BACKGROUND:The impact of advanced therapy prescribing on colectomy rates in ulcerative colitis (UC) is unknown with conflicting published evidence. AIM:To describe advanced therapy prescribing trends and colectomy rates for patients with UC in Lothian, UK between January 1st, 2004 and December 31st, 2023. METHODS:We obtained incidence and prevalence data from the Lothian IBD Registry, a rigorously validated population cohort. We report advanced therapy prescribing and colectomy data as raw numbers and annual incidence rates. We used piecewise linear regression analyses to identify temporal trends in prescription and colectomy rates. RESULTS:The prevalence of UC increased from 216 to 441 per 100,000 population in the 20 years from 2004, culminating in a total of 4115 patients with UC in 2023. We identified 720 patients who had received an advanced therapy. Prescribing of first-line advanced therapy increased from 0 in 2004 to 115 in 2023, equating to 0.00 and 2.82 per 100 patients with UC. We identified 563 patients of the prevalent UC population who had colectomy, of whom 68% were performed as emergencies. Absolute colectomy numbers decreased from 42 in 2004 to 7 in 2023, equating to 2.48 and 0.22 per 100 patients with UC. A join point in 2013 was found for both increased advanced therapy prescribing and decreased colectomy rates. CONCLUSION:The incidence of colectomy in the UC population has decreased over time while the use of advanced therapies has greatly increased.

Background The genetic contribution to inflammatory bowel disease (IBD), encompassing both Crohn's disease (CD) and ulcerative colitis (UC), accounts for around 20% of disease variance, highlighting the need to characterize environmental and epigenetic influences. Recently, considerable progress has been made in characterizing the adult methylome in epigenome-wide association studies. Methods We report detailed analysis of the circulating methylome in 86 patients with childhood-onset CD and UC and 30 controls using the Illumina Infinium Human MethylationEPIC platform. Results We derived and validated a 4-probe methylation biomarker (RPS6KA2, VMP1, CFI, and ARHGEF3), with specificity and high diagnostic accuracy for pediatric IBD in UK and North American cohorts (area under the curve: 0.90-0.94). Significant epigenetic age acceleration is present at diagnosis, with the greatest observed in CD patients. Cis-methylation quantitative trait loci (meQTL) analysis identifies genetic determinants underlying epigenetic alterations notably within the HLA 6p22.1-p21.33 region. Passive smoking exposure is associated with the development of UC rather than CD, contrary to previous findings. Conclusions These data provide new insights into epigenetic alterations in IBD and illustrate the reproducibility and translational potential of epigenome-wide association studies in complex diseases.

AimMicroscopically positive resection margins (R1) are associated with poorer outcomes in colon cancer. While the sequalae of a positive margin related to the primary tumour (R1Tumour) are relatively well known, comparatively less is known when the positive margin pertains to a metastatic lymph node (R1LNM). The aim of this study is to confirm the significance and impact of R1LNM margins in colon cancer patients.MethodA retrospective, observational study of patients treated for American Joint Committee on Cancer Stage 3 colon cancer with potentially curative surgical intervention during a 10-year study period was performed. Patients were stratified into three groups (R0, R1Tumour, R1LNM). Outcomes measured were disease-specific survival (DSS), local recurrence-free survival (LRFS) and systemic recurrence-free survival (SRFS). Cox multivariable analysis and sensitivity analyses (time-stratified, competing-risk and propensity-matched analyses) were performed to determine the independent importance of R1LNM.ResultsA total of 801 patients were included. The R1 resection rate was 6.6% and the R1LNM resection rate was 4.7%. Compared with R0 resection, R1LNM margins had significantly lower 5-year DSS [R1LNM 53.8% (95% CI 37.4%-77.3%) vs. R0 74.2%], LRFS [R1LNM 61% (95% CI 41.7%-89.1%) vs. R0 80.5%] and SRFS [R1LNM 39.5% (95% CI 24.2%-63.8%) vs. R0 70%]. R1LNM was not independently associated with the above outcomes following traditional, time-stratified and competing-risk multivariable analyses, nor following propensity matching.ConclusionR1LNM positivity may reflect other poor-prognosis variables, which themselves play a more substantial role in determining disease outcomes.

