Systematic review and meta-analysis of randomized controlled trials evaluating the effect of the level of ligation of inferior mesenteric artery on functional outcomes in rectal cancer surgery.

BACKGROUND: This systematic review and meta-analysis studied the role of high (HL) versus low (LL) inferior mesenteric artery (IMA) ligation on genitourinary and defecatory dysfunction in patients who had undergone resection for rectal cancer (RC). METHODS: A systematic literature search of four major databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Randomized controlled trials (RCTs) comparing HL and LL of IMA in RC surgery were identified. Those studies that looked at genitourinary or defecatory dysfunction were included. Random-effects modeling to summarize statistics was performed. The risk of bias was assessed using Cochrane's Risk-of-Bias tool 2. RESULTS: Three RCTs were included. There was clinical heterogeneity with regard to cancer stage and location as well as operative techniques and adjuvant treatments. Functional outcomes (FO) that were reported by at least two studies were International Consultation on Incontinence Questionnaire (ICIQ), International Index for Erectile Function (IIEF), Jorge-Wexner incontinence score (J-W). Difference was observed in ICIQ at 9 months after surgery favoring LL (standard mean difference: - 0.66; 95% confidence intervals (CI): - 0.92, - 0.40; P = 0.37; I 2 = 0%). Difference was also observed in IIEF at 9 months favoring LL (mean difference: 7.43; CI: 1.86, 13.00; P = 0.16; I 2 = 50%). CONCLUSIONS: Although our study has demonstrated the superiority of LL in genitourinary function preservation, these results should be taken with consciousness due to significant heterogeneity between included studies, small sample size, and potential bias. More high-quality studies are needed. PROSPERO: CRD4202121099  https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021210998.

Perioperative immunonutrition in hepatectomy: A systematic review and meta-analysis.

BACKGROUNDS/AIMS: The role of immunonutrition (IMN) after liver resections or hepatectomies remains unclear and controversial. We undertook a systematic review to evaluate the effects of IMN on clinical outcomes of patients undergoing hepatectomy. METHODS: Main electronic databases were searched for randomised trials reported clinical outcomes or effects of IMN. The systematic review was conducted in accordance with the PRISMA guideline and meta-analysis was analysed using fixed or random-effects models. RESULTS: Eleven RCTs were identified. A total of 1084 patients (529 IMN and 555 Control) were included in the final pooled analysis. Of these patients, 43% (440/1016) underwent major hepatectomies and the majority are for hepatocellular carcinoma (90%, 956/1055) with Child-Pugh A disease (89%, 793/894). IMN significantly reduced post-operative wound infection (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.43 to 0.96; p=0.03). IMN also had a shorter hospital stay (MD -4.97 days, 95% CI -8.23 to -1.72; p=0.003). There was no statistically significant in other post-operative morbidities and mortality. CONCLUSIONS: Wound infection rate was not significantly different between oral and parenteral IMN group. The length of hospital stay was significantly lower in parenteral IMN group than in oral IMN group. The mortality rates were not affected. Immunonutrition should be recommended routinely as part of the nutritional support in the Enhanced Recovery after Surgery (ERAS) protocol for hepatectomy.

Portal pyaemia secondary to colonic perforation.

Portal pyaemia or pylephlebitis is a form of septic (often suppurative) thrombophlebitis of the portal venous system. It may develop as a complication of intra-abdominal sepsis, such as diverticulitis or appendicitis. Patients typically present with a high fever that is sometimes accompanied by jaundice. We report a case of portal pyaemia associated with multiple liver abscesses and discuss the medical and surgical management of this condition.

Laparoscopy versus laparotomy for the management of penetrating abdominal trauma: A systematic review and meta-analysis.

BACKGROUND: Controversy exists regarding the role of laparoscopy in the evaluation of patients with penetrating abdominal trauma (PAT). Our objective was to perform a comprehensive review of the literature and conduct a meta-analysis to compare outcomes of laparoscopy and laparotomy in PAT. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Missed injury, mortality, and complications were defined as the primary outcome parameters. Procedure time, length of hospital stay, sensitivity and specificity of the procedure were the secondary outcomes. Combined overall effect sizes were calculated using fixed-effect or random-effects models. RESULTS: We identified one randomised controlled trial (RCT) and 8 observational studies comparing outcomes of laparoscopy with laparotomy in PAT. Laparoscopy was associated with a significantly lower risk of wound infection (Odd ratio (OR): 0.55; 95% Confidence interval (CI), 0.37-0.81, P = 0.003) and pneumonia (OR: 0.22; 95% CI, 0.13-0.37, P < 0.00001), and a significantly shorter length of hospital stay (Mean difference (MD): -3.05; 95% CI, -4.68 to -1.42, P = 0.0002) and procedure time (MD: -27.99; 95% CI, -43.17 to -12.80, P = 0.0003) compared with laparotomy. Laparoscopy was 100% sensitive in most of the included studies and avoided non-therapeutic laparotomies in 45.6% of patients. CONCLUSIONS: Our analysis of best available evidence mainly from heterogeneous observational studies has demonstrated that laparoscopic evaluation of haemodynamically stable patients with PAT may be safe and can reduce post-operative complications and length of hospital stay. The most important advantage of laparoscopy is avoidance of non-therapeutic laparotomies which are associated with considerable morbidity. However, no definitive conclusion can be made regarding the therapeutic role of laparoscopy in PAT based on the available evidence and future research is indeed required.

