Post-operative recurrence (POR) of colonic Crohn's Disease (CD) after segmental (SC) or subtotal colectomy (STC) is scarcely described. Therefore, we aimed to report the rates and predictors of POR in this setting. Multicentre, nationwide, retrospective study including colonic CD patients undergoing SC or STC. Clinical, endoscopic, radiologic and surgical POR were assessed and POR-free survival was compared between procedures. Cox regression determined predictors of post-colectomy POR. Inverse probability of treatment weighting (IPTW) was carried out for sensitivity analyses. A total of 224 patients were included (157 SC, 67 STC). Clinical POR occurred less frequently after SC than after STC (38% vs 63%, p = 0.001), as did endoscopic POR (50% vs 71%, p = 0.012); whereas radiologic and surgical POR rates were similar (p = 0.1 and p = 0.992, respectively). Clinical POR-free survival at 1 and 5 years was higher after SC than after STC (82% and 64.8% vs 67.6% and 39%, log-rank p = 0.001). Endoscopic POR-free survival followed a similar pattern (log-rank p < 0.001). In multivariable Cox regression, SC remained protective against clinical (HR 0.54 [0.36-0.81]) and early endoscopic POR (HR 0.54 [0.35-0.82]). After IPTW, SC was still associated with a significantly lower risk of clinical and endoscopic POR. Clinical and endoscopic POR rates are significantly lower following SC compared with STC in colonic CD, while radiologic and surgical recurrence rates were similar. SC shows a protective effect regarding clinical and early endoscopic POR. These data support segmental resection of colonic CD when feasible.

Single-port (SP) robotic platforms represent an evolution of minimally invasive colorectal surgery, enabling complex multi-quadrant procedures through a single incision. Evidence on SP robotic total colectomy (TC) remains limited, and technical standardisation is lacking. We describe a standardised SP robotic TC technique and report the technical/ergonomic considerations for two access configurations: suprapubic and periumbilical. Three consecutive patients with Familial Adenomatous Polyposis underwent SP robotic TC with ileorectal anastomosis at a high-volume colorectal centre. Suprapubic access was used in one case, and periumbilical access in two. Operative steps, quadrant sequence, vascular approach, ergonomics and anastomotic strategy were systematically documented. Operative and short-term postoperative outcomes were analysed. A detailed surgical video accompanies the manuscript. All procedures were completed robotically without conversion. Median operative time was 240min, and median estimated blood loss was 50ml. No intraoperative or 30-day postoperative complications occurred. The suprapubic access facilitated a bottom-up right colectomy but limited direct visualisation of left-sided central vessels, requiring a lateral-to-medial approach. Conversely, the periumbilical access provided a more central operative view, facilitating medial-to-lateral dissection of the left mesocolon and enabling a fully intracorporeal anastomosis. SP robotic TC is feasible and safe in selected patients when performed by experienced colorectal robotic surgeons. Access configuration may influence exposure and dissection strategy, particularly for central vascular control and anastomotic planning. Standardised operative steps and awareness of platform-specific technical considerations may enhance reproducibility and support broader adoption of SP robotic TC.