Abstract Background The evidence for the impact of increased advanced therapy prescribing on colectomy rates in ulcerative colitis (UC) are conflicting. Our aim was to describe prescribing trends of advanced therapies (biologics and small molecules) for patients with UC in Lothian, UK and colectomy rates (elective and emergency) between January 1st, 2004, to December 31st, 2023. Methods Incidence and prevalence data were obtained from the validated Lothian IBD Registry. We identified patients who commenced an advanced therapy using multiple administrative databases, and identified patients who underwent colectomy using the NHS Lothian pathology database, TrakCare theatre lists, NHS Lothian multidisciplinary meetings database, and an inpatient coding database. We collected data by manual review of the electronic health records using the TrakCare (InterSystems Corporation, Cambridge, Massachusetts, USA) system. We used SPSS Version 25 [IBM Inc., Chicago, IL, USA], Prism Version 10.0 [Graphpad Software, San Diego, CA, USA], and R 4.4.0 [R Core Team, Vienna, Austria] for statistical analyses and generation of graphs. We report advanced therapy prescription and colectomy data as both raw numbers and annual incidence rates. Results The prevalence of UC increased from 216 to 441 patients per 100 000 population in the twenty years from 2004, culminating in a total of 4115 patients with UC in 2023 (total Lothian population 1 million). We identified 617 patients who had received an advanced therapy (Table 1). Rates of first line advanced therapy increased from 0 per 100 UC patients in 2004 to 5.15 in 2023 (Figure 1). At the conclusion of 2023, 43%, 20%, 9%, and 3% of the advanced therapy exposed patients had received second, third, fourth, and fifth-line advanced therapy, respectively. We identified 559 patients of the prevalent UC population who had a colectomy, of which 68% were emergency colectomies. Absolute colectomy numbers decreased from 42 in 2004 to 7 in 2023, equating to 2.48 and 0.22 per 100 UC patients. We observed that 66% (339/559) of colectomies occurred in patients with extensive disease (E3), with 68% (355/523) performed for acute severe UC, of which 32% (114/355) occurred within 90 days of diagnosis. A total of 4% (22/559) of colectomies were for cancer (n=14) or dysplasia/suspected cancer (n=8). Colectomies for "chronic active UC refractory to medical treatment" have almost completely disappeared with only 5 colectomies performed for this indication in the last 2 years of follow-up. Conclusion We found the incidence of colectomy in the UC population progressively decreased over time, and correlated with an increased use, and number, of available advanced therapies.

Abstract Background The application of -omics technology offers important opportunities for biomarker discovery to personalise management of patients with inflammatory bowel disease (IBD). In previous work, we reported a characteristic profile of genome-wide DNA methylation in peripheral blood leucocytes from children with paediatric IBD (pIBD) at diagnosis defining the IBD methylome. This characteristic pattern of genome-wide alterations was replicated in inception cohorts of adult patients in UK and Scandinavia. Methods Whole blood DNA methylation profiling was performed using the Illumina EPIC array on 86 pIBD patients and 30 non-IBD controls. Patients had a median age of 12 y and were prospectively recruited from gastroenterology clinics in Oxford and Cambridge, UK. In modelling, we utilised the paediatric BISCUIT and PICTS study cohorts from Scotland as our training data. Publicly available data from the RISK paediatric CD cohort from North America was accessed (GSE11261) to further assess accuracy of the model. The model was then subjected to further testing in an Oxford-based paediatric coeliac cohort and adult cohorts with IBD, and rheumatoid arthritis (RA)(Table 1). Results Genome-wide methylation changes in the Oxford/Cambridge cohort were highly consistent with the index BISCUIT and PICTS cohorts. Four single methylation sites were selected to make up a diagnostic model involving the genes, RPS6KA2, VMP1, CF1 and ARHGEF3 (Figure 1) in the index cohort and validated in the Oxford/Cambridge cohort. Following receiver operating characteristic (ROC) area under the curve (AUC) analyses the model demonstrated an AUC of 0.912 (95% CI: 0.86-0.96) (Table 1). To further validate our model, we compared pIBD who were CRP-positive (>5 mg/l) and CRP-negative (<5 mg/l) at presentation against non-IBD children. In the CRP-positive group, we found an AUC of 0.99 (95% CI: 0.99-1). Within the CRP-negative group an AUC of 0.90 was observed against controls (95% CI: 0.83-0.96). The model was further validated using methylation data at the baseline timepoint in the RISK cohort, with an AUC of 0.93 (95% CI: 0.90-0.96). In further analyses, we demonstrated specificity for IBD compared with paediatric coeliac disease; and accuracy higher in childhood-onset AUC than adult-onset disease AUC; the model is not accurate in diagnosis of RA. Conclusion We confirm a characteristic pattern of DNA methylation changes in childhood-onset IBD; and derive and validate a 4-probe model for diagnosis with high accuracy in both Europe and North America. The model is specific for pIBD compared with symptomatic children with no demonstrable pathology; and children with coeliac disease; and may provide an alternative to current markers in blood and stool, including calprotectin.

