Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients.

Br J Surg. 2012 Jan;99 Suppl 1:52-8

Authors: Sierink JC, Saltzherr TP, Reitsma JB, Van Delden OM, Luitse JS, Goslings JC

Abstract

BACKGROUND: The aim of this review was to assess the value of immediate total-body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT.

METHODS: A systematic search of the literature was performed in MEDLINE, Embase, Web of Science and Cochrane Library databases. Reports were eligible if they contained original data comparing immediate total-body CT with conventional imaging supplemented with selective CT in injured patients. The main outcomes of interest were overall mortality and time in the emergency room (ER).

RESULTS: Four studies were included describing a total of 5470 patients; one study provided 4621 patients (84.5 per cent). All four studies were non-randomized cohort studies with retrospective data collection. Mortality was reported in three studies. Absolute mortality rates differed substantially between studies, but within studies mortality rates were comparable between immediate total-body CT and conventional imaging strategies (pooled odds ratio 0.91, 95 per cent confidence interval 0.79 to 1.05). Time in the ER was described in three studies, and in two was significantly shorter in patients who underwent immediate total-body CT: 70 versus 104 min (P = 0.025) and 47 versus 82 min (P < 0.001) respectively.

CONCLUSION: This review showed differences in time in the ER in favour of immediate total-body CT during the primary trauma survey compared with conventional radiographic imaging supplemented with selective CT. There were no differences in mortality. The substantial reduction in time in the ER is a promising feature of immediate total-body CT but well designed and larger randomized studies are needed to see how this will translate into clinical outcomes.

PMID: 22441856 [PubMed - indexed for MEDLINE]

Palliative resections versus palliative bypass procedures in pancreatic cancer–a systematic review.

Am J Surg. 2012 Apr;203(4):496-502

Authors: Gillen S, Schuster T, Friess H, Kleeff J

Abstract

BACKGROUND: Although resection is the only treatment option that offers a chance for prolonged survival in pancreatic cancer, R2 resections are controversial and not a generally accepted approach.

METHODS: A systematic review and meta-analysis of studies of patients with pancreatic cancer was performed to analyze R2 resections in comparison with palliative surgical bypass procedures. Trials were identified by searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1966 to February 2011.

RESULTS: Four cohort studies were identified comparing 138 patients with R2 resections with 261 patients undergoing surgical bypass procedures. Morbidity and mortality were increased in the R2 resection group, with pooled risk ratios of 1.75 (95% confidence interval [CI], 1.35-2.26; P < .0001) and 2.98 (95% CI, 1.31-6.75; P = .009), respectively. R2 resections were associated with longer operating times (mean difference, 164 minutes; 95% CI, 127-201 minutes; P < .00001) and hospital stays (mean difference, 5 days; 95% CI, 1-9 days; P = .02). Pooled median survival times were 8.2 months for R2 resection and 6.7 months for palliative bypass procedures.

CONCLUSIONS: Planned palliative R2 resections are not justified in patients with pancreatic cancer.

PMID: 21872208 [PubMed - indexed for MEDLINE]

Columnar cell lesions on breast needle biopsies: is surgical excision necessary? A systematic review.

Ann Surg. 2012 Feb;255(2):259-65

Authors: Verschuur-Maes AH, van Deurzen CH, Monninkhof EM, van Diest PJ

Abstract

OBJECTIVE: This systematic review was conducted to provide treatment recommendations for patients with a diagnosis of columnar cell lesions (CCLs) in a breast core needle biopsy (CNB).

BACKGROUND: CCLs are putative breast cancer precursors and are often associated with (in situ) carcinoma in excision specimens. Although several studies reported on the progression risk and underestimation rate of a CNB diagnosis of CCL, there is no consensus regarding optimal clinical management in this context.

METHODS: We searched MEDLINE, Embase, and Cochrane databases from 1990 to October 2010 for studies on patients with a CNB diagnosis of CCL without atypia, CCL with atypia and atypical ductal hyperplasia associated with CCL followed by surgical excision or clinical follow up.

RESULTS: Of 1759 selected articles, 24 were included in this review. The pooled underestimation risks for (in situ) carcinoma were as follow: CCL without atypia 1.5% (95% confidence interval [CI] 0.6%-4%), CCL with atypia 9% (95% CI: 5%-14%), and atypical ductal hyperplasia associated with CCL 20% (95% CI: 13%-28%), based on the whole groups of patients with a CNB. Studies including CCLs with long-term clinical follow-up showed a trend toward a limited elevated breast cancer risk.

CONCLUSIONS: On the basis of the (in situ) carcinoma underestimation rates of patients with a CNB diagnosis of CCL with atypia and atypical ductal hyperplasia associated with CCL, surgical excision should be considered. For CCL without atypia, more studies with a long-term follow-up are required, but so far, surgical excision biopsy does not seem to be necessary.

PMID: 21989373 [PubMed - indexed for MEDLINE]

The impact of obesity on perioperative outcomes after laparoscopic colorectal resection.

Ann Surg. 2012 Feb;255(2):228-36

Authors: Makino T, Shukla PJ, Rubino F, Milsom JW

Abstract

OBJECTIVE: It is commonly perceived that surgery in obese patients is associated with worse outcomes than in nonobese patients. Because of the increasing prevalence of obesity and colonic diseases in the world population, the impact of obesity on outcomes of laparoscopic colectomy remains an important subject. The aim of this review was to evaluate the feasibility and safety of laparoscopic colectomy for colorectal diseases in obese patients compared with nonobese patients.

METHODS: We conducted a comprehensive review for the years 1983-2010 to retrieve all relevant articles.

RESULTS: A total of 33 studies were found to be eligible and included 3 matched case control studies and 1 review article. Obesity, often accompanied by preexisting comorbidities, was associated with longer operative times and higher rates of conversion to open procedures mainly because of the problem of exposure and difficulties in dissection. Although some studies showed obesity was associated with increased postoperative morbidity including cardiopulmonary and systemic complications, or ileus leading to longer hospital stay, there was no evidence about the negative impact of obesity on intraoperative blood loss, perioperative mortality, and reoperation rate. Whether obesity is a risk factor for wound infection after laparoscopic colectomy remains unclear. Though sometimes in obese patients, additional number of ports were necessary to successfully complete the procedure laparoscopically, obesity did not influence the number of dissected lymph nodes in cancer surgery. Lastly, the postoperative recovery of gastrointestinal function was similar between obese and nonobese patients.

CONCLUSIONS: Laparoscopic colorectal surgery appears to be a safe and reasonable option in obese patients offering the benefits of a minimally invasive approach, with no evidence for compromise in treatment of disease.

PMID: 22190113 [PubMed - indexed for MEDLINE]

Transparent cap-assisted colonoscopy versus standard adult colonoscopy: a systematic review and meta-analysis.

Dis Colon Rectum. 2012 Feb;55(2):218-25

Authors: Westwood DA, Alexakis N, Connor SJ

Abstract

BACKGROUND: Cap-assisted colonoscopy uses a transparent plastic hood attached to the tip of the colonoscope to flatten the semilunar folds and improve mucosal exposure. Several studies have examined the effect of cap-assisted colonoscopy on polyp detection, but the data are inconsistent.

OBJECTIVE: This study aimed to evaluate whether cap-assisted colonoscopy improves the yield of colorectal neoplasia detected compared with standard colonoscopy.

DATA SOURCES: A systematic search of the PubMed, MEDLINE, Embase, and Cochrane databases identified 12 studies that met the inclusion criteria for data extraction.

STUDY SELECTION: Publications that compared cap-assisted colonoscopy vs standard colonoscopy in adults in a prospective randomized controlled study were selected for review.

MAIN OUTCOME MEASURES: The primary outcomes used for meta-analysis were cecal intubation rate, cecal intubation time, and polyp detection rate. The analysis was performed using a fixed-effect model. Outcomes were calculated as odds ratios or standardized mean differences with 95% confidence intervals. The average polyp miss rate determined by tandem colonoscopy was also calculated.

RESULTS: The outcomes of 6185 patients were studied. Cap-assisted colonoscopy detected significantly more patients with polyps (OR 1.13; p = 0.030) and had a lower average polyp miss rate (12.2% vs 28.6%) than standard colonoscopy. Cap-assisted colonoscopy had a significantly higher cecal intubation rate than standard colonoscopy (OR 1.36; p = 0.020), whereas the time to cecal intubation (standard mean difference, 0.04 min; p = 0.280) was similar for the 2 colonoscope types.

CONCLUSIONS: Cap-assisted colonoscopy is associated with improved detection of colorectal neoplasia and higher cecal intubation rates than standard adult colonoscopy.

PMID: 22228167 [PubMed - indexed for MEDLINE]

Indications for fenestrated endovascular aneurysm repair.

Br J Surg. 2012 Feb;99(2):217-24

Authors: Cross J, Raine R, Harris P, Richards T,

Abstract

BACKGROUND: Endovascular technology has advanced rapidly in the development of fenestrated endovascular aneurysm repair (FEVAR). Current evidence for endovascular aneurysm repair is limited to infra-renal aortic aneurysms. With increased costs and complexity of FEVAR, its current role is unclear. A national multicentre, cross-disciplinary consensus model was developed to propose indications for FEVAR.

METHODS: All UK FEVAR centres and a wide selection of high-volume aneurysm treatment centres were invited to participate. The RAND appropriateness methodology was used. Five key steps were undertaken: meta-analysis of current literature; survey of current UK practice; nominal group establishment and definition of key clinical attributes; round 1–online survey of case vignettes; and round 2–nominal group consensus meeting.

RESULTS: More than 90 per cent of UK FEVAR centres participated. Literature review showed heterogeneous case series with no clear indications for use of FEVAR. Survey of current practice showed wide variations in aneurysm management. Consensus agreement on the role of FEVAR was achieved in 68·8 per cent of cases. Consensus for FEVAR was agreed in areas of moderate risk from open repair and need for suprarenal clamping, but it was less likely to be indicated in patients aged 85 years or more with 5·5-6-cm aneurysms, or short-necked infrarenal aortic aneurysms.

CONCLUSION: These data record areas of agreement and define the grey area of equipoise. Consequently, guidelines and recommendations can be developed on the indications for FEVAR to inform clinicians, commissioners and health economists.

PMID: 22222802 [PubMed - indexed for MEDLINE]

7.5% saline and 7.5% saline/6% dextran for hypovolemic shock.

J Trauma. 2011 May;70(5 Suppl):S27-9

Authors: Bulger EM

PMID: 21666775 [PubMed - indexed for MEDLINE]

Outcome after open repair of ruptured abdominal aortic aneurysm in patients>80 years old: a systematic review and meta-analysis.

World J Surg. 2011 Jul;35(7):1662-70

Authors: Biancari F, Mazziotti MA, Paone R, Laukontaus S, Venermo M, Lepäntalo M

Abstract

BACKGROUND: The role of open repair in the management of ruptured abdominal aortic aneurysm (RAAA) in patients>80 years old is questioned by the perceived high operative risk of these patients. This issue has been investigated in the present meta-analysis of observational studies.

METHODS: Studies on open repair of RAAA in patients>80 years old were identified in July 2010. The immediate and intermediate results were expressed as pooled proportions with 95% confidence interval (95% CI). Linear regression and meta-regression were performed to evaluate the impact of variables on the immediate postoperative mortality.

RESULTS: Pooled analysis of 29 studies showed that the risk of immediate postoperative mortality in patients>80 years old was significantly higher than in younger patients (risk ratio 1.440, 95%CI 1.365-1.519, I2 36.8%, P=0.002; risk difference 19.4%, 95% CI 16.4-22.4%, I2 38.8%, P=0.019). Pooled analysis of 36 studies showed an immediate postoperative mortality rate of 59.2% (95% CI 55.7-62.5, I2 35.62). Immediate postoperative mortality in patients<80 years old positively correlated with that of patients>80 years old (rho: 0.686, P<0.0001). Intermediate survival data of 111 operative survivors were available from six studies, and their pooled survival rates at 1-, 2-, and 3-year were 82.4, 75.6, and 68.7%, respectively.

CONCLUSIONS: Immediate and intermediate survival rates of patients>80 years old after open repair of RAAA are acceptable. These findings suggest a more confident approach toward emergency repair of RAAA in the very elderly.

PMID: 21523501 [PubMed - indexed for MEDLINE]

Long-term pharmacologic therapy of portal hypertension.

Surg Clin North Am. 1990 Apr;70(2):319-39

Authors: Burroughs AK, McCormick PA

Beta-blockers modify splanchnic hemodynamics in cirrhotic patients. Nonselective beta-blockers are more effective than selective beta-blockers. Azygos blood flow, as a measure of collateral circulation, including that through varices, is always reduced, but the effects on portal pressure, whether measured directly or by the wedged hepatic venous pressure, are variable. The initial reported correlation between a 25% reduction of resting pulse rate and similar percentage reduction in the wedged free hepatic venous gradient has not been reproduced in subsequent studies. Therefore, to study the effect of changes in hemodynamic indices and the likelihood of variceal bleeding, direct measurements of such indices need to be made in clinical trials. At present, only one primary-prevention trial of propranolol suggests that a hemodynamic index can be used to identify patients given propranolol who will not bleed. Some clinical factors may be important in identifying nonresponders in trials of secondary prevention, but these are not universally recognized. The results of secondary-prevention studies are very heterogeneous, and it is difficult to understand why this is so. However, comparative studies versus sclerotherapy suggest that reductions in rebleeding and mortality are similar. Pharmacologic treatment, including beta-blockade, is ideal for primary prevention of variceal bleeding. The initial results from randomized studies are more homogeneous regarding the benefit of beta-blockers than in the secondary-prevention studies, although there is still doubt about the response in cirrhotics with ascites. No fatal complications due to propranolol administration have been reported in cirrhotic patients, and the complications are reversible. The future of pharmacologic therapy for portal hypertension lies in combination therapy. The addition of vasodilators to beta-blockers appears to potentiate their effect on portal pressure reduction. The results of clinical trials are awaited with great interest.

PMID: 1969683 [PubMed - indexed for MEDLINE]

Adjuvant therapy in colorectal cancer: the need for a mega-trial.

Br J Surg. 1990 Aug;77(8):841-2

Authors: Taylor I, Northover JM

PMID: 2144202 [PubMed - indexed for MEDLINE]

Nonshunting operations for variceal hemorrhage.

Surg Clin North Am. 1990 Apr;70(2):425-48

Authors: Wexler MJ, Stein BL

To evaluate the various nonshunting treatment modalities currently being used, it is difficult to make comparative assessments by reviewing the literature. There is varied composition in the groups studied; numerous major modifications, but more often subtle but poorly described differences in surgical techniques; and lack of uniform definitions and methods of reporting even the most basic of results, be it recurrent hemorrhage, encephalopathy, or survival. Series often lump together patients with cirrhosis, both alcoholic and nonalcoholic, noncirrhotic intrahepatic block, and extrahepatic block, each of which has a different natural history, prognosis, and physiologic and hemodynamic response to interventions. Classification of severity of cirrhosis, although commonly referred to as Child’s class A, B, or C, may be based on time of assessment, worst criteria present, or a point scoring system. The operations are described as “emergency,” “urgent,” “emergent,” or “elective,” and the definition of each varies with investigator. Clearly, the ability of the patient to stop bleeding and survive the hazards and high mortality of the early hours of the acute event places him in a better risk group irrespective of whether the surgical intervention is performed “urgently” within 24 hours or electively in 24 days. Expressions of long-term survival frequently do not always take into account the operative deaths or the mean follow-up time. However, some general remarks can be made. The Sugiura procedure can be performed with an extremely low mortality in selected elective patients, particularly the nonalcoholic, with virtually no postoperative encephalopathy and negligible variceal rebleeding. Postoperative major hepatic decompensation does not appear to occur with time, and long-term survival would appear superior to DSR shunt. In the class A or B alcoholic cirrhotic, results are certainly as good as and perhaps better than DSR shunt, and it is a reasonable alternative, particularly when technical and other considerations make the performance of such a shunt difficult. Surgeons who routinely perform the Warren shunt should have this operation available in their repertoire as an alternative. Attempts to compromise and reduce the extent of devascularization utilizing only a thoracic or abdominal venue or to violate Sugiura’s principle of leaving intact the coronary-periesophageal-azygos venous pathway generally result in a progressively higher incidence of recurrent hemorrhage with time. The early success reported by Perecchia, Abouna, and Franco, with a transabdominal approach and lesser thoracic devascularization, which avoids “entry” into the chest, is noted with interest for the future and suggests such an approach for the more critically bleeding patients rather than the initial thoracic approach of others.(ABSTRACT TRUNCATED AT 400 WORDS)

PMID: 2138824 [PubMed - indexed for MEDLINE]

The portacaval shunt. Is it still indicated?

Surg Clin North Am. 1990 Apr;70(2):361-78

Authors: Levine BA, Sirinek KR

This article has attempted to question whether the more recently introduced methods of treating the patient with variceal hemorrhage have resulted in higher salvage rates and a better quality of life. Data concerning other types of central shunts, selective shunting, nonshunt operations, hepatic transplantation, sclerotherapy, and pharmacologic manipulation have all been critically reviewed. It seems clear that, although some of these modalities are roughly equivalent to portacaval shunting, others are inappropriate. This is especially so in the majority of patients with portal hypertension in the United States whose cirrhotic etiology is based on alcohol addiction. Additionally, a large, one-institution series of side-to-side portacaval shunts has been presented that yielded good results. It is hoped that this presentation has succeeded, at a minimum, in causing the reader to question the basis of treatment for variceal hemorrhage and, at a maximum, in convincing him or her to retain the portacaval shunt as a mainstay in treating the hemorrhagic complications of portal hypertension.

PMID: 2138823 [PubMed - indexed for MEDLINE]

Prophylactic antibiotics for the prevention of infectious complications including empyema following tube thoracostomy for trauma: results of meta-analysis.

J Trauma. 1992 Jul;33(1):110-6; discussion 116-7

Authors: Fallon WF, Wears RL

Since 1977, six clinical trials have been performed on the subject of routine antibiotic prophylaxis in patients requiring tube thoracostomy for trauma. No definitive conclusions have been reached regarding the efficacy of antibiotic use in this setting. The results of these clinical trials were pooled to generate an unbiased estimate of the efficacy of antibiotic prophylaxis for tube thoracostomy using the technique of meta-analysis. Meta-analysis is a statistical method for synthesizing results from separate but similar experiments, grouping them, and comparing each to the null hypothesis. Meta-analysis allows synthesis of all of the available data on antibiotic prophylaxis for tube thoracostomy to resolve the controversy surrounding this issue generated by different but similar clinical studies with conflicting results. Despite different conclusions of value when taken individually, the combined analysis does not support the null hypothesis (no effect of antibiotics). The statistical method is highly significant despite different mechanisms of injury, pathologic findings, and antibiotics employed.

PMID: 1386116 [PubMed - indexed for MEDLINE]

Aminoglycoside combinations versus beta-lactams alone for penetrating abdominal trauma: a meta-analysis.

J Trauma. 1991 Aug;31(8):1155-60

Authors: Hooker KD, DiPiro JT, Wynn JJ

Despite several small comparative clinical trials, controversy persists over the best choice of antimicrobial therapy for penetrating abdominal trauma. Some still question whether single drug regimens are as effective as the traditional combinations containing an aminoglycoside. A meta-analysis was performed to address this issue. Meta-analysis is a relatively new statistical tool whereby data from a number of clinical trials is analyzed and pooled to produce useful and more reliable data. In this study, a meta-analysis of 17 published randomized trials was performed to assess the effectiveness of single beta-lactam antimicrobials versus combinations containing aminoglycoside when used for penetrating abdominal trauma. The overall summary odds ratio of the pooled results of these trials was 0.96 (p = 0.833) with a 95% confidence interval of 0.30-3.05. Since not significantly different from unity (1.0), we conclude that single beta-lactam antimicrobials are as effective as traditional combinations containing aminoglycoside in this setting.

PMID: 1831511 [PubMed - indexed for MEDLINE]

Emergency room resuscitative thoracotomy: when is it indicated?