Minimally invasive techniques are the standard of care in colorectal surgery. However, high body mass index (BMI) presents technical and anaesthetic challenges. Robotic-assisted surgery offers potential advantages in this population; however, given its relatively recent adoption, outcome data remain limited. This article presents a single-centre case series evaluating the short-term surgical and anaesthetic outcomes of obese patients undergoing robotic colorectal resections. A retrospective review was performed of patients with BMI > 30kg/m2 who underwent robotic colorectal cancer resection at Liverpool University Hospital NHS Trust between July 2019 and April 2024. Demographic, surgical, anaesthetic, and clinical outcome data were collected from a prospectively maintained database. Key measures included operative time, Trendelenburg positioning, critical care admissions, complications, and mortality. Seventy-five patients [mean BMI 35.8 (range 30.0-66.1)kg/m2] underwent robotic resection. Conversion to open surgery occurred in one case (1.3%). Mean operative time was 380min for rectal and 289min for colonic resections. The average Trendelenburg tilt was 20o (range 15-22), with an average lateral tilt of 15o (range 10-20), and mean head down duration was 225 (range 120-320)min. Fifty-six (74.7%) patients had primary anastomosis; the anastomotic leak rate was 9.3%. Thirty-two per cent of patients were electively admitted to the critical care as part of our institutional pathway for high BMI-cases. Of these, three patients (4.0%) required overnight mechanical ventilation and were both extubated the following morning without further organ support. One case of postoperative visual disturbance, attributed to positioning, resolved fully. The 30- and 90-day mortality rate was 1.3%. Robotic colorectal surgery is a feasible and safe option in elevated BMI patients, with low conversion rates and acceptable morbidity. Importantly, prolonged Trendelenburg position did not appear to increase anaesthetic risk, with only one reversible positioning-related complication observed.

The gut-liver axis is believed to be crucial in the pathogenesis of primary sclerosing cholangitis (PSC). However, the impact of colectomy on liver disease progression is unclear. Our study estimated the effect of colectomy on PSC progression with correction for time dependency and established risk factors by pooling data from several cohorts across different countries. We analysed data from the International PSC Registry (IPSCR), comprising patients from Finland, The Netherlands, Norway, and Sweden. Primary endpoint was defined as liver transplantation (LT) or PSC-related death. Cox proportional hazards regression onto time-dependent colectomy status, with specification for extent, was performed with adjustment for sex, age at diagnosis, large or small duct PSC, features of autoimmune hepatitis, time-dependent inflammatory bowel disease (IBD) status, centre of inclusion, and country of residence. A total of 3,110 participants were included, of whom 470 (15%) had undergone colectomy. During a total follow-up of 32,236 patient-years, 395 deaths and 653 LTs were observed. Compared with patients with PSC with intact colon, the hazard ratio (HR) of reaching LT or PSC-related death was significantly decreased in patients with proctocolectomy with permanent ileostomy (HR 0.41; 95% CI 0.24-0.71). This effect was less pronounced in case of hemi- or subtotal colectomy (HR 0.81; 95% CI: 0.58-1.12) and not observed for proctocolectomy with pouch (HR 1.00; 95% CI: 0.73-1.38). The reduced risk was mainly associated with a lower rate of LT or death resulting from liver failure (HR 0.24; 0.10-0.53). Proctocolectomy with permanent ileostomy was associated with decreased risk for LT and PSC-related death. These findings support the role of the gut-liver axis in the pathophysiology of PSC and call for consideration in counselling patients who face impending colorectal surgery. The impact of the gut-liver axis in the pathophysiology of primary sclerosing cholangitis (PSC) has remained uncertain. In this study, proctocolectomy with ileostomy was associated with improved transplant-free survival, defined as a reduced risk of liver transplantation or PSC-related death, indicating that intestinal factors may influence disease progression. These findings are important for clinicians, researchers, and patients as they suggest that surgical management of colonic disease may have prognostic implications in PSC, and for further studies to clarify mechanisms and guide clinical decision-making.

Clostridioides difficile infection (CDI) is recognized as the leading cause of antibiotic-associated diarrhea. There are several case reports of C. difficile enteritis in patients who have undergone colectomy and end ileostomy or ileal pouch-anal anastomosis. This case report describes a unique case of recurrent C. difficile enteritis following proctocolectomy and ileoanal pouch, treated successfully with faecal microbiota transplantation (FMT) via anterograde and retrograde delivery into the small bowel.