Emergency colorectal surgery carries a high risk of morbidity and mortality. Subspecialisation and split-site geographically distinct services may lead to critically unwell patients presenting to a non-colorectal specialist centre requiring urgent on-site intervention. This study aims to determine outcomes of this high-risk patient cohort. An observational retrospective study of emergency colorectal laparotomies at the Royal Infirmary of Edinburgh (RIE) between January 2016 and August 2020 was performed. The primary outcome was 30-day mortality. Secondary outcomes included rate of primary anastomosis, complications and overall mortality. Subgroup analysis of the vascular ischaemia cohort and colorectal surgeon involvement was performed. One hundred and eighteen patients were included. The median NELA (National Emergency Laparotomy Audit) score was 6.4

BACKGROUND:This study aims to confirm the associations of air pollution with ulcerative colitis (UC) and Crohn's disease (CD); to explore interactions with genetics and lifestyle; and to characterize potential epigenetic mechanisms. METHODS:We identified over 450,000 individuals from the UK Biobank and investigated the relationship between air pollution and incident inflammatory bowel disease (IBD). Cox regression was utilized to calculate hazard ratios (HRs), while also exploring potential interactions with genetics and lifestyle factors. Additionally, we conducted epigenetic Mendelian randomization (MR) analyses to examine the association between air pollution-related DNA methylation and UC. Finally, our findings were validated through genome-wide DNA methylation analysis of UC, as well as co-localization and gene expression analyses. FINDINGS:Higher exposures to NOx (HR = 1.20, 95% CI 1.05-1.38), NO2 (HR = 1.19, 95% CI = 1.03-1.36), PM2.5 (HR = 1.19, 95% CI = 1.05-1.36) and combined air pollution score (HR = 1.26, 95% CI = 1.11-1.45) were associated with incident UC but not CD. Interactions with genetic risk score and lifestyle were observed. In MR analysis, we found five and 22 methylated CpG sites related to PM2.5 and NO2 exposure to be significantly associated with UC. DNA methylation alterations at CXCR2 and sites within the MHC class III region, were validated in genome-wide DNA methylation analysis, co-localization analysis and analysis of colonic tissue. INTERPRETATION:We report a potential causal association between air pollution and UC, modified by lifestyle and genetic influences. Biological pathways implicated include epigenetic alterations in key genetic loci, including CXCR2 and susceptible loci within MHC class III region. FUNDING:Xue Li was supported by the Natural Science Fund for Distinguished Young Scholars of Zhejiang Province (LR22H260001) and the National Nature Science Foundation of China (No. 82204019). ET was supported by the CRUK Career Development Fellowship (C31250/A22804) and the Research Foundation Flanders (FWO). JW was supported by Belgium by a PhD Fellowship strategic basic research (SB) grant (1S06023N). JKN was supported by the National Science Center, Poland (No. 2020/39/D/NZ5/02720). The IBD Character was supported by the European Union's Seventh Framework Programme [FP7] grant IBD Character (No. 2858546).

This work aims to investigate how smoking exerts effect on the development of inflammatory bowel disease (IBD). A prospective cohort study and a Mendelian randomization study are first conducted to evaluate the association between smoking behaviors, smoking-related DNA methylation and the risks of Crohn’s disease (CD) and ulcerative colitis (UC). We then perform both genome-wide methylation analysis and co-localization analysis to validate the observed associations. Compared to never smoking, current and previous smoking habits are associated with increased CD ( P = 7.09 × 10 −10 ) and UC (P < 2 × 10 −16 ) risk, respectively. DNA methylation alteration at cg17742416 [ DNMT3A ] is linked to both CD ( P = 7.30 × 10 −8 ) and UC ( P = 1.04 × 10 −4 ) risk, while cg03599224 [ LTA/TNF ] is associated with CD risk ( P = 1.91 × 10 −6 ), and cg14647125 [ AHRR ] and cg23916896 [ AHRR ] are linked to UC risk ( P = 0.001 and 0.002, respectively). Our study identifies biological mechanisms and pathways involved in the effects of smoking on the pathogenesis of IBD.