J Trauma. 1992 Nov;33(5):714-21

Authors: Boyd M, Vanek VW, Bourguet CC

This study was designed to examine the results of emergency room resuscitative thoracotomy (ERRT) and to formulate cost-effective indications for this procedure. A retrospective study was performed of 28 patients who had ERRT at St. Elizabeth Hospital Medical Center, Youngstown, Ohio, during the 4 years from July 1985 through June 1989. The prognostic factors analyzed included mechanism and site of injury, signs of life (SOL), vital signs (VS), age, gender, and prehospital care. The overall survival rate of ERRT was 7% (2 of 28 patients). The survival rate was 18% (2 of 11 patients) with penetrating trauma, and 0% (none of 17 patients) with blunt trauma. The best survival rate was 66% in the subgroup of patients with penetrating trauma and SOL present at the scene and in the emergency room (ER), (two of three patients). Our observations were combined with those of 23 studies from the literature involving 2294 trauma patients who had ERRT. Using meta-analysis, the survival rate was 11% overall. Improved survival was noted for patients with penetrating trauma compared with patients with blunt trauma (14% vs. 2%, p < 0.01). There were no survivors in the group of patients with no SOL at the scene, and there were no neurologically intact survivors among blunt trauma patients with no SOL upon arrival at the ER. An algorithm based on mechanism of injury and presence or absence of SOL at the scene and in the ER is proposed. This algorithm would decrease the number of ERRTs performed by 41% without decreasing the number of neurologically intact survivors.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID: 1464921 [PubMed - indexed for MEDLINE]

Related Articles

Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis.

Ann Surg. 1992 Aug;216(2):172-83

Authors: Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, Kellum JM, Welling RE, Moore EE

This two-part meta-analysis combined data from eight prospective randomized trials designed to compare the nutritional efficacy of early enteral (TEN) and parenteral (TPN) nutrition in high-risk surgical patients. The combined data gave sufficient patient numbers (TEN, n = 118; TPN, n = 112) to adequately address whether route of substrate delivery affected septic complication incidence. Phase I (dropouts excluded) meta-analysis confirmed data homogeneity across study sites, that TEN and TPN groups were comparable, and that significantly fewer TEN patients experienced septic complications (TEN, 18%; TPN, 35%; p = 0.01). Phase II meta-analysis, an intent-to-treat analysis (dropouts included), confirmed that fewer TEN patients developed septic complications. Further breakdown by patient type showed that all trauma and blunt trauma subgroups had the most significant reduction in septic complications when fed enterally. In conclusion, this meta-analysis attests to the feasibility of early postoperative TEN in high-risk surgical patients and that these patients have reduced septic morbidity rates compared with those administered TPN.

PMID: 1386982 [PubMed - indexed for MEDLINE]

Adjuvant therapy of colorectal cancer.

Dis Colon Rectum. 1994 Feb;37(2 Suppl):S86-91

Authors: Lopez M

PURPOSE: This review was undertaken to examine the evidence of the effectiveness of adjuvant chemotherapy in colorectal cancer. METHODS: Published studies were reviewed and analyzed. RESULTS: For over three decades, a large series of adjuvant systemic trials have been conducted in carcinoma of the colon and rectum in an attempt to reduce recurrence and ultimately improve survival. However, only in the last few years have significant gains been made. In colon cancer with regional nodal metastasis, combined treatment with 5-fluorouracil and levamisole has resulted in significant reduction of tumor recurrence and improved survival. In rectal cancer, combined modality treatment with radiotherapy and chemotherapy is considered the standard for care by many investigators, although numerous questions remain unanswered. CONCLUSIONS: The existing evidence suggests that adjuvant therapy may be of value in selected patients with colorectal cancer. Several currently active trials are pursuing very hopeful leads, and clinicians are encouraged to enter their patients on available trials.

PMID: 8313800 [PubMed - indexed for MEDLINE]

Related Articles

Follow-up of patients with colorectal cancer. A meta-analysis.

Ann Surg. 1994 Feb;219(2):174-82

Authors: Bruinvels DJ, Stiggelbout AM, Kievit J, van Houwelingen HC, Habbema JD, van de Velde CJ

OBJECTIVE: The authors sought to determine whether intensive follow-up improves 5-year survival rates in patients with colorectal cancer who were operated on for cure. SUMMARY BACKGROUND DATA: Intensive follow-up of patients with colorectal cancer is still controversial. The present uncertainty in regard to the value of intensive follow-up could be the result of the absence of prospective randomized studies comparing patients with and without follow-up. METHODS: Studies comparing two follow-up programs of different intensities were identified in the medical literature and were aggregated in a meta-analysis using the “random effects method.” Seven nonrandomized studies describing 3283 patients were analyzed. RESULTS: Patients with intensive follow-up did have 9% better 5-year survival rates than did those with minimal or no follow-up, only when intensive follow-up included carcinoembryonic antigen (CEA) assays. In addition, more asymptomatic recurrences were detected and more recurrences were resected in patients with intensive follow-up. CONCLUSIONS: This meta-analysis indicated that intensive follow-up using CEA assays can identify treatable recurrences at a relatively early stage. Treatment of these recurrences appears to be associated with improved 5-year survival rates. However, not all intensive follow-up strategies will be equally effective. Follow-up may yield the best results if diagnostic tests are used only to detect those recurrences that can be operated on with curative intent and when follow-up is “individualized,” according to patient characteristics.

PMID: 8129488 [PubMed - indexed for MEDLINE]

Endoluminal transrectal ultrasonography: accuracy, reliability, and validity.

Dis Colon Rectum. 1993 Feb;36(2):200-5

Authors: Solomon MJ, McLeod RS

The significant risk of local recurrence after curative resection and the relative inaccuracy of preoperative clinical assessment justify a more sophisticated assessment for carcinoma of the rectum. Endoluminal rectal ultrasonography (EU) can directly visualize the degree of rectal wall penetration by tumor and the immediate pararectal lymph nodes. Despite several reports reporting excellent accuracy of EU compared with pathology in detecting the degree of tumor penetration, EU remains restricted in terms of widespread availability. A review of the literature was performed to determine the accuracy, reliability, and current validity of EU. Raw data were collected from cross-sectional surveys assessing the degree of tumor penetration in 873 patients and lymph node involvement in 571 patients with primary rectal cancer. EU is very accurate at determining tumor penetration (kappa = 0.85) but is only moderately accurate at detecting lymph node involvement (kappa = 0.58). The reliability of EU has not been assessed, and a simple protocol is proposed. The validity of EU was assessed in only a few studies. EU is credible and feasible, makes intuitive biologic sense, and is, perhaps, sensitive to change. The ability to make clinical decisions based on EU (content validity) will decide whether widespread implementation is applicable.

PMID: 8425429 [PubMed - indexed for MEDLINE]

Prophylactic antibiotics in abdominal hysterectomy.

J Am Coll Surg. 1994 Nov;179(5):593-600

Authors: Tanos V, Rojansky N

BACKGROUND: The cephalosporins, which have been widely used in gynecologic surgery, are considered by many to be the drug of choice for chemoprophylaxis. However, their benefit in total abdominal hysterectomy has remained controversial. This study was done to evaluate the effectiveness of the commonly used cephalosporins in preventing inflammatory complications which may occur after elective abdominal hysterectomy. STUDY DESIGN: A MEDLINE and manual review of the literature from the past 15 years (1977 to 1991), using the terms “prophylactic antibiotics,” “abdominal hysterectomy,” and “cephalosporins,” was performed. Seventeen prospective trials using cephalosporin prophylaxis alone for 24 hours perioperatively were evaluated. A meta-analysis of the 2,752 study and control patients abstracted was performed to compare postoperative infection and febrile morbidity rates. RESULTS: The cephalosporin group as well as the various generations and individual drugs were found to be useful in preventing postoperative infection (p < 0.001). Febrile morbidity, however, was effectively prevented (p < 0.001) by first but not by some second and third generation drugs. Multivariate analysis revealed no advantage for the newer, more expensive second and third generation cephalosporins studied. When adjusted for confounding factors, the number of doses, the amount of the dose, and the route of administration had significant impact on the outcome events. CONCLUSIONS: Chemoprophylaxis with cephalosporins was found to be effective in preventing posthysterectomy infectious complications. A single dose, preoperative injection of first (cefazolin) or second (cefoxitin) generation cephalosporin, when administrated intravenously, has been shown to yield the best, cost-effective clinical results.

PMID: 7952465 [PubMed - indexed for MEDLINE]

Related Articles

Autologous splenic transplantation for splenic trauma.

Ann Surg. 1994 Mar;219(3):225-35

Authors: Pisters PW, Pachter HL

OBJECTIVE: The authors reviewed the experimental evidence, surgical technique, complications, and results of clinical trials evaluating the role of autologous splenic transplantation for splenic trauma. SUMMARY BACKGROUND DATA: Splenorrhaphy and nonoperative management of splenic injuries have now become routine aspects in the management of splenic trauma. Unfortunately, not all splenic injuries are readily amenable to conventional spleen-conserving approaches. Heterotopic splenic autotransplantation has been advocated for patients with severe grade IV and V injuries that would otherwise mandate splenectomy. For this subset of patients, splenic salvage by autotransplantation would theoretically preserve the critical role the spleen plays in the host’s defense against infection. METHODS: The relevant literature relating to experimental or clinical aspects of splenic autotransplantation was identified and reviewed. Data are presented on the experimental evaluation of autogenous splenic transplantation, methods and complications of autotransplantation, choice of anatomic site and autograft size, and results of clinical trials in humans. RESULTS: The most commonly used technique of autotransplantation in humans involves implanting tissue homogenates or sections of splenic parenchyma into pouches created in the gastrocolic omentum. Most authors have observed evidence of splenic function with normalization of postsplenectomy thrombocytosis, immunoglobulin M levels, and peripheral blood smears. Some degree of immune function of transplanted grafts has been demonstrated with in vivo assays, but the full extent of immunoprotection provided by human splenic autotransplants is currently unknown. CONCLUSIONS: Multiple human and animal studies have established that splenic autotransplantation is a relatively safe and easily performed procedure that results in the return of some hematologic and immunologic parameters to baseline levels. Some aspects of reticuloendothelial function are also preserved. Whether this translates into a real reduction in the morbidity or mortality rates from overwhelming bacterial infection is unknown and requires further investigation.

PMID: 8147604 [PubMed - indexed for MEDLINE]

Role of the Shouldice technique in inguinal hernia repair: a systematic review of controlled trials and a meta-analysis.

Br J Surg. 1996 Jun;83(6):734-8

Authors: Simons MP, Kleijnen J, van Geldere D, Hoitsma HF, Obertop H

The Shouldice technique for inguinal hernia repair has been suggested by some authors as the best conventional method against which other methods using prostheses should be compared. The paper which follows is a systematic review involving a comprehensive search of the medical literature to identify all clinical trials (article or abstract) evaluating the Shouldice repair. After assessment of certain quality criteria, the best studies were pooled in a meta-analysis. Nine publications were found with 11 study arms. In ten studies the results of the Shouldice technique were better than the results of the control arm. Six studies could be pooled in a meta-analysis of 2500 patients; Shouldice was significantly better than control methods (relative risk 0.62 (95 per cent confidence interval 0.45-0.85)). In spite of possible bias caused by different variables (modifications in operative technique, suture material, level of surgeon, follow-up methods and outcome measurement), the results of this systematic review suggest that the Shouldice method is the best current conventional technique for inguinal hernia repair.

PMID: 8696728 [PubMed - indexed for MEDLINE]

Comparison of hemorrhoidal treatment modalities. A meta-analysis.

Dis Colon Rectum. 1995 Jul;38(7):687-94

Authors: MacRae HM, McLeod RS

PURPOSE: The purpose of this study was to assess whether any method of hemorrhoid therapy has been shown to be superior in randomized, controlled trials. METHOD: A meta-analysis was performed of all randomized, controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. Outcome variables included response to therapy, need for further therapy, complications, and pain. RESULTS: A total of 18 trials were available for analysis. Hemorrhoidectomy was found to be significantly more effective than manual dilation of the anus (P = 0.0017), with less need for further therapy (P = 0.034), no significant difference in complications (P = 0.60), but significantly more pain (P < 0.0001). Patients undergoing hemorrhoidectomy had a better response to treatment than did patients treated with rubber band ligation (P = 0.001), although complications were greater (P = 0.02) as was pain (P < 0.0001). Rubber band ligation was better than sclerotherapy in response to treatment for all hemorrhoids (P = 0.005) as well as for hemorrhoids stratified by grade (Grades 1 to 2; P = 0.007; Grade 3 hemorrhoids, P = 0.042), with no difference in the complication rate (P = 0.35). Patients treated with sclerotherapy (P = 0.031) or infrared coagulation (P = 0.0014) were more likely to require further therapy than those treated with rubber band ligation, although pain was greater after rubber band ligation (P = 0.03 for sclerotherapy; P < 0.0001 for infrared coagulation). CONCLUSION: Rubber band ligation is recommended as the initial mode of therapy for Grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response rates, it is associated with more complications and pain than rubber band ligation, thus should be reserved for patients who fail to respond to rubber band ligation.

PMID: 7607026 [PubMed - indexed for MEDLINE]

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A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy.

Ann Surg. 1995 May;221(5):469-76; discussion 476-8

Authors: Cheatham ML, Chapman WC, Key SP, Sawyers JL

OBJECTIVE: A meta-analysis of all published clinical trials comparing selective versus routine nasogastric decompression was performed in an attempt to evaluate the need for nasogastric decompression after elective laparotomy. BACKGROUND: Many studies have suggested that routine nasogastric decompression is unnecessary after elective laparotomy and may be associated with an increased incidence of complications. Despite these reports, many surgeons continue to practice routine nasogastric decompression, believing that its use significantly decreases the risk of postoperative nausea, vomiting, aspiration, wound dehiscence, and anastomotic leak. METHODS: A comprehensive search of the English language medical literature was performed to identify all published clinical trials evaluating nasogastric decompression. Twenty-six trials (3964 patients) met inclusion criteria. The outcome data extracted from each trial were subsequently “pooled” and analyzed for significant differences using the Mantel-Haenszel estimation of combined relative risk. RESULTS: Fever, atelectasis, and pneumonia were significantly less common and days to first oral intake were significantly fewer in patients managed without nasogastric tubes. Meta-analysis based on study quality revealed significantly fewer pulmonary complications, but significantly greater abdominal distension and vomiting in patients managed without nasogastric tubes. Routine nasogastric decompression did not decrease the incidence of any other complication. CONCLUSIONS: Although patients may develop abdominal distension or vomiting without a nasogastric tube, this is not associated with an increase in complications or length of stay. For every patient requiring insertion of a nasogastric tube in the postoperative period, at least 20 patients will not require nasogastric decompression. Routine nasogastric decompression is not supported by meta-analysis of the literature.

PMID: 7748028 [PubMed - indexed for MEDLINE]

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Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis.

Ann Surg. 1996 Nov;224(5):609-20

Authors: Shea JA, Healey MJ, Berlin JA, Clarke JR, Malet PF, Staroscik RN, Schwartz JS, Williams SV

OBJECTIVE: The purpose of this study was to perform a meta-analysis of large laparoscopic cholecystectomy case-series and compare results concerning complications, particularly bile duct injury, to those reported in open cholecystectomy case-series. SUMMARY BACKGROUND DATA: Since the introduction of laparoscopic cholecystectomy in the United States, hundreds of reports about the technique have been published, many including statements about the advantages of laparoscopic cholecystectomy compared with those of open cholecystectomy. There is an unevenness in scope and quality of the studies. Nevertheless, enough data have accumulated from large series to permit analyses of data regarding some of the most important issues. METHODS: Articles identified via a MEDLINE (the National Library of Medicine’s computerized database) search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes of cholecystectomy were abstracted and summarized across studies. RESULTS: Outcomes of laparoscopic cholecystectomy are examined for 78,747 patients reported on in 98 studies and compared with outcomes of open cholecystectomy for 12,973 patients reported on in 28 studies. Laparoscopic cholecystectomy appears to have a higher common bile duct injury rate and a lower mortality rate. Estimated rates of other types of complications after laparoscopic cholecystectomy generally were low. Most conversions followed operative discoveries (e.g., dense adhesions) and were not the result of injury. CONCLUSIONS: There is wide variability in the amount and type of data reported within any single study, and patient populations may not be comparable across studies. Except for a higher common bile duct injury rate, laparoscopic cholecystectomy appears to be at least as safe a procedure as that of open cholecystectomy.

PMID: 8916876 [PubMed - indexed for MEDLINE]

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Gender-based mortality follow-up from the Program on the Surgical Control of the Hyperlipidemias (POSCH) and meta-analysis of lipid intervention trials. Women in POSCH and other lipid trials.

Ann Surg. 1996 Oct;224(4):486-98; discussion 498-500

Authors: Buchwald H, Campos CT, Boen JR, Nguyen P, Williams SE, Lau J, Chalmers TC

OBJECTIVE: The authors assessed the clinical results of lipid-lowering therapy in women. SUMMARY BACKGROUND DATA: The Program on the Surgical Control of the Hyperlipidemias (POSCH) has demonstrated that effective lowering of total cholesterol and low-density lipoprotein cholesterol in a postmyocardial infarction population significantly reduces atherosclerotic coronary heart disease (ACHD) mortality, ACHD mortality combined with a new confirmed nonfatal myocardial infarction, and the number of coronary artery bypass grafting and angioplasty procedures performed. METHODS: A review and meta-analysis were performed of the seven primary or secondary lipid/ atherosclerosis intervention trials-including POSCH-published in the English-language literature that included women and published results in women separate from the results in men or in the entire trial population. The main outcome measure analyzed was overall mortality. RESULTS: The Scottish Physicians Clofibrate Study, the Newcastle upon Tyne Clofibrate Study, and the Pravastatin Limitation of Atherosclerosis in the Coronary Arteries (PLAC I) Trial may have demonstrated a possible benefit in ACHD prognosis from effective lipid intervention in women. The other four available trials did not. The Minnesota Coronary Survey reported a 15.6% increase in overall mortality rate and a 30.6% increase in a combined cardiovascular endpoint rate in the lipid-intervention group. The Upjohn Colestipol Study demonstrated statistically significant reductions in overall and ACHD mortality in the men, but not in the women. The Scandinavian.

PMID: 8857853 [PubMed - indexed for MEDLINE]

Adjuvant chemotherapy in colorectal carcinoma: results of a meta-analysis.

Dis Colon Rectum. 1997 Jan;40(1):35-41

Authors: Dubé S, Heyen F, Jenicek M

Despite the National Institutes of Health consensus regarding use of adjuvant chemotherapy in colorectal carcinoma, many general surgeons question the efficacy of this approach when considering costs involved for both the individual patient and society at large. PURPOSE: This study was designed to determine the real impact of adjuvant chemotherapy on five-year survival rates of patients. METHOD: A qualitative and quantitative meta-analysis of results from 39 randomized clinical trials published from 1959 to 1993 is described. RESULTS: Design quality of clinical trials had a mean score of 48.6 percent (+/-6.2 standard deviation). A small benefit of therapy in terms of overall survival was noted, with a mortality odds ratio (OR) of 0.91 (confidence interval (CI) 95 percent, 0.83-0.99). For the group of colon carcinomas, the OR was 0.81 (CI 95 percent, 0.69-0.94) with an OR of 0.64 (CI 95 percent, 0.48-0.85) for the group of rectal carcinomas. The effect size was 0.09 for the colon group and 0.20 for the rectal group. For those patients who receive chemotherapy, this effect size implies that we can expect an increase of 5 percent in the survival rate in the group with colon carcinoma and a 9 percent increase in the survival rate in the group with rectal carcinoma. CONCLUSION: Given the high incidence of colorectal carcinoma, the small benefit observed for those patients receiving chemotherapy is far from negligible. However, indications for adjuvant chemotherapy warrant further discussion.

PMID: 9102259 [PubMed - indexed for MEDLINE]

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Laparoscopic hernioplasty: why does it work?

