Routine versus selective computed tomography in non-traumatic acute abdominal pain: meta-analysis of randomised trials.

PURPOSE: To compare the routine vs. selective use of computed tomography (CT) in patients presenting with non-traumatic acute abdominal pain (AAP) to a surgical service. METHODS: We conducted a systematic review of literature and meta-analysis of outcomes according to PRISMA statement standards to compare the routine vs. selective use of CT in adult patients presenting with non-traumatic AAP. RESULTS: Analysis of 722 patients from 4 randomised controlled trials showed no difference between the routine CT and selective CT groups in terms of proportion of correct diagnoses (OR 1.36,95% CI 0.89, 2.07, P = 0.15), mortality (RD 0.03, 95% CI - 0.08, 0.02, P = 0.27] and length of hospital stay (LOS) [MD - 0.26, 95% CI - 2.07, 1.55, P = 0.78). CONCLUSIONS: The routine use of CT does not improve the proportion of correct diagnoses and mortality compared to selective use of CT in adult patients with non-traumatic AAP. The available evidence regarding the influence of routine CT on LOS may be subject to type 2 error. These findings, however, may not apply to the elderly patient with AAP and further studies are required.

The impact of age on complications, survival, and cause of death following colon cancer surgery.

BACKGROUND: Given scarce data regarding the relationship among age, complications, and survival beyond the 30-day postoperative period for oncology patients in the United States, this study identified age-related differences in complications and the rate and cause of 1-year mortality following colon cancer surgery. METHODS: The NY State Cancer Registry and Statewide Planning and Research Cooperative System identified stage I-III colon cancer resections (2004-2011). Multivariable logistic regression and survival analyses assessed the relationship among age (<65, 65-74, ⩾75), complications, 1-year survival, and cause of death. RESULTS: Among 24 426 patients surviving >30 days, 1-year mortality was 8.5%. Older age groups had higher complication rates, and older age and complications were independently associated with 1-year mortality (P<0.0001). Increasing age was associated with a decrease in the proportion of deaths from colon cancer with a concomitant increase in the proportion of deaths from cardiovascular disease. Older age and sepsis were independently associated with higher risk of colon cancer-specific death (65-74: HR=1.59, 95% CI=1.26-2.00; ⩾75: HR=2.57, 95% CI=2.09-3.16; sepsis: HR=2.58, 95% CI=2.13-3.11) and cardiovascular disease-specific death (65-74: HR=3.72, 95% CI=2.29-6.05; ⩾75: HR=7.02, 95% CI=4.44-11.10; sepsis: HR=2.33, 95% CI=1.81-2.99). CONCLUSIONS: Older age and sepsis are associated with higher 1-year overall, cancer-specific, and cardiovascular-specific mortality, highlighting the importance of geriatric assessment, multidisciplinary care, and cardiovascular optimisation for older patients and those with infectious complications.

Injectable anal bulking agent for the management of faecal incontinence.

This study was conducted to determine the safety and efficacy of injectable bulking agents. A total of 13 procedures were performed on 11 patients with faecal incontinence during 2002 to 2007. Patients with internal anal sphincter defect and low incontinence score (Cleveland score < 10) revealed improvement. Patients with higher incontinence score and external sphincter defect secondary to obstetric damage required further intervention. At a median follow-up of 43 months, 7 (63%) patients showed improvement in incontinence score and 4 (32%) showed marked improvement in their symptoms. Fifty six percent of the patients described this as an effective procedure, though the level of effectiveness varied from person to person. Anal injectable collagen was found safe and effective in the management of faecal incontinence. Long-term follow-ups are required to re assess and consider definitive procedure in failed cases.

Oxidative stress in laparoscopic versus open abdominal surgery: a systematic review.

