Gender Comparisons of Surgical Outcomes in Patients Undergoing One Anastomosis Gastric Bypass (OAGB): a Historical Cohort Study.

INTRODUCTION AND PURPOSE: Clinical trials in the field of bariatrics have frequently been gender imbalanced, with males representing only 20% of examinees. Long-term gender-oriented results in one anastomosis gastric bypass (OAGB), and specifically quality of life (QOL) parameters, have not been addressed sufficiently. A better understanding of gender's effect on OAGB outcomes can play an important role in selecting the appropriate bariatric surgery for patients. Our study was aimed at examining mid-term gender-associated outcome of OAGB, including the effect on QOL. MATERIALS AND METHODS: A retrospective cohort study of patients who underwent OAGB at surgical ward A, SUMC, Israel, between 2015 and 2020. Demographics, body mass index (BMI), and comorbidities were extracted from the national medical records system. Follow-up quality of life (QOL) and weight parameters were supplemented via telephone questionnaires, using the Bariatric Analysis and Reporting Outcome System (BAROS). RESULTS: A total of 152 patients were included; of these, 51 (33.6%) were males, with an average follow-up period of 4.1 (± 1.3) years post-surgery. Basic demographics showed no significant pre- or post-surgery differences between males and females, except for pre-op weight (which as expected was higher for males). Males had a higher overall BAROS score than females (3.8 ± 2.1 vs. 2.6 ± 2.1, p < 0.001). CONCLUSIONS: OAGB surgery results in better outcomes for male than for female patients as measured by the BAROS, despite a similar BMI reduction, and with no difference in complications. Gender-specific outcomes are one of the variables that one should be aware of in optimizing patient selection and pre-operative patient counseling.

Laser tissue soldering of the gastrointestinal tract: A systematic review LTS of the gastrointestinal tract.

Background: Laser Tissue Soldering (LTS) is a promising tissue bonding technique in which a solder is applied between the tissues and then irradiated by laser, causing it to solidify and form links with the tissue. Methods: A comprehensive systematic review summarizing the state of research of LTS in the gastrointestinal tract. Results: Most studies were conducted on large animal tissues, using liquid proteinaceous solder, and irradiated by a continuous wave laser at 808 nm. LTS can provide better sealing and burst pressure than conventional methods. The application of LTS on top of or in addition to sutures showed an impressive increase in burst pressures. LTS may decrease the inflammatory and foreign body reaction caused by sutures. Conclusions: LTS has strong potential to be applied in a clinical setting in leak prevention and in closure of gastrointestinal structures as an adjunct or additional anastomotic technology, decreasing leak rates, morbidity, and mortality.

The Effect of Bariatric Surgery upon Diabetes Mellitus: A Proof of Concept by Using the Case of the Mid-Term Effect of Lap Adjustable Gastric Banding (LAGB) on Patients with Diabetes.

Obesity is a worldwide epidemic, with numbers on the rise in the world. Obesity is strongly correlated with increased morbidity and mortality. One of the major factors affecting this increase is comorbid diseases such as diabetes mellitus (DM), which is strongly associated with and dependent on the degree of obesity. Thus, it is not surprising that when efficient surgical treatments were found to battle obesity, researchers soon found them to be relevant and effective for battling DM as well. Laparoscopic Adjustable Gastric Banding (LAGB) is a common surgical treatment for morbid obesity. LAGB has the potential to improve control of the comorbidities of morbid obesity, primarily diabetes mellitus (DM). Our hypothesis was that patients treated with LAGB would have a long-term improvement in the control of DM and that due to its unique mechanism of action, this can lend us a better understanding of how to battle diabetes in an efficient and effective way. This was a cohort study based on patients who underwent LAGB surgery in our institution 4 to 7 years previously and had DM type 2 at the time of surgery. Data were collected from patient's charts and a telephone interview-based questionnaire including demographics, health status, and quality-of-life assessment (Bariatric Analysis and Reporting Outcome System [BAROS]). Seventy patients participated in the current study. The average follow-up time was 5.1 ± 0.9 years post-surgery. The average weight prior to surgery was 122.0 ± 20.2 kg, and on the day of the interview it was 87.0 ± 17.6 kg (p < 0.001). The average body mass index before surgery was 43.8 ± 5.1, and on the day of the interview it was 31.2 ± 4.8 (p < 0.001). On the day of the interview, 47.1% of the participants were cured of DM (not receiving treatment, whether dietary or pharmacologic). The sum of ranks for diabetes was lower after the surgery (p < 0.001), as was HTN and its treatment (p < 0.001). We have shown in this study that LAGB is an effective treatment for morbid obesity, as well as two comorbidities that come with it­DM type 2 and Hypertension (HTN)­in a longer period than previously shown, and with a unique look at the underlying mechanism of action of this procedure. There is a need for further studies to consolidate our findings and characterize which patients are more prone to enjoy these remarkable surgical benefits.