In this study, we aim first to assess the association between cigarette smoking and the risk of IBD through a prospective cohort study in the UK Biobank. Then, we evaluate the potential causal association between smoking behaviors and smoking-related DNA methylation with IBD by performing MR analysis, and finally validate the associations via genome-wide methylation and colocalization analyses.These are the source data for Tables and Figures of the manuscript. Each one has been labed as "Source data for figure/table xxx". If you have any question about the datasets, please do not hesitate to contact us.

BACKGROUND & AIMS: DNA methylation alterations may provide important insights into gene-environment interaction in cancer, aging, and complex diseases, such as inflammatory bowel disease (IBD). We aim first to determine whether the circulating DNA methylome in patients requiring surgery may predict Crohn's disease (CD) recurrence following intestinal resection; and second to compare the circulating methylome seen in patients with established CD with that we had reported in a series of inception cohorts. METHODS: TOPPIC was a placebo-controlled, randomized controlled trial of 6-mercaptopurine at 29 UK centers in pa-tients with CD undergoing ileocolic resection between 2008 and 2012. Genomic DNA was extracted from whole blood samples from 229 of the 240 patients taken before intestinal surgery and analyzed using 450KHumanMethylation and Infinium Omni Express Exome arrays (Illumina, San Diego, CA). Coprimary objectives were to determine whether methylation alterations may predict clinical disease recurrence; and to assess whether the epigenetic alterations previously reported in newly diagnosed IBD were present in the patients with CD recruited into the TOPPIC study. Differential methylation and variance analysis was performed comparing patients with and without clinical evidence of recurrence. Secondary analyses included investigation of methylation associations with smok-ing, genotype (MeQTLs), and chronologic age. Validation of our previously published case-control observation of the methyl-ome was performed using historical control data (CD, n = 123; Control, n = 198). RESULTS: CD recurrence in patients following surgery is associated with 5 differentially methylated positions (Holm P < .05), including probes mapping to WHSC1 (P = 4.1 x 10(-9), Holm P = .002) and EFNA3 (P = 4.9 x 10(-8,) Holm P = .02). Five differentially variable positions are demonstrated in the group of patients with evidence of disease recurrence including a probe mapping to MAD1L1 (P = 6.4 x 10(-5)). DNA methylation clock analyses demonstrated significant age acceleration in CD compared with control subjects (GrimAge + 2 years; 95% confidence interval, 1.2-2.7 years), with some evidence for accelerated aging in patients with CD with disease recurrence following surgery (GrimAge +1.04 years; 95% confidence in-terval,-0.04 to 2.22). Significant methylation differences be-tween CD cases and control subjects were seen by comparing this cohort in conjunction with previously published control data, including validation of our previously described differ-entially methylated positions (RPS6KA2 P = 1.2 x 10(-19), SBNO2 = 1.2 x 10(-11)) and regions (TXK [false discovery rate, P = 3.6 x 10(-14)], WRAP73 [false discovery rate, P = 1.9 x 10(-9)], VMP1 [false discovery rate, P = 1.7 x 10(-7)], and ITGB2 [false discovery rate, P = 1.4 x 10(-7)]). CONCLUSIONS: We demonstrate differential methylation and differentially variable methylation in patients developing clin-ical recurrence within 3 years of surgery. Moreover, we report replication of the CD-associated methylome, previously char-acterized only in adult and pediatric inception cohorts, in pa-tients with medically refractory disease needing surgery. (Cell Mol Gastroenterol Hepatol 2023

Biomarkers to guide clinical decision making at diagnosis of inflammatory bowel disease [IBD] are urgently needed. We investigated a composite serum N-glycomic biomarker to predict future disease course in a discovery cohort of 244 newly diagnosed IBD patients. In all, 47 individual glycan peaks were analysed using ultra-high performance liquid chromatography, identifying 105 glycoforms from which 24 derived glycan traits were calculated. Multivariable logistic regression was performed to determine associations of derived glycan traits with disease. Cox proportional hazard models were used to predict treatment escalation from first-line treatment to biologics or surgery (hazard ratio [HR] 25.9, p = 1.1 × 10-12; 95% confidence interval [CI], 8.52-78.78). Application to an independent replication cohort of 54 IBD patients yielded an HR of 5.1 [p = 1.1 × 10-5; 95% CI, 2.54-10.1]. These data demonstrate the prognostic capacity of serum N-glycan biomarkers and represent a step towards personalised medicine in IBD.

