Timed up and go test and long-term survival in older adults after oncologic surgery.

BACKGROUND: Physical performance tests are a reflection of health in older adults. The Timed Up and Go test is an easy-to-administer tool measuring physical performance. In older adults undergoing oncologic surgery, an impaired TUG has been associated with higher rates of postoperative complications and increased short term mortality. The objective of this study is to investigate the association between physical performance and long term outcomes. METHODS: Patients aged ≥65 years undergoing surgery for solid tumors in three prospective cohort studies, 'PICNIC', 'PICNIC B-HAPPY' and 'PREOP', were included. The TUG was administered 2 weeks before surgery, a score of ≥12 seconds was considered to be impaired. Primary endpoint was 5-year survival, secondary endpoint was 30-day major complications. Survival proportions were estimated using Kaplan-Meier curves. Cox- and logistic regression analysis were used for survival and complications respectively. Hazard ratios (aHRs) and Odds ratios (aOR) were adjusted for literature-based and clinically relevant variables, and 95% confidence intervals (95% CIs) were estimated using multivariable models. RESULTS: In total, 528 patients were included into analysis. Mean age was 75 years (SD 5.98), in 123 (23.3%) patients, the TUG was impaired. Five-year survival proportions were 0.56 and 0.49 for patients with normal TUG and impaired TUG respectively. An impaired TUG was an independent predictor of increased 5-year mortality (aHR 1.43, 95% CI 1.02-2.02). The TUG was not a significant predictor of 30-day major complications (aOR 1.46, 95% CI 0.70-3.06). CONCLUSIONS: An impaired TUG is associated with increased 5-year mortality in older adults undergoing surgery for solid tumors. It requires further investigation whether an impaired TUG can be reversed and thus improve long-term outcomes. TRIAL REGISTRATION: The PICNIC studies are registered in the Dutch Clinical Trial database at www.trialregister.nl: NL4219 (2010-07-22) and NL4441 (2014-06-01). The PREOP study was registered with the Dutch trial registry at www.trialregister.nl: NL1497 (2008-11-28) and in the United Kingdom register (Research Ethics Committee reference 10/H1008/59).  https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/?page=15&query=preop&date_from=&date_to=&research_type=&rec_opinion=&relevance=true .

Long-Term Survival and Risk of Institutionalization in Onco-Geriatric Surgical Patients: Long-Term Results of the PREOP Study.

OBJECTIVES: To evaluate long-term survival and institutionalization in onco-geriatric surgical patients, and to analyze the association between these outcomes and a preoperative risk score. DESIGN: Prospective cohort study with long-term follow-up. SETTING: International and multicenter locations. PARTICIPANTS: Patients aged 70 years or older undergoing elective surgery for a malignant solid tumor at five centers (n = 229). MEASUREMENTS: We assessed long-term survival and institutionalization using the Preoperative Risk Estimation for Onco-geriatric Patients (PREOP) score, developed to predict the 30-day risk of major complications. The PREOP score collected data about sex, type of surgery, and the American Society for Anesthesiologists classification, as well as the Timed Up & Go test and the Nutritional Risk Screening results. An overall score higher than 8 was considered abnormal. RESULTS: We included 149 women and 80 men (median age = 76 y; interquartile range = 8). Survival at 1, 2, and 5 years postoperatively was 84%, 77%, and 56%, respectively. Moreover, survival at 1 year was worse for patients with a PREOP risk score higher than 8 (70%) compared with 8 or lower (91%). Of those alive at 1 year, 43 (26%) were institutionalized, and by 2 years, almost half of the entire cohort (46%) were institutionalized or had died. A PREOP risk score higher than 8 was associated with increased mortality (hazard ratio = 2.6; 95% confidence interval [CI] = 1.7-4.0), irrespective of stage and age, but not with being institutionalized (odds ratios = 1 y, 1.6 [95% CI = .7-3.8]; 2 y, 2.2 [95% CI = .9-5.5]). CONCLUSION: A high PREOP score is associated with mortality but not with remaining independent. Despite acceptable survival rates, physical function may deteriorate after surgery. It is imperative to discuss treatment goals and expectations preoperatively to determine if they are feasible. Using the PREOP risk score can provide an objective measure on which to base decisions. J Am Geriatr Soc 68:1235-1241, 2020.

Unusual case of respiratory embarrassment secondary to tracheal compression by a dilated oesophagus in a patient with recurrent achalasia.