The impact of the COVID-19 pandemic on colorectal and gastric cancer diagnosis, disease stage and mortality.

Background: Since the outbreak of COVID-19, a significant decline in endoscopic procedures has been observed. Aims: We investigated the change of incidence, clinical characteristics, disease stage and mortality of patients with gastric cancer (GC) or colorectal cancer (CRC) diagnosed in 2020 compared to the pre-pandemic year 2019. Methods: Demographic, clinical and laboratory data on all patients diagnosed with GC or CRC at the Soroka University Medical Center were retrospectively collected and compared. Number of cases, time of diagnosis, clinical presentation, staging at diagnosis and mortality rates were compared. Results: Two hundred sixteen patients were diagnosed with CRC in 2019, whereas only 162 were diagnosed in 2020 (25% reduction), while 36 GC diagnoses were made in 2019 compared to 24 in 2020 (33% reduction). The age-adjusted incidence was calculated to be 24.28 for CRC and 5.0 for GC in 2020 compared to 29.93 and 5.32 in 2019, respectively. CRC patients had a significantly lower rate of rectal bleeding as their presenting symptom in 2020 compared with 2019, 8.1 vs. 19% (p = 0.003), but higher rate of diarrhea as their presenting symptom, 4.3 vs. 1% (p = 0.044). No significant differences regarding other presenting symptoms, comorbidities, surgery or mortality rates were found between the groups diagnosed in 2019 or 2020. Conclusion: A decrease in GC and CRC incidence was observed during the year 2020; lower rate of rectal bleeding and higher rate of diarrhea as presenting symptoms were noted in 2020, but no significant difference was found regarding other presenting symptoms, disease stage, surgery or mortality.

[SURGICAL PALLIATION FOR PANCREATIC CANCER].

INTRODUCTION: Pancreatic cancer (PC) is the 11th most common malignancy worldwide, however, entailing a mortality in excess of 90% within 5 years from diagnosis, it is the 4th most fatal malignant disease. PC is commonly diagnosed at an advanced stage, in which curative resection is no longer possible. Even patients who present with potentially curable disease will have upward of 30% recurrence of their disease within the first year. Thus, palliative therapy has paramount importance in patient management. The purpose of palliative care in these patients is to relieve symptoms and improve quality of life. This article reviews the current state of invasive palliation techniques for advanced PC, which are commonly directed towards three main symptoms: gastric/duodenal obstruction, obstructive jaundice, and epigastric pain. We describe the pros and cons of the different techniques, along with current front-line technology advancements. Endoscopic stenting is highly efficient in patients with gastric/duodenal obstruction or obstructive jaundice, with a generally low complication rate, short hospitalization and sustained quality of life. Bypass surgery should be considered in patients with a long-anticipated life expectancy, following higher rates of long-term stent failure, or when endoscopic stent procedure is not possible or has failed. When treating abdominal pain, celiac plexus neurolysis is considered as the first-line treatment. Pancreatic cancer is a complex and commonly lethal disease strongly affecting patient quality of life. It is important to consider the specific patient's personal characteristics and disease status when planning their palliative care.

A Comparison of One- and Two-Stage Laparoscopic Sleeve Gastrectomy Following Failed Laparoscopic Adjustable Gastric Banding Using the BAROS Score.