Background and Aims Over the past decade, the DNA methylome has been increasingly studied in peripheral blood of inflammatory bowel disease [IBD] patients. However, a comprehensive summary and meta-analysis of peripheral blood leukocyte [PBL] DNA methylation studies has thus far not been conducted. Here, we systematically reviewed all available literature up to February 2022 and summarized the observations by means of meta-analysis. Methods We conducted a systematic search and critical appraisal of IBD-associated DNA methylation studies in PBL using the biomarker-based cross-sectional studies [BIOCROSS] tool. Subsequently, we performed meta-analyses on the summary statistics obtained from epigenome-wide association studies [EWAS] that included patients with Crohn's disease [CD], ulcerative colitis [UC] and/or healthy controls [HC]. Results Altogether, we included 15 studies for systematic review. Critical appraisal revealed large methodological and outcome heterogeneity between studies. Summary statistics were obtained from four studies based on a cumulative 552 samples [177 CD, 132 UC and 243 HC]. Consistent differential methylation was identified for 256 differentially methylated probes [DMPs; Bonferroni-adjusted p <= 0.05] when comparing CD with HC and 103 when comparing UC with HC. Comparing IBD [CD + UC] with HC resulted in 224 DMPs. Importantly, several of the previously identified DMPs, such as VMP1/TMEM49/MIR21 and RPS6KA2, were consistently differentially methylated across all studies. Conclusion Methodological homogenization of IBD epigenetic studies is needed to allow for easier aggregation and independent validation. Nonetheless, we were able to confirm previous observations. Our results can serve as the basis for future IBD epigenetic biomarker research in PBL.

Question: A 79-year-old man presented with a 1-week history of rectal pain. He had passed a painful, jagged stool with fresh red rectal bleeding. The patient reported that it felt like passing “broken glass.” He had previously undergone a laparoscopic anterior resection with a nonfunctioning ileostomy for adenocarcinoma of rectum (T3 M0 N1) 7 years prior. His ileostomy had been closed and there had been no evidence of disease recurrence on follow-up. In addition, he has atrial fibrillation, hypertension, type 2 diabetes mellitus, and had acute cholecystitis with calcification that was managed conservatively 4 years ago. On examination, he was hemodynamically stable. His abdomen was soft and nontender. An internal rectal examination was tender with intraluminal glass-like material palpable within the rectum. Admission blood tests including liver function tests were normal apart from a C-reactive protein of 37 mg/L and lactate of 3.1 mmol/L. Previous imaging (plain radiograph [Figure A]) from 4 years ago is compared with contemporary imaging (plain radiograph (Figure B) and a computed tomography scan of the abdomen and pelvis with contrast was performed (Figure C, D). What is the most likely diagnosis? Look on page 1181 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. A previous plain radiograph (Figure A) from 4 years before presentation demonstrated an intact porcelain gallbladder. Imaging at the current presentation, a plain radiograph (Figure B) and a computed tomography scan of the abdomen and pelvis (Figure C) demonstrated a porcelain gallbladder and cholecystocolonic fistula. A large portion of the porcelain gallbladder wall had fragmented, passed via the fistula into the transverse colon and had transited to the rectum (Figure D). The patient underwent examination under anesthesia and removal of this part of the porcelain gallbladder wall per rectum (Figure E). Histopathological analysis demonstrated fragments of fibrous tissue with the epithelial lining entirely replaced by extensive calcification and metaplastic bone formation with no evidence of malignancy (Figure F; microscopic section; original magnification ×12.5; Figure G, original magnification ×100, demonstrating metaplastic bone formation). The histopathologist favored a final diagnosis of porcelain gallbladder wall passing via the cholecystocolonic fistula into the colon to the rectum. Postoperatively, the patient recovered well with no further intervention required for the gallbladder or cholecystocolonic fistula. Porcelain gallbladder is also known as calcified gallbladder or calcifying cholecystitis, where the gallbladder becomes encrusted with calcium, brittle, hard, and takes on a bluish discoloration.1Geller S.A. de Campos F.P. Porcelain gallbladder.Autops Case Rep. 2015; 5: 5-7Crossref Google Scholar Patients are often asymptomatic, but occasionally present with right upper quadrant pain, a palpable mass, or symptoms of biliary obstruction.1Geller S.A. de Campos F.P. Porcelain gallbladder.Autops Case Rep. 2015; 5: 5-7Crossref Google Scholar The diagnosis is frequently incidental on an abdominal radiograph or computed tomography scan.1Geller S.A. de Campos F.P. Porcelain gallbladder.Autops Case Rep. 2015; 5: 5-7Crossref Google Scholar The decision to manage porcelain gallbladder conservatively or with cholecystectomy considers the presence of symptoms, biliary complications, and comorbid medical conditions. Although porcelain gallbladder has previously been regarded as a risk factor for gallbladder adenocarcinoma, a recent review of 7 published case series that included 60,665 cholecystectomies suggests that cancer risk is low (<3%).2Khan Z.S. Livingston E.H. Huerta S. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature.Arch Surg. 2011; 146: 1143-1147Crossref PubMed Scopus (57) Google Scholar Among patients who are asymptomatic with good functional status, prophylactic cholecystectomy is recommended despite the limited data regarding true risks of gallbladder cancer because the prognosis of gallbladder cancer is poor.2Khan Z.S. Livingston E.H. Huerta S. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature.Arch Surg. 2011; 146: 1143-1147Crossref PubMed Scopus (57) Google Scholar Gallstone ileus caused by large stones passing through duodenal fistulae causing small bowel obstruction is common. We previously reported a case of large bowel obstruction caused by a large gallstone passing via cholecystocolic fistula into the sigmoid colon.3Ventham N.T. Eves T. Raje D. et al.Sigmoid gallstone ileus: a rare cause of large bowel obstruction.BMJ Case Rep. 2010; 2010Crossref Scopus (4) Google Scholar Previous cases of sigmoid gallstone ileus have been managed conservatively, endoscopically (including use of ultrasonic lithotripsy) and surgically.3Ventham N.T. Eves T. Raje D. et al.Sigmoid gallstone ileus: a rare cause of large bowel obstruction.BMJ Case Rep. 2010; 2010Crossref Scopus (4) Google Scholar This case is the first reported of actual fragments of gallbladder itself, rather than stones, passing via the fistula into the colon. The presentation was with rectal pain alone, rather than any right hypochondral or other colonic or biliary symptoms. Currently, the present authors are not suggesting this as a novel way to perform a cholecystectomy.