Two-step treatment with laparoscopic fistula closure for colocutaneous fistula secondary to sigmoid colon diverticulitis without colonic resection: A case report

Filiform Polyposis (FP) is a rare form of pseudopolyps, occurring most commonly in the large intestine. It usually occurs as a rare complication of inflammatory bowel disease (Crohn’s disease or, more commonly, ulcerative colitis). But it can also occur in other chronic inflammatory or infectious diseases affecting the large bowel. Most common locations are the rectum and sigmoid colon for FP, but they can involve any length of the large intestine. They can occur as finger-like projections, sometimes with interconnections and can affect the entire colonic mucosa in a diffuse manner. Colonoscopy is the usual and most common modality for diagnosis. They are known to occur as a reparative process to chronic inflammatory conditions affecting the bowel. Inflammatory Bowel Disease (IBD) patients harbouring Cytomegalovirus (CMV) infection can also predispose the colonic mucosa to develop FP. Management usually depends on the symptoms. Surgical management is restricted in cases of complications like intestinal obstruction or bleeding and pain. Here, we report a case of a 55-year-old male with pre-existing ulcerative colitis with co-existing CMV infection, now presenting with severe intestinal obstruction. Colonoscopy revealed many polypoidal projections involving the rectum and sigmoid colon, following which he underwent subtotal colectomy. The colon specimen histopathologically revealed to have multiple interconnecting polypoidal projections lined by normal colonic mucosa with areas of chronic inflammatory changes, which was confirmed to be FP in a known case of ulcerative colitis. Though FP has no malignant potential, it can lead to intestinal obstruction and other complications, making routine follow-up necessary for patients with IBD.

To explore the prognostic value of body compositions and radiomics in patients withresectable colon cancer, and to develop and validate a clinical-radiomics model for predicting the postoperative overall survival of patients with resectable colon cancer. This study included 296 patients (43months of median follow-up) with resectable colon cancer. Non-contrast CT images were used to quantify the body composition at the level of the third lumbar vertebra. Radiomics features were extracted from portal venous-phase CT scans. The recursive feature elimination and the least absolute shrinkage and selection operator regression were used for feature selection and construction of radiomic signatures. Univariate and multivariate Cox regression analysis were used to identify body composition. Combined with radiomics features, clinical-radiomics prediction model was constructed and plotted by nomogram, with performance metrics including the area under the receiver operating characteristic curve, calibration curves, decision curve analysis, and integrated discrimination improvement index. Low skeletal muscle density (HR = 0.398, 95%CI = 0.168-0.939, P = 0.035) and low visceral fat area (HR = 0.238, 95%CI = 0.108-0.524, P < 0.001) were significantly associated with poor OS. The integrated clinical-radiomics model achieved C-index of 0.802 and 0.786 in the training and test cohorts, with superior 3-year OS AUC values of 0.804 and 0.828. Furthermore, clinical-radiomics model has a significant improvement in performance compared with radiomics model (IDI: 23.2%, P < 0.001) and clinical model (IDI:5.2%, P = 0.008). Nomogram combining body composition and tumor radiomics features can help predict the long-term prognosis of patients with resectable colon cancer and may serve as an effective tool to promote individualized treatment.

ABSTRACT Background and Aims The purpose of restorative surgery after colectomy is to improve quality of life. Still, little is known about patient perspectives. We explored factors influencing ulcerative colitis patients' choice between restorative procedures and stoma, and their experiences of associated healthcare. Methods Semi‐structured interviews were conducted with 21 ulcerative colitis patients subjected to subtotal colectomy and who had either chosen restorative surgery or a permanent stoma. Participants were recruited from two hospitals within the CRUISE trial. Interviews were conducted in person or digitally and analyzed using conventional content analysis as described by Elo and Kyngäs. The COREQ checklist guided reporting. Data collection continued until saturation was reached. Results Twenty‐one participants (14 men, 7 women; median age 34) were interviewed 43 months post‐colectomy. Analysis revealed three main categories and seven subcategories: (1) decisive factors in surgical choice, (2) shared decision‐making, and (3) facilitating factors in patients' choice of restorative surgery or stoma. Participants emphasized striving for normality and high quality of life, regardless of surgical choice. Informed decision‐making and active involvement were central themes. Additionally, the attitude of healthcare professionals, continuity of care, and support structures significantly shaped patients' perceptions and choices. The findings highlight the complex interplay of physical, psychosocial, and systemic factors influencing surgical decisions. Conclusions This study explores the experiences of ulcerative colitis patients after colectomy. Key factors influencing treatment satisfaction and QoL include adequate information, shared decision‐making, and the pursuit of normality. A patient‐centred approach, focusing on informed and individualized decisions, could improve both physical and emotional outcomes in surgical care.

