James Wei Tatt Toh

Westmead Hospital | SWAHS · Division of Colorectal Surgery, Department of Surgery

Background: Most patients with Crohn's disease still require surgery despite significant advances in medical therapy, surveillance, and management strategies. Objective: The purpose of this study was to assess surgical strategies and outcomes in Crohn's disease, including surgical recurrence and emergency surgery. Design: This was a multicente...

There has been a resurgence of interest in the use of mechanical bowel preparation (MBP) and oral antibiotics (OAB) before elective colorectal surgery. Until now, clinical trials and meta-analyses have not compared all 4 approaches (MBP with OAB, OAB only, MBP only, or no preparation) simultaneously. Objective: To perform a network meta-analysis t...

Minimally invasive laparoscopic low or ultra-low anterior resection may present as a complex, technically difficult challenge to even the most experienced of colorectal surgeons. This is because, within the narrow confines of the pelvis, there is usually limited visibility, and difficult manoeuvrability of rigid laparoscopic instrumentation with re...

BACKGROUND Recent studies in non-colorectal malignancy have associated T resident memory (TRM) cells with improved patient survival. It is unknown if TRM plays a role in colorectal cancer (CRC). AIM To examine the potential role of TRM cells in providing immunogenicity in CRC stratified by microsatellite instability (MSI) and BRAF status. METHODS...

Background Lynch syndrome is associated with the most common form of heritable bowel cancer. There remains limited level 1 evidence on survival outcomes and rate of metachronous tumor associated with Lynch syndrome colorectal cancer. Methods A systematic literature search of original studies was performed on Ovid searching MEDLINE, Embase, Cochran...

Venous thromboembolism (VTE) is the most common cause of early mortality contributing to ~50% post cancer surgery mortality • Patients undergoing colorectal surgery have risk factors for VTE such as malignancy, pelvic dissection, malignancy, IBD and surgical positioning (stirrups) • Approximately 1/3 of postoperative DVT and PE occurs after hospita...

Kono-S decreases surgical recurrence at 5 years compared to other anastomosis configurations. There was no difference between LME or EME however more studies are needed as the current evidence is limited.

Metastatic squamous cell carcinoma of the anal canal is a rare presentation either found at the index presentation of anal cancer or dissemination may occur after the definitive chemoradiation of the primary.

Rectal cancer surgery is complex and more technically challenging than colonic surgery. Over the last 30 years internationally, there has been a growing impetus for centralizing care to improve outcomes for rectal cancer. Centralizing care may potentially reduce variations of care, increase standardization and compliance with clinical practice guid...

Over the last two decades, there have been major advances in imaging, endoscopy, and laparoscopy in the field of gastrointestinal (GI) surgery. GI surgery is the newest super-specialty branch of general surgery, where enhanced expertise and high-volume centres have made a difference in the outcomes of complex operations. Surgeons can now do difficu...

A 70-year-old immunocompetent Lebanese male presented with 3-month history of watery diarrhoea and abdominal pain after recently arriving to Australia from Lebanon. He had a colectomy for an iatrogenic bowel perforation associated with a colonoscopy in Lebanon several months prior. His computed tomography (CT) scan demonstrated pancolitis. Stool cu...

AXL⁺ Siglec-6⁺ dendritic cells (ASDC) are novel myeloid DCs which can be subdivided into CD11c⁺ and CD123⁺ expressing subsets. We showed for the first time that these two ASDC subsets are present in inflamed human anogenital tissues where HIV transmission occurs. Their presence in inflamed tissues was supported by single cell RNA analysis of public...

Purpose The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. Methods A systematic review of Medline, Embase and Cochrane e...

Purpose The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. Methods A systematic review of Medline, EMBASE and Cochrane e...

Background Colorectal cancer is the third most common cancer, with nearly 2 million cases worldwide and just under 1 million deaths in 2020. Several trials have demonstrated that aspirin has the potential to reduce the incidence and/or recurrence of colorectal cancer; however, the optimal aspirin dose is unclear. Methods Relevant studies were iden...

Purpose Preoperative hypoalbuminemia has traditionally been used as a marker of nutritional status and is considered a significant risk factor for anastomotic leak (AL). Methods The Westmead Enhanced Recovery After Surgery (WERAS) prospectively collected database, consisting of 361 patients who underwent colorectal surgery with primary anastomosis...

Purpose: Preoperative hypoalbuminaemia has traditionally been used as a marker of nutritional status and is considered a significant risk factor for anastomotic leak (AL). Methods: The Westmead Enhanced Recovery After Surgery (WERAS) prospectively collected database, consisting of 361 patients who underwent colorectal surgery with primary anastomos...

Stercoral perforation is a rare but life-threatening condition that is increasingly being recognised as a sequelae of severe constipation. We present the case of a 45-year-old female who presented with stercoral perforation secondary to severe constipation related to adjuvant chemotherapy for colorectal cancer on a background of long-term antipsych...

Aim: To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs). Methods: The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool an...