Abstract Introduction Lower GI bleeding (LGIB) has an estimated 1-year prevalence of 10% in the UK, accounting for 3% of emergency surgical referrals. The British Society of Gastroenterology (BSG) recommend risk scoring for LGIB to categorise severity and plan management. Experience in a tertiary colorectal centre suggests this potentially overestimates the severity of bleeding and the requirement for inpatient admission. Method Data was retrospectively collected for all patients referred from primary care or emergency departments with LGIB from 01/05/20–01/04/21. Demographics and an Oakland score (OS), recommended in BSG guidelines, were collected. OS >8 suggests admission. Outcomes following referral, including admission, discharge, blood transfusion and radiological/surgical intervention, were assessed. Results 294 patients were assessed. 176 patients (59.9%) were admitted for further management. The median OS for admitted patients was 12 (IQR 9–17). 30 patients (10.2%) required blood transfusion, 3 required radiological/surgical intervention (1%). 118 (40.1%) patients were discharged. The median OS was 10 (IQR 8–12). 80 patients discharged had a score >8, recommending admission; 4 patients required readmission (5.0%), however, none required intervention. 38 patients were discharged with a score ≤8; again, 4 patients (10.5%) required readmission for LGIB, with none requiring intervention. Fisher's exact test showed no statistical significance between OS and readmission (p=0.22). Conclusion Risk assessment scoring recommended admission for a large cohort of patients safely discharged after initial assessment in our centre. A small number required readmission, however, none suffered significant adverse outcomes. Further investigation should assess whether such scoring systems are too cautious for use in specialist colorectal centres.