We present the case of a 79-year-old woman with recurrent achalasia following a laparoscopic Heller's cardiomyotomy. The patient presented to the emergency department, with epigastric pain, severe dyspnoea and profound respiratory acidosis. She required intubation and ventilation followed by gastric decompression with nasogastric tube and the administration of intravenous antibiotics for a lower respiratory tract infection. Once stable, she underwent a CT scan revealing a massively dilated oesophagus causing marked tracheal compression. She received a period of continuous positive airway pressure ventilation while on the intensive care unit, for persistent low saturations, however, this was promptly ceased due to exacerbation of gastric dilation and fears over perforation. The patient responded well to conservative measures and was discharged home 18 days later awaiting follow-up with operating consultant surgeon.

Non-operative management versus operative management in high-grade blunt hepatic injury.

BACKGROUND: Surgery used to be the treatment of choice in cases of blunt hepatic injury, but this approach gradually changed over the last two decades as increasing non-operative management (NOM) of splenic injury led to its use for hepatic injury. The improvement in critical care monitoring and computed tomographic scanning, as well as the more frequent use of interventional radiology techniques, has helped to bring about this change to non-operative management. Liver trauma ranges from a small capsular tear, without parenchymal laceration, to massive parenchymal injury with major hepatic vein/retrohepatic vena cava lesions. In 1994, the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (AAST) revised the Hepatic Injury Scale to have a range from grade I to VI. Minor injuries (grade I or II) are the most frequent liver injuries (80% to 90% of all cases); severe injuries are grade III-V lesions; grade VI lesions are frequently incompatible with survival. In the medical literature, the majority of patients who have undergone NOM have low-grade liver injuries. The safety of NOM in high-grade liver lesions, AAST grade IV and V, remains a subject of debate as a high incidence of liver and collateral extra-abdominal complications are still described. OBJECTIVES: To assess the effects of non-operative management compared to operative management in high-grade (grade III-V) blunt hepatic injury. SEARCH METHODS: The search for studies was run on 14 April 2014. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), PubMed, ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), clinical trials registries, conference proceedings, and we screened reference lists. SELECTION CRITERIA: All randomised trials that compare non-operative management versus operative management in high-grade blunt hepatic injury. DATA COLLECTION AND ANALYSIS: Two authors independently applied the selection criteria to relevant study reports. We used standard methodological procedures as defined by the Cochrane Collaboration. MAIN RESULTS: We were unable to find any randomised controlled trials of non-operative management versus operative management in high-grade blunt hepatic injury. AUTHORS' CONCLUSIONS: In order to further explore the preliminary findings provided by animal models and observational clinical studies that suggests there may be a beneficial effect of non-operative management versus operative management in high-grade blunt hepatic injury, large, high quality randomised trials are needed.

Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy.

Many of the treatment strategies for sigmoid diverticulitis are actually focusing on nonoperative and minimally invasive approaches. The aim of this systematic review was to evaluate the actual role of damage control surgery (DCS) in the treatment of generalized peritonitis caused by perforated sigmoid diverticulitis.A literature search was performed in PubMed and Google Scholar for articles published from 1960 to July 2013. Comparative and noncomparative studies that included patients who underwent DCS for complicated diverticulitis were considered.Acute Physiology and Chronic Health Evaluation score, duration of open abdomen, intensive care unit length of stay, reoperation, bowel resection performed at first operation, fecal diversion, method, and timing of closure of abdominal wall were the main outcomes of interest.According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses algorithm for the literature search and review, 10 studies were included in this systematic review. DCS was exclusively performed in diverticulitis patients with septic shock or requiring vasopressors intraoperatively. Two surgical different approaches were highlighted: limited resection of the diseased colonic segment with or without stoma or reconstruction in situ, and laparoscopic washing and drainage without colonic resection.Despite the heterogeneity of patient groups, clinical settings, and interventions included in this review, DCS appears to be a promising strategy for the treatment of Hinchey III and IV diverticulitis, complicated by septic shock. A tailored approach to each patient seems to be appropriate.

"Timed Up & Go": a screening tool for predicting 30-day morbidity in onco-geriatric surgical patients? A multicenter cohort study.

OBJECTIVE: To determine the predictive value of the "Timed Up & Go" (TUG), a validated assessment tool, on a prospective cohort study and to compare these findings to the ASA classification, an instrument commonly used for quantifying patients' physical status and anesthetic risk. BACKGROUND: In the onco-geriatric surgical population it is important to identify patients at increased risk of adverse post-operative outcome to minimize the risk of over- and under-treatment and improve outcome in this population. METHODS: 280 patients ≥70 years undergoing elective surgery for solid tumors were prospectively recruited. Primary endpoint was 30-day morbidity. Pre-operatively TUG was administered and ASA-classification was registered. Data were analyzed using multivariable logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (95%-CI). Absolute risks and area under the receiver operating characteristic curves (AUC's) were calculated. RESULTS: 180 (64.3%) patients (median age: 76) underwent major surgery. 55 (20.1%) patients experienced major complications. 50.0% of patients with high TUG and 25.6% of patients with ASA≥3 experienced major complications (absolute risks). TUG and ASA were independent predictors of the occurrence of major complications (TUG:OR 3.43; 95%-CI = 1.14-10.35. ASA1 vs. 2:OR 5.91; 95%-CI = 0.93-37.77. ASA1 vs. 3&4:OR 12.77; 95%-CI = 1.84-88.74). AUCTUG was 0.64 (95%-CI = 0.55-0.73, p = 0.001) and AUCASA was 0.59 (95%-CI = 0.51-0.67, p = 0.04). CONCLUSIONS: Twice as many onco-geriatric patients at risk of post-operative complications, who might benefit from pre-operative interventions, are identified using TUG than when using ASA.

