Background No standardized approach is available for the management of complicated appendicitis defined as appendiceal abscess and phlegmon. This study used meta-analytic techniques to compare ...conservative treatment versus acute appendectomy. Methods Comparative studies were identified by a literature search. The end points evaluated were overall complications, need for reoperation, duration of hospital stay, and duration of intravenous antibiotics. Heterogeneity was assessed and a sensitivity analysis was performed to account for bias in patient selection. Results Seventeen studies (16 nonrandomized retrospective and 1 nonrandomized prospective) reported on 1,572 patients: 847 patients received conservative treatment and 725 had acute appendectomy. Conservative treatment was associated with significantly less overall complications, wound infections, abdominal/pelvic abscesses, ileus/bowel obstructions, and reoperations. No significant difference was found in the duration of first hospitalization, the overall duration of hospital stay, and the duration of intravenous antibiotics. Overall complications remained significantly less in the conservative treatment group during sensitivity analysis of studies including only pediatric patients, high-quality studies, more recent studies, and studies with a larger group of patients. Conclusion The conservative management of complicated appendicitis is associated with a decrease in complication and reoperation rate compared with acute appendectomy, and it has a similar duration of hospital stay. Because of significant heterogeneity between studies, additional studies should be undertaken to confirm these findings.
Abstract Background Obese women are at increased risk for many pregnancy complications, and bariatric surgery (BS) before pregnancy has shown to improve some of these. Objectives To review the ...current literature and quantitatively assess the obstetric and neonatal outcomes in pregnant women who have undergone BS. Search strategy MEDLINE, EMBASE and Cochrane databases were searched using relevant keywords to identify studies that reported on pregnancy outcomes after BS. Selection criteria Pregnancy outcome in firstly, women after BS compared to obese or BMI-matched women with no BS and secondly, women after BS compared to the same or different women before BS. Only observational studies were included. Data collection and analysis Two investigators independently collected data on study characteristics and outcome measures of interest. These were analysed using the random effects model. Heterogeneity was assessed and sensitivity analysis was performed to account for publication bias. Main results The entry criteria were fulfilled by 17 non-randomised cohort or case-control studies, including seven with high methodological quality scores. In the BS group, compared to controls, there was a lower incidence of preeclampsia (OR 0.45, 95% CI 0.25–0.80; P = 0.007), GDM (OR 0.47, 95% CI 0.40–0.56; P < 0.001) and large neonates (OR 0.46, 95% CI 0.34–0.62; P < 0.001) and a higher incidence of small neonates (OR 1.93, 95% CI 1.52–2.44; P < 0.001), preterm birth (OR 1.31, 95% CI 1.08–1.58; P = 0.006), admission for neonatal intensive care (OR 1.33, 95% CI 1.02–1.72; P = 0.03) and maternal anaemia (OR 3.41, 95% CI 1.56–7.44, P = 0.002). Conclusions BS as a whole improves some pregnancy outcomes. Laparoscopic adjustable gastric banding does not appear to increase the rate of small neonates that was seen with other BS procedures. Obese women of childbearing age undergoing BS need to be aware of these outcomes.
Several treatment strategies for avoiding post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these ...different therapeutic interventions on ileus outcome measures.
A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing treatments for post-operative ileus following colorectal surgery. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis.
A total of 48 randomised controlled trials were included in this network meta-analysis reporting on 3614 participants. Early feeding was found to be the best treatment for time to solid diet tolerance and length of hospital stay with a probability of P = 0.96 and P = 0.47, respectively. Early feeding resulted in significantly shorter time to solid diet tolerance (Mean Difference (MD) 58.85 h; 95% Credible Interval (CrI) −73.41, −43.15) and shorter length of hospital stay (MD 2.33 days; CrI −3.51, −1.18) compared to no treatment. Epidural analgesia was ranked best treatment for time to flatus (P = 0.29) and time to stool (P = 0.268). Epidural analgesia resulted in significantly shorter time to flatus (MD -18.88 h; CrI −33.67, −3.44) and shorter time to stool (MD -26.05 h; 95% CrI −66.42, 15.65) compared to no intervention. Gastrograffin was ranked best treatment to avoid the requirement for post-operative nasogastric tube insertion (P = 0.61) however demonstrated limited efficacy (OR 0.50; CrI 0.143, 1.621) compared to no intervention. Nasogastric and nasointestinal tube insertion, probiotics, and acupuncture were found to be least efficacious as interventions to reduce ileus.