Gastric perforation secondary to metastasis from breast cancer.

Gastric perforation secondary to metastasis from breast cancer occurs infrequently. We present the case of a 72-year-old postmenopausal female patient with a known history of lobular carcinoma of the breast who presented to a district general hospital with a clinical diagnosis of an acute abdomen. Further contrast-enhanced CT scan demonstrated free gas and fluid in the abdomen. She underwent emergency exploratory laparotomy and onlay Graham's omentopexy patch due to 1×1 cm prepyloric gastric perforation. Final histopathology proved the presence of metastatic malignant cells in the breast origin. We discuss the issues involved in postoperative investigation and management.

A systematic review of preoperative duplex ultrasonography and arteriovenous fistula formation.

BACKGROUND: Arteriovenous fistula (AVF) formation for dialysis access is a common procedure. Fistula maturation is unpredictable. Preoperative duplex mapping may increase procedural success. We undertook a systematic review to assess the effect of preoperative duplex mapping on subsequent AVF patency. METHODS: The published literature was searched on PubMed and the Cochrane Library using the following keywords: 'arteriovenous fistula,' 'venous mapping,' 'ultrasound,' 'hemodialysis,' 'vascular access,' and 'perioperative vessel mapping.' Conference proceedings were hand searched for otherwise unpublished trials. Only randomized controlled trials in which preoperative duplex mapping was compared with clinical evaluation were eligible. RESULTS: Three trials (402 patients) were identified. More patients who underwent ultrasound successfully started using their fistula for dialysis access, although the difference did not reach statistical significance (174/214 vs 130/188; pooled odds ratio, 1.96; P = .11). CONCLUSIONS: Preoperative duplex mapping may improve fistula maturation rates. However, the results do not reach statistical significance and there are no cost-effectiveness data. Further work is required.

Pneumobilia: a case report and literature review on its surgical approaches.

Gallstones ileus is an uncommon cause but important cause of small bowel obstruction. The gallstone enters the intestinal lumen via a fistula located in the duodenum (cholecystoduodenal), or rarely, in the colon (cholecystocolonic) or stomach (cholecystogastric). This may result in large bowel or gastric outlet obstruction (Bouveret's Syndrome). Gallstone ileus affects the elderly females pre-dominantly and is associated with a high morbidity and mortality rate if diagnosis and urgent surgical intervention are delayed. In this paper, we report on the case of an elderly lady who presented with classical symptoms and signs of small bowel obstruction. She was subsequently diagnosed with gallstone ileus due to a large gallstones lodged in the intestinal lumen. We perform a literature review on this rare disease and discuss the two main surgical approaches in managing this condition. Gallstone ileus should be considered in the differential diagnosis of small bowel obstruction especially in elderly women who have no history of abdominal surgery or abdominal hernia. Early intervention is important because of the high mortality rate due to the poor general condition that often exists in this subgroup of patients. There is no general consensus on gold standard surgical approach in these cases but a two-stage procedure (either enterotomy alone or enterotomy and subsequent cholecystectomy) has been shown to be associated with lower mortality rates.

Appendicular perforation at the base of the caecum, a rare operative challenge in acute appendicitis, a literature review.

BACKGROUND: Acute appendicitis is the most common acute surgical condition of the abdomen. Diagnosis is made based on full clinical history and examination as well as supported by a routine blood investigation and urine test. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complications. The mortality rate of non-perforated appendicitis is less than 1 percent. Perforated appendicitis is associated with a higher mortality rate - as high as five percent and may be particularly more in extreme of age group attributed to delay in clinical presentation or diagnosis in the younger group and multiple co-morbidities in the elderly group. The aetiology is unknown. It may be linked with lack of fibre, familial tendency, or viral infection. It may be precipitated by faecaliths. The commonest site of the appendix is retrocaecal. CASE REPORT: We report a case of a 46 year old male who was admitted under the surgical service in Mid-Western Regional Hospital, Limerick with suspected appendicitis which turned out to be a perforated caecum, a rare complication of an acute appendicitis. We performed a literature review comparing two main approaches - right hemicolectomy and primary closure with omental patch - discuss and highlight their differences as well as a guide to its management. CONCLUSION: There are limited studies to compare these two surgical options in the literature. A larger prospective study is needed to compare both approaches and long term outcome.