Surg Endosc. 1997 Jan;11(1):36-41

Authors: Felix EL, Michas CA, Gonzalez MH

BACKGROUND: To understand how laparoscopic hernioplasty prevents early recurrence of hernia, we reviewed our first 1,000 patients. We analyzed the patients by age, sex, and hernia type and by whether their hernia was primary or recurrent. METHODS: The 1,000 patients had 1,336 hernias repaired by the transabdominal preperitoneal or the totally extraperitoneal approach. One thousand one hundred seventy-three hernias were primary and 163 were recurrent. The type of hernia found varied with the patient’s age (p < 0.001), and with whether the hernia was primary or recurrent (p < 0.001); 14% of primary and 27% of recurrent hernias were complex, a surprisingly high incidence compared to historical controls. RESULTS: With a median follow-up of 2 years, five hernias have recurred and all were due to technical errors. CONCLUSIONS: The laparoscopic repair’s success may partially be due to its unique ability to diagnose previously overlooked complex elements. The defects are repaired without creating tension and the groin is reinforced with mesh, eliminating inherent weakness.

PMID: 8994986 [PubMed - indexed for MEDLINE]

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Role of splenectomy in gastric cancer surgery: adverse effect of elective splenectomy on longterm survival.

J Am Coll Surg. 1997 Aug;185(2):177-84

Authors: Wanebo HJ, Kennedy BJ, Winchester DP, Stewart AK, Fremgen AM

BACKGROUND: Splenectomy, and in some cases pancreatico splenectomy, has been advocated by surgeons in an effort to improve clearance of metastatic nodes to splenic hilum (node 10) and splenic artery (node 11). Although splenectomy has known effects on increasing morbidity and even mortality after a variety of surgical maneuvers including gastrectomy, the longterm effect on survival is controversial. The purpose of this study is to review and analyze the effect of splenectomy on survival in patients having curative gastrectomy for stomach cancer. METHODS: We reviewed the role of splenectomy in patients having curative gastrectomy in a data base of stomach cancer patients that had been collected in 1987 as part of an American College of Surgeons Patterns of Care Study. This analysis had involved 18,344 patients, of whom 11,252 were first diagnosed in 1982 as part of a longterm study, and 7,092 were first diagnosed in 1987 as part of a shortterm study. From the two data collection periods information was available on 12,439 patients who received cancer directed abdominal surgery; 21.2% of these patients received a splenectomy. Among the 3,477 patients reported as having a curative gastrectomy (pathologically clear margins), 26.2% received a splenectomy. RESULTS: The operative mortality was 9.8% with splenectomy and 8.6% without splenectomy. In patients having a curative gastrectomy, the 5-year observed survival rate was 20.9% in patients having splenectomy versus 31% in patients who did not receive splenectomy (p < 0.0001). Examination of differences in survival by stage of diagnosis showed significantly reduced survival outcomes among patients with stage II and III, but not for those diagnosed with stage I or IV disease. The pattern of recurrence was moderately different with a larger proportion of patients having distant metastases among the group of patients who had undergone splenectomy compared with the patients who had not, 29% and 15.5%, respectively. Whether these differences are inherent in the splenectomy or in the associated cofactors was not determined in this study. CONCLUSIONS: The data suggest elective splenectomy should generally be avoided in patients with stage II and III gastric cancer. In patients with resectable proximal advanced (stage IV) cancer or who have extension to spleen and pancreas or macroscopic nodal metastases to splenic hilum, splenectomy might be necessary to facilitate complete removal of the tumor in an effort to achieve longterm tumor control. The importance of surgical judgment is emphasized as the major deciding factor in determining the need for splenectomy in the individual cancer patient.

PMID: 9249086 [PubMed - indexed for MEDLINE]

Surgical treatment for carcinoma of the oesophagus in Chinese language publications.

Br J Surg. 1997 Jun;84(6):855-7

Authors: Li H, Yao SC

INTRODUCTION: This review is a meta-analysis of Chinese language publications on surgical treatment for oesophageal cancer. METHODS: Between 1980 and 1994, 17,815 patients had surgery for carcinoma of the oesophagus. The male:female ratio was 3.9:1 and mean age was 51.9 (range 16-80) years. RESULTS: Mean resectability rate was 86.7 per cent and hospital mortality rate was 3.8 per cent. The crude 5-year and 10-year survival rates for all patients were 29.6 and 16.4 per cent respectively. For patients with stage 0 and stage I tumours, the 5-year survival rate was 95 and 89 per cent respectively, significantly greater than that for those with stage II, III and IV tumours (19.4 per cent, P < 0.01). The 5-year survival rate of all 2226 patients with tumour resection after radiotherapy was 38.0 per cent. There was no significant difference in survival following combination therapy compared with surgery alone. When compared with a report for the interval 1940-1979, there was no significant difference in the resectability, hospital mortality or 5-year survival rates. CONCLUSION: Oesophageal carcinoma remains a disease with dismal prognosis but surgery still offers the best chance of long-term survival. Adjuvant therapy has not yet proved an advantage in terms of survival but can be useful for palliation. Mass screening might improve survival but only in a population with a high incidence of oesophageal carcinoma.

PMID: 9189108 [PubMed - indexed for MEDLINE]

Low molecular weight heparin and unfractionated heparin in thrombosis prophylaxis after major surgical intervention: update of previous meta-analyses.

Br J Surg. 1997 Jun;84(6):750-9

Authors: Koch A, Bouges S, Ziegler S, Dinkel H, Daures JP, Victor N

BACKGROUND: Previous meta-analyses comparing low molecular weight heparin (LMWH) and unfractionated heparin for thrombosis prophylaxis after surgical interventions need updating. METHODS: This is a publication-based meta-analysis of 36 double-blind studies including 16583 patients. Main outcome measures are incidence of deep vein thrombosis (efficacy) and wound haematoma (safety). RESULTS: In general surgery there is no increased efficacy in favour of LMWH (odds ratio (OR) 0.88, 95 per cent confidence interval (c.i.) 0.60-1.30) but there exists a higher incidence of bleeding complications (OR 1.47, 95 per cent c.i. 1.07-2.01). Low-dose LMWH is equally efficacious (OR 1.03, 95 per cent c.i. 0.85-1.26) but safer than unfractionated heparin (OR 0.68, 95 per cent c.i. 0.56-0.82). In orthopaedic surgery there is a trend towards an increased efficacy for LMWH (OR 0.83, 95 per cent c.i. 0.68-1.02) with equivalent safety (OR 0.96, 95 per cent c.i. 0.68-1.36). CONCLUSION: A superiority of LMWH is suggested but heterogeneity might make generalizability to future patients questionable. A meta-analysis on individual patient data should be the next step before randomizing additional patients in future trials.

PMID: 9189079 [PubMed - indexed for MEDLINE]

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Meta-analysis of the risk of metachronous hernia in infants and children.

Am J Surg. 1997 Dec;174(6):741-4

Authors: Miltenburg DM, Nuchtern JG, Jaksic T, Kozinetz CA, Brandt ML

BACKGROUND: Inguinal herniorrhaphy is the most common general surgical procedure performed in children. The presence of a contralateral patent processus vaginalis forms the basis of the recommendation for contralateral exploration in patients undergoing unilateral herniorrhaphy. However, a patent processus vaginalis does not necessarily go on to become a clinically apparent inguinal hernia. METHODS: All published pediatric series, in which patients underwent unilateral inguinal hernia repair and were evaluated for the development of a metachronous hernia, were included. The incidence of and risk factors associated with development a metachronous hernia were evaluated with meta-analysis. RESULTS: There were 15,310 patients ranging in age from birth to 16 years, including premature infants. Of these, 1,062 patients (7%) developed a metachronous hernia. Gender and age were not risk factors. There was an 11% risk of metachronous hernia if the original hernia was on the left side, a risk that was 50% greater than if the original hernia was on the right. Of patients who developed a metachronous hernia, 90% did so within 5 years. The complication rate of metachronous hernia was 0.5%. CONCLUSION: There is no role for routine contralateral groin exploration. High-risk infants and children, especially those who undergo left inguinal herniorrhaphy, may benefit from contralateral groin exploration. If a patent processus vaginalis is found, it should be ligated. Patients who do not undergo contralateral groin exploration should be followed up for 5 years.

PMID: 9409609 [PubMed - indexed for MEDLINE]

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Meta-analysis of the clinical outcome of carbapenem monotherapy in the adjunctive treatment of intra-abdominal infections.

Am J Surg. 1997 Sep;174(3):284-90

Authors: Chang DC, Wilson SE

BACKGROUND: The carbapenems, a class of beta-lactam antimicrobials with efficacy against both aerobic and anaerobic organisms, have demonstrated potential as monotherapeutic regimens in the treatment of serious intra-abdominal infections. Clinical trials have been conducted in the past decade to compare carbapenem monotherapy versus combinations of antibiotic therapy. We report here a meta-analysis of 10 such trials. DATA SOURCES: An 11-year Medline search (from 1985 through 1996) of the English-language literature identified clinical trials that compared the outcomes of carbapenem monotherapy, either imipenem/cilastatin or meropenem, versus another antibiotic regimen in intra-abdominal infections in human subjects. Ten randomized, prospective trials were found, with a total of 1,227 clinically evaluable patients. A meta-analysis of these clinical trials was performed to determine the difference in clinical outcomes between carbapenem monotherapy versus other antibiotic regimens. We found a difference in response rates of -1.6% (95% confidence interval [CI] -5.7% to 2.5%) and a response ratio of 0.99 (95% CI, 0.90 to 1.09), indicating no statistical significant difference. CONCLUSIONS: A meta-analysis of 10 clinical trials from 1985 through 1996 has revealed no statistical significant difference in clinical response between carbapenem monotherapy and combinations of antibiotic therapy in intra-abdominal infections. We noted, however, that the earlier studies reported more favorable response ratios for carbapenems than later publications. This may have been due to the selection of less effective comparators in earlier studies. We conclude that carbapenem monotherapy is as effective as combinations of antimicrobials for the treatment of intra-abdominal infections.

PMID: 9324138 [PubMed - indexed for MEDLINE]

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Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies.

Surgery. 1997 Sep;122(3):609-16

Authors: Wade CE, Kramer GC, Grady JJ, Fabian TC, Younes RN

BACKGROUND: Individual trials of small-volume resuscitation of 7.5% NaCl (HS) with and without 6% dextran 70 (HSD) for the treatment of trauma have failed to provide convincing evidence of efficacy. We performed a meta-analysis to evaluate the effects of HS and HSD on survival until discharge or for 30 days. We identified eight double-blinded, randomized controlled trials of HSD and six trials of HS. In all cases, administration of 250 ml of HSD or HS was compared with a control group administration of 250 ml of isotonic crystalloid for the treatment of hypotension either in the field or at admission to the emergency department. METHODS: A fixed-effects meta-analysis was performed with the Mantel-Haenszel method of combining results from multiple studies. RESULTS: Overall, HS was not effective in improving survival with a weighted mean difference in survival of the HS group versus the isotonic control group equal to 0.6%. The results with HSD were more positive, with an increase in survival in seven of eight trials. The mean difference in survival rates favoring HSD (n = 615) over controls (n = 618) was 3.5% (p = 0.14, two-tailed; p = 0.07, one-tailed). The odds ratio was estimated to be 1.20 in favor of HSD with a 95% confidence interval of 0.94 to 1.57. CONCLUSIONS: The meta-analysis of the available data shows that HS is not different from the standard of care and that HSD may be superior.

PMID: 9308620 [PubMed - indexed for MEDLINE]

Handsewn vs. stapled anastomoses in colon and rectal surgery: a meta-analysis.

Dis Colon Rectum. 1998 Feb;41(2):180-9

Authors: MacRae HM, McLeod RS

PURPOSE: Trials comparing handsewn with stapled anastomoses in colon and rectal surgery have not found statistical differences. Despite this, authors have differed in their conclusions as to which technique is superior. To help determine whether differences in patient outcomes are present, a meta-analysis of all trials was performed. METHOD: A meta-analysis of all randomized, controlled trials assessing handsewn and stapled colon and rectal anastomoses was done using a fixed-effects model. Outcome variables were mortality, technical problems, leak rates, wound infections, strictures, and cancer recurrence. Outcomes were assessed for all anastomoses involving the colon and for the subset of colorectal anastomoses. RESULTS: Thirteen distinct trials met the inclusion criteria. Intraoperative technical problems were more likely to occur with stapled than with handsewn anastomoses for all anastomoses (P < 0.0001) and for colorectal anastomoses (P < 0.001). Strictures were also more common following stapled anastomoses (P = 0.015 for all anastomoses; P = 0.028 for colorectal anastomoses). All other outcome measures, including mortality, clinical and radiologic leak rates, and local cancer recurrence rates showed no difference between groups. CONCLUSION: Although intraoperative technical problems and postoperative strictures were more common with stapled anastomoses, other outcome measures showed no difference between groups. Thus, both techniques are effective, and the choice may be based on personal preference.

PMID: 9556242 [PubMed - indexed for MEDLINE]

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Cost-effectiveness of preoperative sestamibi scan for primary hyperparathyroidism is dependent solely upon the surgeon’s choice of operative procedure.

J Am Coll Surg. 1998 Mar;186(3):293-305

Authors: Denham DW, Norman J

BACKGROUND: In 1991, a National Institutes of Health Consensus Panel stated that preoperative localization for primary hyperparathyroidism is not cost effective. Since then, the sestamibi scan has been applied to parathyroid disease with excellent results, even allowing unilateral exploration under local anesthesia. STUDY DESIGN: A metaanalysis of the English literature over the past 10 years was performed to determine the collective sensitivity and specificity of sestamibi scanning to establish its utility in directing a unilateral procedure. The cost effectiveness of scanning all patients with sporadic primary hyperparathyroidism was examined by determining the costs of seven operative technique-dependent variables that could be reduced with a limited procedure. RESULTS: The average sensitivity and specificity of sestamibi were 90.7% and 98.8%, respectively, indicating its ability to guide an accurate unilateral exploration. The analysis of 6,331 patients showed that 87% had solitary adenomas. An average cost savings of $650 was demonstrated for a unilateral operation, which could be realized in as many as 90% (sestamibi sensitivity) of those with solitary adenomas. CONCLUSIONS: A preoperative sestamibi scan is specific enough in identifying solitary adenomas to allow unilateral exploration with a < 1% failure rate. The sensitivity of this scan suggests that 78% of all patients with sporadic primary hyperparathyroidism (90% of the 87% with solitary adenomas) are candidates for unilateral exploration. This rate is significantly higher than the 51% rate at which scanning all patients becomes cost effective.

PMID: 9510260 [PubMed - indexed for MEDLINE]

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Perioperative allogeneic blood transfusion does not cause adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies.

Br J Surg. 1998 Feb;85(2):171-8

Authors: McAlister FA, Clark HD, Wells PS, Laupacis A

BACKGROUND: There is controversy over whether perioperative allogeneic red blood cell transfusions are associated with an increased risk of cancer recurrence, postoperative infection or death in patients with cancer undergoing surgery. METHODS: A systematic meta-analysis was performed to answer this question. Studies were identified from electronic databases (Medline 1966-1997, Cancerlit 1983-1997, Current Contents, Cinahl 1982-1996, Healthstar 1990-1997, Bioabstracts 1990-1996 and Embase), by hand search of the bibliographies of identified studies and relevant journals, and by contact with experts in the field. All randomized controlled trials or prospective cohort studies with active comparator controls (autologous or leucocyte-depleted allogeneic blood) were eligible for inclusion if they reported on mortality, infection or recurrence rate in patients with cancer undergoing potentially curative surgical resection. The validity of the identified studies was assessed by means of a standardized scale, and data abstraction was carried out by two investigators independently. A random effects model was used for data synthesis. RESULTS: Of the 2172 references identified, only 17 studies fulfilled the inclusion criteria. After exclusion of duplicate publications, six randomized controlled trials and two prospective cohort studies with appropriate concurrent controls were included in the analysis. The summary risk ratios were 0.95 (95 per cent confidence interval (c.i.) 0.79-1.15) for all-cause mortality and 1.06 (95 per cent c.i. 0.88-1.28) for cancer recurrence, the two endpoints that were appropriate to combine statistically. There was significant heterogeneity (explainable by differences in study design and patient characteristics) in the postoperative infection data and the summary risk ratio was 1.00 (95 per cent c.i. 0.76-1.32) for the four studies that were appropriate to subject to meta-analysis. Given the sample sizes of these eight studies, this meta-analysis had insufficient power to detect a relative difference of less than 20 per cent in the frequency of death, cancer recurrence or infection between the allogeneic and control transfusion arms. CONCLUSION: Although more studies are required before a definitive statement can be made, at this time there is no evidence that allogeneic blood transfusion increases the risk of clinically important adverse sequelae in patients with cancer undergoing surgery.

PMID: 9501809 [PubMed - indexed for MEDLINE]

Effect of perioperative blood transfusions on recurrence of colorectal cancer: meta-analysis stratified on risk factors.

Dis Colon Rectum. 1998 May;41(5):570-85

Authors: Amato AC, Pescatori M

PURPOSE: This study was undertaken to evaluate the influence of perioperative blood transfusions on colorectal cancer recurrence. METHODS: All articles published up to December 1996 in English (or with an English abstract) were retrieved, both using MEDLINE and scanning their references, to be considered for this meta-analysis. RESULTS: One hundred thirty-one articles were identified, and 99 of them were excluded because they analyzed survival or mortality, were repetitive publications, or were reviews or letters. Thirty-two original studies (9 were prospective) on 11,071 patients were included for further analysis; 20 showed a detrimental effect of perioperative blood transfusions. Nineteen articles used also multivariable techniques, and 11 found perioperative blood transfusions to be an independent prognostic factor. Pooled estimates of the effect of perioperative blood transfusions on colorectal cancer recurrence yielded an overall odds ratio of 1.68 (95 percent confidence interval, 1.54-1.83) and a rate difference of 0.13 (95 percent confidence interval, 0.09-0.17) against patients who received transfusions. Stratified meta-analyses also confirmed these findings when stratifying patients by site and stage of disease. The effect of perioperative blood transfusion was observed in a dose-related fashion, regardless of timing and type, although some heterogeneity was detected. Data on surgical techniques were not available for further analysis. CONCLUSIONS: A consistently detrimental association was discovered between the use of perioperative blood transfusion and colorectal cancer recurrence. Further studies are needed to confirm that blood transfusion has a causal association.

PMID: 9593238 [PubMed - indexed for MEDLINE]

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Laparoscopic versus open appendectomy: a metaanalysis.

J Am Coll Surg. 1998 May;186(5):545-53

Authors: Golub R, Siddiqui F, Pohl D

BACKGROUND: There have been numerous retrospective and uncontrolled series of laparoscopic appendectomy (LA), as well as 16 prospective randomized studies published to date. Although most of these have concluded that the laparoscopic technique is as least as good as open appendectomy (OA), there has been considerable controversy as to whether LA is superior. To help clarify this issue, we performed a metaanalysis of the randomized prospective studies. STUDY DESIGN: A metaanalysis of all formally randomized prospective trials of LA versus OA in adults. RESULTS: A total of 1,682 patients were analyzed. When compared with OA, LA results in significantly less postoperative pain, earlier resumption of solid foods, a shorter hospital stay, and a faster return to normal activities. The wound infection rate in the LA patients is less than one half the rate in patients undergoing OA. LA, however, requires longer operating times and the incidence of intraabdominal abscess is higher, but this failed to reach statistical significance. There were no differences in complications or hospital charges. CONCLUSIONS: LA offers considerable advantages over OA, primarily because of its ability to reduce the incidence of wound infections and shorten recovery times. Its widespread acceptance should be considered. The trend toward increased intraabdominal abscess formation is worrisome, however, and demands further investigation.

PMID: 9583695 [PubMed - indexed for MEDLINE]

Follow-up of colorectal cancer: a meta-analysis.