There is a lack of evidence regarding hospital academic status and survival following colorectal cancer surgery and there is a paucity of data from European countries. The aim of this study was to investigate this association between hospital academic status and mortality after colon and rectal cancer surgery. All 49 032 patients who underwent resection for colorectal cancer in years 1987-2016 in Finland were included, with complete follow-up until December 31, 2019. Primary outcome was all-cause 5-year mortality. Cox regression provided hazard ratios (HR) with 95% confidence intervals (CI) in academic and non-academic hospitals for colorectal surgery, adjusted for calendar period, age, sex, comorbidity, stage, tumor location and oncological therapy. Additionally, colon and rectal cancer surgery were assessed separately. Total colectomies were included in the study, and the cancer location was based on the first location information that was reported by the cancer registry or in the ICD code if not reported in the cancer registry. The manuscript was written according to Equator network guidelines. Compared to academic hospitals, the patients operated in non-academic hospitals had a slightly increased 5-year all-cause mortality (adjusted HR 1.07, 95% CI 1.04-1.11) and also the 30-day and 90-day mortality was increased in patients operated in non-academic hospitals. Sensitivity analysis including only patients operated with confirmed curative intent suggested no differences between academic and non-academic hospitals in colorectal cancer for 5-year all-cause mortality or in 5-year cancer specific mortality, respectively. In analysis including hospital volume as an explanatory covariate, the increase in 5-year mortality in non-academic hospitals compared to academic hospitals was stronger than in main analysis. A pre-planned subgroup-analysis stratified by cancer type (colon, or rectal) suggested a slightly decreased 5-year all-cause mortality in academic institutions for rectal but not for colon cancer surgery. Hospital academic status is associated with slightly improved 5-year mortality in colorectal cancer surgery, but benefits of centralization to academic hospitals may be limited to rectal cancer surgery.

This study aimed to evaluate how hospital distance and changes in surveillance hospitals influence adherence to surveillance, the cumulative risk of familial adenomatous polyposis-related tumors, and survival outcomes in patients with familial adenomatous polyposis. We conducted a multicenter retrospective study in a specific region of Japan and analyzed 79 patients with familial adenomatous polyposis who underwent total colectomy or proctocolectomy between 1987 and 2025 across 9 accredited hospitals. We examined the associations between straight-line distance to the hospital, changes in surveillance centers, and surveillance adherence, as well as the cumulative risk of familial adenomatous polyposis-related tumors and survival outcomes. The 10-year surveillance adherence rate was 86.5%. During follow-up, 31.6% of patients changed hospitals. Hospital distance did not differ significantly between those who maintained or dropped out of surveillance. However, patients residing ≥40 km from their hospital were significantly more likely to switch hospitals (61.5% vs. 13.2%, p < 0.001). Importantly, changes in surveillance hospitals showed no significant association with the cumulative risk of familial adenomatous polyposis-related tumors or survival outcomes. Surveillance dropout occurred in 7.6% of patients. No specific clinical predictors of surveillance dropout were identified; the most common reason for surveillance dropout was patients' self-assessed low risk following negative screening results. This multicenter study found that hospital distance or changes in surveillance hospitals did not significantly affect adherence to surveillance or clinical outcomes in patients with familial adenomatous polyposis.

