Background
Postoperative ileus (POI) remains a common complication following bowel resection. Selective opioid antagonists have been increasingly studied as prophylactic pharmaceutical aids to reduce ...rates of POI. The aim of this study was to evaluate the impact of selective opioid antagonists on return of bowel function following bowel resection.
Methods
MEDLINE, Embase, and CENTRAL were systematically searched. Articles were included if they compared the incidence of POI and/or length of stay (LOS) in patients receiving and not receiving selective opioid antagonists following elective bowel resection. A pairwise meta-analyses using inverse variance random effects was performed.
Results
From 636 citations, 30 studies with 45,051 patients receiving selective opioid antagonists (51.3% female, mean age: 60.9) and 55,071 patients not receiving selective opioid antagonists (51.2% female, mean age: 61.1) were included. Patients receiving selective opioid antagonists had a significantly lower rate of POI (10.1% vs. 13.8%, RR 0.68, 95%CI 0.63–0.75,
p <
0.01). Selective opioid antagonists also significantly reduced LOS (MD − 1.08, 95%CI − 1.47 to − 0.69,
p <
0.01), readmission (RR 0.94, 95%CI 0.89–0.99,
p =
0.03), and 30-day morbidity (RR 0.85, 95%CI 0.79–0.90,
p <
0.01). Improvements in LOS, readmission rate, and morbidity were not significant when analysis was limited to laparoscopic surgery. There was no significant difference in inpatient healthcare costs (SMD − 0.33, 95%CI − 0.71–0.04,
p =
0.08).
Conclusions
Rate of POI decreases with the use of selective opioid antagonists in patients undergoing bowel resection. Selective opioid antagonists also improve LOS, rates of readmission, and 30-day morbidity for patients undergoing open bowel resection. Addition of these medications to enhance recovery after surgery protocols should be considered.
•Recurrence rates for full-thickness rectal prolapse following proctosigmoidectomy with levatorplasty occur at an average of 13.8%.•Addition of levatorplasty does not significantly reduce recurrence ...rates.•Levatorplasty may provide improvement in functional outcomes such as obstructive defecation and fecal incontinence.
Full-thickness rectal prolapse remains a challenging pathology to correct surgically with significant recurrence rates. Among perineal approaches, the proctosigmoidectomy with levatorplasty, commonly referred to as the Altemeier procedure is frequently performed. The addition of levatorplasty has been postulated to improve recurrence rates, however, its efficacy varies across studies. The aim of this study was to systematically review recurrence rates following proctosigmoidectomy with levatorplasty, and to meta-analyze pooled data comparing recurrence rates between proctosigmoidectomy with and without a levatorplasty.
A search of EMBASE, OVID Medline, and CENTRAL was performed from database inception to October 2021 aimed at identifying studies investigating recurrences of rectal prolapse following proctosigmoidectomy with levatorplasty. Primary endpoint was recurrence of rectal prolapse. Articles that did not report this endpoint or did not evaluate proctosigmoidectomy with levatorplasty were excluded. A pairwise meta-analysis was performed using Mantel-Haenszel random effects.
From 200 citations, 14 primary studies met inclusion criteria. A total of 620 patients (88.9% female, mean age: 71 years) underwent proctosigmoidectomy with levatorplasty, and 117 without levatorplasty. Of the patients undergoing levatorplasty, 86 (13.8%) experienced a recurrence. Mean follow up was 46 months. Meta-analysis comparing recurrence rates between proctosigmoidectomy with and without levatorplasty demonstrated no significant difference (RR 0.80, 0.92, 95% CI 0.32–2.59, P = 0.87, I2 = 77%). Narrative review of postoperative quality of life metrics demonstrated decreased incontinence with levatorplasty as measured by Wexner and ICIQ-SIF scores.
The addition of a levatorplasty does not significantly reduce the risk of recurrent rectal prolapse after proctosigmoidectomy, however it may improve postoperative continence.
•A lymph node harvest cut-off of 12 can predict five-year overall survival.•Lymph node harvest cut-offs as low as 7 can predict five-year overall survival.•Lymph node harvest cut-offs other than 12 ...have not been as rigorously studied.•Further prospective study evaluating cut-offs other than 12 are warranted.
The number of lymph nodes found harboring metastasis can be impacted by the extent of harvest. Guidelines recommend 12 lymph nodes for adequate lymphadenectomy to predict long-term oncologic outcomes, yet different cut-offs remain unevaluated. The aim of this review was to determine cut-offs that may predict survival outcomes.
Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared overall survival (OS) or disease-free survival (DFS) above and below a lymph node harvest cut-off. Studies solely examining rectal cancer or stage-IV disease were excluded. Pairwise meta-analyses using inverse variance random effects were performed.