Dis Colon Rectum. 1998 Sep;41(9):1116-26

Authors: Rosen M, Chan L, Beart RW, Vukasin P, Anthone G

PURPOSE: The value of intensive follow-up for patients after resection of colorectal cancer remains controversial. This study reviews all randomized and prospective cohort studies to assess the value of aggressive follow-up. METHODS: The literature was searched from the years 1972 to 1996 for studies reporting on the follow-up of patients with colorectal cancer. Randomized and comparative-cohort studies that included history, physical examination, and carcinoembrionic antigen values at least three times a year for at least two years were included in a meta-analysis. Single-cohort studies with intensive follow-up and traditional follow-up were also included in a two-group comparative analysis for each outcome indicator. Outcome indicators were 1) curative resection rates after recurrent cancer, 2) survival rates of curative re-resections, 3) length of survival after recurrence, and 4) cumulative five-year survival. RESULTS: Two randomized and three comparative-cohort studies met these criteria and included 2,005 patients, which were evaluated in the meta-analysis. The cumulative five-year survival was 1.16 times higher in the intensively followed group (P = 0.003). Two and one-half times more curative re-resections were performed for recurrent cancer in those patients undergoing intensive follow-up (P = 0.0001). Those patients in the intensive follow-up group with a recurrence had a 3.62-times higher survival rate than the control (P = 0.0004). Fourteen single-cohort studies were also included in the comparative analysis of 6,641 patients. The findings from these aggregated studies support the results of the meta-analysis. CONCLUSION: Our study concludes that intensive follow-up detects more recurrent cancers at a stage amenable to curative resection, resulting in an improvement in survival of recurrences and an increased overall five-year cumulative rate of survival.

PMID: 9749495 [PubMed - indexed for MEDLINE]

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Penetrating cardiac injuries: a population-based study.

J Trauma. 1998 Aug;45(2):366-70

Authors: Rhee PM, Foy H, Kaufmann C, Areola C, Boyle E, Maier RV, Jurkovich G

BACKGROUND: Wide variances exist in reports of survival rates after penetrating cardiac injuries because most are hospital-based reports and thus are affected by the local trauma system. The objective of this study was to report population-based, as well as hospital-based, survival rates after penetrating cardiac injury. METHODS: Retrospective cohort analysis was performed during a 7-year period of 20,181 consecutive trauma admissions to a regional Level I trauma center and 6,492 medical examiner’s reports. A meta-analysis was performed comparing survival rates with available population-based reports. RESULTS: There were 212 penetrating cardiac injuries identified, for an incidence of approximately 1 per 100,000 man years and 1 per 210 admissions. The overall survival rate was 19.3% (41 of 212) for the population studied, with survival rates of 9.7% (12 of 123) for gunshot wounds and 32.6% (29 of 89) for stab wounds. Ninety-six of the 212 patients were transported to the trauma center for treatment, resulting in an overall hospital survival rate of 42.7% (41 of 96), with a hospital survival rate of 29.3% (12 of 41) for gunshot wounds and 52.7% (29 of 55) for stab wounds. CONCLUSION: Review of population-based studies indicates that there has been only a minor improvement in the survival rates for the treatment of penetrating cardiac injuries.

PMID: 9715197 [PubMed - indexed for MEDLINE]

What is the role of mechanical bowel preparation in patients undergoing colorectal surgery?

Dis Colon Rectum. 1998 Jul;41(7):875-82; discussion 882-3

Authors: Platell C, Hall J

BACKGROUND: Most surgeons use mechanical bowel preparation before performing operations on the colon and rectum. The aim of this study is to determine if there is any published literature that supports this practice. METHODS: We undertook a review of the literature on the benefits of mechanical bowel preparation in patients undergoing surgery on the colon and rectum. A meta-analysis was conducted on all available clinical trials addressing this issue. RESULTS: A meta-analysis of three clinical trials revealed a significantly greater incidence of wound infection in patients who received a mechanical bowel preparation (10.8 vs. 7.4 percent; P < 0.002; 95 percent confidence interval of the difference, -1.6-8.4 percent). Patients who received mechanical bowel preparation had an incidence of anastomotic leakage that was twice that of control patients; however, this difference was not significant (8.1 vs. 4 percent; P < 0. 1 14; 95 percent confidence interval of the difference, -0.4-8.4 percent). CONCLUSION: There is limited evidence in the literature to support the use of mechanical bowel preparation in patients undergoing colorectal surgery. Hence, there is a need for clinical trials comparing the more traditional, aggressive forms of bowel preparation (e.g., polyethylene glycol solutions, sodium phosphate) with either no preparation or simpler techniques, such as a single phosphate enema.

PMID: 9678373 [PubMed - indexed for MEDLINE]

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Choosing the best abdominal closure by meta-analysis.

Am J Surg. 1998 Dec;176(6):666-70

Authors: Weiland DE, Bay RC, Del Sordi S

BACKGROUND: Local custom, rather than evidence-based medicine, dictates how a surgeon closes abdominal wounds. Closures might be more secure if grounded on statistical data. MATERIALS AND METHODS: A meta-analysis of 12,249 patients with abdominal wound closures was made. Infections, hernias, and dehiscences were compared examining continuous versus interrupted closures, continuous (absorbable versus nonabsorbable), interrupted (absorbable versus nonabsorbable), and mass versus layered. RESULTS: Continuous absorbable closures showed more hernias (P = 0.0007). Dehiscences were significantly more with continuous nonabsorbable suture (P = 0.01). Interrupted nonabsorbable closures showed a higher incidence of hernias and dehiscences (P = 0.0002, P = 0.04). Mass closures produced significantly less hernias and dehiscences when compared with layered closures (P = 0.02, P = 0.0002). CONCLUSIONS: Continuous closures with nonabsorbable suture should be used to close most abdominal wounds. However, if infection or distention is anticipated, interrupted absorbable sutures are preferred. Mass closures are superior to layered closures.

PMID: 9926810 [PubMed - indexed for MEDLINE]

The results of colorectal cancer treatment by p53 status: treatment-specific overview.

Dis Colon Rectum. 2001 Mar;44(3):322-33; discussion 333-4

Authors: Petersen S, Thames HD, Nieder C, Petersen C, Baumann M

PURPOSE: Both negative and positive influences of mutant p53 on treatment outcome have been reported, and we present here a meta-analysis of published studies where outcome was reported for defined treatment groups. METHODS: We identified articles on the effect of p53 status by treatment modality, excluding those not stratified by method of treatment. A common hazard ratio was estimated from studies that reported a multivariate analysis. We also estimated the numbers of patients expressing the endpoint at the mean or median follow-up time and calculated a pooled odds ratio. RESULTS: Twenty-eight articles were evaluable (23 using immunohistochemistry to detect overexpression of p53 and 8 using DNA sequencing), for a total of 4,416 patients. For patients treated with surgery only, the immunohistochemistry studies showed a significant influence of p53 status on disease-free survival and a marginally significant influence on overall survival. In the studies using DNA sequencing, by contrast, there was a significant influence of p53 mutations on overall survival, but not disease-free survival. For patients treated with surgery and radiotherapy, the influence of p53 status on disease-free survival was either insignificant or marginally significant, depending on test used; there was no influence on overall survival. CONCLUSIONS: Although this pooled analysis of published studies where treatment was accounted for shows that there is a borderline significant hazard associated with p53 overexpression or mutation vs. p53 wild-type, it is unlikely that p53 can be applied in a routine clinical setting alongside factors such as T stage, nodal status, and residual tumor, whose prognostic value is much stronger.

PMID: 11289276 [PubMed - indexed for MEDLINE]

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Appendectomy and subsequent risk of inflammatory bowel diseases.

Surgery. 2001 Jul;130(1):36-43

Authors: Frisch M, Johansen C, Mellemkjaer L, Engels EA, Gridley G, Biggar RJ, Olsen JH

BACKGROUND: Case-control studies have reported an inverse relationship between appendectomy and the risk of ulcerative colitis, but the association has not been confirmed in prospective studies. METHODS: Using national hospital discharge registry data in Denmark, the authors followed up 154,434 patients who underwent appendectomy during the period 1977 to 1989 to investigate whether they had subsequent hospitalizations for ulcerative colitis and Crohn’s disease. Ratios of observed-to-expected first hospitalizations for inflammatory bowel diseases served as measures of the relative risk (RR). RESULTS: Hospitalization for ulcerative colitis occurred in 84 patients who had appendectomies versus 97.0 expected (RR = 0.87; 95% CI, 0.69-1.07). RRs were not significantly reduced in subgroups defined by sex, age, time since appendectomy, calendar period, or cause of appendectomy. Hospitalization for Crohn’s disease occurred in excess (RR = 2.88; 95% CI, 2.45-3.39; n = 150), notably in the first year after appendectomy (RR = 10.83; 95% CI, 8.49-13.62; n = 73); but after 5 years, the RR was not significantly elevated. CONCLUSIONS: This large population-based cohort study failed to support a significant inverse association between appendectomy and ulcerative colitis risk in the first decade after the operation. The excess of Crohn’s disease shortly after appendectomy most likely reflects differential diagnostic problems in patients newly presenting with abdominal pain.

PMID: 11436010 [PubMed - indexed for MEDLINE]

Biofeedback treatment of fecal incontinence: a critical review.

Dis Colon Rectum. 2001 May;44(5):728-36

Authors: Heymen S, Jones KR, Ringel Y, Scarlett Y, Whitehead WE

PURPOSE: The aims of this review are 1) to critically evaluate the literature on the efficacy of biofeedback treatment for fecal incontinence, 2) to compare different types of biofeedback, and 3) to identify patient characteristics which predict a successful outcome. METHODS: The MEDLINE database was searched for articles published between 1973 and 1999 which included the terms “biofeedback” and “fecal incontinence.” Pediatric and adult articles in any language were screened. Inclusion for review required that the study be prospective, have five or more subjects, and have a description of the treatment protocol. RESULTS: Thirty-five studies were reviewed. Only six studies used a parallel treatment design and just three of those randomized subjects to treatment groups. A meta-analysis (weighted by subjects) was performed to compare the results of two treatment protocols that dominate the literature. The mean success rate of studies using Coordination training (i.e., coordinating pelvic floor muscle contraction with the sensation of rectal filling) was 67 percent, while the mean success rate for studies using Strength training (i.e., pelvic floor muscle contraction) was 70 percent. Furthermore, the mean success rate for those Strength training studies using electromyographic biofeedback was 74 percent, while the mean success rate for studies using anal canal pressure biofeedback Strength training was 64 percent. However, these conclusions are limited by the absence of clearly identified criteria for determining success. There are also inconsistencies in the literature regarding the patient selection criteria, severity and cause of symptoms, amount of treatment, as well as the type of biofeedback protocols and instrumentation used. Finally, no patient characteristics were identified that would assist in predicting successful outcome. CONCLUSION: Although most studies report positive results using biofeedback to treat fecal incontinence, quality research is lacking. Recommendations are made for future investigations to 1) improve experimental design, 2) include long term follow-up data, and 3) to use an adequate sample size that allows for meaningful analysis.

PMID: 11357037 [PubMed - indexed for MEDLINE]

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Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery.

Br J Surg. 2001 Jul;88(7):913-30

Authors: Mismetti P, Laporte S, Darmon JY, Buchmüller A, Decousus H

BACKGROUND: Low molecular weight heparins (LMWHs) have become routine thromboprophylaxis in general surgery. However, their actual clinical effect, its magnitude relative to that of unfractionated heparin (UFH), and the optimal dose are still debated. METHODS: A meta-analysis was performed of all available randomized trials in general surgery comparing LMWH with placebo or no treatment, or with UFH. RESULTS: Comparison versus placebo or no treatment confirmed that the significant reduction in asymptomatic deep vein thrombosis (DVT) obtained with LMWH (n = 513; relative risk (RR) 0.28 (95 per cent confidence interval 0.14-0.54)) was associated with a significant reduction in clinical pulmonary embolism (n = 5456; RR 0.25 (0.08-0.79)) and clinical venous thromboembolism (VTE) (n = 4890; RR 0.29 (0.11-0.73)), and a trend towards a reduction in overall mortality rate. Comparison versus UFH showed a trend in favour of LMWH, with a significant reduction in clinical VTE (P = 0.049), a trend also found for cancer surgery. LMWH at doses below 3400 anti-Xa units seemed to be as effective as, and safer than, UFH, while higher doses yielded slightly superior efficacy but increased haemorrhagic risk, including that of major haemorrhage. CONCLUSION: Asymptomatic DVT may be regarded as a reliable surrogate endpoint for clinical outcome in studies investigating thromboprophylaxis in general surgery. LMWH seems to be as effective and safe as UFH. Determination of the optimal dose regimen of LMWH for this indication requires further investigation.

PMID: 11442521 [PubMed - indexed for MEDLINE]

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Laparoscopic-assisted resection of colorectal malignancies: a systematic review.

Ann Surg. 2001 Nov;234(5):590-606

Authors: Chapman AE, Levitt MD, Hewett P, Woods R, Sheiner H, Maddern GJ

OBJECTIVE: To compare the safety and efficacy of laparoscopic-assisted resection of colorectal malignancies with open colectomy. METHODS: Two search strategies were devised to retrieve literature from the Medline, Current Contents, Embase, and Cochrane Library databases until July 1999. Inclusion of papers was determined using a predetermined protocol, independent assessments by two reviewers, and a final consensus decision. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials, case series, or case reports. Fifty-two papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding, and chance. RESULTS: Little high-level evidence was available. Laparoscopic resection of colorectal malignancy was more expensive and time-consuming, but little evidence suggests high rates of port site recurrence. The new procedure’s advantages revolve around early recovery from surgery and reduced pain. CONCLUSIONS: The evidence base for laparoscopic-assisted resection of colorectal malignancies is inadequate to determine the procedure’s safety and efficacy. Because of inadequate evidence detailing circumferential marginal clearance of tumors and the necessity of determining a precise incidence of cardiac and other major complications, along with wound and port site recurrence, it is recommended that a controlled clinical trial, ideally with random allocation to an intervention and control group, be conducted. Long-term survival rates need to be a primary aim of such a trial.

PMID: 11685021 [PubMed - indexed for MEDLINE]

Local excision of rectal cancer: what is the evidence?

Dis Colon Rectum. 2001 Sep;44(9):1345-61

Authors: Sengupta S, Tjandra JJ

PURPOSE: Although local excision of rectal cancers is a less morbid alternative to radical resection, its role as a curative procedure is unclear. The role of adjuvant therapy after local excision is also controversial. This review aims to examine current evidence on local excision of rectal cancers and how it fits into the management algorithm for rectal cancer. METHODS: A literature review was undertaken through the MEDLINE database and by cross-referencing previous publications, thus identifying 41 studies on curative local excision of rectal cancer published in English. Details of preoperative staging, surgical procedures, adjuvant therapy, follow-up, and outcome measures, including complications, survival data, recurrences, and salvage were examined. RESULTS: Preoperative staging of rectal cancers is variable. Digital rectal examination and computerized tomography are used in most studies. Endorectal ultrasound is used in some patients in 9 of 41 studies. Local excision preserves anorectal function, and seems to have limited morbidity (0-22 percent). Local excision alone is associated with local recurrences in 9.7 (range, 0-24) percent of T1, 25 (range, 0-67) percent of T2 and 38 (range, 0-100) percent of T3 cancers. The addition of adjuvant chemoradiotherapy after local excision yields local recurrence rates of 9.5 (range, 0-50) percent for T1, 13.6 (range, 0-24) percent for T2, and 13.8 (range, 0-50) percent for T3 cancers. Data on local excision after preoperative chemoradiotherapy for tumor down staging are limited. Factors other than T-stage that lead to higher local recurrence rates after local excision include poor histologic grade, the presence of lymphovascular invasion, and positive margins. Local recurrences after local excision can be surgically salvaged (84 of 114 patients in 15 studies), with a disease-free survival rates between 40 and 100 percent at a follow-up of 0.1 to 13.5 years. CONCLUSIONS: Local excision for rectal cancers is associated with a low morbidity and provides satisfactory local control and disease-free survival rates for T1 rectal cancers. There is, however, a need for a randomized, controlled trial for T2 cancers, comparing local excision with adjuvant chemoradiotherapy to radical resection.

PMID: 11584215 [PubMed - indexed for MEDLINE]

Converted laparoscopic colorectal surgery.

Surg Endosc. 2001 Aug;15(8):827-32

Authors: Gervaz P, Pikarsky A, Utech M, Secic M, Efron J, Belin B, Jain A, Wexner S

BACKGROUND: Conversion rates following laparoscopic colorectal surgery vary widely between studies, and the outcome of converted patients remains controversial. METHODS: A comprehensive search of the English-language literature was updated until May 1999. RESULTS: Twenty-eight studies on 3232 patients were considered for analysis. The overall conversion rate was 15.38%. Seventy nine percent of the studies did not include a definition for conversion; in these studies, the conversion rate was significantly lower than in the series where a specific definition was considered (13.7% vs 18.9%, chi-square test, p < 0.001). Converted patients had a prolonged hospital stay (11.38 vs 7.41 days) and operative time (209 vs 189 min) in comparison with laparoscopically completed patients (95% confidence interval (CI), 1.70-4.00 and 35.90-37.10, respectively). The factors associated with an increased rate for conversion were left colectomy (Odds Ratio [OR] = 1.061), anterior resection of the rectum (OR = 1.088), diverticulitis (OR = 1.302), and cancer (OR = 2.944) (for each parameter, Wald chi-square value, p < 0.001). CONCLUSIONS: In nonrandomized studies, the rate of laparoscopically completed colorectal resections is close to 85%. Because converted patients have a distinct outcome, a clear definition of conversion is required to compare the results of randomized trials. Such trials should also consider a 20% rate of conversion when estimating the sample size for the desired power level. It is likely that converted patients will have a significant impact on the results of future clinical research in laparoscopic colorectal surgery.

PMID: 11443444 [PubMed - indexed for MEDLINE]

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Can we do better with postoperative pain management?

Am J Surg. 2001 Nov;182(5):440-8

Authors: Huang N, Cunningham F, Laurito CE, Chen C

BACKGROUND: In the last decade, there has been heightened awareness that pain management needs to be a priority for all health care settings and clinicians. The article will overview practice guidelines and new technology, and assess their impact on pain relief in inpatient and outpatient surgeries from a patient’s perspective. METHODS: Literature was retrieved by searches from 1996 to 2000 Medline and CINAHL (nursing database), using keywords “postoperative pain,” “postsurgical pain,” “patient outcomes,” “pain outcomes,” “survey,” “questionnaire,” and “practice guidelines.” RESULTS: Overall, current practice standards have had minimal impact on decreasing patients’ reports of pain. The incidence of moderate to severe pain with cardiac, abdominal, and orthopedic inpatient procedures has been reported as high as 25% to 50%, and incidence of moderate pain after ambulatory procedures is 25% or higher. CONCLUSIONS: Despite the advances, the incidence of pain remains high. Yet the future is promising, with new standards from the Joint Commission on Accreditation of Health care Organizations paving the way for reduction of institutional barriers and improved implementation of guidelines.

PMID: 11754848 [PubMed - indexed for MEDLINE]

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Ligation versus anticoagulation: treatment of above-knee superficial thrombophlebitis not involving the deep venous system.

J Am Coll Surg. 2001 Nov;193(5):556-62

Authors: Sullivan V, Denk PM, Sonnad SS, Eagleton MJ, Wakefield TW

PMID: 11708514 [PubMed - indexed for MEDLINE]

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A meta-analysis of randomized controlled trials of route of reconstruction after esophagectomy for cancer.

Am J Surg. 2001 Nov;182(5):470-5

Authors: Urschel JD, Urschel DM, Miller JD, Bennett WF, Young JE

BACKGROUND: A gastric conduit is usually used to reconstruct the foregut after esophagectomy for cancer. It can be transposed through a posterior or anterior mediastinal route. The choice of route is often debated but there is little evidence to support the use of one route over the other. We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of route of reconstruction on patient outcomes. METHODS: Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of route of gastric conduit reconstruction after esophagectomy for cancer. The selection process was inclusive; no trials were excluded. Trial validity assessment was done and a trial quality score was assigned. Major outcomes for quantitative data synthesis included operative mortality, anastomotic leaks, cardiac morbidity, and pulmonary morbidity. A random-effects model was used and relative risk was the principal measure of effect. Systematic qualitative review was used for other outcomes such as duration of ventilation, length of hospital stay, operative blood loss, duration of surgery, anastomotic strictures, dysphagia, gastric emptying, and quality of life. Data on cancer survival were not available in the RCTs. RESULTS: Six RCTs were selected with quality scores ranging from 1 to 4 (5-point Jadad scale). Selection and validity agreement was strong. Relative risk (95% confidence interval; P value), expressed as posterior versus anterior mediastinal route (treatment versus control), was 0.56 (0.17, 1.82; P = 0.34) for mortality, 1.01 (0.35, 2.94; P = 0.98) for leaks, 0.43 (0.17, 1.12; P = 0.08) for cardiac complications, and 0.67 (0.34, 1.33; P = 0.26) for pulmonary complications. Systematic qualitative review did not suggest any difference in other perioperative outcomes or conduit function for the two routes of reconstruction. CONCLUSIONS: Data synthesized from existing RCTs show that posterior and anterior mediastinal routes of reconstruction are associated with similar outcomes after esophagectomy for cancer. However, a difference in outcomes for the two reconstructive routes remains possible. Further trials with larger numbers of patients are needed.