Anastomotic leak remains a leading cause of morbidity and mortality following colon resection. There is increasing evidence to suggest that failure to rescue (FTR), defined as death after a complication, is the culmination of a series of cascading events, which may be exacerbated by delays in diagnosis. Timely identification and management of anastomotic leaks may represent a crucial strategy for reducing FTR after colon resection. To determine whether delayed diagnosis of anastomotic leak is associated with FTR following colon resection. This cohort study used the Veterans Affairs Surgical Quality Improvement Program dataset from 2004 to 2023 to assess the rate of FTR after postoperative organ space surgical site infection (OSSI) among patients who underwent colon resection at a Veteran Affairs hospital. Data were analyzed from September 1, 2024, to December 13, 2025. Colon resection. FTR rate after diagnosis of OSSI. OSSI was used as a surrogate for anastomotic leak and categorized as delayed (occurring after a sepsis diagnosis) or early (before or without a sepsis diagnosis). FTR rate after delayed or early OSSI diagnosis was compared. Multivariable logistic regression was performed to identify factors associated with FTR after OSSI. Of 39 175 patients (37 228 males [95.0%] and 1947 females [5.0%]; mean [SD] age, 65.3 [11.1] years) included in the analysis who underwent colon resection, 219 were Asian (0.6%) individuals, 6386 were Black (16.3%) individuals, 1820 were Hispanic (4.7) individuals, 24 612 were White (62.8%) individuals, and 6138 were individuals of other or unknown race and ethnicity (15.7%). The indication for resection was colon cancer in 17 067 patients (43.6%), diverticular disease in 4678 (11.9%), inflammatory bowel disease in 658 (1.7%) and colitis, ischemia, or other indication in 16 772 (42.8%). OSSI was diagnosed in 1227 patients (3.1%); of these diagnoses, 381 (31.1%) were delayed and 846 (68.9%) were early. On multivariable analysis, those with delayed OSSI had a significantly higher mean (95% CI) number of total discrete complications compared with those with early OSSI (3.0 [2.9-3.2] vs 1.7 [1.6-1.8], P < .001), higher probability of reoperation (62.1% vs 40.3%, P < .001), longer mean (95% CI) length of stay (22.6 [20.4-24.8] days vs 17.6 [16.5-18.7] days, P < .001), and higher probability of FTR (7.8% vs 2.2%, P < .001). Probability of FTR was 6.7% higher in patients who developed sepsis (8.1%) compared with those who never developed sepsis (1.4%). Findings of this study suggest that FTR after OSSI, which served as a proxy for anastomotic leak, was associated with delayed diagnosis, not the leak itself. Early identification of leaks and avoidance of progression to sepsis could reduce FTR rates. Quality initiatives aimed at earlier identification and timely and appropriate management of anastomotic leak may improve the mortality associated with colon resection.

Fulminant Clostridioides difficile colitis (CDC) carries high morbidity and mortality, often necessitating emergent surgical intervention. While total abdominal colectomy (TAC) remains the standard of care, diverting loop ileostomy with antegrade colonic lavage (DLI) has emerged as a colon-preserving alternative. This study aimed to compare outcomes between DLI and TAC and evaluate the safety of a DLI first approach, including cases that ultimately failed DLI. We performed a retrospective analysis of adult patients with CDC undergoing TAC or DLI between 2012 and 2021 using the National Inpatient Sample. Patients with abdominal compartment syndrome, colonic perforation, or alternative surgical indications were excluded. Patients who required TAC because of failed DLI trial were included in the DLI group. Propensity score matching was performed 1:1 to adjust for demographics, illness severity, and comorbidities. Outcomes assessed included mortality, discharge disposition, hospital length of stay, complications, and costs. A subgroup analysis compared patients with failed DLI with primary TAC. Of 6,618 patients undergoing surgery for CDC, 10.7% received DLI and 89.3% underwent TAC. After matching, 668 patients remained in each group. No significant difference was observed in mortality (24.4% DLI vs. 26.0% TAC, p = 0.600), although DLI patients had longer hospital stays and higher costs ( p < 0.05). Postoperative wound disruption and infection were significantly less common in the DLI group ( p < 0.05). Among patients with failed DLI (n = 116), outcomes including mortality, length of stay, and complications were comparable with primary TAC postmatching. Diverting loop ileostomy with antegrade colonic lavage appears to be a safe alternative to colectomy in select patients with fulminant CDC. Although it does not confer a survival benefit, it is associated with lower wound morbidity and does not worsen outcomes even when conversion to colectomy is required. These findings support the selective use of DLI as a colon-preserving surgical strategy. Therapeutic/Care Management; Level III.

