Systematic review and meta-analyses of cholecystectomy as a treatment of biliary hyperkinesia.

Biliary hyperkinesia is typically diagnosed in patients with biliary-like pain and no evidence of gall stones on imaging modalities but who have had biliary scintigraphy scan (HIDA) that shows ejection fraction ≥ 80%. This study aims to identify whether the removal of the gall bladder can alleviate the symptoms associated with biliary hyperkinesia. Systematic search following PRISMA guidelines was done from inception to January 2020 using PubMed/Medline, OVID, Embase, Cochrane database of systemic reviews, Cochrane central register of controlled trials, The Database of Abstracts of Reviews of Effects (DARE) and Cochrane library databases. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardized MD (SMD) for continuous outcomes. A meta-analysis was done using random-effect model in RevMan 5.4® software. Thirteen studies met the inclusion criteria and were included in the review. A total of 332 patients diagnosed with biliary hyperkinesia underwent cholecystectomy, of whom 303 (91.3%) reported symptomatic improvement RR 8.67 (95% CI 4.95, 15.16) P = 0.01. Six studies described abnormal histological features in 163/181 (90.05%) with high GB EF. RR 7.88 (95% CI 3.94, 15.75) P = 0.08. Chronic cholecystitis n = 155 (95%), cholesterolosis n = 7 (4.3%), and one showed features of acute cholecystitis. Patients with typical biliary colic symptoms without gallstones and markedly high ejection fraction might benefit from having cholecystectomy to alleviate their symptoms.

Urethral Catheterization Is Not Necessary During Nononcological Laparoscopic Pelvic Surgery.

OBJECTIVES: Expert opinion remains divided regarding whether routine urethral catheterization is required before nononcological laparoscopic pelvic surgery. Catheterization is thought to reduce the incidence of bladder injury when inserting a suprapubic laparoscopic port and prevent obstruction of the view of the pelvis because of bladder filling. However, catheterization comes with a risk of nosocomial infection and harbors financial cost. Moreover, indwelling catheters inhibit early mobilization and increase postoperative discomfort. METHODS: A systematic review was undertaken using the Meta-Analysis of Observational Studies guidelines to identify eligible publications. End points included bladder injury, positive postoperative urinary microbiology, and postoperative urinary symptoms. RESULTS: The reported incidence rates of laparoscopic bladder injury in included publications ranges from 0% to 1.3%. Importantly, bladder injury has occurred during both catheterized and noncatheterized operations. Our meta-analysis also shows that patients who are catheterized have a 2.33 times relative risk of developing postoperative positive microbiology in their urine (P = 0.01) and a 2.41 times relative risk of postoperative urinary symptoms (P = 0.005), when compared with noncatheterized patients. CONCLUSIONS: This meta-analysis indicates that omitting a catheter in emergency and elective nononcological laparoscopic pelvic surgery may be a safe option. Catheterization does not remove the risk of bladder injury but results in more urinary tract infections and symptoms. It may be reasonable to ask a patient to void immediately before anesthesia, after which an on-table bladder scan should be performed. If there is minimal residual volume, a urinary catheter may not be necessary, unless operative time is estimated to be greater than 90 minutes.

Lateral sinus thrombosis: a review of seven cases and proposal of a management algorithm.

OBJECTIVE: To evaluate the demographics, diagnosis, management, and outcomes of lateral sinus thrombosis in a pediatric population, and to propose a new treatment algorithm. METHODS: Retrospective review of seven patients. RESULTS: Patients averaged 7.4 years of age. They commonly presented with headache and otalgia (seven of seven patients), and nausea and vomiting (six of seven patients). All patients had abnormal otoscopy, and four of seven patients had a lateral rectus palsy, but fever was not always present (only three of seven patients). All patients underwent MRI with venography (MRV) for diagnosis. All patients were admitted to the hospital (average length of stay 8 days) and treated with antibiotics (six of seven patients with i.v. ceftriaxone). Five of seven were treated with simple mastoidectomy and concurrent middle ear ventilation tubes; two patients received only medical treatment. The average follow up was 114 months (range 33-387 months). Two patients had long-term sequela: one had persistent mild lateral gaze diplopia and another had unilateral moderate to severe high frequency sensorineural hearing loss. Six of seven patients had follow up imaging (average 15 months, range 1-40 months). Four of six patients showed recanalization of the lateral sinus on repeat imaging. Based on the current experience in the modern era of MRV and broad-spectrum antibiotics, a new treatment algorithm is proposed. CONCLUSIONS: Lateral sinus thrombosis is an uncommon cranial complication of otitis media. The advent of non-invasive diagnosis and effective broad-spectrum antibiotics has drastically decreased the mortality and altered the diagnostic and treatment paradigm.

Gastric cancer surgery--a balance of risk and radicality.

INTRODUCTION: The aim of this study was to determine whether tailoring the extent of resection would allow radical gastric cancer surgery to be performed safely in a UK population. PATIENTS AND METHODS: A total of 180 consecutive patients (median age 70 years; male:female ratio 2:1) undergoing resection for gastric adenocarcinoma with curative intent were studied. Extent of lymphadenectomy was based upon pre-operative and intra-operative staging, and balanced against the patient's age and fitness. RESULTS: In the study group, 83 patients underwent subtotal or distal partial gastrectomy and 97 patients underwent total or proximal partial gastrectomy. Operative procedures were: D1 lymphadenectomy (n = 62); modified (spleen and pancreas pre-serving) D2 lymphadenectomy (n = 73); D2 lymphadenectomy (n = 42); and extended resection (n = 3). TNM classification was: stage 1 (n = 45); stage 2 (n = 37); stage 3 (n = 61); and stage 4 (n = 37). Of the patients, 48 developed postoperative complications including 17 patients with a major surgical complication. The in-hospital mortality was 1.7% (3 of 180). Predicted mortality according to POSSUM and P-POSSUM was 21.4% and 7.8%, respectively. Disease-specific 5-year survival according to stage was 85.4%, 64.2%, 33.3%, and 6.9%. CONCLUSIONS: By tailoring the extent of resection and balancing risk and radicality, gastric cancer surgery can be performed with low mortality in Western patients.