INTRODUCTION: Revision of a failed band can be done by laparoscopic sleeve gastrectomy (LSG). It can be performed synchronously with band removal or during two separate procedures. AIM: Comparing single- and two-staged LSG following a failed LAGB in terms of short- and mid-term outcomes, with an emphasis on postoperative quality of life. METHODS: A retrospective cohort study comparing revisional LSG's safety and efficacy after failed LAGB removal. Data included patients' medical files, as telephone interviews. We compared demographics, weight loss, complications, long-term outcomes, and quality-of-life measures, including the Bariatric Analysis and Reporting Outcome System (BAROS). RESULTS: Ninety-three patients were enrolled, of which 68 (73.1%) underwent a single-stage revisional LSG. Of these, 40 were males (35.1%) with a mean age of 44.9 years (± 12.9). The two-staged group were older. The reasons for band removal differed between the groups: whereas in the two-stage surgery, the common causes were slippage (29.2%) or band intolerance (25%); in the single-stage group, it was weight gain (51%). There were no differences in short- and mid-term complications, weight loss, and quality of life. CONCLUSION: In selected cases, laparoscopic sleeve gastrectomy as a revision of failed gastric banding in one stage is as safe as a two-stage procedure in terms of short- and mid-term complications, weight loss, and quality of life. We believe that there is little benefit in performing elective surgery in two stages unless there are clinical indications. Exceptions for two-stage revision should include cases of band erosion and acute slippage with patient preference for band removal.

Circulating Cell-free DNA in Patients With Acute Biliary Pancreatitis: Association With Disease Markers and Prolonged Hospitalization Time-A Prospective Cohort Study.

OBJECTIVE: To evaluate cfDNA as an indicator of pancreatitis severity. BACKGROUND: Acute pancreatitis severity scores have limited proficiency, and are complex and challenging to use clinically. Elevation of circulating cfDNA concentration has been shown to be associated with hospital length of stay (LOS) and mortality. METHODS: In a prospective study, cfDNA concentration was measured by a simple fluorometric test, at admission and for 2 consecutive days, in patients with acute biliary pancreatitis (ABP). Ranson and APACHE II scores were used as measures of pancreatitis severity. Hospital LOS and mortality were used as outcome measures. RESULTS: Seventy-eight patients were included. Patients with severe disease according to Ranson's Criteria (n = 24) had elevated median admission cfDNA compared to patients with mild disease (n = 54, 2252ng/ml vs 1228 ng/ml, P < 0.05 ). Admission cfDNA levels correlated with Ranson and APACHE II scores and markers of bile duct obstruction. LOS did not differ between patients with mild and severe disease according to Ranson and APACHE II scores. Patients with cfDNA at 24 hours concentrations above the cutoff value of healthy patients (>850 ng/ml) had a significantly longer LOS compared to those with normal cfDNA levels ( P < 0.001 ). CONCLUSIONS: cfDNA, measured by a rapid simple assay, proved a valuable early marker of severity in ABP with clear advantages for prediction of LOS over Ranson and APACHE II. Measurement of cfDNA has the potential to be an effective practical approach to predict the course of ABP and should be further evaluated in larger trials.

Laparoscopic Sleeve Gastrectomy Following Failed Laparoscopic Adjustable Gastric Banding-a Comparison Between One- and two-Stage Procedures, an Israeli National Database Study.

PURPOSE: The optimal revisional bariatric surgery procedure following a previous failed gastric band surgery is yet to be determined. The aim of our study was to compare single- and two-stage laparoscopic sleeve gastrectomy (LSG) following laparoscopic adjustable gastric banding (LAGB) in terms of short- and mid-term outcomes. MATERIALS AND METHODS: Patients who underwent LSG after a failed LAGB in Israel during 2014-2017 were included. Data were obtained from the Israeli National Bariatric Surgery Registry. Data analyzed included comorbidities, postoperative complications, and anthropometric outcomes. RESULTS: Of 595 patients included in the data analysis, 381 (64%) underwent one-stage and 214 (36%) had two-stage LSG. No differences were observed between the groups in complication rates (5.0 vs. 5.1%, p=0.93). Percent of total weight loss was lower following one-stage than two-stage procedure at both 6 months (19.3±9.3 vs. 21.5±8.1%; p=0.02) and 1 year postoperative (24.9±10.4 vs. 27.8±9.9%; p=0.02). No difference was observed in the percent excess weight loss (51 vs. 56%; p=0.34 and 66 vs. 72%; p=0.38, at 6 months and 12 months postoperative, respectively). In a regression analysis, percent excess weight loss was greater in the two-stage procedure (p=0.02), with no difference in the complication rates (p=0.98). CONCLUSION: Single-step LSG had a similar safety profile as two-stage LSG following a failed LAGB. Better weight loss was seen following two-stage LSG. Further prospective studies should investigate long-term follow-up after one- and two-stage procedure.