PMID: 11754853 [PubMed - indexed for MEDLINE]

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Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy.

Am J Surg. 2002 Jan;183(1):42-52

Authors: Poon RT, Lo SH, Fong D, Fan ST, Wong J

BACKGROUND: Leakage at the pancreaticoenteric anastomosis remains a common and serious complication after pancreaticoduodenectomy. Over the past decade, various measures directed towards prevention of pancreatic leakage have been studied. This article reviews the available data on the efficacy of these measures. DATA SOURCES: The Medline database from 1990 to 2000 was searched for studies on the prevention of pancreatic anastomotic leakage, and the bibliographies of the articles were reviewed for additional references. RESULTS: A meta-analysis of the results of prophylactic octreotide in preventing pancreatic fistula after pancreaticoduodenectomy from data available in three randomized controlled studies yielded an odds ratio of 1.08 (95% confidence interval 0.64 to 1.84). Pending further trials to clarify its role, the routine use of octreotide in pancreaticoduodenectomy cannot be recommended. Retrospective or nonrandomized prospective studies suggested that technical modifications such as duct-to-mucosa anastomosis, pancreaticogastrostomy and external pancreatic duct stenting may reduce the leakage rate, but there is a paucity of randomized trials. A randomized trial comparing pancreaticogastrostomy and pancreaticojejunostomy did not reveal a significant difference in the leakage rate. CONCLUSIONS: Further randomized controlled studies are required to determine the optimum technique of pancreaticoenteric anastomosis after pancreaticoduodenectomy.

PMID: 11869701 [PubMed - indexed for MEDLINE]

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Laparoscopic herniorrhaphy: beyond the learning curve.

J Am Coll Surg. 2002 Jan;194(1):65-73

Authors: DeTurris SV, Cacchione RN, Mungara A, Pecoraro A, Ferzli GS

PMID: 11800341 [PubMed - indexed for MEDLINE]

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Intrapelvic complications after total hip arthroplasty failure.

Am J Surg. 2002 Jan;183(1):75-9

Authors: Bach CM, Steingruber IE, Ogon M, Maurer H, Nogler M, Wimmer C

BACKGROUND: Severe total hip arthroplasty failure with central migration of prosthetic components is uncommon. If perforation of the medial acetabular wall occurs, injuries of intrapelvic structures may result. DATA SOURCES: A meta-analysis of the English literature was performed. A human pelvic cadaver was used to demonstrate the proximity of intrapelvic structures to a centrally dislocated cup. RESULTS: Fifty cases of intrapelvic injury were identified. Structures involved most frequently were the external iliac artery and the bladder. The most common types of complication included fistula formation, development of a false aneurysm, and hemorrhage. The human cadaver pelvis demonstrated the proximity of intrapelvic vessels, the bladder, the ureter, the vagina, the deferent duct, the sigmoid colon, the rectum, and the sciatic nerve to an intrapelvically intruded prosthesis. CONCLUSIONS: Failed total hip replacements should be considered to cause damage to pelvic viscera.

PMID: 11869708 [PubMed - indexed for MEDLINE]

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Elective lymph node dissection in patients with melanoma: systematic review and meta-analysis of randomized controlled trials.

Arch Surg. 2002 Apr;137(4):458-61

Authors: Lens MB, Dawes M, Goodacre T, Newton-Bishop JA

HYPOTHESIS: Elective lymph node dissection does not improve survival in patients with melanoma without clinically detectable lymph node metastases. OBJECTIVE: To determine whether elective lymph node dissection in patients with melanoma without clinically detectable regional metastases decreases overall mortality. DESIGN: Systematic review and meta-analysis of randomized controlled trials comparing elective lymph node dissection with delayed lymphadenectomy at the time of clinical recurrence. SETTING: Randomized controlled trials available by February 2001. SUBJECTS: The included trials comprised 1533 participants. INTERVENTION: Elective lymph node dissection compared with delayed lymphadenectomy or no lymphadenectomy in patients with melanoma without clinically detectable regional metastases. MAIN OUTCOME MEASURE: Overall mortality in treatment groups as compared with control groups at the end of a 5-year follow-up period. RESULTS: Three randomized controlled trials met the inclusion criteria. The pooled odds ratio for overall mortality for the 3 trials was 0.86 (95% confidence interval, 0.68-1.09). Results are statistically nonsignificant, but they have potential clinical significance. CONCLUSIONS: This systematic review of randomized controlled trials comparing elective lymph node dissection with surgery delayed until the time of clinical recurrence shows no significant overall survival benefit for patients undergoing elective lymph node dissection. Trials included in this review, however, contain significant bias. The question is not answered for all patients, and the results do not exclude the possibility that some subgroups may benefit from elective lymph node dissection. Further research is required.

PMID: 11926952 [PubMed - indexed for MEDLINE]

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Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials.

Ann Surg. 2002 Mar;235(3):322-32

Authors:

OBJECTIVE: To measure the effects of laparoscopic and open placement of synthetic mesh on recurrence and persisting pain following groin hernia repair. SUMMARY BACKGROUND DATA: Synthetic mesh techniques are claimed to reduce the risk of recurrence but there are concerns about costs and possible long-term complications, particularly pain. METHODS: Electronic databases were searched and experts consulted to identify randomized or quasi-randomized trials that compared mesh with non-mesh methods, or laparoscopic with open mesh placement. Individual patient data were sought for each trial. Aggregated data were used where individual patient data were not available. Meta-analyses of hernia recurrence and persisting pain were based on intention to treat. RESULTS: There were 62 relevant comparisons in 58 trials. These included 11,174 participants: individual patient data were available for 6,901 patients, supplementary aggregated data for 2,390 patients, and published data for 1883 patients. Recurrence and persisting pain were less after mesh repair (overall recurrences: 88 in 4,426 vs. 187 in 3,795; OR 0.43, 95% CI 0.34-0.55; P <.001) (overall persistent pain: 120 in 2,368 vs. 215 in 1,998; OR 0.36, 95% CI 0.29-0.46; P <.001), regardless of the non-mesh comparator. Whereas the reduction in recurrence was similar after laparoscopic and open mesh placement (OR 1.26, 95% CI 0.76-2.08; P =.36), persistent pain was less common after laparoscopic than open mesh placement (OR 0.64; 95% CI 0.52-0.78; P <.001). CONCLUSIONS: The use of synthetic mesh substantially reduces the risk of hernia recurrence irrespective of placement method. Mesh repair appears to reduce the chance of persisting pain rather than increase it.

PMID: 11882753 [PubMed - indexed for MEDLINE]

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Systematic review of the use of fibrin sealant to minimize perioperative allogeneic blood transfusion.

Br J Surg. 2002 Jun;89(6):695-703

Authors: Carless PA, Anthony DM, Henry DA

BACKGROUND: Fibrin sealants have become popular in improving perioperative haemostasis and reducing the need for allogeneic red cell transfusion. METHODS: A systematic review of randomized controlled trials was conducted to examine the efficacy of fibrin sealants in reducing perioperative blood loss and allogeneic red blood cell transfusion. Studies were identified by computer searches of Medline, Embase, Current Contents, the Cochrane Library, manufacturer websites (to January 2001), and bibliographic searches of published articles. Trials were eligible for inclusion if they involved adult elective surgery and reported quantitative data on blood loss, the proportion of patients exposed to allogeneic red cell transfusion and/or the volume of blood transfused. RESULTS: Twelve trials met the criteria for inclusion. Fibrin sealants reduced the rate of allogeneic blood transfusion (relative risk 0.40 (95 per cent confidence interval (c.i.) 0.26 to 0.61); five trials with 275 subjects) and reduced blood loss (weighted mean difference–151.68 (95 per cent c.i. – 251.91 to – 51.46) ml; seven trials with 391 subjects). Generally, the trials were small and of poor methodological quality. CONCLUSION: Overall the results suggest that fibrin sealants are efficacious. Owing to lack of blinding, transfusion practices may have been influenced by knowledge of the patient’s treatment status. This raises concern about blood transfusion practice as a response variable. Large methodologically rigorous trials of fibrin sealants with clinical outcomes are needed.

PMID: 12027978 [PubMed - indexed for MEDLINE]

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A meta-analysis of randomized controlled trials that compared neoadjuvant chemotherapy and surgery to surgery alone for resectable esophageal cancer.

Am J Surg. 2002 Mar;183(3):274-9

Authors: Urschel JD, Vasan H, Blewett CJ

BACKGROUND: Esophagectomy is often considered the standard treatment for resectable esophageal cancer but the rate of cure is low. Combining neoadjuvant chemotherapy with surgery has theoretical appeal and some clinical evidence suggests a benefit. We performed a meta-analysis of randomized controlled trials (RCTs) that compared neoadjuvant chemotherapy and surgery with surgery alone for esophageal cancer. METHODS: Medline and manual searches were done to identify all published RCTs that compared neoadjuvant chemotherapy and surgery to surgery alone for esophageal cancer. The selection process was inclusive; no trials were excluded. Trial validity assessment was done and a trial quality score was assigned. Outcomes assessed by meta-analysis included 1-, 2-, and 3-year survival, rate of resection, rate of complete resection, operative mortality, anastomotic leaks, postoperative pulmonary complications, all treatment mortality, local-regional cancer recurrence, distant cancer recurrence, and all cancer recurrence. A random-effects model was used and odds ratio was the principal measure of effect. Systematic quantitative review was done for outcomes unique to the neoadjuvant chemotherapy treatment group (clinical response, pathological complete response, and chemotherapy mortality). RESULTS: Eleven RCTs, which included 1,976 patients, were selected with quality scores ranging from 1 to 3 (5-point Jadad scale). Odds ratio (95% confidence interval [CI]; P value), expressed as chemotherapy and surgery versus surgery alone (treatment versus control; values <1 favor chemotherapy-surgery arm), was 1.00 (0.76, 1.30; P = 0.98) for 1-year survival, 0.88 (0.62, 1.24; P = 0.45) for 2-year survival, 0.77 (0.37, 1.59; P = 0.48) for 3-year survival, 1.71 (1.22, 2.40; P = 0.002) for rate of resection, 0.71 (0.58, 0.87; P = 0.001) for rate of complete resection, 0.94 (0.66, 1.35; P = 0.76) for operative mortality, 1.08 (0.45, 2.60; P = 0.87) for anastomotic leaks, 1.31 (0.77, 2.23; P = 0.32) for postoperative pulmonary complications, 1.36 (0.83, 2.25; P = 0.22) for all treatment mortality, 0.71 (0.36, 1.42; P = 0.33) for local-regional cancer recurrence, 0.79 (0.57, 1.10; P = 0.16) for distant cancer recurrence, and 0.63 (0.28, 1.41; P = 0.26) for all cancer recurrence. A clinical response to chemotherapy was observed in 31% of patients and 5% had a complete pathological response. Chemotherapy mortality (before surgery) was 1.6%. CONCLUSIONS: Compared with surgery alone, neoadjuvant chemotherapy and surgery is associated with a lower rate of esophageal resection but a higher rate of complete (R0) resection. It does not increase treatment related mortality. This meta-analysis did not demonstrate a survival benefit for the combination of neoadjuvant chemotherapy and surgery.

PMID: 11943125 [PubMed - indexed for MEDLINE]

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Quality of complication reporting in the surgical literature.

Ann Surg. 2002 Jun;235(6):803-13

Authors: Martin RC, Brennan MF, Jaques DP

OBJECTIVE: To identify 10 critical elements of accurate and comprehensive reports of surgical complications. SUMMARY BACKGROUND DATA: Despite a venerable tradition of weekly morbidity and mortality conferences, inconsistent complication reporting is common in the surgical literature. METHODS: An analysis of articles reporting short-term outcomes after pancreatectomy, esophagectomy, and hepatectomy was performed. Randomized clinical trials (RCTs) published from 1975 to 2001 and retrospective series of more than 100 patients published from 1990 to 2001 were reviewed. RESULTS: A total of 119 articles reporting outcomes in 22,530 patients were analyzed. This included 42 RCTs and 77 retrospective series. Of the 10 criteria developed, no articles met all criteria; 2% met 9 criteria, 38% 7 or 8, 34% 5 or 6, 40% 3 or 4, and 12% 1 or 2. Outpatient information (22% of articles), definitions of complications provided (34% of articles), severity grade used (20% of articles), and risk factors included in analysis (29% of articles) were the most commonly unmet quality reporting criteria. Type of study (RCT vs. retrospective), site of institution (U.S. vs. non-U.S.) and journal (U.S. vs. non-U.S.) did not influence the quality of complication reporting. CONCLUSIONS: Short-term surgical outcomes are routinely included in the data reported in the surgical literature. This is often used to show improvements over time or to assess the impact of therapeutic changes on patient outcome. The inconsistency of reporting and the lack of accepted principles of accrual, display, and analysis of complication data argue strongly for the creation and generalized use of standards for reporting this information.

PMID: 12035036 [PubMed - indexed for MEDLINE]

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A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair.

Br J Surg. 2002 Jun;89(6):714-30

Authors: Bown MJ, Sutton AJ, Bell PR, Sayers RD

BACKGROUND: Operative repair of ruptured abdominal aortic aneurysm (RAAA) is associated with a high mortality rate but reported figures vary widely. The aim of this study was to estimate the operative mortality of RAAA repair and determine how it has changed over time. METHODS: A meta-analysis of all English language literature quoting figures for operative mortality of RAAA repair. RESULTS: The pooled estimate for the overall operative mortality rate of RAAA repair from 1955 to 1998 was 48 (95 per cent confidence interval 46 to 50) per cent. Meta-regression analysis of operative mortality over time demonstrated a constant reduction of approximately 3.5 per cent per decade (1954-1997) with an operative mortality rate estimate for the year 2000 of 41 per cent. Seventy-seven studies reported intraoperative mortality but, while this appears to have remained constant over time, there was evidence of the presence of publication bias in the subgroup of papers reporting this outcome. There was no evidence of publication bias for the overall operative mortality outcome. CONCLUSION: Contrary to the conclusion of recent studies, this paper demonstrates a gradual reduction with time in the operative mortality rate of RAAA repair.

PMID: 12027981 [PubMed - indexed for MEDLINE]

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Meta-analysis of laparoscopic inguinal hernia trials favors open hernia repair with preperitoneal mesh prosthesis.

Am J Surg. 2002 Jul;184(1):6-10

Authors: Voyles CR, Hamilton BJ, Johnson WD, Kano N

BACKGROUND: This meta-analysis was performed to determine the degree to which improvements in open hernia repair (OHR) in the last decade have altered the relative benefit of laparoscopic hernia repair (LHR). METHODS: Twenty-seven comparative trials including 4,688 randomized patients were evaluated. RESULTS: Within the control OHR, patients with routine mesh repair returned to work earlier than a sutured repair (16.4 versus 27.3 days, P = 0.010). During the study period, the increased use of mesh in OHR (3 of 12 initially versus 9 of 15 subsequent studies) was associated with an earlier return to work (25.9 to 16.8 days, P = 0.017); there was no significant improvement with corresponding LHR. CONCLUSIONS: Although LHR was associated with an earlier return to work compared with conventional sutured OHR, more recent mesh OHRs provide equivalent outcomes but at lower costs and potentially less severe complications, supporting an open technique using preperitoneal mesh prostheses as the optimal hernia repair.

PMID: 12135710 [PubMed - indexed for MEDLINE]

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A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice.

Ann Surg. 2002 Jul;236(1):17-27

Authors: Sewnath ME, Karsten TM, Prins MH, Rauws EJ, Obertop H, Gouma DJ

OBJECTIVE: To review the effectiveness of preoperative biliary drainage (PBD) in patients with obstructive jaundice resulting from tumors. SUMMARY BACKGROUND DATA: This was a systematic review, including a meta-analysis, of randomized controlled trials and comparative cohort studies conducted worldwide and published between 1966 and September 2001, classified on methodologic strength and subdivided into level 1 (randomized controlled trials) and level 2 (comparative cohort studies). METHODS: Comparison was made of PBD versus no PBD in jaundiced patients undergoing resection of a tumor. Outcome measures were in-hospital death rate, overall complications resulting from the treatment modality (drainage- and surgery-related complications), and hospital stay. Effect sizes were calculated and combined in meta-analyses. Relative differences (%) were calculated to compare effects on outcome measures. RESULTS: Five randomized controlled studies comprising 302 patients met the inclusion criteria for level 1 studies, and 18 cohort studies comprising 2,853 patients met the criteria for level 2 studies. Meta-analysis of level 1 studies showed no difference in the overall death rate between patients who had PBD and those who had surgery without PBD. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. At level 2, there was no difference in the death rate between the two treatment modalities. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. If PBD had been without complications, then complications would be in favor of drainage based on level 1 studies, and no difference based on level 2 studies. Further, PBD was not able to reduce the length of postoperative hospital stay compared with surgery without PBD; instead, it prolonged the stay. CONCLUSIONS: This meta-analysis shows that PBD with current standards for patients with obstructive jaundice resulting from tumors carries no benefit and should not be performed routinely. The potential benefit of PBD in terms of postoperative rates of death and complications does not outweigh the disadvantage of the drainage procedure. Only if PBD-related complications could be reduced by 27% and consequently diminish hospital stay could PBD be beneficial. Further randomized controlled trials with improved PBD techniques are necessary.

PMID: 12131081 [PubMed - indexed for MEDLINE]

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Systematic review and meta-analysis of interventions for postoperative fatigue.

Br J Surg. 2002 Aug;89(8):971-84

Authors: Rubin GJ, Hotopf M

BACKGROUND: Postoperative fatigue is common, even after uncomplicated operations. Various theories have been presented regarding its aetiology, each suggesting different possible interventions. The purpose of this review was to identify all studies that have assessed interventions for postoperative fatigue and to evaluate these interventions using meta-analytical techniques. METHODS: Randomized controlled trials of interventions, identified from a systematic search of relevant databases, were evaluated according to standardized criteria and categorized according to intervention modality. Data relating to the efficacy of each intervention at four different postoperative time-points were collated and data synthesis by meta-analysis was performed. RESULTS: Analgesia is effective in reducing fatigue immediately after operation. Perioperative administration of human growth hormone reduces fatigue between 8 and 30 days after abdominal surgery. Weaker evidence was found to suggest an influence of glucocorticoid administration and of surgical technique on fatigue in the first week after operation. No evidence was found to support the theory that psychosocial or nutritional interventions affect the symptom. CONCLUSION: While the results demonstrate that improved analgesia can attenuate immediate postoperative fatigue in most patient groups, further research is needed to determine whether the efficacy of human growth hormone and glucocorticoids extends beyond abdominal surgery. The paucity of research into cognitive-behavioural, sleep and activity-based interventions also needs to be addressed.

PMID: 12153621 [PubMed - indexed for MEDLINE]

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Contribution of intraoperative cholangiography to incidence and outcome of common bile duct injuries during laparoscopic cholecystectomy.

Surg Endosc. 2002 Jul;16(7):1098-104

Authors: Ludwig K, Bernhardt J, Steffen H, Lorenz D

BACKGROUND: In the present study we examined, in a meta-analysis of the literature, the contribution of intraoperative cholangiography (IOC) to incidence, type, and time of diagnosis of common bile duct (CBD) injuries during laparoscopic cholecystectomy (LC). MATERIALS AND METHODS: Forty of 2104 reports were enrolled for analysis. In 26 reports we found exact information on type, location and repair of 405 major injuries and in a subgroup examination we selected 103 major injuries with detailed information as to the event and size of CBD injury in association with IOC. RESULTS: The main incidence of CBD injuries was 0.36%. Using the method of routine IOC the incidence was 0.21% and the rate of diagnosis at the time of cholecystectomy 87% in contrast to selective use of IOC with 0.43% and 44.5%. In 405 cases of major CBD injuries, severe injuries predominated in 83.9% of the cases. Reconstruction with the help of a bilio-digestive anastomosis was necessary in 45.7% of all patients. In 34.8% of the cases a second intervention had to be made in the follow-up of 4 years after LC. The analysis of type, severity, recognition, and follow-up of CBD injuries during LC w/wo IOC showed significant advantages for doing routine IOC. CONCLUSIONS: The use of IOC can avoid severe types of CBD injuries during LC, increase the recognition at the time operation, and influence the success of repair and outcome of the patients.