Is non-operative management safe and effective for all splenic blunt trauma? A systematic review.

INTRODUCTION: The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay. METHODS: For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST. RESULTS: We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison. CONCLUSIONS: NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

Damage control surgery for abdominal trauma.

BACKGROUND: Trauma is one of the leading causes of death in any age group. The 'lethal triad' of acidosis, hypothermia, and coagulopathy has been recognized as a significant cause of death in patients with traumatic injuries. In order to prevent the lethal triad two factors are essential, early control of bleeding and prevention of further heat loss. In patients with major abdominal trauma, damage control surgery (DCS) avoids extensive procedures on unstable patients, stabilizes potentially fatal problems at initial operation, and applies staged surgery after successful initial resuscitation. It is not currently known whether DCS is superior to immediate surgery for patients with major abdominal trauma. OBJECTIVES: To assess the effects of damage control surgery compared to traditional immediate definitive surgical treatment for patients with major abdominal trauma. SEARCH METHODS: We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2012, Issue 12 of 12), MEDLINE, EMBASE, Web of Science: Science Citation Index & ISI Proceedings, Current Controlled Trials MetaRegister, Clinicaltrials.gov, Zetoc, and CINAHL for all published and unpublished randomised controlled trials. We did not restrict the searches by language, date, or publication status. The search was through December 2012. SELECTION CRITERIA: Randomised controlled trials of damage control surgery versus immediate traditional surgical repair were included in this review. We included patients with major abdominal trauma (Abbreviated Injury Scale > 3) who were undergoing surgery. Patient selection was crucial as patients with relatively simple abdominal injuries should not undergo unnecessary procedures. DATA COLLECTION AND ANALYSIS: Two authors independently evaluated the search results. MAIN RESULTS: A total of 2551 studies were identified by our search. No randomised controlled trials comparing DCS with immediate and definitive repair in patients with major abdominal trauma were found. A total of 2551 studies were excluded because they were not relevant to the review topic and two studies were excluded with reasons after examining the full-text. AUTHORS' CONCLUSIONS: Evidence that supports the efficacy of damage control surgery with respect to traditional laparotomy in patients with major abdominal trauma is limited.

Thromboprophylaxis for trauma patients.

BACKGROUND: Trauma is a leading causes of death and disability in young people. Venous thromboembolism (VTE) is a principal cause of death. Trauma patients are at high risk of deep vein thrombosis (DVT). The incidence varies according to the method used to measure the DVT and the location of the thrombosis. Due to prolonged rest and coagulation abnormalities, trauma patients are at increased risk of thrombus formation. Thromboprohylaxis, either mechanical or pharmacological, may decrease mortality and morbidity in trauma patients who survive beyond the first day in hospital, by decreasing the risk of VTE in this population.A previous systematic review did not find evidence of effectiveness for either pharmacological or mechanical interventions. However, this systematic review was conducted 10 years ago and most of the included studies were of poor quality. Since then new trials have been conducted. Although current guidelines recommend the use of thromboprophylaxis in trauma patients, there has not been a comprehensive and updated systematic review since the one published. OBJECTIVES: To assess the effects of thromboprophylaxis in trauma patients on mortality and incidence of deep vein thrombosis and pulmonary embolism. To compare the effects of different thromboprophylaxis interventions and their effects according to the type of trauma. SEARCH METHODS: We searched The Cochrane Injuries Group Specialised Register (searched April 30 2009), Cochrane Central Register of Controlled Trials 2009, issue 2 (The Cochrane Library), MEDLINE (Ovid) 1950 to April (week 3) 2009, EMBASE (Ovid) 1980 to (week 17) April 2009, PubMed (searched 29 April 2009), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to April 2009), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to April 2009). SELECTION CRITERIA: Randomized controlled clinical trials involving people of any age with major trauma defined by one or more of the following criteria: physiological: penetrating or blunt trauma with more than two organs and unstable vital signs, anatomical: people with an Injury Severity Score (ISS) higher than 9, mechanism: people who are involved in a 'high energy' event with a risk for severe injury despite stable or normal vital signs. We excluded trials that only recruited outpatients, trials that recruited people with hip fractures only, or people with acute spinal injuries. DATA COLLECTION AND ANALYSIS: Four authors, in pairs (LB and CM, EF and RC), independently examined the titles and the abstracts, extracted data, assessed the risk of bias of the trials and analysed the data. PP resolved any disagreement between the authors. MAIN RESULTS: Sixteen studies were included (n=3005). Four trials compared the effect of any type (mechanical and/or pharmacological) of prophylaxis versus no prophylaxis. Prophylaxis reduced the risk of DVT in people with trauma (RR 0.52; 95% CI 0.32 to 0.84). Mechanical prophylaxis reduced the risk of DVT (RR = 0.43; 95% CI 0.25 to 0.73). Pharmacological prophylaxis was more effective than mechanical methods at reducing the risk of DVT (RR 0.48; 95% CI 0.25 to 0.95). LMWH appeared to reduce the risk of DVT compared to UH (RR 0.68; 95% CI 0.50 to 0.94). People who received both mechanical and pharmacological prophylaxis had a lower risk of DVT (RR 0.34; 95% CI 0.19 to 0.60) AUTHORS' CONCLUSIONS: We did not find evidence that thromboprophylaxis reduces mortality or PE in any of the comparisons assessed. However, we found some evidence that thromboprophylaxis prevents DVT. Although the strength of the evidence was not high, taking into account existing information from other related conditions such as surgery, we recommend the use of any DVT prophylactic method for people with severe trauma.

