of patients were male and 45% of patients were female. Whereas in group-B (Non-nasogastric intubation) 52% of patients were male and 48% of patients were female. Group-A (Non-nasogastric intubation), mean hospital stay was 4 days±3.12 and the meantime to pass first flatus was 38 hours±7.42. Where as group-B (nasogastric intubation), mean hospital stay was 7 days±2.91 and the meantime to pass first flatus was 42 hours±8.57. Conclusion: We concludes that mean hospital stay and mean time to pass flatus is less with no nasogastric intubation compared to nasogastric intubation after small bowel anastomosis. [ABSTRACT FROM AUTHOR]

Background: Interventional inflammatory bowel disease (IIBD) therapies can play a key role in inflammatory bowel disease (IBD) related stricture/fistula/abscess deferring or avoiding invasive surgery. Methods: A total of 112 studies pertaining to IIBD therapy for strictures/fistula/abscess between 2002 and December 2022 were included by searching Pubmed, Medline and Embase with a focus on technical/clinical success, recurrence, re-intervention and complications. Results: IIBD therapy for strictures include endoscopic balloon dilation (EBD), endoscopic stricturotomy (ES) and self-expanding metal stent (SEMS) placement. EBD is the primary therapy for short strictures while ES and SEMS can be used for refractory strictures. ES has higher long-term efficacy than EBD. SEMS is inferior to EBD although it can be useful in long, refractory strictures. Fistula therapy includes endoscopic incision and drainage (perianal fistula)/endoscopic seton (simple, low fistula) and endoscopic ultrasound-guided drainage (pelvic abscess). Fistulotomy can be done for short, superficial, single tract, bowel-bowel fistula. Endoscopic injection of filling agents (fistula plug/glue/stem cell) is feasible although durability is unknown. Endoscopic closure therapies like over-the-scope clips (OTSC), suturing and SEMS should be avoided for de-novo/bowel to hollow organ fistulas. Conclusion: IIBD therapies have the potential to act as a bridge between medical and surgical therapy for properly selected IBD-related stricture/fistula/abscess although future controlled studies are warranted. [ABSTRACT FROM AUTHOR]

Purpose: Anastomotic leakage after esophagectomy is associated with increased mortality; therefore, early diagnosis is highly important. This study aimed to identify the characteristic computed tomography (CT) findings of cervical anastomotic leakage after esophagectomy for esophageal cancer and evaluate the effectiveness of CT scoring in screening the anastomotic leakage. Methods: Overall, 91 patients who underwent thoracoscopic esophagectomy with cervical esophago-gastric anastomosis were included. We investigated the correlation between anastomotic leakage and the presence of the microbubble sign, evident air retention, and fluid collection in the cervical and mediastinal regions. CT findings were scored, and the cutoff value was set to 2 points on the receiver operating characteristic curve. The patients were divided into two groups based on the CT score (≥ 2 points and ≤ 1 point). Results: CT findings of the microbubble sign (p = 0.01; odds ratio [OR], 8.545; 95% confidence interval [CI], 1.596–45.73), cervical air retention (p < 0.01; OR, 12.43; 95% CI, 2.084–74.17), and cervical fluid collection (p < 0.01; OR, 9.359; 95% CI, 1.753–49.96) significantly correlated with anastomotic leakage. The ≥ 2-point CT score group showed a significantly higher incidence of anastomotic leakage than the ≤ 1-point group (p < 0.01; OR, 16.28; 95% CI [4.704–56.38]). A ≥ 2-point CT score had higher sensitivity (84.2%) than upper gastrointestinal series (36.8%). Conclusion: The presence of microbubble sign, air retention, and fluid collection in the cervical area correlated with anastomotic leakage after cervical anastomosis in thoracoscopic esophagectomy. CT scores are useful early anastomotic leakage detectors. [ABSTRACT FROM AUTHOR]

Honey is considered to be a functional food with health-promoting properties. However, its potential health benefits can be affected by individual composition that varies between honey types. Although studies describing the health benefits of Tualang honey (TH), Kelulut honey (KH), and Sidr honey (SH) are scarce, these honey types showed a comparable therapeutic efficacy to Manuka honey (MH). The purpose of this review is to characterise the physicochemical, biological, and therapeutic properties of TH, KH, and SH. Findings showed that these honeys have antibacterial, antifungal, antiviral, antioxidant, antidiabetic, antiobesity, anticancer, anti-inflammatory and wound-healing properties and effects on the cardiovascular system, nervous system, and respiratory system. The physicochemical characteristics of TH, KH, and SH were compared with MH and discussed, and results showed that they have high-quality contents and excellent biological activity sources. Flavonoids and polyphenols, which act as antioxidants, are two main bioactive molecules present in honey. The activity of honey depends on the type of bee, sources of nectar, and the geographic region where the bees are established. In conclusion, TH, KH, and SH could be considered as natural therapeutic agents for various medicinal purposes compared with MH. Therefore, TH, KH, and SH have a great potential to be developed for modern medicinal use. [ABSTRACT FROM AUTHOR]

Hand-sewn anastomosis is an essential and fundamental skill for surgeons dealing with any gastrointestinal anastomosis. Despite the advances in minimally invasive surgery and stapling devices, there are still complex surgical circumstances when the surgeon’s surgical know-how are necessary. Therefore, a safe hand-sewn technique for bowel anastomosis is required to establish a tension-free, well-perfused, and sealed anastomosis that allows gastrointestinal continuity with no unexpected complications. We describe a step-by-step procedure for hand-sewn double-layered anastomosis that reflects these principles and is practical for small and large bowel anastomosis.