PMID: 12165830 [PubMed - indexed for MEDLINE]

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Meta-analysis of techniques for closure of midline abdominal incisions.

Br J Surg. 2002 Nov;89(11):1350-6

Authors: van ‘t Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J

BACKGROUND: Various randomized studies have evaluated techniques of abdominal fascia closure but controversy remains, leaving surgeons uncertain about the optimal method of preventing incisional hernia. METHOD: Medline and Embase databases were searched. All trials with a follow-up of at least 1 year that randomized patients with midline laparotomies to closure of the fascia by different suture techniques and/or suture materials were subjected to meta-analysis. Primary outcome was incisional hernia; secondary outcomes were wound dehiscence, wound infection, wound pain and suture sinus formation. RESULTS: Fifteen studies were identified with a total of 6566 patients. Closure by continuous rapidly absorbable suture was followed by significantly more incisional hernias than closure by continuous slowly absorbable suture (P < 0.009) or non-absorbable suture (P = 0.001). No difference in incisional hernia incidence was found between slowly absorbable and non-absorbable sutures (P = 0.75), but more wound pain (P < 0.005) and more suture sinuses (P = 0.02) occurred after the use of non-absorbable suture. Similar outcomes were observed with continuous and interrupted sutures, but continuous sutures took less time to insert. CONCLUSION: To reduce the incidence of incisional hernia without increasing wound pain or suture sinus frequency, slowly absorbable continuous sutures appear to be the optimal method of fascial closure.

PMID: 12390373 [PubMed - indexed for MEDLINE]

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Short-term outcomes of laparoscopic and open ventral hernia repair: a meta-analysis.

Arch Surg. 2002 Oct;137(10):1161-5

Authors: Goodney PP, Birkmeyer CM, Birkmeyer JD

BACKGROUND: Although laparoscopic repair of ventral hernia has become increasingly popular, its outcomes relative to open repair have not been well characterized. For this reason, we performed a meta-analysis of studies comparing open and laparoscopic ventral (including incisional) hernia repair. HYPOTHESIS: Laparoscopic ventral hernia repair results in better short-term outcomes than open ventral hernia repair. DATA SOURCES: Structured MEDLINE search for published studies. One unpublished study was also identified. STUDY SELECTION: Studies were selected on the basis of study design (comparison of laparoscopic and open ventral hernia repair). The 3 main outcome measures were perioperative complications, operative time, and length of hospital stay. Of 83 potential studies identified by abstract review, 8 (10%) met the inclusion criteria. DATA EXTRACTION: Two reviewers assessed each article to determine eligibility for inclusion and, where appropriate, abstracted information on patient characteristics and main outcome measures. DATA SYNTHESIS: Across 8 studies, 390 patients underwent open repair and 322 underwent laparoscopic repair. Perioperative complications were less than half as likely to occur in patients undergoing laparoscopic repair (14% vs 27%; P =.03; odds ratio, 0.42; 95% confidence interval, 0.29-0.68). Average length of stay was shorter in the laparoscopic group (2.0 vs 4.0 days; P =.02). No statistically significant difference in operative times was noted between laparoscopic and open repair (99 vs 96 minutes; P =.38). CONCLUSIONS: Laparoscopic ventral hernia repair offers lower complication rates and shorter length of stay than open repair. However, randomized controlled trials and studies with long-term follow-up are needed to confirm these findings and to assess long-term rates of hernia recurrence.

PMID: 12361426 [PubMed - indexed for MEDLINE]

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Meta-analysis of relaparotomy for secondary peritonitis.

Br J Surg. 2002 Dec;89(12):1516-24

Authors: Lamme B, Boermeester MA, Reitsma JB, Mahler CW, Obertop H, Gouma DJ

BACKGROUND: Planned relaparotomy and relaparotomy on demand are two frequently employed surgical treatment strategies for patients with abdominal sepsis. METHODS: The available literature was evaluated to compare the efficacy of both surgical treatment strategies. A systematic search for studies comparing planned and on-demand relaparotomy strategies in adult patients with secondary peritonitis was employed. Studies were reviewed independently for design features, inclusion and exclusion criteria, and outcomes. The primary outcome measure was in-hospital mortality. RESULTS: No randomized studies were found; eight observational studies with a total of 1266 patients (planned relaparotomy, 286; relaparotomy on demand, 980) met the inclusion criteria and were included in the meta-analysis. These eight studies were heterogeneous on clinical and statistical grounds (chi2= 40.7, d.f. = 7, P < 0.001). Using a random-effects approach, the combined odds ratio for in-hospital mortality was 0.70 (95 per cent confidence interval 0.27 to 1.80) in favour of the on-demand strategy. CONCLUSION: The combined results of observational studies show a statistically non-significant reduction in mortality for the on-demand relaparotomy strategy compared with the planned relaparotomy strategy when corrected for heterogeneity in a random-effects model. Owing to the non-randomized nature of the studies, the limited number of patients per study, and the heterogeneity between studies, the overall evidence generated by the eight studies was inconclusive.

PMID: 12445059 [PubMed - indexed for MEDLINE]

Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches.

Dis Colon Rectum. 2002 Nov;45(11):1458-67

Authors: Petersen S, Koch R, Stelzner S, Wendlandt TP, Ludwig K

PURPOSE: Pilonidal sinus is a common disease and surgical removal and subsequent wound closure is crucial for lasting cure. To evaluate the outcome of different primary closure techniques we performed a pooled analysis of data published in the past 35 years. METHODS: We identified reports on wound infection, early failure, and late recurrence status in relation to treatment modality. Surgical techniques were classified into five groups: simple closure technique in the midline, asymmetric or oblique closure techniques, and full-thickness flap techniques like rhomboid flaps, vy-plasty, and z-plasty. Estimations of the incidences resulted from the quotient of number of responses and the number of patients for each study, and these quotients were summarized over all studies. RESULTS: The MEDLINE search identified 74 publications including 10,090 patients. Pooled data analysis revealed an inhomogeneous effect of the surgical techniques on the infection rate. In contrast, there was a significantly lower early failure rate and late recurrence rate of both the asymmetric-oblique closure techniques and the full-thickness flap techniques when compared with the midline repair technique. No difference was found between the asymmetric repairs and the full-thickness flap techniques. CONCLUSION: Beside the various statistical considerations when using a pooled data analysis combining results from the literature, this overview suggests a significant benefit of asymmetric-oblique closure techniques or flap techniques in comparison with simple closure in the midline. Thus, we recommend an asymmetric closure technique for primary closure of a chronic pilonidal sinus. These asymmetric procedures provide better results than the simple closure in the natal midline. Furthermore, they are not as sophisticated as the full-thickness plasty techniques.

PMID: 12432292 [PubMed - indexed for MEDLINE]

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A cost–utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients.

Surg Endosc. 2003 Feb;17(2):180-9

Authors: Stylopoulos N, Gazelle GS, Rattner DW

BACKGROUND: The controversial issue of the cost-effectiveness of laparoscopic inguinal hernia repair is examined, employing a decision analytic method. MATERIALS AND METHODS: The NSAS, NHDS (National Center for Health Statistics), HCUP-NIS (Agency for Healthcare Research and Quality) databases and 51 randomized controlled trials were analyzed. The study group constituted of a total of 1,513,008 hernia repairs. Projection of the clinical, economic, and quality-of-life outcomes expected from the different treatment options was done by using a Markov Monte Carlo decision model. Two logistic regression models were used to predict the probability of hospital admission after an ambulatory procedure and the probability of death after inguinal hernia repair. Four treatment strategies were modeled: (1) laparoscopic repair (LR), (2) open mesh (OM), (3) open non-mesh (ONM), and (4) expectant management. Costs were expressed in US dollars and effectiveness in quality-adjusted life years (QALYs). The main outcome measures were the average and the incremental cost-effectiveness (ICER) ratios. RESULTS: Compared to the expectant management, the incremental cost per QALY gained was 605 dollars (4086 dollars, 9.04 QALYs) for LR, 697 dollars (4290 dollars, 8.975 QALYs) for OM, and 1711 dollars (6200 dollars, 8.546 QALYs) for ONM. In sensitivity analysis the two major components that affect the cost-effectiveness ratio of the different types of repair were the ambulatory facility cost and the recurrence rate. At a LR ambulatory facility cost of 5526 dollars the ICER of LR compared to OM surpasses the threshold of 50,000 dollars/QALY. CONCLUSIONS: On the basis of our assumptions this mathematical model shows that from a societal perspective laparoscopic approach can be a cost-effective treatment option for inguinal hernia repair.

PMID: 12415334 [PubMed - indexed for MEDLINE]

Primary repair of penetrating colon injuries: a systematic review.

Dis Colon Rectum. 2002 Dec;45(12):1579-87

Authors: Singer MA, Nelson RL

PURPOSE: Primary repair of penetrating colon injuries is an appealing management option; however, uncertainty about its safety persists. This study was conducted to compare the morbidity and mortality of primary repair with fecal diversion in the management of penetrating colon injuries by use of a meta-analysis of randomized, prospective trials. METHODS: We searched for prospective, randomized trials in MEDLINE (1966 to November 2001), the Cochrane Library, and EMBase using the terms colon, penetrating, injury, colostomy, prospective, and randomized. Studies were included if they were randomized, controlled trials that compared the outcomes of primary repair with fecal diversion in the management of penetrating colon injuries. Five studies were included. Reviewers performed data extraction independently. Outcomes evaluated from each trial included mortality, total complications, infectious complications, intra-abdominal infections, wound complications, penetrating abdominal trauma index, and length of stay. Peto odds ratios for combined effect were calculated with a 95 percent confidence interval for each outcome. Heterogeneity was also assessed for each outcome. RESULTS: The penetrating abdominal trauma index of included subjects did not differ significantly between studies. Mortality was not significantly different between groups (odds ratio, 1.70; 95 percent confidence interval, 0.51-5.66). However, total complications (odds ratio, 0.28; 95 percent confidence interval, 0.18-0.42), total infectious complications (odds ratio, 0.41; 95 percent confidence interval, 0.27-0.63), abdominal infections including dehiscence (odds ratio, 0.59; 95 percent confidence interval, 0.38-0.94), abdominal infections excluding dehiscence (odds ratio, 0.52; 95 percent confidence interval, 0.31-0.86), wound complications including dehiscence (odds ratio, 0.55; 95 percent confidence interval, 0.34-0.89), and wound complications excluding dehiscence (odds ratio, 0.43; 95 percent confidence interval, 0.25-0.76) all significantly favored primary repair. CONCLUSION: Meta-analysis of currently published randomized, controlled trials favors primary repair over fecal diversion for penetrating colon injuries.

PMID: 12473879 [PubMed - indexed for MEDLINE]

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A systematic review of stapled hemorrhoidectomy.

Arch Surg. 2002 Dec;137(12):1395-406; discussion 1407

Authors: Sutherland LM, Burchard AK, Matsuda K, Sweeney JL, Bokey EL, Childs PA, Roberts AK, Waxman BP, Maddern GJ

HYPOTHESIS: Use of circular stapled hemorrhoidectomy will result in the same or improved safety and efficacy outcomes as those of the conventional methods for hemorrhoidectomy in patients with hemorrhoids. DATA SOURCES: Studies on stapled hemorrhoidectomy were identified using PREMEDLINE and MEDLINE (June 1966-June 2001), EMBASE (January 1980-June 2001), Current Contents (June 1993-June 2001), Ovid HEALTHSTAR (January 1975-June 2001), the National Institutes of Health Clinical Trials database (searched June 13, 2001), and The National Coordinating Centre for Health Technology Assessment database (searched June 14, 2001). The search terms were as follows: haemorrhoid* and (stapl* or convent*) or hemorrhoid* and (stapl* or convent*). The Cochrane Library (2001, issue 2) was searched using the search terms haemorrhoid* or hemorrhoid*. STUDY SELECTION: Articles detailing randomized controlled trials were included if they compared circular stapled with conventional hemorrhoidectomy and provided relevant safety and efficacy outcome information. DATA EXTRACTION: Data from all included studies were extracted using standardized data extraction tables that were developed a priori. In addition, the randomized controlled trials were examined with respect to the adequacy of allocation concealment, handling of those unavailable for follow-up, and any other aspect of the study design or execution that may have introduced bias. DATA SYNTHESIS: Seven randomized controlled trials met the inclusion criteria. A meta-analysis was conducted when the studies had comparable outcomes, inclusion criteria, and follow-up. There was reasonably clear evidence in favor of the stapled procedure for bleeding at 2 weeks (relative risk, 0.55; 95% confidence interval, 0.37-0.82) and length of hospital stay (weighted mean difference, -0.89 days; 95% confidence interval, -1.42 to -0.36). Other less robust results in favor of the stapled hemorrhoidectomy related to pain, bleeding, anal discharge, wound healing, tenderness to per rectal examination, incontinence scores, earlier return of bowel function, analgesic requirement, and resumption of normal activities. One trial showed that prolapse occurred at significantly higher rates in the stapled hemorrhoidectomy group. However, the outcomes were poorly reported and generally showed statistically significant heterogeneity. CONCLUSIONS: Stapled hemorrhoidectomy may be at least as safe as conventional hemorrhoidal surgical techniques. However, the efficacy of the stapled procedure compared with the conventional techniques could not be determined. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.

PMID: 12470107 [PubMed - indexed for MEDLINE]

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Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis.

J Trauma. 2002 Dec;53(6):1109-14

Authors: Barnes CJ, Pietrobon R, Higgins LD

BACKGROUND: This systematic review aimed at evaluating the diagnostic accuracy of pulse examination in detecting surgical arterial lesions associated with knee dislocation. METHODS: MEDLINE, CINAHL, and SportDiscus databases were searched in all languages to review articles concerning human knee dislocation and associated vascular injuries. RESULTS: We reviewed 116 articles. Seven met our inclusion criteria, providing detailed data on 284 injuries. Pooled data demonstrated that abnormal pedal pulses present a sensitivity of 0.79 (95% confidence interval [CI], 0.64-0.89), a specificity of 0.91 (95% CI 0.78-0.96), a positive predictive value of 0.75 (95% CI, 0.61-0.83), and a negative predictive value of 0.93 (95% CI, 0.85-.96). CONCLUSION: Our findings suggest that the isolated presence of abnormal pedal pulses on initial examination of patients with knee dislocations is not sensitive enough to detect a surgical vascular injury. On the basis of this meta-analysis, an algorithm for the evaluation of these patients is presented.

PMID: 12478036 [PubMed - indexed for MEDLINE]

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Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials.

Ann Surg. 2003 Mar;237(3):319-34

Authors: Vincent JL, Dubois MJ, Navickis RJ, Wilkes MM

OBJECTIVE: To determine whether hypoalbuminemia is an independent risk factor for poor outcome in the acutely ill, and to assess the potential of exogenous albumin administration for improving outcomes in hypoalbuminemic patients. SUMMARY BACKGROUND DATA: Hypoalbuminemia is associated with poor outcomes in acutely ill patients, but whether this association is causal has remained unclear. Trials investigating albumin therapy to correct hypoalbuminemia have proven inconclusive. METHODS: A meta-analysis was conducted of 90 cohort studies with 291,433 total patients evaluating hypoalbuminemia as an outcome predictor by multivariate analysis and, separately, of nine prospective controlled trials with 535 total patients on correcting hypoalbuminemia. RESULTS: Hypoalbuminemia was a potent, dose-dependent independent predictor of poor outcome. Each 10-g/L decline in serum albumin concentration significantly raised the odds of mortality by 137%, morbidity by 89%, prolonged intensive care unit and hospital stay respectively by 28% and 71%, and increased resource utilization by 66%. The association between hypoalbuminemia and poor outcome appeared to be independent of both nutritional status and inflammation. Analysis of dose-dependency in controlled trials of albumin therapy suggested that complication rates may be reduced when the serum albumin level attained during albumin administration exceeds 30 g/L. CONCLUSIONS: Hypoalbuminemia is strongly associated with poor clinical outcomes. Further well-designed trials are needed to characterize the effects of albumin therapy in hypoalbuminemic patients. In the interim, there is no compelling basis to withhold albumin therapy if it is judged clinically appropriate.

PMID: 12616115 [PubMed - indexed for MEDLINE]

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Meta-analysis suggests antibiotic prophylaxis is not warranted in low-risk patients undergoing laparoscopic cholecystectomy.

Br J Surg. 2003 Mar;90(3):365-6

Authors: Al-Ghnaniem R, Benjamin IS, Patel AG

PMID: 12594674 [PubMed - indexed for MEDLINE]

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Current status of an antireflux procedure in laparoscopic Heller myotomy.

Surg Endosc. 2003 Apr;17(4):554-8

Authors: Lyass S, Thoman D, Steiner JP, Phillips E

BACKGROUND: Persistent dysphagia and postoperative gastroesophageal reflux (GER) are the most cited reasons for surgical failure of laparoscopic Heller myotomy. Adding an antireflux procedure to Heller myotomy has been proposed to prevent reflux. We hypothesized that an antireflux procedure added to laparoscopic Heller myotomy has little effect on preventing the symptoms or long-term sequelae of GER in achalasia patients. METHODS: We performed a meta-analysis of studies on human subjects reported in the English language literature from 1991 to 2001 years. RESULTS: An antireflux procedure accompanied laparoscopic myotomy in 15 studies with 532 patients. In 6 studies of 69 patients, no antireflux procedure was added to laparoscopic myotomy. Follow-up was available on 489 patients (92%) with partial fundoplication. The rate of GER diagnosed in pH studies was 7.9% (18 of 228 patients studied), whereas only 5.9% of patients experienced symptoms of GER (29 of 489 patients followed). Of the 69 patients without fundoplication, 47 (68%) were available for follow-up. Forty patients (85%) were studied with pH monitoring postoperatively, with 4 (10%) demonstrating reflux. Six (13%) of 47 patients had symptoms of GER. The difference in the rate of GER diagnosed in postmyotomy pH studies in wrapped and nonwrapped patients was not significant (7.9 vs 10%, respectively; p = 0.75). There was also no significant difference in the incidence of postmyotomy GER symptoms in wrapped and nonwrapped patients (5.9 vs 13% respectively; p = 0.12). CONCLUSIONS: Reflux is not necessarily eliminated with the addition of a partial fundoplication. Based on the published data, recommendations cannot be made regarding the efficacy of adding an antireflux procedure to laparoscopic Heller myotomy. Prospective randomized study is needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.

PMID: 12582776 [PubMed - indexed for MEDLINE]

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Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis.

J Trauma. 2003 May;54(5):908-14

Authors: Hill GE, Frawley WH, Griffith KE, Forestner JE, Minei JP

BACKGROUND: Immunosuppression is a consequence of allogeneic (homologous) blood transfusion (ABT) in humans and is associated with an increased risk in cancer recurrence rates after potentially curative surgery as well as an increase in the frequency of postoperative bacterial infections. Although a meta-analysis has been reported demonstrating the relationship between ABT and colon cancer recurrence, no meta-analysis has been reported demonstrating the relationship of ABT to postoperative bacterial infection. METHODS: Twenty peer-reviewed articles published from 1986 to 2000 were included in a meta-analysis. Criteria for inclusion included a clearly defined control group (nontransfused) compared with a treated (transfused) group and statistical analysis of accumulated data that included stepwise multivariate logistic regression analysis. In addition, a subgroup of publications that included only the traumatically injured patient was included in a separate meta-analysis. A fixed effects analysis was conducted with odds ratios obtained by using the conditional maximum likelihood method and 95% confidence intervals on the obtained odds ratios were determined using the mid-p technique. RESULTS: The total number of subjects included in this meta-analysis was 13,152 (5,215 in the transfused group and 7,937 in the nontransfused group). The common odds ratio for all articles included in this meta-analysis evaluating the association of ABT to the incidence of postoperative bacterial infection was 3.45 (range, 1.43-15.15), with 17 of the 20 studies demonstrating a value of p < or = 0.05. These results provide overwhelming evidence that ABT is associated with a significantly increased risk of postoperative bacterial infection in the surgical patient. The common odds ratio of the subgroup of trauma patients was 5.263 (range, 5.03-5.43), with all studies showing a value of p < 0.05 (0.005-0.0001). These results demonstrate that ABT is associated with a greater risk of postoperative bacterial infection in the trauma patient when compared with those patients receiving ABT during or after elective surgery. CONCLUSION: These results demonstrate that ABT is an associated and apparently significant and frequently overlooked risk factor for the development of postoperative bacterial infection in the surgical patient. Allogeneic blood transfusion is a greater risk factor in the traumatically injured patient when compared with the elective surgical patient for the development of postoperative bacterial infection.