Abstract Background Since 1999, the Scottish National Service for Thoracoabdominal Aneurysms has offered repair of thoracoabdominal aneurysms (TAAAs) to a population of 5.5 million people. The open operation most commonly performed by the service is the extent IV TAAA repair. Methods All extent IV open TAAA repairs performed at the Scottish National Service for TAAAs from June 1999 until April 2021 were evaluated for clinical features, technical details, and clinical outcomes. The primary outcome measure was 30-day mortality; secondary outcomes included short-term (90 days, 6 months, 1 and 2 years) and long-term (5 and 10 years) survival, perioperative complications, and reintervention. Survival was assessed using Kaplan–Meier analysis. Results Some 248 patients underwent extent IV TAAA repair, with elective surgery in 204 (82.3 per cent). A totally abdominal transperitoneal approach was used for all patients, with a median visceral ischaemia time of 40 (i.q.r. 35–48) min. Overall, 18 patients (7.3 per cent) died within 30 days. The proportion of patients surviving at 90 days, 6 months, 1, 2, 5, and 10 years was 0.91, 0.90, 0.89, 0.85, 0.72, and 0.41, respectively. Ten patients (4.0 per cent) required a reintervention while in hospital, four (1.6 per cent) experienced permanent spinal cord ischaemia, 19 (7.9 per cent) required temporary renal replacement therapy (RRT), and four (1.6 per cent) required permanent RRT. Conclusion Open extent IV TAAA repair performed in a high-volume national centre is associated with favourable short- and long-term survival, and acceptable complication rates.

Question: A 79-year-old man presented with a 1-week history of rectal pain. He had passed a painful, jagged stool with fresh red rectal bleeding. The patient reported that it felt like passing “broken glass.” He had previously undergone a laparoscopic anterior resection with a nonfunctioning ileostomy for adenocarcinoma of rectum (T3 M0 N1) 7 years prior. His ileostomy had been closed and there had been no evidence of disease recurrence on follow-up. In addition, he has atrial fibrillation, hypertension, type 2 diabetes mellitus, and had acute cholecystitis with calcification that was managed conservatively 4 years ago. On examination, he was hemodynamically stable. His abdomen was soft and nontender. An internal rectal examination was tender with intraluminal glass-like material palpable within the rectum. Admission blood tests including liver function tests were normal apart from a C-reactive protein of 37 mg/L and lactate of 3.1 mmol/L. Previous imaging (plain radiograph [Figure A]) from 4 years ago is compared with contemporary imaging (plain radiograph (Figure B) and a computed tomography scan of the abdomen and pelvis with contrast was performed (Figure C, D). What is the most likely diagnosis? Look on page 1181 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. A previous plain radiograph (Figure A) from 4 years before presentation demonstrated an intact porcelain gallbladder. Imaging at the current presentation, a plain radiograph (Figure B) and a computed tomography scan of the abdomen and pelvis (Figure C) demonstrated a porcelain gallbladder and cholecystocolonic fistula. A large portion of the porcelain gallbladder wall had fragmented, passed via the fistula into the transverse colon and had transited to the rectum (Figure D). The patient underwent examination under anesthesia and removal of this part of the porcelain gallbladder wall per rectum (Figure E). Histopathological analysis demonstrated fragments of fibrous tissue with the epithelial lining entirely replaced by extensive calcification and metaplastic bone formation with no evidence of malignancy (Figure F; microscopic section; original magnification ×12.5; Figure G, original magnification ×100, demonstrating metaplastic bone formation). The histopathologist favored a final diagnosis of porcelain gallbladder wall passing via the cholecystocolonic fistula into the colon to the rectum. Postoperatively, the patient recovered well with no further intervention required for the gallbladder or cholecystocolonic fistula. Porcelain gallbladder is also known as calcified gallbladder or calcifying cholecystitis, where the gallbladder becomes encrusted with calcium, brittle, hard, and takes on a bluish discoloration.1Geller S.A. de Campos F.P. Porcelain gallbladder.Autops Case Rep. 2015; 5: 5-7Crossref Google Scholar Patients are often asymptomatic, but occasionally present with right upper quadrant pain, a palpable mass, or symptoms of biliary obstruction.1Geller S.A. de Campos F.P. Porcelain gallbladder.Autops Case Rep. 2015; 5: 5-7Crossref Google Scholar The diagnosis is frequently incidental on an abdominal radiograph or computed tomography scan.1Geller S.A. de Campos F.P. Porcelain gallbladder.Autops Case Rep. 2015; 5: 5-7Crossref Google Scholar The decision to manage porcelain gallbladder conservatively or with cholecystectomy considers the presence of symptoms, biliary complications, and comorbid medical conditions. Although porcelain gallbladder has previously been regarded as a risk factor for gallbladder adenocarcinoma, a recent review of 7 published case series that included 60,665 cholecystectomies suggests that cancer risk is low (<3%).2Khan Z.S. Livingston E.H. Huerta S. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature.Arch Surg. 2011; 146: 1143-1147Crossref PubMed Scopus (57) Google Scholar Among patients who are asymptomatic with good functional status, prophylactic cholecystectomy is recommended despite the limited data regarding true risks of gallbladder cancer because the prognosis of gallbladder cancer is poor.2Khan Z.S. Livingston E.H. Huerta S. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature.Arch Surg. 2011; 146: 1143-1147Crossref PubMed Scopus (57) Google Scholar Gallstone ileus caused by large stones passing through duodenal fistulae causing small bowel obstruction is common. We previously reported a case of large bowel obstruction caused by a large gallstone passing via cholecystocolic fistula into the sigmoid colon.3Ventham N.T. Eves T. Raje D. et al.Sigmoid gallstone ileus: a rare cause of large bowel obstruction.BMJ Case Rep. 2010; 2010Crossref Scopus (4) Google Scholar Previous cases of sigmoid gallstone ileus have been managed conservatively, endoscopically (including use of ultrasonic lithotripsy) and surgically.3Ventham N.T. Eves T. Raje D. et al.Sigmoid gallstone ileus: a rare cause of large bowel obstruction.BMJ Case Rep. 2010; 2010Crossref Scopus (4) Google Scholar This case is the first reported of actual fragments of gallbladder itself, rather than stones, passing via the fistula into the colon. The presentation was with rectal pain alone, rather than any right hypochondral or other colonic or biliary symptoms. Currently, the present authors are not suggesting this as a novel way to perform a cholecystectomy.