This network meta-analysis identified early feeding as the most efficacious therapeutic intervention to reduce post-operative ileus in patients undergoing colorectal surgery, in addition to highlighting other therapies that require further investigation by high quality study. In patients undergoing colorectal surgery, emphasis should be placed on early feeding as soon as can be appropriately initiated to support the return of gastrointestinal motility.
The aim of this study was to assess resection margin status and its impact on survival after abdominoperineal excision and pelvic exenteration for primary or recurrent rectal cancer.
Resection margin ...is important to guide therapy and to evaluate patient prognosis.
A meta-analysis was performed to assess the impact of resection margin status on survival, and a regression analysis to analyze positive resection margin rates reported in the literature.
The analysis included 111 studies reporting on 19,607 participants after abdominoperineal excision, and 30 studies reporting on 1326 participants after pelvic exenteration. The positive resection margin rates for abdominoperineal excision were 14.7% and 24.0% for pelvic exenteration. The overall survival and disease-free survival rates were significantly worse for patients with positive compared with negative resection margins after abdominoperineal excision hazard ratio (HR) 2.64, P < 0.01; HR 3.70, P < 0.01, respectively and after pelvic exenteration (HR 2.23, P < 0.01; HR 2.93, P < 0.01, respectively). For patients undergoing abdominoperineal excision with positive resection margins, the reported tumor sites were 57% anterior, 15% posterior, 10% left or right lateral, 8% circumferential, 10% unspecified. A significant decrease in positive resection margin rates was identified over time for abdominoperineal excision. Although positive resection margin rates did not significantly change with the size of the study, some small size studies reported higher than expected positive resection margin rates.
Resection margin status influences survival and a multidisciplinary approach in experienced centers may result in reduced positive resection margins. For advanced anterior rectal cancer, posterior pelvic exenteration instead of abdominoperineal excision may improve resection margins.
Social media (SM) can provide information and medical knowledge to patients. Our aim was to review the literature and web-based content on SM that is used by Colorectal Cancer (CRC) patients, as well ...as surgeons' interaction with SM.
Studies published between 2006 and 2016 were assessed. We also assessed the impact of several hashtags on Twitter with a freeware (Symplur).
Nine studies were included assessing Twitter (78%), Forums/Cancer-survivor networks (33%), and Facebook (22%). Aims included use of SM by CRC patients (67%), cancer-specific usage of SM with different types of cancer (44%), content credibility (33%), and influence in CRC awareness (33%). Prevention was the most common information that CRC patients looked for, followed by treatment side-effects. Only 2% of CRC SM users are doctors. SM use by colorectal consultants was suboptimal. Only 38% of surgeons had a LinkedIn account (most with less than 50 connections), and 3% used Twitter. A steep increase of tweets was observed for searched Hashtags over time, which was more marked for #ColonCancer (+67%vs+38%, #Coloncancer vs #RectalCancer). Participants engaged with colon cancer increased by 85%, whereas rectal cancer ones increased by 29%. The hashtag '#RectalCancer' was mostly tweeted by colorectal surgeons. The official twitter account of American Society of Colorectal Surgeons (@fascrs_updates) was the most active account.
CRC patients and relatives are increasingly engaging with SM. CRC surgeons' participation is poor, but we confirm a trend toward a greater involvement. Most SM lack of authoritative validation and the quality of shared content still is largely anecdotic and not scientifically evidenced-based. However, SM may offer several advantages over conventional information sharing sources for CRC patients and surgeons, and create connections with mutual enrichment.
