Meta-analysis of the use of sterilized mosquito net mesh for inguinal hernia repair in less economically developed countries.

Background: Inguinal hernias are common in less economically developed countries (LEDCs), and associated with significant morbidity and mortality. Tension-free mesh repair is the standard treatment worldwide. Lack of resources combined with the high cost of commercial synthetic mesh (CSM) have limited its use in LEDCs. Sterilized mosquito net mesh (MNM) has emerged as a low-cost, readily available alternative to CSM. The aim of this systematic review and meta-analysis was to evaluate the safety and efficacy of MNM for the use in hernia repair in LEDCs. Methods: A systematic review and data meta-analysis of all published articles from inception to August 2018 was performed. Cochrane Central Register of Controlled Trials, MEDLINE and Embase databases were searched. The primary outcome measure was the overall postoperative complication rate of hernia repair when using MNM. Secondary outcome measures were comparisons between MNM and CSM with regard to overall complication rate, wound infection, chronic pain and haematoma formation. Results: A total of nine studies were considered relevant (3 RCTs, 1 non-randomized trial and 5 prospective studies), providing a total cohort of 1085 patients using MNM. The overall complication rate for hernia repair using MNM was 9·3 per cent. There was no significant difference between MNM and CSM regarding the overall postoperative complication rate (odds ratio 0·99, 95 per cent c.i. 0·65 to 1·53; P = 0·98), severe or chronic pain (OR 2·52, 0·36 to 17·42; P = 0·35), infection (OR 0·56, 0·19 to 1·61; P = 0·28) or haematoma (OR 1·05, 0·62 to 1·78; P = 0·86). Conclusion: MNM has a low overall postoperative complication rate and is unlikely to be inferior to CSM in terms of safety and efficacy. MNM is a suitable low-cost alternative to CSM in the presence of financial constraint.

Systematic review and meta-analysis on outcomes of salvage therapy in patients with tumour recurrence during 'watch and wait' in rectal cancer.

INTRODUCTION: The 'watch and wait' approach has recently emerged as an alternative approach for managing patients with complete clinical response in rectal cancer. However, less is understood whether the intervention is associated with a favourable outcome among patients who require salvage therapy following local recurrence. MATERIALS AND METHODS: A comprehensive systematic search was performed using EMBASE, PubMed, MEDLINE, Journals@Ovid as well as hand searches; published between 2004 and 2018, to identify studies where outcomes of patients undergoing watch and wait were compared with conventional surgery. Study quality was assessed using the Newcastle-Ottawa assessment scale. The main outcome was relative risks for overall and disease specific mortality in salvage therapy. RESULTS: Nine eligible studies were included in the meta-analysis. Of 248 patients who followed the watch and wait strategy, 10.5% had salvage therapy for recurrent disease. No statistical heterogeneity was found in the results. The relative risk of overall mortality in the salvage therapy group was 2.42 (95% confidence interval 0.96-6.13) compared with the group who had conventional surgery, but this was not statistically significant (P > 0.05). The relative risk of disease specific mortality in salvage therapy was 2.63 (95% confidence interval 0.81-8.53). CONCLUSION: Our findings demonstrated that there was no significant difference in overall and disease specific mortality in patients who had salvage treatment following recurrence of disease in the watch and wait group compared with the standard treatment group. However, future research into the oncological safety of salvage treatment is needed.

Stapled haemorrhoidopexy: is it time to move on?

Stapled haemorrhoidectomy was proposed as an 'ideal' solution for symptomatic haemorrhoids, with minimal postoperative pain, no perianal wound requiring postoperative wound care and a relatively short operative time. Some randomised controlled trials and reviews confirmed these findings, claiming that stapled haemorrhoidopexy is the most effective and safe procedure for haemorrhoids. However, there are increasing number of publications highlighting that the technique is associated with serious and life threatening complications. Maybe it is now the time to accept that stapled haemorrhoidopexy has done its role in directing our attention to the fact that modern surgical treatment of haemorrhoids should avoid excision of anorectal skin but should instead aim at treatment intervention above the dentate line.