Abstract Aims This audit aimed to assess pre-operative NELA risk score documentation and subsequent specialist peri-operative critical care involvement. Methods This complete audit cycle retrospectively reviewed notes (electronic patient records, anaesthetic charts and CEPOD booking forms) of all patients undergoing emergency laparotomy between March and May 2019. The NELA score was calculated retrospectively if not documented. Following the initial audit, the following multi-disciplinary interventions were instituted: alteration of the physical CEPOD booking form to include NELA score (Surgical); a sticker added to anaesthetic charts to prompt NELA calculation (Anaesthetic), formal recording of NELA score during theatre brief (Theatre staff); and by increasing awareness of NELA via departmental education (All). The audit cycle was completed by reassessment between October and November 2020. Results The initial cycle included 34 patients, with only 2 (6%) having a NELA documented. The repeat cycle included 35 patients, with 29 (83%) having a NELA documented. Regarding post-operative critical care admissions, both cycles found that 100% of patients with a NELA of ≥ 5%, were admitted to either surgical HDU or ICU (n = 17 in first cycle, n = 17 in second cycle). For those with a high-risk NELA of ≥ 10% (n = 11 in first cycle, n = 7 in second cycle), only 2 (18%) were admitted to ICU in the first cycle vs 7 (100%) in the second cycle. Conclusions This complete audit cycle demonstrates improved NELA score calculation following institution of several multidisciplinary interventions. The improved NELA score uptake was associated with increased critical care review and admission to ITU in high-risk cases.

Abstract Aims Within this region, Upper GI and Colorectal subspecialties are located at separate hospitals. This study aims to determine outcomes of critically unwell patients undergoing emergency colorectal surgery off-site at the non-colorectal specialist centre. Methods An observational retrospective study of emergency colorectal laparotomies at a major acute teaching hospital (non-colorectal specialist centre) between January 2016 and August 2020 was performed. The primary outcome was 30-day mortality. Secondary outcomes included rate of primary anastomosis, complications and overall mortality. The NELA predicted mortality risk was obtained from notes or retrospectively calculated. Subgroup analysis of colorectal surgeon involvement was performed. Results One hundred and eighteen patients were included (median age 64 years, 55% female). The median NELA mortality score was 5.8% (IQR 1.9 – 14.7%). The 30-day mortality rate was 22% (26/118). The rate of primary anastomosis was 31%. Patients having an anastomosis had a lower median NELA score compared those patients who did not (1.6% vs. 7.85%). Forty five (38%) patients had Clavien-Dindo grade IV-V complication. Colorectal Surgeon involvement in the operation (23/118), was associated with a lower 30-day mortality (17.4% colorectal surgeon vs. 23.2% emergency general surgeon alone) albeit in patients with a lower median NELA score (4.5% vs. 6.7%) and a similar rate of primary anastomosis was achieved (31.6% vs. 30.9%). Conclusions The high mortality rate highlights a specific group of acutely unwell patients unfit for transfer to the subspecialist unit. Good outcomes were seen where a colorectal surgeon was involved, however a similar rate of primary anastomosis was demonstrated.