Introduction: Abdominal surgeries or laparotomies are standard procedures for the treatment of different acute gastrointestinal pathologies and gastric decompression is commonly used before the majority of such surgeries. Nasogastric tubes are commonly used in the normal routine of abdominal surgeries and to achieve normal bowel function it is kept post-operatively as well for at least a couple of days. Several surgeons prefer to employ gastric decompression as they consider that it can decrease the incidence of side effects of surgeries such as post-operative ileus, nausea, aspiration, vomiting, and anastomotic leakage. We recommend no nasogastric intubation after small bowel anastomosis as the mean hospital time and stay for passage of first flatus was less compared to the intubated group and also it does not affect the prevention of intestinal anastomotic leak. Objective: To compare mean hospital stay and mean time for passage of first flatus between post-operative nasogastric intubation with no intubation after small bowel anastomosis. Material and Methods: This Randomized controlled trial was conducted at departments of surgery in Lady Reading Hospital and Mercy Teaching Hospital Peshawar from 1st July 2020 to 30th June 2021 as part of an endeavor to do an RCT and included cases operated both in the government and private sector i.e., Lady Reading Hospital Peshawar and Mercy Teaching Hospital Peshawar. In this study, a total of 60 patients in each group were observed. All patients were randomly allocated into two groups by the Lottery method. Patients in group A were not subjected to post-operative nasogastric intubation while patients in group-B were subjected to post-operative nasogastric intubation for 24 hours. Results: Our study shows that in group-A (Non-nasogastric intubation) mean age was 42 years with SD±0.76, whereas in group-B (nasogastric intubation) mean age was 44 years with SD±9.11. In group-A (Non-nasogastric intubation) 55% of patients were male and 45% of patients were female. Whereas in group-B (Non-nasogastric intubation) 52% of patients were male and 48% of patients were female. Group-A (Non-nasogastric intubation), mean hospital stay was 4 days±3.12 and the meantime to pass first flatus was 38 hours±7.42. Where as group-B (nasogastric intubation), mean hospital stay was 7 days±2.91 and the meantime to pass first flatus was 42 hours±8.57. Conclusion:We concludes that mean hospital stay and mean time to pass flatus is less with no nasogastric intubation compared to nasogastric intubation after small bowel anastomosis. [ABSTRACT FROM AUTHOR]

Background: Emergency general surgery (EGS) patients account for more than one-third of admissions to hospitals in the National Health Service (NHS) in England. The associated mortality of these patients has been quoted as approximately eight times higher than that of elective surgical admissions. This study used a modified Delphi approach to identify research priorities in EGS. The aim was to establish a research agenda using a formal consensus-based approach in an effort to identify questions relevant to EGS that could ultimately guide research to improve outcomes for this cohort. Methods: Three rounds were conducted using an electronic questionnaire and involved health care professionals, research personnel, patients and their relatives. In the first round, stakeholders were invited to submit clinical research questions that they felt were priorities for future research. In rounds two and three, participants were asked to score individual questions in order of priority using a 5-point Likert scale. Between rounds, an expert panel analysed results before forwarding questions to subsequent rounds. Results: Ninety-two EGS research questions were proposed in Phase 1. Following the first round of prioritisation, forty-seven questions progressed to the final phase. A final list of seventeen research questions were identified from the final round of prioritisation, categorised as condition-specific questions of high interest within general EGS, emergency colorectal surgery, non-technical and health services research. A broad range of research questions were identified including questions on peri-operative strategies, EGS outcomes in older patients, as well as non-technical and technical influences on EGS outcomes. Conclusions: Our study provides a consensus delivered framework that should determine the research agenda for future EGS projects. It may also assist setting priorities for research funding and multi-centre collaborative strategies within the academic clinical interest of EGS. [ABSTRACT FROM AUTHOR]