BACKGROUND: Any form of trauma, including surgery, is known to result in oxidative stress. Increased intra-abdominal pressure during pneumoperitoneum and inflation-deflation may cause ischemia reperfusion and, hence, oxidative stress may be greater during laparoscopic surgery. The aim of this study was to systemically review the literature to compare oxidative stress in laparoscopic and open procedures. METHODS: A systematic search of the Medline, Pub Med, EMBASE, and Cochrane databases was performed with the following keywords: pneumoperitoneum AND surger $ OR laparoscop $ AND oxida $. The search was limited to articles published between 1980 and August 2010. RESULTS: The initial search identified 197 papers. After review of the abstracts, 17 papers met the inclusion criteria. Six more papers were identified through the reference lists. It was not possible to perform a meta-analysis due to heterogeneity of patient data, patient selection criteria, and diversity of biomarkers used. The majority of studies demonstrated greater immediate oxidative stress after open surgery. There was, however, a paucity of studies comparing open versus laparoscopic surgery with regards to tissue oxidative stress. CONCLUSION: Laparoscopic surgery seems to produce less systemic oxidative stress. However the effect of pneumoperitoneum on local oxidative stress and tissue hypoxia and its clinical significance need further investigation.

Early restoration of intestinal continuity in acute mesenteric ischaemia using Bishop-Koop stoma.

INTRODUCTION: Acute mesenteric ischaemia frequently requires extensive bowel resection. Primary anastomosis is unsafe necessitating exteriorisation of proximal small bowel and distal colon. Inevitably, therefore, patients are left with high output stomas with concomitant fluid and nutritional problems. SUBJECTS: We present two cases of acute mesenteric ischaemia both of which required extensive bowel resection. In both patients, we re-established intestinal continuity early by fashioning a Bishop-Koop type of reconstruction. RESULTS: Both patients had uneventful postoperative recoveries with no stoma-related complication or anastomosis problems. Neither patient required prolonged parenteral therapy. CONCLUSIONS: Bishop-Koop procedure may be used safely in a selected group of patients, with potential advantages of early restoration of intestinal continuity and easier closure.

Current pattern of perioperative practice in elective colorectal surgery; a questionnaire survey of ACPGBI members.

INTRODUCTION: Enhanced recovery programmes (ERAS) are safe and have been shown to decrease the length of the hospital stay and complications following colorectal surgery. However implementation of ERAS requires dedicated resources. In addition, the practice of ERAS still varies between different surgeons and in different centres. AIM: The aim of this paper is to investigate the prevailing perioperative practice among members of the Association of Coloproctology of Great Britain and Ireland (APGBI). METHODS: A questionnaire was developed based on the principles of ERAS. The questionnaire was emailed to all members of the ACPGBI as extracted from the membership directory of the association of the year 2008. A postal questionnaire was subsequently sent to those who did not reply to the initial email. RESULTS: The response rate was 64%. Certain aspects of ERAS such as pre-operative information and assessment, intra-operative warming, avoidance of nasogastric tubes and drains and early initiation of fluid and solid food was in practice by majority of the surgeons. The routine use of bowel preparation for left sided colonic resections is in practice by nearly 60% of the surgeons. The use of carbohydrate loading prior to surgery has not been adopted by more than half of the surgeons. There was no difference between type of hospital and adherence to ERAS. Some surgeons tend to have a slightly different approach to perioperative care in open and laparoscopic surgery. CONCLUSION: Adherence to ERAS among colorectal surgeons is relatively high. Certain aspects of perioperative practice have potential for improvement. Practice of ERAS should be encouraged in both laparoscopic and open surgery.

Intramucosal carcinoma on biopsy reliably predicts invasive colorectal cancer.

BACKGROUND: The diagnosis of invasive malignancy on biopsies from colorectal neoplasms can be challenging. The concept of intramucosal carcinoma as an indicator of invasive malignancy is somewhat controversial within histopathology circles despite current World Health Organization (WHO) definitions. This study was designed to correlate the biopsy finding of intramucosal carcinoma with the pathology findings after formal surgical excision. METHODOLOGY: We evaluated 89 patients whose initial forceps biopsy contained only intramucosal carcinoma. All tumors were subsequently resected and subjected to formal pathology assessment. RESULTS: Of 89 patients, 97% were shown to have frankly invasive adenocarcinoma by the current WHO definition. The positive predictive value of intramucosal carcinoma at biopsy for invasive cancer was 96.6% CONCLUSIONS: This study indicated that there should be a greater willingness among colorectal pathologists to accept the biopsy finding of intramucosal carcinoma as the earlier form of invasive malignancy. Clinicians should alter their treatment algorithms accordingly.