Catastrophic antiphospholipid syndrome is a rare variant of antiphospholipid syndrome where the presence of antiphospholipid antibodies and systemic inflammation leads to the rapid onset of multifocal thrombosis. Eosinophilia is known to accompany conditions such as allergy, parasite infection, malignancy, or autoimmune diseases; however, catastrophic antiphospholipid syndrome with eosinophilia has not been reported and its clinical influence remains unknown. We describe the first case of probable catastrophic antiphospholipid syndrome with eosinophilia, which mimicked eosinophil-associated disorders such as hypereosinophilic syndromes or eosinophilic granulomatosis with polyangiitis with disseminated intravascular coagulation, adding a new aspect of differential diagnosis of eosinophilia. A 46-year-old previously healthy Japanese man presenting with fever, abdominal pain, and skin lesions with pruritus showed marked eosinophilia, thrombocytopenia, and coagulopathy. A dynamic contrast-enhanced computed tomography scan of the abdomen showed some nonenhancing lesions in both lobes of the liver and the portal vein thrombosis. Upper gastrointestinal endoscopy showed gastric erosions, and lower gastrointestinal endoscopy revealed transverse colon and cecum ulcers. Common causes of eosinophilia including allergy, infection, and medication were not detected. He was initially suspected with hypereosinophilic syndromes or vasculitis such as eosinophilic granulomatosis with polyangiitis complicated by disseminated intravascular coagulation, and was treated with prednisone and thrombomodulin from hospital day 4 after bone marrow examination and the biopsies of the skin, stomach, and colon; however, these examinations excluded neoplastic hypereosinophilic syndromes and vasculitis. Later examination revealed positive antiphospholipid antibodies including lupus anticoagulant, anticardiolipin antibodies immunoglobulin G, and anticardiolipin β2-glycoprotein 1 complex antibodies. He was complicated by colonic perforation and bilateral adrenal hemorrhage on day 10. Histopathology of the resected colon and liver biopsy confirmed arterial and venous small-vessel thrombosis and microthrombi, leading to the diagnosis of probable catastrophic antiphospholipid syndrome. He was successfully treated with plasma exchange and rituximab. He has been in remission of catastrophic antiphospholipid syndrome for 4 years, and his antiphospholipid antibodies have been negative post-rituximab treatment. His eosinophil count has been between normal to slightly increased, possibly due to the chronic adrenal insufficiency. Our case shows that eosinophilia can accompany catastrophic antiphospholipid syndrome, and this can mimic eosinophil-associated disorders with disseminated intravascular coagulation. Identifying antiphospholipid antibodies is important for differential diagnosis when treating unexplained eosinophilia, thrombocytopenia, and thrombosis.