Circulating plasma microRNAs in colorectal neoplasia: A pilot study in assessing response to therapy.

INTRODUCTION: Current serological surveillance markers to monitor colorectal cancer (CRC) or colorectal advanced adenomas (CAA) are hampered by poor sensitivity and specificity. The aim of this study is to identify and validate a panel of plasma microRNAs which change in expression after resection of such lesions. METHODS: A prospectively maintained colorectal surgery database was queried for patients in whom both pre- and post-procedural serum samples had been obtained. An initial screening analysis of CRC and CAA patients (5 each) was conducted using screening cards for 380 miRNAs. Four identified miRNAs were combined with a previously described panel of 7 miRNAs that were diagnostically predictive of CRC and CAA. Differential miRNA expression was assessed using quantitative real-time polymerase chain reaction(qRT-PCR). RESULTS: Fifty patients were included (n = 27 CRC, n = 23 CAA). There was no difference in age, gender, or race profile of CRC patients compared to CAA patients. Six miRNA were significantly increased after CRC resection (miR-324, let7b, miR-454, miR-374a, miR-122, miR-19b, all p<0.05), while three miRNAs were significantly increased following CAA resection (miR-454, miR-374a, miR-122, all p<0.05). Three miRNA were increased in common for both (miR-454, miR-374a, miR-122). DISCUSSION: The expression of miRNAs associated with neoplasia (either CRC or CAA) was significantly increased following surgical resection or endoscopic removal of CRC or CAA. Future studies should focus on the evaluation of these miRNAs in CRC and CAA prognosis.

Robot-assisted laser tissue soldering system.

Fast and reliable incision closure is critical in any surgical intervention. Common solutions are sutures and clips or adhesives, but they all present difficulties. These difficulties are especially pronounced in classical and robot-assisted minimally-invasive interventions. Laser soldering methods present a promising alternative, but their reproducibility is limited. We present a system that combines a previously reported laser soldering system with a robotic system, and demonstrate its feasibility on the incision-closure of ex-vivo mice skins. In this demonstration, we measured tearing forces of ~2.5N, 73% of the tearing force of a mouse skin without an incision. This robot-assisted laser soldering technique has the potential to make laser tissue soldering more reproducible and revolutionize surgical tissue bonding.

Long-term outcomes following ileal pouch-anal anastomosis in patients with indeterminate colitis.

BACKGROUND: The advisability of performing ileal pouch-anal anastomosis for patients with indeterminate colitis is debated. Indeterminate colitis is found in up to 15% of inflammatory bowel disease colectomy specimens. We determined long-term outcomes in patients diagnosed with indeterminate colitis undergoing ileal pouch-anal anastomosis. METHODS: Fifty-six patients were included with a mean follow-up of 14 ± 7 years. Long-term behavior was defined based on surgeon assessment as "Crohn disease-like" in patients who subsequently developed clear signs of Crohn disease and as "non-Crohn disease-like." Long-term function was assessed using the Cleveland Global Quality of Life and Pouch Functional Score. RESULTS: Thirty-nine percent of patients developed Crohn disease-like behavior, and 61% developed non-Crohn disease-like behavior. Both groups experienced a high rate of pouchitis (57%). Crohn disease-like patients required more anti-inflammatory/immunomodulatory medications (95% vs 18%, P < .001), dilatations for afferent-limb strictures (41% vs 0%, P < .001), and pouch reoperations (32% vs 6%, P = .02). Eight patients required pouch excision or diversion (7 with Crohn disease-like behavior). The Pouch Functional Score was equivalent between groups. CONCLUSION: Long-term function after ileal pouch-anal anastomosis for the majority of indeterminate colitis patients was good. Approximately 40% eventually exhibited Crohn disease-like behavior, but the majority had acceptable function and quality of life. Ileal pouch-anal anastomosis is an appropriate surgical option for indeterminate colitis patients after informed consent.

Do Male Patients Benefit from Laparoscopic Adjustable Gastric Banding More than Female Patients? A Retrospective Cohort Study.