Validation of a grading system for complicated diverticulitis in the prediction of need for operative or percutaneous intervention.

INTRODUCTION: The current surgical management of acute complicated diverticulitis has seen a major paradigm shift from routine operative intervention to a more conservative approach. This has been made possible by the widespread availability of computed tomography (CT) to enable stratification of the disease severity of acute complicated diverticulitis. The aim of this study was to retrospectively validate a CT grading system for acute complicated diverticulitis in the prediction of the need for operative or percutaneous intervention. METHODS: Hospital and radiology records were reviewed to identify patients with acute complicated diverticulitis confirmed by CT. A consultant gastrointestinal radiologist, blinded to the clinical outcomes of patients, assigned a score according to the CT grading system. RESULTS: Three hundred and sixty-seven patients (34.6%) had CT performed for acute diverticulitis during the study period. Forty-four patients (12.0%) had acute complicated diverticulitis (abscess and/or free intraperitoneal air) confirmed on CT. There were 22 women (50%) and the overall median age was 59 years (range: 19-92 years). According to the CT findings, there was one case with grade 1, eighteen patients with grade 2, four with grade 3 and twenty-one with grade 4 diverticulitis. Three patients with grade 2, three patients with grade 3 and ten patients with grade 4 disease underwent acute radiological or surgical intervention. CONCLUSIONS: The use of a CT grading system for acute complicated diverticulitis did not predict the need for acute radiological or operative intervention in this small study. Decision making guided by the patient's clinical condition still retains a primary role in the management of acute complicated diverticulitis.

Current outcomes of emergency large bowel surgery.

INTRODUCTION: Emergency large bowel surgery (ELBS) is known to carry an increased risk of morbidity and mortality. Previous studies have reported morbidity and mortality rates up to 14.3%. However, there has not been a recent study to document the outcomes of ELBS following several major changes in surgical training and provision of emergency surgery. The aim of this study was therefore to explore the current outcomes of ELBS. METHODS: A retrospective review was performed of a prospectively maintained database of the clinical records of all patients who had ELBS between 2006 and 2013. Data pertaining to patient demographics, ASA (American Society of Anesthesiologists) grade, diagnosis, surgical procedure performed, grade of operating surgeon and assistant, length of hospital stay, postoperative complications and in-hospital mortality were analysed. RESULTS: A total of 202 patients underwent ELBS during the study period. The mean patient age was 62 years and the most common cause was colonic carcinoma (n=67, 33%). There were 32 patients (15.8%) who presented with obstruction and 64 (31.7%) had bowel perforation. The overall in-hospital mortality rate was 14.8% (n=30). A consultant surgeon was involved in 187 cases (92.6%) as either first operator, assistant or available in theatre. CONCLUSIONS: ELBS continues to carry a high risk despite several major changes in the provision of emergency surgery. Further developments are needed to improve postoperative outcomes in these patients.

Robotic colorectal surgery: summary of the current evidence.

BACKGROUND: Several studies have confirmed that laparoscopic colorectal surgery results in improved early post-operative outcomes. Nevertheless, conventional laparoscopic approach and instruments have several limitations. Robotic approach could potentially address of many of these limitations. OBJECTIVES: This review aims to present a summary of the current evidence on the role of robotic colorectal surgery. METHODS: A comprehensive search of electronic databases (Pubmed, Science Direct and Google scholar) using the key words "rectal surgery", "laparoscopic", "colonic" and "robotic." Evidence from these data was critically analysed and summarised to produce this article. RESULTS: Robotic colorectal surgery is both safe and feasible. However, it has no clear advantages over standard laparoscopic colorectal surgery in terms of early postoperative outcomes or complications profile. It has shorter learning curve but increased operative time and cost. It could offer potential advantage in resection of rectal cancer as it has a lower conversion rates even in obese individuals, distal rectal tumours and patients who had preoperative chemoradiotherpy. There is also a trend towards better outcome in anastomotic leak rates, circumferential margin positivity and perseveration of autonomic function, but there was no clear statistical significance to support this from the currently available data. CONCLUSION: The use of robotic approach seems to be capable of addressing most of the shortcomings of the standard laparoscopic surgery. The technique has proved its safety profile in both colonic and rectal surgery. However, the cost involved may restrict its use to patients with challenging rectal cancer and in specialist centres.