To report a single-center experience with a multidisciplinary minimally invasive surgical approach for pediatric ulcerative colitis (UC) and identify risk factors for early postoperative complications (EPC). A retrospective analysis was conducted on UC patients followed at the Gastroenterology Unit of Meyer Children's Hospital, who underwent surgery between 2010 and 2023. Seventy-four surgical procedures in 31 patients were analyzed. All patients underwent subtotal colectomy; 24 proceeded to ileal-pouch-anal anastomosis (IPAA), and 19 had completed ileostomy closure at the time of analysis. Twenty-five (80.7%) colectomies were laparoscopic, and 6 (19.3%) were open. Among IPAA procedures, 20.8% (n = 5) were open, 50% (n = 12) were laparoscopic, and 29.2% (n = 7) were robotic. Eight patients (25.8%) experienced EPC after colectomy. Univariate analysis identified diagnosis before 6 years of age (very early onset inflammatory bowel disease) as a significant risk factor for EPC (p = 0.026; OR: 10.5; 95% CI: 1.4-38). Open and laparoscopic approaches showed comparable EPC rates (colectomy: 16.7% vs. 28%, p = 0.998; IPAA: 20% vs. 8.3%, p = 0.515). Laparoscopic surgery was associated with a significantly lower time to enteral feeding, bowel function recovery, and hospital discharge for both colectomies (p = 0.005, 0.002, and 0.025, respectively) and IPAA procedures (p = 0.008, 0.001, and 0.044, respectively). Robotic approach further shortened return of bowel function compared to both laparoscopic and to open approach (p = 0.032 and p = 0.002, respectively). Minimally invasive surgery for pediatric UC is safe and associated with improved postoperative recovery. Younger age and poor nutritional status may increase the risk of early complications. The robotic approach also shows promise in further improving recovery times.

Delayed return of gut function after colonic resection is a common impediment to early postoperative recovery. Small clinical studies, combined into meta-analyses, have suggested that intravenous lidocaine can improve return of gut function after colorectal surgery. To determine the clinical effectiveness and cost-effectiveness of perioperative intravenous lidocaine infusion compared with placebo in return of gut function after elective minimally invasive colonic resection. Multicentre, pragmatic, placebo-controlled, randomised trial with cost-effectiveness analysis. Twenty-seven hospital sites across the United Kingdom. Adult patients scheduled for elective minimally invasive colon resection were randomised in 1 : 1 ratio to treatment or control groups using a web-based portal, stratified by age, sex and trial site. A sterile solution of 2% lidocaine (made isotonic with sodium chloride) and matching placebo (a sterile solution of 0.9% sodium chloride). Participants received an intravenous bolus of study drug/placebo at induction of anaesthesia (1.5 mg/kg ideal body weight) given over 20 minutes, followed by intravenous infusion of 1.5 mg/hour/kg ideal body weight with a maximum rate of 120 mg/hour (6ml/hour) for a minimum of 6 hours up to a maximum of 12 hours. The planned duration of infusion was determined by the participating unit's availability of postoperative continuous cardiac monitoring. Primary outcome: return of gut function at 72 hours postoperatively measured by 'GI-3 recovery' (defined as tolerating diet and passage of flatus or stool). Other outcomes were GI-2 recovery, prolonged postoperative ileus, patient-reported measures of quality of life, recovery and pain, 30- and 90-day mortality, unplanned re-admissions, adverse events, serious adverse events and cost per quality-adjusted life-year at 30 days. Participants, care givers and those assessing the outcomes were blinded to group assignment. The trial enrolled 590 patients (295 interventions, 295 control); after 33 post-randomisation exclusions, 557 patients were included (279 interventions, 278 control). There was no statistically significant or clinically meaningful difference in GI-3 recovery at 72 hours after surgery [160/279 patients (57.3%) for intravenous lidocaine versus 164/278 patients (59%) for placebo (absolute difference 1.9% (-8.0 to 4.2), odds ratio 0.97 (0.88 to 1.07), p = 0.54)]. There was no effect of intravenous lidocaine found in predetermined subgroup analyses (6- vs. 12-hour duration of infusion, right vs. non-right colectomy, sex, age band and enhanced recovery after surgery compliance). There was no evidence of a difference in other measures of gut function return, pain, quality of recovery, quality of life, perioperative complications, length of stay or total healthcare costs. There was no clinical difference between the groups in the usage of anti-emetic drug and postoperative analgesia. The intervention was not cost-effective under National Institute for Health and Care Excellence reference case criteria. Adverse events were few and evenly distributed between arms. For pragmatic reasons, relatively short durations of infusion were delivered in the ALLEGRO trial - we cannot discount the possibility that longer durations might be effective. We found no evidence for benefit from perioperative intravenous lidocaine on return of gut function, nor any other objective patient-reported outcome measure, nor cost-efficiency. There remains a need for an effective, acceptable, safe and affordable intervention to improve recovery of gut function after minimally invasive colonic surgery. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 15/130/95.