From 2587 citations, 20 studies with 854,359 patients (51.9% female, mean age: 68.9) were included, with 19 studies included in quantitative synthesis. A lymph node harvest cut-off of 12 predicted improved five-year OS (7 studies; OR 1.11, 95% CI 1.08–1.14, p<0.00001). A cut-off as low as 7 was associated with improved five-year OS (2 studies; OR 1.16, 95% CI 1.08–1.25, p<0.0001) and DFS (3 studies; OR 1.66, 95% CI 1.32–2.10, p<0.00001). All cut-offs greater than 12 demonstrated improved survival.
A lymph node cut-off of 12 distinguishes differences in five-year oncologic outcomes. Contrarily, lymph node harvests other than 12 have not been rigorously studied and thus lack the statistical power to derive meaningful conclusions compared to the 12-lymph node cut-off. Nonetheless, it is possible that a lymph node harvest cut-offs less than 12 may be adequate in predicting long-term survival. Further prospective study evaluating cut-offs below 12 are warranted.
Background: Full-thickness rectal prolapse is associated with significant morbidity and remains a challenging pathology to correct surgically with significant recurrence rates. Among perineal ...surgical approaches, the perineal rectosigmoidectomy, commonly referred to as the Altemeier procedure, is the most frequently performed. The addition of levatorplasty has been postulated to improve recurrence rates; however, its efficacy varies across prospective studies. The aim of this study was to systematically review recurrence rates following Altemeier with levatorplasty, and to meta-analyze pooled data comparing recurrence rates between Altemeier with and without a levatorplasty. Methods: A search of Embase, Ovid MEDLINE, and CENTRAL was performed from database inception to October 2021 aimed at identifying all studies investigating recurrence rate of rectal prolapse following Alteimer with levatorplasty. The primary end point was recurrence of rectal prolapse. Articles that did not report the primary end point or did not evaluate Altemeir procedure with levatorplasty were excluded. A pairwise meta-analysis was performed using Mantel-Haenszel random effects. Results: From 200 citations, a total of 14 primary studies met inclusion criteria. A total of 620 patients (88.9% female, mean age 71 yr) underwent Altemeier with levatorplasty. Of the patients undergoing levatorplasty, 86 (13.8%) experienced a recurrence. Mean follow-up was 46 months. Meta-analysis of recurrence rates between Altemeier with and without levatorplasty demonstrated no significant difference (relative risk 0.92, 95% confidence interval 0.32-2.59, p = 0.87, I2 = 77%). Conclusion: Narrative review of postoperative quality of life metrics demonstrated an improvement in incontinence following Altemeier with levatorplasty as measured by the Wexner and ICIQ-SIF scores. The addition of a levatorplasty does not significantly reduce the risk of recurrent rectal prolapse after an Altemeier; however, it may improve incontinence. Additional randomized controlled trials with standardized surgical techniques are needed to confirm the findings of this review.
Background
Lymph node ratio is the number of lymph nodes with evidence of metastases on pathological review compared to the total number of lymph nodes harvested during oncologic resection. Lymph ...node ratio is a proven predictor of long-term survival. These data have not been meta-analyzed to determine the prognosis associated with different lymph node ratio cut-offs in colon cancer.
Methods
Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared 5-year overall survival (OS) or disease-free survival (DFS) between different lymph node ratios for patients undergoing oncologic resection for stages I-III colon cancer. Pairwise meta-analyses using inverse variance random effects were performed.
Results
From 2587 citations, nine studies with 97,631 patients (female: 51.9%, median age: 61.65 years) were included. A lymph node ratio above .1 resulted in a 49% decrease in the odds of 5-year OS (2 studies; OR: 0.51, 95% CI: 0.49-.53, P < .00001). A lymph node ratio above .25 resulted in a 56% decrease in the odds of 5-year OS (3 studies; OR: 0.44, 95% CI: 0.43-.45, P < .00001). A lymph node ratio above .5 resulted in a 65% decrease in the odds of 5-year OS (3 studies; OR: 0.35, 95% CI: 0.33-.37, P < .00001).
Conclusions
Lymph node ratios from .1 to .5 are effective predictors of 5-year OS for colon cancer. There appears to be an inverse dose-response relationship between lymph node ratio and 5-year OS. Further study is required to determine whether there is an optimal lymph node ratio cut-off for prognostication and whether it can inform which patients may benefit from more aggressive adjuvant therapy and follow-up protocols.
Purpose
Dexamethasone is a glucocorticoid that is often administered intraoperatively as prophylaxis for postoperative nausea and vomiting (PONV). Several randomized controlled trials (RCTs) have ...examined its use in colorectal surgery. This systematic review aims to assess the postoperative impacts of dexamethasone use in colorectal surgery.
Methods
MEDLINE, Embase, and CENTRAL were searched from database inception to January 2023. Articles were included if they compared perioperative intravenous dexamethasone to a control group in patients undergoing elective colorectal surgery in terms of postoperative morbidity. The primary outcomes were prolonged postoperative ileus (PPOI) and PONV. Secondary outcomes included postoperative infectious morbidity and return of bowel function. A pair-wise meta-analysis and GRADE assessment of the quality of evidence were performed.