PMID: 12777903 [PubMed - indexed for MEDLINE]

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Efficacy of hypertonic saline dextran fluid resuscitation for patients with hypotension from penetrating trauma.

J Trauma. 2003 May;54(5 Suppl):S144-8

Authors: Wade CE, Grady JJ, Kramer GC

BACKGROUND: The purpose of this study was to assess whether the administration of hypertonic saline dextran (HSD) was detrimental when administered to patients who were hypotensive because of penetrating injuries to the torso. The administration of HSD causes an immediate and sustained increase in blood pressure that could contribute to an increase in bleeding in the presence of uncontrolled hemorrhage. We prospectively designed a series of questions to be addressed by a meta-analysis of individual patient data using a computerized data file and case report forms from a multicenter study of HSD. METHODS: The investigators were “blind” as to the treatment the patient received. Patients (n = 230) with penetrating injuries to the torso were studied as to survival until discharge. The patients were administered 250 mL of HSD or normal saline (standard of care [SOC]) as the initial fluid therapy. RESULTS: Of the 120 patients treated with HSD, 82.5% survived compared with 75.5% for 110 SOC patients (p = 0.19). Sixty-eight percent (n = 157) of these patients required surgery. HSD treatment (n = 84) in this population improved survival, 84.5% compared with 67.1% with SOC (n = 73) (p = 0.01). HSD resulted in an increase in blood pressure and a reduction in hematocrit, with no differences noted in fluid requirements or indices of clotting. CONCLUSION: For patients with penetrating injuries to the torso that result in hypotension, initial fluid resuscitation with HSD is beneficial in improving survival, especially if surgery is subsequently required.

PMID: 12768117 [PubMed - indexed for MEDLINE]

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Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery.

Br J Surg. 2003 Jun;90(6):668-79

Authors: Merlin TL, Hiller JE, Maddern GJ, Jamieson GG, Brown AR, Kolbe A

BACKGROUND: A systematic review was conducted to determine which of the methods of obtaining peritoneal access and establishing pneumoperitoneum is the safest and most effective. METHODS: Studies that met the inclusion criteria were identified from six bibliographic databases up to May 2002, the internet, hand-searches and reference lists. They were critically appraised using a validated checklist and data were extracted using standardized protocols. RESULTS: Meta-analysis of prospective, non-randomized studies of open versus closed (needle/trocar) access indicated a trend during open access towards a reduced risk of major complications (pooled relative risk (RR(p)) 0.30, 95 per cent confidence interval (c.i.) 0.09 to 1.03). Open access was also associated with a trend towards a reduced risk of access-site herniation (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.03) and, in non-obese patients, a 57 per cent reduced risk of minor complications (RR(p) 0.43, 95 per cent c.i. 0.20 to 0.92) and a trend for fewer conversions to laparotomy (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.17). Data on major complications in studies of direct trocar versus needle/trocar access were inconclusive. Minor complications in randomized controlled trials were fewer with direct trocar access (RR(p) 0.19, 95 per cent c.i. 0.09 to 0.40), predominantly owing to a reduction in extraperitoneal insufflation. CONCLUSION: The evidence on the comparative safety and effectiveness of the different access methods was not definitive, but there were trends in the data that merit further exploration.

PMID: 12808613 [PubMed - indexed for MEDLINE]

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Abdominal symptoms: do they disappear after cholecystectomy?

Surg Endosc. 2003 Nov;17(11):1723-8

Authors: Berger MY, Olde Hartman TC, Bohnen AM

OBJECTIVE: To evaluate the effect of cholecystectomy in patients with gallstones on preoperative abdominal symptoms. METHODS: A systematic search was made of the Medline database in combination with reference checking. Articles were excluded if patients aged <18 years, symptom relief rates could not be calculated, if follow-up after cholecystectomy was less than 1 month, or when the included patients were at extraordinary risk for a complicated outcome. Potential differences in relief rates due to patient selection, retrospective versus prospective design, duration of follow-up, or intervention were analyzed using logistic regression. RESULTS: The pooled relief rate for “biliary pain” was high 92% (95% confidence interval 86 to 96%). Symptom relief rates were consistently higher in studies that included acute cholecystectomies. For upper abdominal pain–without restrictions for intensity or duration–pooled relief rates ranged from 72% (66 to 77%) after elective cholecystectomy, to 86% (83 to 91%) after acute cholecystectomy. The relief rate of food intolerance was higher in studies with a follow-up < or =12 months (88%, 76 to 91%) compared to studies with a follow-up of more than 12 months (65%, 55 to 74%). CONCLUSION: In almost all patients with gallstones biliary pain disappeared after cholecystectomy. There is insufficient evidence, however, that this relief was due to cholecystectomy. Relief rates of other isolated symptoms were low in patients with an elective cholecystectomy. A proper evaluation of the effectiveness of cholecystectomy in terms of abdominal symptom relief rates requires a randomized trial.

PMID: 12802649 [PubMed - indexed for MEDLINE]

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A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer.

Am J Surg. 2003 Jun;185(6):538-43

Authors: Urschel JD, Vasan H

BACKGROUND: Esophagectomy is a standard treatment for resectable esophageal cancer but relatively few patients are cured. Combining neoadjuvant chemoradiation with surgery may improve survival but treatment morbidity is a concern. We performed a meta-analysis of randomized controlled trials (RCTs) that compared the use of neoadjuvant chemoradiation and surgery with the use of surgery alone for esophageal cancer. METHODS: Medline and manual searches were done to identify all published RCTs that compared neoadjuvant chemoradiation and surgery with surgery alone for esophageal cancer. A random-effects model was used and the odds ratio (OR) was the principal measure of effect. Systematic quantitative review was done for outcomes unique to the neoadjuvant chemoradiation treatment group, such as pathological complete response. RESULTS: Nine RCTs that included 1,116 patients were selected with quality scores ranging from 1 to 3 (5-point Jadad scale). Odds ratio (95% confidence interval [CI]; P value), expressed as chemoradiation and surgery versus surgery alone (treatment versus control; values <1 favor chemoradiation-surgery arm), was 0.79 (0.59, 1.06; P = 0.12) for 1-year survival, 0.77 (0.56, 1.05; P = 0.10) for 2-year survival, 0.66 (0.47, 0.92; P = 0.016) for 3-year survival, 2.50 (1.05, 5.96; P = 0.038) for rate of resection, 0.53 (0.33, 0.84; P = 0.007) for rate of complete resection, 1.72 (0.96, 3.07; P = 0.07) for operative mortality, 1.63 (0.99, 2.68; P = 0.053) for all treatment mortality, 0.38 (0.23, 0.63; P = 0.0002) for local-regional cancer recurrence, 0.88 (0.55, 1.41; P = 0.60) for distant cancer recurrence, and 0.47 (0.16, 1.45; P = 0.19) for all cancer recurrence. A complete pathological response to chemoradiation occurred in 21% of patients. The 3-year survival benefit was most pronounced when chemotherapy and radiotherapy were given concurrently (OR 0.45, 95% CI 0.26 to 0.79, P = 0.005) instead of sequentially (OR 0.82, 95% CI 0.54 to 1.25, P = 0.36). CONCLUSIONS: Compared with surgery alone, neoadjuvant chemoradiation and surgery improved 3-year survival and reduced local-regional cancer recurrence. It was associated with a lower rate of esophageal resection, but a higher rate of complete (R0) resection. There was a nonsignificant trend toward increased treatment mortality with neoadjuvant chemoradiation. Concurrent administration of neoadjuvant chemotherapy and radiotherapy was superior to sequential chemoradiation treatment scheduling.

PMID: 12781882 [PubMed - indexed for MEDLINE]

Biofeedback treatment of constipation: a critical review.

Dis Colon Rectum. 2003 Sep;46(9):1208-17

Authors: Heymen S, Jones KR, Scarlett Y, Whitehead WE

PURPOSE: This review was designed to 1) critically examine the research design used in investigations of biofeedback for pelvic floor dyssynergia, 2) compare the various biofeedback treatment protocols for pelvic floor dyssynergia-type constipation used in this research, 3) identify factors that influence treatment outcome, and 4) identify goals for future biofeedback research for pelvic floor dyssynergia. METHODS: A comprehensive review of both the pediatric and adult research from 1970 to 2002 on “biofeedback for constipation” was conducted using a Medline search in all languages. Only prospective studies including five or more subjects that described the treatment protocol were included. In addition, a meta-analysis of these studies was performed to compare the outcome of different biofeedback protocols for treating constipation. RESULTS: Thirty-eight studies were reviewed, and sample size, treatment protocol, outcome rates, number of sessions, and etiology are shown in a table. Ten studies using a parallel treatment design were reviewed in detail, including seven that randomized subjects to treatment groups. A meta-analysis (weighted by subjects) was performed to compare the results of two treatment protocols prevalent in the literature. The mean success rate of studies using pressure biofeedback (78 percent) was superior (P = 0.018) to the mean success rate for studies using electromyography biofeedback (70 percent). However, the mean success rates comparing studies using intra-anal electromyography sensors to studies using perianal electromyography sensors were 69 and 72 percent, respectively, indicating no advantages for one type of electromyography protocol over the other (P = 0.428). In addition to the varied protocols and instrumentation used, there also are inconsistencies in the literature regarding the severity and etiology of symptoms, patient selection criteria, and the definition of a successful outcome. Finally, no anatomic, physiologic, or demographic variables were identified that would assist in predicting successful outcome. Having significant psychological symptoms was identified as a factor that may influence treatment outcome, but this requires further study. CONCLUSION: Although most studies report positive results using biofeedback to treat constipation, quality research is lacking. Specific recommendations are made for future investigations to 1) improve experimental design, 2) clearly define outcome measures, 3) identify the etiology and severity of symptoms, 4) determine which treatment protocol and which component of treatment is most effective for different types of subjects, 5) systematically explore the role of psychopathology in this population, 6) use an adequate sample size that allows for meaningful analysis, and 7) include long-term follow-up data.

PMID: 12972965 [PubMed - indexed for MEDLINE]

Clinical value of preoperative mechanical bowel cleansing in elective colorectal surgery: a systematic review.

Dis Colon Rectum. 2003 Aug;46(8):1013-20

Authors: Wille-Jørgensen P, Guenaga KF, Castro AA, Matos D

PURPOSE: This study was designed to establish scientific evidence for and clinical results of preoperative mechanical bowel cleansing before elective colorectal surgery. METHODS: Systematic literature searches in electronic databases, conference proceedings, and hand searches of reference lists of previously retrieved literature without any language restrictions were used. Only randomized trials were included. A quality assessment of each retrieved trial was performed. Outcome measures were surgical infections, mortality, and anastomotic dehiscence. Meta-analyses of the selected trials were performed using the Peto odds ratio. RESULTS: The results of each outcome were as follows. 1). Overall anastomotic leakage-six studies: 5.5 percent with cleansing compared with 2.9 percent without cleansing; odds ratio 1.94, 95 percent confidence interval: 1.09 to 3.43 (P = 0.02). 2). Peritonitis-three studies: 5.1 percent with cleansing compared with 2.8 percent without cleansing; odds ratio 1.90, 95 percent confidence interval: 0.78 to 4.64 (not significant). 3). Wound infection-six studies: 7.4 percent with cleansing compared with 5.7 percent without cleansing; odds ratio 1.34, 95 percent confidence interval: 0.85 to 2.13 (not significant). CONCLUSIONS: There is no evidence in the literature for beneficial effects from the use of bowel cleansing before elective colorectal surgery. Cleansing seems to be associated with an increased risk of more anastomotic dehiscence. Further studies stratifying between rectal and colonic surgery are warranted.

PMID: 12907890 [PubMed - indexed for MEDLINE]

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Boerhaave’s syndrome: primary repair vs. esophageal resection–case reports and meta-analysis of the literature.

J Gastrointest Surg. 2003 Sep-Oct;7(6):726-34

Authors: Kollmar O, Lindemann W, Richter S, Steffen I, Pistorius G, Schilling MK

Boerhaave’s syndrome is a life-threatening disease with a high mortality. With regard to the heterogeneity of treatment strategies, no comparative studies exist and recommendations remain controversial. Seventeen cases of Boerhaave’s syndrome operated on between 1989 and 2000 at our hospital were reviewed retrospectively to compare the time period between perforation and diagnosis, and the morbidity and mortality among the different treatment options. In addition, we conducted a meta-analysis of the literature including all series containing five or more patients and compared the findings with our own data. Our patients with a perforation history of less than 12 hours showed significantly fewer signs of sepsis compared to patients with a history of more than 12 hours. In a comparison of patients with primary repair vs. patients treated with esophageal resection or an exclusion operation, no differences were found. In the literature, patients with a long period of perforation (more than 24 hours) were treated more often with an esophageal resection than patients with primary repair. In cases of Boerhaave’s syndrome, primary suturing of the esophageal perforation should be reserved only for those patients presenting within 12 hours after perforation. In all other cases, depending on the extent of the tissue damage, a two-stage esophageal resection with cervical esophagostomy and gastrostomy is recommended as the safest treatment.

PMID: 13129548 [PubMed - indexed for MEDLINE]

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Meta-analysis to determine the incidence of obstetric anal sphincter damage.

Br J Surg. 2003 Nov;90(11):1333-7

Authors: Oberwalder M, Connor J, Wexner SD

BACKGROUND: The reported incidence of anal sphincter injury after first (11.5-35.0 per cent) and subsequent (3.4-12.1 per cent) vaginal deliveries varies widely. In addition, the reported incidence of associated faecal incontinence ranges from zero to 68.2 per cent. The aim of this study was to perform a meta-analysis of reported incidences of postpartum anal sphincter defect diagnosed by endoanal ultrasonography (EAUS) and associated incidences of faecal incontinence. METHODS: A Medline search yielded five studies with more than 100 subjects who underwent EAUS after childbirth for evaluation of anal sphincter disruption and who were questioned about symptoms of faecal incontinence, defined as any impairment in flatus and stool control but not including urgency of defaecation. A Bayesian meta-analysis was performed to produce one inference while accounting for potential heterogeneity among the five study populations. RESULTS: Meta-analysis of 717 vaginal deliveries revealed a 26.9 per cent incidence of anal sphincter defect in primiparous women and an 8.5 per cent incidence of new sphincter defects in multiparous women. Overall, 29.7 per cent of anal sphincter defects were symptomatic. Some 3.4 per cent of women experienced postpartum faecal incontinence without an anal sphincter defect. In a Bayesian calculation, the probability of postpartum faecal incontinence due to a sphincter defect was 76.8-82.8 per cent. CONCLUSION:: The incidence of occult anal sphincter disruption following vaginal delivery is much higher than commonly estimated. However, at least two-thirds of occult defects are asymptomatic postpartum. The probability of faecal incontinence associated with an anal sphincter defect was 76.8-82.8 per cent.

PMID: 14598410 [PubMed - indexed for MEDLINE]

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Perioperative outcomes of laparoscopic versus open splenectomy: a meta-analysis with an emphasis on complications.

Surgery. 2003 Oct;134(4):647-53; discussion 654-5

Authors: Winslow ER, Brunt LM

BACKGROUND: The purpose of this study was to analyze the published perioperative results of laparoscopic splenectomy (LS) compared to open splenectomy (OS), and to determine the impact of LS on the incidence and type of splenectomy-related complications. METHODS: Perioperative results and complications were tabulated from all English-language reports of LS from 1991 through 2002, and complications were analyzed further by type. Data were taken from 26 series that compared OS to LS within an institution (paired analysis) and from an additional 25 series of only LS (unpaired analysis), and a meta-analysis was performed. RESULTS: A total of 2940 patients from 51 published series were included (LS, 2119 patients; OS, 821 patients). Age, gender, and American Society of Anesthesiologists class were similar. In the analysis of paired OS and LS studies, the mean operative time for LS was significantly longer (LS, 180 minutes; OS, 114 minutes; P<.0001,) but the postoperative hospital stay was shorter (LS, 3.6 days; OS, 7.2 days; P<.001). Accessory spleens were identified in 11% of cases in both groups. The total complication rate for LS was 15.5%, compared with 26.6% for OS (P<.0001). LS was associated with significantly fewer pulmonary, wound, and infectious complications (P<.001 for all) but with more hemorrhagic complications, when conversions for bleeding were included. Mortality rates for LS and OS were similar (OS, 1.1%; LS, 0.6%; P=not significant). Comparable results were obtained when the unpaired LS series were added to the analysis. CONCLUSIONS: Although operative times are longer for LS than OS, LS is associated with a significant reduction in splenectomy-related morbidity, primarily as a function of fewer pulmonary, wound, and infectious complications.

PMID: 14605626 [PubMed - indexed for MEDLINE]

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Causalgia: a meta-analysis of the literature.

Arch Surg. 2003 Nov;138(11):1226-31

Authors: Hassantash SA, Afrakhteh M, Maier RV

BACKGROUND: Causalgia is not familiar to most physicians whose training and experience are limited to civilian practice. HYPOTHESIS: Through a thorough review of the literature, we attempted to determine the boundaries of causalgia and separate it from other sympathetically related disorders. DATA SOURCES: Database search for English-language articles in MEDLINE and Index Medicus up to the year 2000 as both keyword and subject under causalgia. STUDY SELECTION: References that described any new cases referred to as “causalgia” by their authors were included in a meta-analysis. DATA SYNTHESIS: One hundred ten articles contained a total of 1528 cases of causalgia. High-velocity missiles caused at least 77% of the injuries. In 72% and 90% of the cases reported, the time from injury to onset of pain was within 1 week and 1 month, respectively. Median nerve alone or in combination with other nerves (56%) and sciatic trunk injury (60%) were the most common nerves involved. In 92%, the nerve injury was incomplete. The most prominent clinical manifestations included burning pain in 86%, increased sweating in 73%, relief with application of cold in 62%, warmth in 50%, paresthesias in 96%, absence of anesthesia in 81%, and sensitivity to stimuli in 98%. Response to sympathetic blocks was observed in 88%. Finally, a total of 94% of the patients undergoing sympathectomy were cured. CONCLUSIONS: Cases of causalgia are easy to recognize and treat, with excellent results. Causalgia always follows a somatic nerve injury, usually partial, and is associated with near-constant, very severe pain distal to the injury in the extremity, varied in nature but characteristically with a predominantly burning quality. An effective anesthetic block of the appropriate part of the sympathetic chain frequently immediately relieves the pain. Most cases are cured by surgical sympathectomy.

PMID: 14609871 [PubMed - indexed for MEDLINE]

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A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis.