Vaginal metastases from colorectal cancer.

BACKGROUND: Vaginal metastases originating from colorectal carcinoma are very rare. Due to the limited number of reported cases, there is no proposed standard treatment and little is known about its management outcome. AIM: The aim of this article is to review the available literature to establish the clinical presentation, trends in treatment and prognosis of vaginal metastases from colorectal malignancy. METHODS: A literature search using keywords used for database search were 'colorectal carcinoma', 'colorectal cancer', 'colon cancer' and 'vaginal metastasis'. RESULTS: Of the 30 articles identified, 37 reported cases, were accessible for full evaluation. Cases reported originates from various countries and majority presented with vaginal bleeding. Diagnosis was established after histological examination and treatment options consist of surgical resection, radiotherapy or chemotherapy that have been used individually or in combination. Association with disseminated metastatic disease indicates ominous prognosis as seen in 32.4% (n = 12) cases. CONCLUSION: Vaginal metastasis of colorectal cancer should be included in the differential diagnosis of a vaginal swelling. There is no proposed standard treatment for vaginal metastases but surgical resection is an appropriate approach for local control when no disseminated metastatic disease is documented.

Operative strategy for fistula-in-ano without division of the anal sphincter.

INTRODUCTION: The treatment of perianal fistulas is diverse because no single technique is universally effective. Fistulotomy remains the most effective way of eradicating the pathology but it renders the patient at some risk of faecal incontinence, which many patients are reluctant to take. There are no data in the literature to indicate the healing rate of perianal fistulas when using an operative strategy that routinely avoids division of any part of the anal sphincter. The aim of this paper is to present the long-term results with an operative strategy that aims to avoid division of any part of the anal sphincter complex when treating all types of perianal fistulas, thereby minimising/eliminating the risk of postoperative incontinence. METHODS: We report 54 consecutive cases of anal fistula that presented electively and as an emergency. Patients with known or subsequently diagnosed inflammatory bowel disease or malignancy were excluded from the study. RESULT: Overall, 46 patients (37 male and 9 female) with a median age at presentation of 42 years (range: 19-73 years) were treated by lay-open of the subcutaneous tract of the perianal fistula and insertion of a loose seton for the part of the fistula tract related to the sphincter complex. The types of fistula treated were intersphincteric (89%), transsphincteric (4%) and high suprasphincteric (7%). The median length of time that the seton was left in place was 7 months (range: 1.5-24 months). The healing rate was 86% with a recurrence rate of 19% and a median follow-up duration of 42 months. CONCLUSIONS: Patients who are reluctant to take any risk of faecal incontinence could be treated using an operative strategy that routinely avoids division of any part of the anal sphincter complex as this has a recurrence rate that compares well with other treatment modalities.

An unusual cause of acute internal haemorrhage: cystic artery pseudoaneurysm secondary to acute cholecystitis.

Spontaneous cystic artery haemorrhage is a rare complication of acute cholecystitis. Here we describe a case report of this unusual cause of internal haemorrhage, and discuss the pathogenesis and management strategies.

Have early postoperative complications from laparoscopic rectal cancer surgery improved over the past 20 years?

AIM: Laparoscopic rectal cancer surgery has been increasingly used since 1991 following the publication of the first case series. Since then, several studies have confirmed that laparoscopic surgery for rectal cancer is challenging with associated morbidity and mortality. The aim of this study was to determine if the rates of early postoperative complications in laparoscopic rectal cancer surgery have improved over the past 20 years. METHOD: A literature search of the EMBASE and MEDLINE databases between August 1991 and August 2011 was conducted using the keywords laparoscopy, rectal cancer and postoperative complications. Data were analysed using linear regression ANOVA performed in GNUMERICS software. RESULTS: Ninety-seven studies were included for analysis. Over the last 20 years there has been no significant change in the rate of any early postoperative complications (anastomotic leak, conversion, sexual, urinary or faecal dysfunction, wound infection, overall morbidity or mortality). However, in the last 3 years, the rate of positive resection margins has decreased significantly (P = 0.01). CONCLUSION: There was no evidence of a statistically significant change in early postoperative complications until 3 years ago. This may reflect the inherent morbidity associated with rectal surgery regardless of the approach used, the limitations of the current laparoscopic instrumentation or the relatively long learning curve. With increasing experience, a repeat analysis in the near future following the publication of ongoing randomized clinical trials might show improved outcomes.