BACKGROUND: Clinical trials in the field of bariatrics, and specifically laparoscopic adjustable gastric banding (LAGB), have frequently been gender imbalanced, with males representing only 20% of examinees. Long-term gender-oriented results, and specifically quality of life (QOL) parameters, have not been addressed sufficiently. The aim of our study was to examine the long-term gender association with outcome of LAGB including the impact on QOL. METHODS: A retrospective cohort study of patients who underwent LAGB between 2006 and 2014 by a single surgeon was conducted. Data were collected from the hospital registry and a telephone interview that included a standardized questionnaire. Outcomes including BMI reduction, evolution of comorbidities, complications, reoperations, and QOL were compared according to the Bariatric Analysis and Reporting Outcome System (BAROS). RESULTS: Included were 114 males and 127 females, with a mean age of 38.2 years at surgery, and an average post-surgery follow-up of 6.5 years. Similar BMI reduction (p = 0.68) and perioperative complication rates (p = 0.99) were observed. Males had a greater improvement in comorbidities (p < 0.001), less band slippage (p = 0.006), underwent fewer reoperations (p = 0.02), and reported higher QOL scores (p = 0.02) than females. The total BAROS score was significantly higher for males than females (p < 0.001). CONCLUSIONS: LAGB surgery results in better outcomes for male than female patients as measured by the BAROS, despite a similar BMI reduction. Gender-specific outcomes should be taken into consideration in optimizing patient selection and preoperative patient counseling.

Comparison of the Long-Term Oncological Outcomes of Stent as a Bridge to Surgery and Surgery Alone in Malignant Colonic Obstruction.

BACKGROUND: Self-expanding metallic stents (SEMS) insertion is an alternative to emergency surgery in malignant colonic obstruction. However, the long-term oncological outcome of stents as a bridge to surgery is limited and controversial. OBJECTIVES: To determine the long-term oncological outcome of stents as a bridge to surgery. METHODS: Data of patients who underwent emergency surgery and endoscopic stent insertion as a bridge to surgery due to obstructing colon cancer at Soroka Medical Center during a 14 year period were collected retrospectively. Preoperative data, tumor staging, and oncological outcomes in terms of local recurrence, metastatic spread, and overall survival of the patients were compared. RESULTS: Sixty-four patients (56% female, mean age 72 years) were included in the study: 43 (67%) following emergency surgery, 21 stent inserted prior to surgery. A stent was inserted within 24-48 hours of hospital admission. The mean time between SEMS insertion and surgery was 15 days (range 0-30). Most of the patients had stage II (41%) and stage III (34%) colonic cancer. There was no difference in tumor staging and localization between groups. There was no significant difference in disease recurrence between SEMS and surgery groups, 24% and 32%, respectively. Disease-free survival rates were similar between the SEMS group (23.8%) and surgery group (22%). Four year and overall survival rates were 52.4% vs. 47.6%, 33.3% vs. 39.5%, respectively. CONCLUSIONS: SEMS as a bridge to surgery in patients with obstructing colon cancer provide an equivalent long-term oncological outcome to surgery alone.

Plasma microRNA Profile Differentiates Crohn's Colitis From Ulcerative Colitis.

Background: Inflammatory bowel disease (IBD) is commonly divided into 2 entities: Crohn's disease (CD) and ulcerative colitis (UC). Differentiating between these entities when dealing with IBD confined to the colon is important, especially when planning surgical treatment. Due to ambiguous histological or endoscopic findings, accurate diagnosis is not possible in up to 15% of cases. The aim of this study was to determine whether plasma microRNAs (miRNAs) can help differentiate Crohn's colitis (CC) from ulcerative colitis. Methods: Patients with isolated CC and with UC were enrolled in our study from January 2010 to May 2016. Peripheral blood was collected, and total RNA was isolated from plasma. Screening was performed for 380 common miRNAs. miRNAs that were differentially expressed between these 2 groups were chosen, and their differential expression was confirmed using single miRNA assays in a larger sample size. A predictive model was generated using these data. Significantly differentially expressed miRNAs were then validated utilizing the predictive model to assess blinded data from the single assays. Results: Screening was performed on 8 patients from each group. Seven differentially expressed miRNAs were chosen for single assay confirmation. Two miRNAs (miR-598, miR-642) were consistently different between the patient groups (P = 0.013, P = 0.005). Using blinded data, these 2 miRNAs were validated using the predictive model, achieving an overall accuracy of 75% (95% confidence interval, 40.7-92.9). Conclusions: We identified 2 plasma miRNAs that differentiated CC from UC. Our data indicate the promise and feasibility of a plasma miRNA-based assay to distinguish between these 2 conditions.