Abstract Background Antibody testing pre-infliximab re-initiation is not available in Canada. Aims Review an aggressive Crohn’s case Methods A 32 year-old previously healthy male was admitted after a few days rectal bleeding and diarrhea with CT showing features of acute pancolitis presumed to be infectious. He was treated conservatively with negative stool cultures and a sigmoidoscopy demonstrating acute inflammation and biopsies not suggestive of IBD. After 1 week, he did not improve and had full colonoscopy (terminated at transverse colon) with severe colitis seen now presumed to be IBD. Results He responded to IV steroids and switched to oral after 3 days. After 2 days of oral steroids, he had a recurrence of symptoms and infliximab was started. One day after starting infliximab (one dose given), he had massive lower GI bleed with hemodynamic instability. CT confirmed a transverse colon arterial bleed that was unsuccessfully embolized leading to emergency subtotal colectomy with end-ileostomy. Infliximab was not continued and 4 months later, ileoscopy and sigmoidoscopy were normal. Six months after re-anastamosis, sigmoidoscopy showed 3 small ulcers at anastomosis (Rutgeerts i2) but normal ileum and distal colon. Three months later he presented with new rectal bleeding and repeat sigmoidoscopy showed multiple ulcers (Rutgeerts i3) and ulcers in neo-ileum. The patient elected to start upadacitinib. Nine months later he had improved symptoms but formed a new fistula in ano requiring seton placement. He also had notable acne and it was decided to re-initiate infliximab again. It was presumed safe to restart infliximab with low risk of antibody to infliximab (ATI). He was not started on immunomodulator but had hydrocortisone pre-infusion. He had a favourable clinical response to infliximab, and at 6 months, we repeated his sigmoidoscopy which showed almost normal mucosa with small ulcer seen (Rutgeerts i1) but his infliximab levels were undetectable and ATI was markedly elevated at &amp;gt; 875 AU/mL. We decided to change his therapy again. Conclusions Infliximab re-induction after drug holiday should be preceded by ATI testing which is currently not available in Canada. In this case, robust ATI formation occurred despite a good clinical response and only 1 infliximab dose prior. Concomitant hydrocortisone was administered, but immunomodulator could also be considered in future cases to mitigate antibody risk. The rate at which ATI’s become undetectable following treatment cessation remains uncertain; however, it is postulated that antibodies may be undetectable within 12 months of therapy cessation. Accordingly, it would be reasonable to offer ATI testing when re-inducing therapy within 12 months of a drug holiday, though additional data are needed to better define this timeframe and its clinical implications. Funding Agencies None

Temporal trends and regional variation in the use of palliative care after colorectal cancer surgery.

The patient was a 78‒year‒old woman. A liver tumor was detected on abdominal computed tomography(CT)performed for follow‒up after breast cancer surgery. Further examination revealed transverse colon cancer and liver metastases; therefore, transverse colon resection with D3 lymph node dissection and resection of the central 2 segments of the liver were performed. Four months later, liver recurrence was found on CT, which was diagnosed as unresectable, and chemotherapy was planned. Chemotherapy with capecitabine+oxaliplatin+bevacizumab was initiated. The capecitabine and oxaliplatin dosages were reduced due to adverse events. The CT scan showed PR; therefore, maintenance therapy with capecitabine+bevacizumab was initiated. The recurrent tumor continued to gradually shrink, and only a cystic lesion was observed on CT. CT performed 4 years and 1 month after the initiation of chemotherapy showed that the cystic lesion had almost disappeared from the liver. We believe that the factor contributing to the long‒term response in this case was the appropriate dose reduction and cessation of chemotherapy.

Secondary cytoreductive surgery including ureteral and sigmoid colon resection for recurrent high-grade serous carcinoma