Rectal impalement injury through the pelvis, abdomen and thorax.

Impalement rectal injuries with intraperitoneal organ injuries are rare. It is even rarer for such injuries to result in pelvic, abdominal and thoracic internal injuries. We present the case of a 39-year-old man who was admitted after an assault where a broken broomstick was inserted forcibly into his rectum. Surgery revealed penetration through the rectum, dome of the bladder, mesentery, liver and right lung. The patient survived following management by a multispecialty surgical team. Our literature review identified four similar cases with one fatality only. Prognosis seems to be good in these types of injuries provided there is an early presentation, the penetrating object is left in situ before the operation and, most importantly, there is an organised team approach to deal with the various injuries.

Systematic review of single-incision laparoscopic colonic surgery.

BACKGROUND: Randomized clinical trials (RCTs) have shown multiport laparoscopic surgery to be safe compared with open surgery in elective colonic disease. Single-incision laparoscopic surgery (SILS) represents the latest advance in laparoscopic surgery. The aim of this systematic review was to establish the safety and complication profile of colonic SILS. METHODS: The search was performed in October 2011 using PubMed, MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. Search terms were 'colorectal', 'colon', 'colectomy', 'rectal' and single incision/port/trocar/site/scar. Only pure single-incision laparoscopic colonic surgery for benign and malignant colonic disease was included. Primary outcomes were the early postoperative complication profiles of colonic SILS. Secondary outcomes were duration of operation, lymph node yields, conversion rate and duration of hospital stay. RESULTS: Colonic SILS data were compared with data from a Cochrane review on the short-term outcomes of laparoscopic colonic surgery and four main RCTs on laparoscopic colonic surgery. Median operating times and time to first bowel motion for colonic SILS were comparable with those for laparoscopic colonic surgery. The median lymph node retrieval for malignant disease achieved with SILS was acceptable. Evidence for a reduction in postoperative pain with SILS was conflicting. There was no significant reduction in length of hospital stay with SILS. Most patients selected for colonic SILS had a low body mass index, non-bulky tumours and were operated on by experienced laparoscopic surgeons. There was significant heterogeneity in study group characteristics, indications for surgery, research methodology, operative techniques and follow-up time. CONCLUSION: Colonic SILS should be restricted to highly selected patients; operations should be performed by experienced laparoscopic surgeons, with critical appraisal of clinical outcomes.

Dieulafoy's lesion: current trends in diagnosis and management.

BACKGROUND: Dieulafoy's lesion is a relatively rare, but potentially life-threatening, condition. It accounts for 1-2% of acute gastrointestinal (GI) bleeding, but arguably is under-recognised rather than rare. Its serious nature makes it necessary to include it in the differential diagnosis of obscure GI bleeding. The aim of this study was to review the current trends in the diagnosis and management of Dieulafoy's lesion. MATERIALS AND METHODS: Using Medline, a literature search was performed for articles published in English, using the search words 'Dieulafoy'(s)' and 'gastrointestinal bleeding'. All retrieved papers were analysed and the findings are summarised in this review. RESULTS: There is no consensus on the treatment of Dieulafoy's lesions. Therapeutic endoscopy can control the bleeding in 90% of patients while angiography is being accepted as a valuable alternative to endoscopy for inaccessible lesions. Currently, surgical intervention is kept for failure of therapeutic endoscopic or angiographic interventions and it should be guided by pre-operative localisation. CONCLUSIONS: Advances in endoscopy have increased the detection of Dieulafoy's lesions and decreased the mortality from 80% to 8.6%. There are recent encouraging reports on the successful use of laparoscopic surgery in managing symptomatic Dieulafoy's lesions.