Purpose
There is no consensus in the literature regarding the association between operative blood loss and postoperative outcomes in colorectal surgery, despite evidence suggesting a link. Therefore, ...this systematic review assesses the association between operative blood loss, perioperative and long-term outcomes after colorectal surgery.
Methods
A literature search of MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane was performed to identify studies reporting on operative blood loss in colorectal surgery.
Results
The review included forty-nine studies reporting on 61,312 participants, with a mean age ranging from 53.4 to 78.1 years. The included studies demonstrated that major operative blood loss was found to be a risk factor for mortality, anastomotic leak, presacral abscess, and postoperative ileus, leading to an increased duration of hospital stay. In the long term, the studies suggest that significant blood loss was an independent risk factor for future small bowel obstruction due to colorectal cancer recurrence and adhesions. Studies found that survival was significantly reduced, whilst the risk of colorectal cancer recurrence was increased. Reoperation and cancer-specific survival were not associated with major blood loss.
Conclusion
The results of this systematic review suggest that major operative blood loss increases the risk of perioperative adverse events and has short and long-term repercussions on postoperative outcomes. Laparoscopic and robotic surgery, vessel ligation technology and anaesthetic considerations are essential for reducing blood loss and improving outcomes. This review highlights the need for further high quality, prospective, multicentre trials with a greater number of participants, and accurate and standardised methods of measuring operative blood loss.
Neurotensin, originally isolated in 1973 has both endocrine and neuromodulator activity and acts through its three main receptors. Their role in promoting tumour cell proliferation, migration, DNA ...synthesis has been studied in a wide range of cancers. Expression of Neurotensin and its receptors has also been correlated to prognosis and prediction to treatment.
The effects of NT are mediated through mitogen-activated protein kinases, epidermal growth factor receptors and phosphatidylinositol-3 kinases amongst others. This review is a comprehensive summary of the molecular pathways by which Neurotensin and its receptors act in cancer cells.
Identifying the role of Neurotensin in the underlying molecular mechanisms in various cancers can give way to developing new agnostic drugs and personalizing treatment according to the genomic structure of various cancers. Video abstract.
Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management.
The aim of the study was to ...review the literature on the medical management of rectovaginal and enterovesical fistulae in Crohn's disease and to assess their response to treatment.
A literature search of MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane was performed.
Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae. The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response. Specifically, response to anti-tumor necrosis factor therapy of 78 rectovaginal fistulae was: 41.0% complete response, 21.8% partial response, and 37.2% no response. Response of 14 enterovesical fistulae to anti-tumor necrosis factor therapy was: 57.1% complete response, 35.7% partial response, and 7.1% no response. The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response.
Medical therapy, alone or in combination with surgery, appears to benefit some patients with rectovaginal or enterovesical fistula. However, given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment. Larger, better quality studies are required to assess response to medical treatment and evaluate indications for surgery.
Background Laparoscopic surgery for hepatic neoplasms aims to provide curative resection while minimizing complications. The present study compared laparoscopic versus open surgery for patients with ...hepatic neoplasms with regard to short-term outcomes. Methods Comparative studies published between 1998 and 2005 were included. Evaluated endpoints were operative, functional, and adverse events. A random-effects model was used and sensitivity analysis performed to account for bias in patient selection. Results Eight nonrandomized studies were included, reporting on 409 resections of hepatic neoplasms, of which 165 (40.3%) were laparoscopic and 244 (59.7%) were open. Operative blood loss (weighted mean difference = −123 mL; confidence interval = −179, −67 mL) and duration of hospital stay (weighted mean difference = −2.6 days; confidence interval = −3.8, −1.4 days) were significantly reduced after laparoscopic surgery. These findings remained consistent when considering studies matched for the presence of malignancy and segment resection. There was no difference in postoperative adverse events and extent of oncologic clearance. Conclusions Laparoscopic resection results in reduced operative blood loss and earlier recovery with oncologic clearance comparable with open surgery. When performed by experienced surgeons in selected patients it may be a safe and feasible option. Because of the potential of significant bias arising from the included studies, further randomized controlled trials should be undertaken to confirm this bias and to assess long-term survival rates.
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