Genetic polymorphisms predict response to anti-tumor necrosis factor treatment in Crohn's disease.

AIM: To investigate genetic factors that might help define which Crohn's disease (CD) patients are likely to benefit from anti-tumor necrosis factor (TNF) therapy. METHODS: This was a prospective cohort study. Patients were recruited from a university digestive disease practice database. We included CD patients who received anti-TNF therapy, had available medical records (with information on treatment duration and efficacy) and who consented to participation. Patients with allergic reactions were excluded. Patients were grouped as ever-responders or non-responders. Genomic DNA was extracted from peripheral blood, and 7 single nucleotide polymorphisms (SNPs) were assessed. The main outcome measure (following exposure to the drug) was response to therapy. The patient genotypes were assessed as the predictors of outcome. Possible confounders and effect modifiers included age, gender, race, and socioeconomic status disease, as well as disease characteristics (such as Montreal criteria). RESULTS: 121 patients were included. Twenty-one were non-responders, and 100 were ever-responders. Fas ligand SNP (rs763110) genotype frequencies, TNF gene -308 SNP (rs1800629) genotype frequencies, and their combination, were significantly different between groups on multivariable analysis controlling for Montreal disease behavior and perianal disease. The odds of a patient with a Fas ligand CC genotype being a non-responder were four-fold higher as compared to a TC or TT genotype (P = 0.009, OR = 4.30, 95%CI: 1.45-12.80). The presence of the A (minor) TNF gene -308 allele correlated with three-fold higher odds of being a non-responder (P = 0.049, OR = 2.88, 95%CI: 1.01-8.22). Patients with the combination of the Fas ligand CC genotype and the TNF -308 A allele had nearly five-fold higher odds of being a non-responder (P = 0.015, OR = 4.76, 95%CI: 1.35-16.77). No difference was seen for the remaining SNPs. CONCLUSION: The Fas-ligand SNP and TNF gene -308 SNP are associated with anti-TNF treatment response in CD and may help select patients likely to benefit from therapy.

Cell-free deoxyribonucleic acid as a prognostic marker of bowel ischemia in patients with small bowel obstruction.

BACKGROUND: Patients with strangulation small bowel obstruction are at a high risk for serious morbidity and mortality due to ischemic bowel. Measuring serum, cell-free deoxyribonucleic acid levels could help recognize early cell death. Our hypothesis was that small bowel ischemia or necrosis is associated with increases in serum cell-free deoxyribonucleic acid and that recovery is associated with a decrease in cell-free deoxyribonucleic acid levels. METHODS: A prospective cohort study in addition to standard treatment of patients admitted with a diagnosis of small bowel obstruction. The participants were divided into groups depending on the presence of ischemic or necrotic bowel according to operative and clinical outcome. Clinical data and serum-based cell-free deoxyribonucleic acid levels were compared. Cell-free deoxyribonucleic acid levels from these 2 groups also were compared with a third group of healthy controls. RESULTS: In the study, 58 patients were enrolled, and 18 patients (31%) underwent operation. During the operative procedure, ischemic or necrotic bowel was found in 10 cases (17%). Serum levels of cell-free deoxyribonucleic acid at the time of admission in the ischemic/necrotic bowel group were increased compared with patients with well perfused or spontaneously recovered bowel (P = .03). Cell-free deoxyribonucleic acid levels decreased on the day after admission in 88% of the nonoperated patients. No significant differences were found in demographics, medical background, imaging performed, and cause of obstruction nor in clinical admission data. CONCLUSION: Surgeons currently rely on imprecise clinical parameters, including degree of pain, abdominal tenderness, leukocytosis etc to decide when operative intervention is needed. The association of cell-free deoxyribonucleic acid with small bowel obstruction, ischemia, and recovery supports our hypothesis and suggests that this biomarker is a potential surrogate of small bowel perfusion.

Laparoscopic Lavage in the Management of Perforated Diverticulitis: a Contemporary Meta-analysis.