J Am Coll Surg. 2003 Dec;197(6):921-6

Authors: Puggioni A, Wong LL

BACKGROUND: Few articles address the issue of LC in patients with cirrhosis. Existing articles are retrospective and with small sample sizes, which makes it difficult to draw conclusions about indications and complications with LC in this setting. STUDY DESIGN: An extensive search of the Medline, Embase, and Cochrane databases using the terms “laparoscopic cholecystectomy” and “cirrhosis” or “cirrhotic” was conducted. The data from each study were extracted, combined with those of similar studies, and analyzed. RESULTS: Twenty-five publications (400 patients with cirrhosis undergoing LC) from 1993 to 2001 were identified. Four articles compared LC with open cholecystectomy in patients with cirrhosis, and six compared patients with cirrhosis to patients without cirrhosis. Patients were primarily in Child-Pugh class A or B, with only six patients in Child-Pugh class C. Compared with patients without cirrhosis, patients with cirrhosis had higher conversion rates (7.06% versus 3.64%, p = 0.024), operative times (98.2 minutes versus 70 minutes, p = 0.005), bleeding complications (26.4% versus 3.1%, p < 0.001), and overall morbidity (20.86% versus 7.99%, p < 0.001). Acute cholecystitis was evident in 47% of patients with cirrhosis versus 14.7% of patients without cirrhosis (p < 0.001). When LC was compared with open cholecystectomy in patients with cirrhosis, LC was associated with less operative blood loss (113 mL versus 425.2 mL, p = 0.015), operative time (123.3 minutes versus 150.2 minutes, p < 0.042), and length of hospital stay (6 days versus 12.2 days, p < 0.001). CONCLUSIONS: Patients with cirrhosis undergo cholecystectomies for more emergent reasons and have higher morbidity. The laparoscopic approach offers advantages of less blood loss, shorter operative time, and shorter length of hospitalization in patients with cirrhosis. Prospective studies will establish which factors affect outcomes and determine the appropriateness of LC in Child’s-Pugh class C cirrhosis.

PMID: 14644279 [PubMed - indexed for MEDLINE]

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Clinical value of parathyroid scintigraphy with technetium-99m methoxyisobutylisonitrile: discrepancies in clinical data and a systematic metaanalysis of the literature.

World J Surg. 2004 Jan;28(1):100-7

Authors: Gotthardt M, Lohmann B, Behr TM, Bauhofer A, Franzius C, Schipper ML, Wagner M, Höffken H, Sitter H, Rothmund M, Joseph K, Nies C

There is a considerable discrepancy in the literature concerning the sensitivity of parathyroid scintigraphy (PS) with 99mTc-MIBI. We therefore analyzed our own data and compared them to the literature in a metaanalysis. All patients who received 99mTc -MIBI scintigraphy and subsequent surgery in our department for the detection of enlarged parathyroid glands in primary (pHPT) or secondary (sHPT) hyperparathyroidism between 1991 and 1999 were included in our retrospective analysis. The results of surgery served as the gold standard. For a true positive result, the scintigraphy had to predict the exact location of parathyroid adenoma (PA) or parathyroid hyperplasia (PH). We then compared these data to the results of a nonstatistical systematic metaanalysis of the literature. Patients (178) underwent PS between 1991 and 1999; 139 were operated on and included in this study. Of these, 109 had pHPT and 30 had sHPT. The sensitivity and specificity of the PS were found to be 45%/94% for pHPT and 39%/40% for sHPT. Fifty-two studies concerning PS were included in the metaanalysis. Sensitivities reported varied from 39% to >90%. Consideration of the different possible techniques used for PS could not explain these discrepancies. Our data show that the sensitivity of PS in clinical routine may be lower than expected from the literature. Our data are consistent with other studies and with partially unpublished clinical observations from other university hospitals. We believe that a well-designed and properly conducted prospective study is necessary to evaluate the reasons for the differences observed.

PMID: 14639488 [PubMed - indexed for MEDLINE]

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Evidence-based compression: prevention of stasis and deep vein thrombosis.

Ann Surg. 2004 Feb;239(2):162-71

Authors: Morris RJ, Woodcock JP

OBJECTIVE: To summarize the currently published scientific evidence for the venous flow effects of mechanical devices, particularly intermittent pneumatic compression, and the relation to prevention of deep vein thrombosis (DVT). SUMMARY BACKGROUND DATA: While intermittent pneumatic compression is an established method of DVT prophylaxis, the variety of systems that are available can use very different compression techniques and sequences. In order for appropriate choices to be made to provide the optimum protection for patients, the general performance of systems, and physiological effects of particular properties, must be analyzed objectively. METHODS: Medline was searched from 1970 to 2002, and all relevant papers were searched for further appropriate references. Papers were selected for inclusion when they addressed specifically the questions posed in this review. RESULTS: All the major types of intermittent compression systems are successful in emptying deep veins of the lower limb and preventing stasis in a variety of subject groups. Compression stockings appear to function more by preventing distension of veins. Rapid inflation, high pressures, and graded sequential intermittent compression systems will have particular augmentation profiles, but there is no evidence that such features improve the prophylactic ability of the system. CONCLUSIONS: The most important factors in selecting a mechanical prophylactic system, particularly during and after surgery, are patient compliance and the appropriateness of the site of compression. There is no evidence that the peak venous velocity produced by a system is a valid measure of medical performance.

PMID: 14745323 [PubMed - indexed for MEDLINE]

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Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair.

Br J Surg. 2003 Dec;90(12):1479-92

Authors: Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR

BACKGROUND: The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic (LIHR) and open (OIHR) inguinal hernia repair. METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified all randomized clinical trials that compared OIHR and LIHR and were published in the English language between January 1990 and the end of October 2000. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The six outcome variables analysed were operating time, time to discharge from hospital, return to normal activity and return to work, postoperative complications and recurrence rate. Random effects meta-analyses were performed using odds ratios and weighted mean differences. RESULTS: Twenty-nine trials were considered suitable for meta-analysis. Some 3017 hernias were repaired laparoscopically and 2972 hernias were repaired using an open method in 5588 patients. For four of the six outcomes the summary point estimates favoured LIHR over OIHR; there was a significant reduction of 38 per cent in the relative odds of postoperative complications (odds ratio 0.62 (95 per cent confidence interval (c.i.) 0.46 to 0.84); P = 0.002), 4.73 (95 per cent c.i. 3.51 to 5.96) days in time to return to normal activity (P < 0.001), 6.96 (95 per cent c.i. 5.34 to 8.58) days in time to return to work (P < 0.001) and 3.43 (95 per cent c.i. 0.35 to 6.50) h in time to discharge from hospital (P = 0.029). There was a significant increase of 15.20 (95 per cent c.i. 7.78 to 22.63) min in the mean operating time for LIHR (P < 0.001). The relative odds of short-term recurrence were increased by 50 per cent for LIHR compared with OIHR, although this result was not statistically significant (odds ratio 1.51 (95 per cent c.i. 0.81 to 2.79); P = 0.194). CONCLUSION: LIHR was associated with earlier discharge from hospital, quicker return to normal activity and work, and significantly fewer postoperative complications than OIHR. However, the operating time was significantly longer and there was a trend towards an increase in the relative odds of recurrence after laparoscopic repair.

PMID: 14648725 [PubMed - indexed for MEDLINE]

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Meta-analysis of the clinical and laboratory diagnosis of appendicitis.

Br J Surg. 2004 Jan;91(1):28-37

Authors: Andersson RE

BACKGROUND: The importance of specific elements in the clinical diagnosis of appendicitis is controversial. This review analyses the diagnostic value of elements of disease history, clinical findings and laboratory test results in suspected appendicitis. METHODS: A systematic Medline search was made of all published studies on the clinical and laboratory diagnosis of appendicitis in patients admitted to hospital with suspected disease. Meta-analyses of receiver-operator characteristic (ROC) areas, and positive and negative likelihood ratios, of 28 diagnostic variables described in 24 studies are presented. RESULTS: Inflammatory response variables (granulocyte count, proportion of polymorphonuclear blood cells, white blood cell count and C-reactive protein concentration), descriptors of peritoneal irritation (rebound and percussion tenderness, guarding and rigidity) and migration of pain were the strongest discriminators, with ROC areas of 0.78 to 0.68. The discriminatory power of the inflammatory variables was particularly strong for perforated appendicitis, with ROC areas of 0.85 to 0.87. Appendicitis was likely when two or more inflammatory variables were increased and unlikely when all were normal. CONCLUSION: Although all clinical and laboratory variables are weak discriminators individually, they achieve a high discriminatory power when combined. Laboratory examination of the inflammatory response, clinical descriptors of peritoneal irritation, and a history of migration of pain yield the most important diagnostic information and should be included in any diagnostic assessment.

PMID: 14716790 [PubMed - indexed for MEDLINE]

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A review of the literature on octylcyanoacrylate tissue adhesive.

Am J Surg. 2004 Feb;187(2):238-48

Authors: Singer AJ, Thode HC

BACKGROUND: Octylcyanoacrylate is a medical grade topical tissue adhesive that has been approved for closing surgical incisions and traumatic lacerations. We reviewed animal and human studies that evaluated its use for a variety of surgical indications and specialties. We also performed a meta-analysis of all clinical trials using octylcyanoacrylate. DATA SOURCES: Animal and human studies published in peer-reviewed articles as well as published abstracts. A search of Medline was performed using the MESH terms: tissue adhesives, cyanoacrylates, and octylcyanoacrylate. CONCLUSIONS: The current review and metanalysis demonstrate that octylcyanoacrylate can be used successfully in a wide variety of clinical and surgical settings for multiple types of wounds covering most of the surface of the human body. Prior knowledge of the limitations and technical aspects specific to wound closure with octylcyanoacrylate as well as appropriate wound selection and preparation will help ensure optimal results.

PMID: 14769312 [PubMed - indexed for MEDLINE]

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Antibiotic prophylaxis in elective laparoscopic cholecystectomy. Lack of need or lack of evidence?

Surg Endosc. 2004 Apr;18(4):638-41

Authors: Catarci M, Mancini S, Gentileschi P, Camplone C, Sileri P, Grassi GB

BACKGROUND: The need to administer antibiotic prophylaxis (ABP) during laparoscopic cholecystectomy (LC) is still a matter of significant controversy. The purpose of this study was to resolve this issue by performing a meta-analysis of the available randomized controlled trials (RCT) on this topic. METHODS: Papers identified via a systematic literature search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes were abstracted and summarized across studies. The outcome measures were the rates of all perioperative infections, the rates of surgical site infections, and the rates of infections at other sites. Results were examined for 974 patients randomized to ABP or placebo prior to LC in six RCT published from 1997 to 2001. RESULTS: The cumulative rates of all infections were 2.8% in the ABP group and 4.4% in the placebo group. The pooled odds ratio (OR) (95% confidence interval [CI]) was 0.69 (0.34-1.43; p = 0.32). The cumulative rates of surgical site infections were 2.1% in the ABP group and 2.9% in the placebo group. The pooled OR (95% CI) was 0.82 (0.36-1.86; p = 0.63). The cumulative rates of infections at other sites were 0.7% in the ABP group and 1.5% in the placebo group. Pooled OR (95% CI) was 0.82 (0.18-1.90; p = 0.37). No significant heterogeneity was found in any data pooling. CONCLUSIONS: Based on the available evidence, there appears to be no need to administer routine ABP to low-risk patients during LC. However, the number of patients enrolled to date into RCT is insufficient to avoid a type II error. A large and well-designed trial is urgently needed to find a conclusive answer to this question.

PMID: 14752639 [PubMed - indexed for MEDLINE]

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A systematic review of hepatic artery chemotherapy after hepatic resection of colorectal cancer metastatic to the liver.

Dis Colon Rectum. 2004 May;47(5):739-45

Authors: Nelson RL, Freels S

PURPOSE: Colorectal cancer metastatic to the liver, when technically feasible, is resected with a moderate chance of cure. The most common site of failure after resection is in the remaining liver. To enhance survival, chemotherapy has been delivered directly to the liver postresection via the hepatic artery. This study was designed to assess the effect of posthepatic resection, hepatic artery chemotherapy on overall survival. METHODS: Trials were sought in Medline, the Cochrane Controlled Trial Register, The Cochrane Hepatobiliary Group Trials Register, and through contact of trial authors and reference lists using key words: colorectal, cancer, hepatic metastases, hepatic artery, chemotherapy, and randomized. Trials were chosen in which patients having resection of colorectal cancer metastatic to the liver were randomized to hepatic artery chemotherapy or any alternative treatment. Survival data were obtained principally from abstraction from survival curves in published studies using the method of Parmar to calculate a study-specific, log-hazard ratio and then combined-effect, log-hazard ratio, as well as a combined Kaplan-Meier survival probability curve. RESULTS: Overall survival at five years in the hepatic artery group was 45 percent and 40 percent in the control group. Forty-three individuals developed recurrent liver metastases in the hepatic artery chemotherapy group, and 97 developed liver recurrence in the control group. However, no significant advantage was found in the meta-analysis for hepatic artery chemotherapy measuring overall survival and calculating survival based on “intention to treat” (log-hazard ratio = 0.0848, favoring the control group; 95 percent confidence interval = +/-0.2037). Adverse events related to hepatic artery therapy were common, including five therapy-related deaths. CONCLUSIONS: Although recurrence in the remaining liver happened less frequently in the hepatic artery chemotherapy group, overall survival was not improved. The log-hazard ratio even favored the control group, although not significantly. This added intervention for the treatment of metastatic colorectal cancer cannot be recommended at this time.

PMID: 15037930 [PubMed - indexed for MEDLINE]

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A systematic review of medical therapy for anal fissure.

Dis Colon Rectum. 2004 Apr;47(4):422-31

Authors: Nelson R

PURPOSE: This is a meta-analysis of randomized, controlled trials to assess the efficacy and morbidity of medical therapies for anal fissure. METHODS: Medline and the Cochrane Controlled Trials Register and the Cochrane Colorectal Cancer Review Groups Controlled Trials Register were searched using the terms “anal fissure randomized” from 1966 to 2002. Studies in which participants were randomized to a nonsurgical therapy for anal fissure were the focus of this review. Comparison groups included an operative procedure, an alternate medical therapy, or placebo. Chronic fissure, acute fissure, and fissure in children were included in the review, however, atypical fissure associated with inflammatory bowel disease, cancer, or anal infection were excluded. Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, “intention to treat” and dropouts, therapies, supportive measures, dosing and frequency, and crossovers. Outcome measures included nonhealing of the fissure and adverse events. RESULTS: Twenty one different comparisons of medical therapies to heal anal fissure have been reported in 31 trials, including 9 agents-glyceryl trinitrate, isosorbide dinitrate, botulinum toxin, diltiazem, nifedipine, hydrocortisone, lidocaine, bran, placebo-as well as anal dilators and surgical sphincterotomy. Glyceryl trinitrate was favored in the analysis over placebo (odds ratio = 0.55, 95 percent confidence interval, 0.41-0.74). After excluding two studies from analysis because of placebo response rates >2 standard deviations below the mean for all studies, the advantage of glyceryl trinitrate over placebo was no longer statistically significant (odds ratio = 0.78; 95 percent confidence interval, 0.56-1.08). Nifedipine and diltiazem did not differ from glyceryl trinitrate in their ability to cure fissure (0.66; 0.22-2.01). Botulinum toxin compared with placebo showed no significant efficacy (0.75; 0.32-1.77), and was also no better than glyceryl trinitrate (0.48; 0.21-1.10). Surgery was more effective than medical therapy in curing fissure (0.12; 0.07-0.22). CONCLUSIONS: Medical therapy for chronic anal fissure, acute fissure, and fissure in children may be applied with a chance of cure that is only marginally better than placebo, and for chronic fissure, far less effective than surgery.

PMID: 14994109 [PubMed - indexed for MEDLINE]

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Systematic review and meta-analysis of controlled trials assessing spinal cord stimulation for inoperable critical leg ischaemia.

Br J Surg. 2004 Aug;91(8):948-55

Authors: Ubbink DT, Vermeulen H, Spincemaille GH, Gersbach PA, Berg P, Amann W

BACKGROUND: Spinal cord stimulation (SCS) may have a place in the treatment of patients with inoperable chronic critical leg ischaemia. METHODS: A systematic review and meta-analysis was performed of all controlled studies comparing SCS in addition to any form of conservative treatment for inoperable chronic critical leg ischaemia. Main endpoints were limb salvage, pain relief and clinical situation. Systematic methodological appraisal and data extraction were performed by independent reviewers. RESULTS: Of the 18 reports found, nine trials, comprising 444 patients, matched the selection criteria. After pooling, limb salvage at 12 months appeared significantly greater in the SCS group (risk difference (RD) -0.13 (95 per cent confidence interval (c.i.) -0.04 to -0.22)). Significant pain relief occurred in both treatment groups, but patients who received SCS required significantly less analgesia and reached Fontaine stage 2 more often than those who did not have SCS (RD 0.33 (95 per cent c.i. 0.19 to 0.47)). Complications of SCS were problems of implantation (8.2 per cent), changes in stimulation requiring reintervention (14.8 per cent) and infection (2.9 per cent). CONCLUSION: The addition of SCS to standard conservative treatment improves limb salvage, ischaemic pain and the general clinical situation in patients with inoperable chronic critical leg ischaemia. These benefits should be weighed against the cost and the (minor) complications associated with the technique.

PMID: 15286954 [PubMed - indexed for MEDLINE]

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Endorectal ultrasound detection of focal carcinoma within rectal adenomas.

Am J Surg. 2004 May;187(5):625-9; discussion 629

Authors: Worrell S, Horvath K, Blakemore T, Flum D

BACKGROUND: The misdiagnosis of a rectal adenoma by biopsy and subsequent finding of invasive cancer after transanal excision is associated with a number of pitfalls. Problems include suboptimal therapy for a potentially curable cancerous lesion, potential tumor transgression of the local site with increased chance for local recurrence, and increased potential for more radical surgery or adjuvant chemoradiation. The utility of endorectal ultrasound (ERUS) in guiding treatment decisions of rectal villous adenomas has been reported, but series are small and are from single institutions. To determine the utility of ERUS in the diagnosis of rectal adenomas, we compared diagnosis made by biopsy alone to diagnosis made by a combination of biopsy and ERUS. METHODS: A systematic literature review was performed by way of a PubMed search to find articles with the following terms: “biopsy-negative rectal adenomas,” “preoperative ERUS diagnosis,” and “surgical histopathology.” Five studies met the criteria, thus providing data for 258 adenomas. A quantitative meta-analysis was performed on the data. RESULTS: Among the 258 biopsy-negative rectal adenomas, 24% had focal carcinoma on histopathology. ERUS correctly established a cancer diagnosis in 81% (95% confidence interval 69 to 90) of these misdiagnosed lesions. Thus, ERUS diagnosis of biopsy-negative rectal adenomas could be expected to decrease the need for additional surgery and other associated problems caused by misdiagnosis from 24% to 5%. CONCLUSIONS: ERUS is a useful adjunct to biopsy in the preoperative workup of rectal villous adenomas, and we recommend its routine use. Accurate preoperative assessment allows the surgeon to counsel the patient appropriately regarding the best operation, the perioperative risks, and the chances of local recurrence.

PMID: 15135679 [PubMed - indexed for MEDLINE]

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Choice of surveillance after hepatectomy for colorectal metastases.

Arch Surg. 2004 Jul;139(7):749-54

Authors: Metcalfe MS, Mullin EJ, Maddern GJ

HYPOTHESIS: By review of a reported series, is outcome related to surveillance after hepatectomy? DESIGN: We reviewed English-language literature indexed on MEDLINE from January 1, 1990, through December 31, 2002. Indexing terms were combinations of hepatectomy, colorectal metastases, and recurrence with prognostic, repeat, follow-up, or surveillance. STUDY SELECTION: Studies containing any of the following data fields were included: recurrence after hepatectomy, rates of repeat hepatectomy, 5-year survival (overall or disease free) after hepatectomy (initial or repeat), posthepatectomy surveillance protocol, and detection of recurrence by surveillance modality. DATA EXTRACTION: Data were taken directly from a small number of articles and pooled across studies for analysis. We highlighted difficulties in assessing data quality and validity as a caveat to the interpretation of the results. RESULTS: The rate of recurrence after hepatectomy was 58%, and the rate of hepatic recurrence was 30%. Repeat hepatectomy was performed in 9.6% of cases. Five-year survivals after initial and repeat hepatectomy were 29% and 38%, respectively. Many studies did not report their surveillance protocols. For those that did, computed tomography or ultrasonography with carcinoembryonic antigen measurement most commonly formed the basis of surveillance. No data related surveillance techniques to the outcomes of recurrence detection, repeat hepatectomy, or survival. CONCLUSIONS: This review confirmed the value of repeat hepatectomy for recurrent disease, but uncovered no direct evidence supporting any surveillance modalities. Further studies are clearly needed, and approaches to these are discussed.

PMID: 15249408 [PubMed - indexed for MEDLINE]