Purpose: Anastomosis creation after resective gastrointestinal surgery is a crucial task. The present review examines the techniques and implants currently available for anastomosis creation and analyses to which extent they already address our clinical needs, with a special focus on their potential to enable further trauma minimization in visceral surgery.Methods: A multi-database research was conducted in MEDLINE, Scopus, and Cochrane Library. Comparative controlled and uncontrolled clinical trials dealing with anastomosis creation techniques in the intestinal tract in both German and English were included and statistically significant differences in postoperative complication incidences were assessed using the RevMan5.4 Review Manager (Cochrane Collaboration, Oxford, UK).Results: All methods and implant types were analyzed and compared with respect to four dimensions, assessing the techniques' current performances and further potentials for surgical trauma reduction. Postoperative outcome measures, such as leakage, stenosis, reoperation and mortality rates, as well as the tendency to cause bleeding, wound infections, abscesses, anastomotic hemorrhages, pulmonary embolisms, and fistulas were assessed, revealing the only statistically significant superiority of hand-suture over stapling anastomoses with respect to the occurrence of obstructions.Conclusion: Based on the overall complication rates, it is concluded that none of the anastomosis systems addresses the demands of operative trauma minimization sufficiently yet. Major problems are furthermore either low standardization potentials due to dependence on the surgeons' levels of experience, high force application requirements for the actual anastomosis creation, or large and rigid device designs interfering with flexibility demands and size restrictions of the body's natural access routes. There is still a need for innovative technologies, especially with regard to enabling incisionless interventions. [ABSTRACT FROM AUTHOR]

Objectives: Perianastomotic ulceration (PAU) is an uncommon but potentially devastating condition, with a wide range of presenting symptoms. However, treatment approaches differ between centres as they are well known to be difficult to treat, and recurrences are common. Methods: This is a case series with literature review on PAU. We report 2 cases under the care of a tertiary pediatric surgical centre in Hong Kong with a background of neonatal necrotizing enterocolitis who underwent massive bowel resection, followed by small bowel to large bowel anastomosis. Results: The presentation of PAU was delayed for a median of 38 months, with varying severity of presentation from per rectal bleeding without need for transfusion to massive gastrointestinal bleeding requiring pediatric intensive care unit admission and immediate laparotomy. Recurrent bleeding was still evident in one of the patients after multiple courses of anti-inflammatory agents. Conclusions: PAU is a rare condition as a result of multiple factors and a consensus on management is lacking. Patients with short bowel syndrome with small to large bowel anastomoses appear to be more prone to PAU development. Due to its delayed presentation, long-term follow up and regular surveillance for PAU for patients with short bowel syndrome is recommended.

Background: Anastomotic leak after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a dreaded complication. There is no consensus statement regarding the optimal timing for bowel anastomoses to perform after or before HIPEC. Methods: Patients who underwent CRS+HIPEC and had at least one bowel anastomosis were retrospectively analyzed to evaluate if timing of anastomosis done after or before HIPEC had an impact on bowel complication rates (anastomotic leak and perforation). Results: From 2013 to 2019, 214 of 370 patients underwent CRS+HIPEC and had at least one bowel anastomosis. Of these 214 patients, 104 and 110 patients had anastomosis after and before HIPEC, respectively. A total of 324 anastomoses were performed, with a mean of 0.87 anastomoses per patient (range 1–4). The incidence of anastomotic leaks was comparable between the pre- and post-HIPEC groups (3.6% vs. 4.8%; p > 0.05), as was the bowel complication rate (7.6% vs. 7.2%). After multivariate analysis, prior surgical score >1 (odds ratio [OR] 4.3), recurrent cancers (OR 7.4), and more than two anastomosis (OR 3.8) were considered independent risk factors for bowel complications. Conclusion: Anastomosis of the bowel performed after or before HIPEC does not affect bowel complication rates (leak/perforation). Higher prior surgical score, surgery for recurrent cancers, and more than two bowel anastomosis are independent risk factors for predicting bowel complications. Prehabilitation, standardization of steps, immediate attention and repair of serosal tears, and thorough inspection of the bowel before closure helps to decrease bowel complications. The timing of anastomosis can be at the discretion of the surgeon. [ABSTRACT FROM AUTHOR]

Background: In colorectal cancer, C-reactive protein (CRP) levels on postoperative days 3–4 have a strong negative predictive value for an anastomotic leak, with threshold values of ~15 on post-operative day (POD) 3 and ~13 on POD 4. In Crohn's disease, CRP levels are perceived as unreliable in the postoperative period because of the underlying inflammatory process. The aim of this study was to determine whether postoperative CRP levels can be used to rule out anastomotic leaks in patients with Crohn's disease and to set CRP threshold values for this population. Methods: This was a retrospective study of a population of Crohn's disease patients who underwent surgery with bowel anastomoses at a single high-volume center between 1/2012 and 12/2017. The operations were performed by a single colorectal consultant who is an inflammatory bowel disease specialist. Results: Ninety-two operations were performed. A CRP level of 19.56 mg/dL on postoperative day 3 had an area under the curve of 0.865 (sensitivity 88%, specificity 73%) and a negative predictive value (NPV) of 98% for an anastomotic leak. Patients with an anastomotic leak showed a trend towards decreased postoperative albumin levels (p = 0.06). Conclusions: Mean CRP levels and CRP threshold values were indeed higher in the study population compared with those in colorectal cancer patients. Threshold values were set at 20.3 mg/dL on POD 3, 19.5 mg/dL on POD 4 and 16.7 mg/dL on POD 5. These values had high NPVs and can be used to rule out anastomotic leaks in patients with Crohn's disease after surgery with bowel anastomosis. [ABSTRACT FROM AUTHOR]