Hemorrhoidal banding is considered a safe, low-risk technique for the management of grade-I–III internal hemorrhoids. Furthermore, information in the literature regarding serious complications associated with banding is limited. Bleeding post hemorrhoidal banding is often considered minor and is expected to resolve spontaneously. Therefore, major h...

Laparoscopic rectal surgery within the confines of a narrow pelvis may be associated with a high rate of open conversion. In the obese and morbidly obese patient, the complexity of laparoscopic surgery increases substantially. Robotic technology is known to reduce the risk of conversion, but it is unclear if it can overcome the technical challenges...

The management of Crohn’s disease has evolved rapidly in the era of immunomodulators and biologicals. Despite this, a significant proportion of patients with Crohn’s disease ultimately require surgical management. One of the indications for operative management includes failure of medical therapy. We report two cases of patients with complicated Cr...

The initial immune response to HIV determines transmission. However, due to technical limitations we still do not have a comparative map of early mucosal transmission events. By combining RNAscope, cyclic immunofluorescence, and image analysis tools, we quantify HIV transmission signatures in intact human colorectal explants within 2 h of topical e...

Background Recent studies have described the finding of the Arc of Riolan (AoR) crossing the inferior mesenteric vein (IMV) seen during high ligation of IMV while performing minimally invasive colectomies. However, the AoR usually has a medial course, and this variant AoR anatomic course and the clinical importance of its preservation during spleni...

Introduction: Sigmoid volvulus is a potentially devastating and life-threatening condition associated with sigmoid colon redundancy. Many of the classical radiological signs are considered to represent the two adjacent loops of bowel in a mesentero-axial volvulus. However, limited case reports and series have reported on an organo-axial subtype of...

Lymphatic drainage is typically in the direction of arterial supply, and lymphatic drainage for right-sided colon cancers typically travels to ileocolic lymph nodes. It is rare for right-sided colon cancers to metastasize to the lateral pelvic side wall lymph nodes in the absence of local invasion or other distant metastases. In this report, we pre...

Background Whilst Enhanced Recovery after Surgery (ERAS) has been widely accepted in the international colorectal surgery community, there remains significant variations in ERAS programme implementations, compliance rates and best practice recommendations in international guidelines. Methods A questionnaire was distributed to colorectal surgeons f...

ANZ chapter of the ACS "Scientific Forum" session

The initial immune response to HIV is critical in determining transmission. However, due to technical limitations we still do not have a comparative map of early mucosal transmission events. We combined RNAscope, cyclic-immunofluorescence and novel image analysis tools to quantify HIV transmission dynamics in intact human colorectal tissue. We mapp...

Background To inform effective genomic medicine strategies, it is important to examine current approaches and gaps in well-established applications. Lynch syndrome (LS) causes 3–5% of colorectal cancers (CRCs). While guidelines commonly recommend LS tumour testing of all CRC patients, implementation in health systems is known to be highly variable....

There is not a clear consensus on which pathological features and biomarkers are important in guiding prognosis and adjuvant therapy in colon cancer. The Pathology in Colon Cancer, Prognosis and Uptake of Adjuvant Therapy (PiCC UP) Australia and New Zealand questionnaire was distributed to colorectal surgeons, medical oncologists and pathologists a...

The prognostication of colorectal cancer (CRC) has traditionally relied on staging as defined by the Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC) TNM staging classifications. However, clinically, there appears to be differences in survival patterns independent of stage, suggesting a complex interaction...

Background Intestinal neutrophil recruitment is a characteristic feature of the earliest stages of inflammatory bowel disease (IBD). Neutrophil elastase (NE) and myeloperoxidase (MPO) mediate the formation of neutrophil extracellular traps (NETs); NETs produce the bactericidal oxidant hypochlorous acid (HOCl), causing host tissue damage when unregu...

The human intestine contains numerous mononuclear phagocytes (MNP), including subsets of conventional dendritic cells (cDC), macrophages (Mf) and monocytes, each playing their own unique role within the intestinal immune system and homeostasis. The ability to isolate and interrogate MNPs from fresh human tissue is crucial if we are to understand th...

Restorative low anterior resection (LAR) for rectal cancer carries a significant risk of anastomotic leak: one of the most feared complications in colorectal surgery. Operative management may include takedown of the anastomosis and end colostomy which, in some cases, is permanent. Other contemporary operative measures include over the scope clips a...

Introduction For the past two decades, microsatellite instability (MSI) has been reported as a robust clinical biomarker associated with survival advantage attributed to its immunogenicity. However, MSI is also associated with high-risk adverse pathological features (poorly differentiated, mucinous, signet cell, higher grade) and exhibits a double-...

Background: Microsatellite instability (MSI) testing is important for the classification of Lynch syndrome, as a prognostic marker and as a guide for adjuvant chemotherapy in colorectal cancer (CRC). The gold standard for determining MSI status has traditionally been fluorescent multiplex polymerase chain reaction (PCR) and capillary gel electroph...