IMPORTANCE: Perforated diverticulitis carries the risk of significant comorbidity and mortality. Although colon resection provides adequate source control, the procedure itself carries morbidity, as well as later stoma reversal procedures. The effectiveness of laparoscopic lavage to treat perforated diverticulitis remains unclear. OBJECTIVE: We aimed to conduct a meta-analysis to evaluate current studies comparing laparoscopic lavage with colon resection in cases of perforated diverticulitis for the effectiveness in source control, without the need for subsequent interventions, stoma formation, and death. DATA SOURCES: Electronic database searches were conducted using EMBASE, Pubmed, CINAHL, Cochrane databases, and clinicaltrials.gov following PRISMA guidelines. STUDY SELECTION: Randomized controlled trials (RCTs) were included that compared laparoscopic lavage against colon resection for perforated diverticulitis. DATA EXTRACTION AND SYNTHESIS: Risk of bias in RCT's was assessed the Cochrane Assessment of Bias risk tool and Jadad scale. A meta-analysis was performed using random-effects risk ratios (RR) and 95% confidence intervals (CI). MAIN OUTCOME: Outcome measures included the total rate of reoperation, rate of reoperation for infection, need for subsequent percutaneous drainage, stoma formation, and mortality rate within 90 days. RESULTS: Three eligible randomized controlled studies were identified, with a combined total of 372 patients. Laparoscopic lavage carried an increased rate of total reoperations (RR 2.07; CI 1.12-3.84; p = 0.021) and an increased rate of reoperation for infection (RR 5.56; CI 1.97-15.69; p = 0.001) compared with colon resection. In addition, laparoscopic lavage increased the rate of subsequent percutaneous drainage (RR 6.54; CI 1.77-24.16; p = 0.005) compared with colon resection, but a lesser risk of stoma formation within 90 days (RR 0.18; CI 0.12-0.27; p < 0.001). No difference in mortality rate was observed between treatments (RR 1.03; CI 0.45-2.34; p = 0.950). CONCLUSION: Despite decreased rates of stoma formation and equivalent mortality rates as compared with colon resection, laparoscopic lavage for Hinchey III diverticulitis fails to completely control the source of infection. Our data show that laparoscopic lavage is associated with increased rates of total reoperations, increased rates of reoperation for infections, and need for subsequent percutaneous drainage.

Genetic polymorphisms in 5-Fluorouracil-related enzymes predict pathologic response after neoadjuvant chemoradiation for rectal cancer.

BACKGROUND: Many patients with rectal cancer undergo preoperative neoadjuvant chemoradiation, with approximately 70% exhibiting pathologic downstaging in response to treatment. Currently, there is no accurate test to predict patients who are likely to be complete responders to therapy. 5-Fluorouracil is used regularly in the neoadjuvant treatment of rectal cancer. Genetic polymorphisms affect the activity of thymidylate synthase, an enzyme involved in 5-Fluorouracil metabolism, which may account for observed differences in response to neoadjuvant treatment between patients. Detection of genetic polymorphisms might identify patients who are likely to have a complete response to neoadjuvant therapy and perhaps allow them to avoid operation. METHODS: DNA was isolated from whole blood taken from patients with newly diagnosed rectal cancer who received neoadjuvant therapy (n = 50). Response to therapy was calculated with a tumor regression score based on histology from the time of operation. Polymerase chain reaction was performed targeting the promoter region of thymidylate synthase. Polymerase chain reaction products were separated using electrophoresis to determine whether patients were homozygous for a double-tandem repeat (2R), a triple-tandem repeat (3R), or were heterozygous (2R/3R). A single nucleotide polymorphism, 3G or 3C, also may be present in the second repeat unit of the triple-tandem repeat allele. Restriction fragment length polymorphism assays were performed in patients with at least one 3R allele using HaeIII. RESULTS: Patients with at least 1 thymidylate synthase 3G allele were more likely to have a complete or partial pathologic response to 5-Fluorouracil neoadjuvant therapy (odds ratio 10.4; 95% confidence interval, 1.3-81.6; P = .01) than those without at least one 3G allele. CONCLUSION: Identification of rectal cancer patients with specific genetic polymorphisms in enzymes involved in 5-Fluorouracil metabolism seems to predict the likelihood of complete or partial pathologic response to preoperative neoadjuvant therapy.