Results
After reviewing 3476 relevant citations, seven articles (five RCTs, two retrospective cohorts) met the inclusion criteria. Overall, 1568 patients received perioperative dexamethasone and 1459 patients received a control. Patients receiving perioperative dexamethasone experienced significantly less PPOI based on moderate-quality evidence (three studies, OR 0.46, 95%CI 0.28–0.74,
p
< 0.01). Time to first flatus was significantly reduced with intravenous dexamethasone. There was no difference between groups in terms of PONV (four studies, OR 0.90, 95%CI 0.64–1.27,
p
= 0.55), postoperative morbidity (OR 0.93, 95%CI 0.63–1.39,
p
= 0.74), or rate of postoperative infectious complications (seven studies, OR 0.74, 95%CI 0.55–1.01,
p
= 0.06).
Conclusion
This review presents moderate-quality evidence that perioperative intravenous dexamethasone may reduce PPOI and enhance the return of bowel function following elective colorectal surgery. There was no significant observed effect on PONV or postoperative infectious complications.
Background: Lymph node ratio (LNR) is the number of lymph nodes with evidence of metastases on pathological review compared with the total number of lymph nodes harvested during oncologic resection. ...LNR is a proven predictor of long-term survival following oncologic resection for colon cancer. Yet these data have not been meta-analyzed to determine the long-term prognosis associated with different LNR cut-offs. Methods: MEDLINE, Embase, and CENTRAL were systematically searched. Articles were included if they compared 5-year overall survival (OS) or disease-free survival (DFS) between different LNRs for patients undergoing oncologic resection for stage I-III colon cancer. Studies examining LNRs in rectal cancer patients or with metastatic disease were excluded. Pairwise meta-analyses using inverse variance random effects were performed. Risk of bias was evaluated according to the Methodological Index for Non-Randomized Studies (MINORS). Results: From 2587 citations, 8 studies conducted between 2009 and 2018 with 97 631 patients (52.0% female, mean age 62.9 yr) were included. The median stage of colon cancer among the included patients was stage III. An LNR above 0.1 resulted in a 49% decrease in the odds of 5-year OS (2 studies, odds ratio OR 0.51, 95% confidence interval CI 0.49-0.53,p < 0.00001). An LNR above 0.25 resulted in a 56% decrease in the odds of 5-year OS (3 studies, OR 0.44, 95% CI 0.43-0.45, p < 0.00001). An LNR above 0.5 resulted in a 65% decrease in the odds of 5-year OS (2 studies, OR 0.35, 95% CI 0.33-0.37,p < 0.00001). Mean MINORS score was 16.75 ± 2.19. Conclusion: LNRs from 0.1 to 0.5 are effective predictors of 5-year OS for colon cancer. Greater LNRs do not confer worsened survival. Further study is required to determine whether LNR can inform which patients may benefit from more aggressive adjuvant therapy and follow-up protocols.
Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with poor clinical outcomes. The objective of this systematic review and meta-analysis was to ...assess the performance of risk scores to predict POAF in cardiac surgery patients. We searched MEDLINE, Embase, and Cochrane CENTRAL for studies that developed/evaluated a POAF risk prediction model. Pairs of reviewers independently screened studies and extracted data. We pooled area under the receiver operating curves (AUCs), sensitivity and specificity, and adjusted odds ratios from multivariable regression analyses using the generic inverse variance method and random effects models. Forty-three studies (n = 63,847) were included in the quantitative synthesis. Most scores were originally developed for other purposes but evaluated for predicting POAF. Pooled AUC revealed moderate POAF discrimination for the EuroSCORE II (AUC 0.59, 95% confidence interval CI 0.54 to 0.65), Society of Thoracic Surgeons (AUC 0.60, 95% CI 0.56 to 0.63), EuroSCORE (AUC 0.63, 95% CI 0.58 to 0.68), CHADS
(AUC 0.66, 95% CI 0.57 to 0.75), POAF Score (AUC 0.66, 95% CI 0.63 to 0.68), HATCH (AUC 0.67, 95% CI 0.57 to 0.75), CHA
DS
-VASc (AUC 0.68, 95% CI 0.60 to 0.75) and SYNTAX scores (AUC 0.74, 95% CI 0.71 to 0.78). Pooled analyses at specific cutoffs of the CHA
DS
-VASc, CHADS
, HATCH, and POAF scores demonstrated moderate-to-high sensitivity (range 46% to 87%) and low-to-moderate specificity (range 31% to 70%) for POAF prediction. In conclusion, existing clinical risk scores offer at best moderate prediction for POAF after cardiac surgery. Better models are needed to guide POAF risk stratification in cardiac surgery patients.