Aims Overseas birth is associated with survival advantage in colorectal cancer in Australia. We wished to analyse this survival based on global region of birth, controlling for cancer-specific and other causes of death. Methods Patients from a database of colorectal cancers resected from 5 hospitals in Western Sydney from 2010 to 2016 (n = 1596)...

Purpose: Enhanced Recovery After Surgery (ERAS) has become standard of care in colorectal surgery. However, there is not a universally accepted colorectal ERAS protocol and significant variations in care exist between institutions. The aim of this study was to examine the impact of variations in ERAS interventions and complications on length of sta...

PurposeFournier’s gangrene (FG) is a rare potentially lethal necrotising infection of the perineum. While the gold standard management is early and aggressive surgical debridement, the evidence in the literature is unclear as to the role and outcomes of diversional stoma.MethodsA systematic review was conducted to identify studies investigating the...

Background: The incidence of rectal cancer is higher in the older population. In developed nations, there has been a rise in incidence in young onset colorectal cancer (CRC). We examined the outcomes of locally advanced rectal cancer (LARC) in younger patients (yRC) compared with older patients, using a retrospective audit. Methods: All cases of...

The recent results of the robotic-assisted vs. conventional laparoscopic surgery for rectal cancer (ROLARR) trial reported no difference in risk of conversion to open laparotomy between the robotic and laparoscopic group. The study concluded that robotic-assisted laparoscopic surgery, when performed by surgeons with varying experience with robotic...

Background: There has been much debate as to the importance of mechanical bowel preparation (MBP) and oral antibiotic agents (OAB) prior to elective colorectal surgery over the past two decades. There is no consensus between international guidelines. Methods: The Australia and New Zealand Mechanical Bowel Preparation and Oral Antibiotics (ANZ-MBP-...

BACKGROUND Surgical site infections (SSIs) are the most common cause of health care-associated infections in surgical patients. It is unclear if incisional negative pressure wound therapy (NPWT) can reduce the risk of SSIs in patients after open abdominal surgery. METHODS A prospective, non-blinded multi-centre randomised controlled trial (RCT) wa...

Introduction: The standard of care for locoregionally advanced rectal cancer is neoadjuvant therapy (NA CRT) prior to surgery, of which 10-30% experience a complete pathologic response (pCR). There has been interest in using imaging features, also known as radiomics features, to predict pCR and potentially avoid surgery. This systematic review aims...

Background: There is significant variation in attitude both towards the role of microsatellite instability (MSI) in predicting prognosis, and towards its role in guiding which Stage II colon cancer patients may benefit from adjuvant chemotherapy. Aim: To examine the current status of specialist attitudes towards MSI in guiding prognosis and adju...

Fournier's gangrene (FG) is a rapidly progressing infective necrotising fasciitis of the perianal, perineal and genital region. It is characterised by its aggressive nature and high mortality rates of between 15% and 50%. While it has been commonly found to primarily develop from urological sources, there have been increasing reports of the role of...

Helicobacter pylori is a class one carcinogen which causes chronic atrophic gastritis, gastric intestinal metaplasia, dysplasia and adenocarcinoma. The mechanisms by which H. pylori interacts with other risk and protective factors, particularly vitamin C in gastric carcinogenesis are complex. Gastric carcinogenesis includes metabolic, environmental...

Purpose: Watch-and-wait for clinical complete response (cCR) following neoadjuvant chemoradiotherapy is gaining momentum. cCR is seen when there is only a flat white scar without an ulcer or nodularity. However, there have been recent concerns raised in the literature regarding misclassification, early regrowth and metastases. Method: A 61-year-ol...

Purpose: There is debate as to whether oral metronidazole provides any benefit in post‐operative pain post haemorrhoidectomy. Methodology: Five electronic databases including Pubmed, Medline, Embase, Ovid and Cochrane Register of Controlled Trials as well as the clinical trial registries were searched from date of inception to 12th February 2019....

Purpose: ERAS programs vary between institutions, and different pre‐operative, intra‐operative and post‐operative strategies are utilized by different colorectal units / surgeons to improve the quality of care received by patients undergoing elective colorectal surgery. Methods: As part of the ANZ‐MBP‐OAB questionnaire, questions used to assess sp...

Purpose: Approximately ten percent of patient undergoing colorectal surgery have prolonged post‐operative ileus, impacting on length of stay, hospital costs, readmission rates and morbidity. Methods: Data on 207 consecutive patients undergoing elective colorectal surgery were entered prospectively into an Enhanced Recovery After Surgery (ERAS) dat...

Purpose: There are concerns that bowel preparation with or without antibiotics may impact the microbiome. Methodology: Five electronic databases including Pubmed, Medline, Embase, Ovid and Cochrane Register of Controlled Trials as well as the clinical trial registries were searched from date of inception to 19th September 2019. Any studies reporti...

Purpose: Open haemorrhoidectomy is associated with significant postoperative pain. Metronidazole is commonly prescribed in the postoperative period as an adjunct to analgesia in pain management. Methods: In our systematic review, studies were identified using PubMed/MEDLINE, Embase/Ovid and Cochrane Register of Controlled Trials databases. Studi...