Intracorporeal versus extracorporeal anastomosis during laparoscopic right hemicolectomy - systematic review and meta-analysis.

BACKGROUND: Since 2005, after an initial scanty spreading, the vast majority of surgeons advice against the intracorporeal ileocolic anastomosis following right hemicolectomies. In the subsequent years, greater interest was re-discovered for the intracorporeal ileocolic anastomosis formed after video-assisted right hemicolectomies OBJECTIVE: The aim of this systematic review is to compare the intra-abdominal versus extra-abdominal anastomosis after right laparoscopic colectomy. DATA SOURCES: A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central and the Science Citation Index. STUDY SELECTION: A total of 191 publications were identified; seven non-randomized studies published between 2004 and 2012 with a total of 945 patients, who underwent laparoscopic right colectomy for malignant and benign disease, were included in this systematic review. INTERVENTION: Intra-abdominal versus extra-abdominal confectioning of ileo-coloc anastomosis after right laparoscopic colectomy. MAIN OUTCOME MEASURES: Anastomotic leak, overall post-operative morbidity and overall 30-days post-operative mortality. RESULTS: Anastomotic leak rate resulted similar in IA (1.13%) and EA (1.84%) group (P=0.81, OR of 0.90, 95% CI 0.24-3.10) (Chi(2)=3.90, P=0.42, I(2)=0%). The mortality rate was lower in the IA group (0.34% versus 1.32%), although no statistically difference was demonstrated between the two groups (P = 0.48, OR of 0.52 95% CI 0.09-3.10). It was not possible to conduct a meta-analysis of post-operative morbidity as the data reported in the included studies were too heterogeneous. LIMITATIONS: The weakness in our results was due to the lack of evidence in current published literature. CONCLUSIONS: The present systematic review of literature and meta-analysis failed to solve the controversies between intracorporeal and extracorporeal anastomosis after laparoscopic right hemicolectomy. Future randomized, controlled trials are needed to further evaluate different surgical anastomosis after laparoscopic right hemicolectomy.

Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: a systematic review and meta-analysis.

INTRODUCTION: Colorectal carcinoma can present with acute intestinal obstruction in 7%-30% of cases, especially if tumor is located at or distal to the splenic flexure. In these cases, emergency surgical decompression becomes mandatory as the traditional treatment option. It involves defunctioning stoma with or without primary resection of obstructing tumor. An alternative to surgery is endoluminal decompression. The aim of this review is to assess the effectiveness of colonic stents, used as a bridge to surgery, in the management of malignant left colonic and rectal obstruction. METHODS: We considered only randomized trials which compared stent vs surgery for intestinal obstruction from left sided colorectal cancer (as a bridge to surgery) irrespective of their size. No language or publication status restrictions were imposed. A systematic search was conducted in Medline, Cochrane Central Register of Controlled Trials and the Science Citation Index (from inception to December 2011) RESULTS: We identified 3109 citations through our electronic search and 3 through other sources. Initial screening of the titles and abstracts resulted in the exclusion of 3104 citations. A further 5 citations were excluded after detailed screening of full articles. Three published studies were included in this systematic review. A total of 197 patients were included in our analysis, 97 of them had colorectal stent vs 100 who had emergency surgery. Clinical success has been defined in different manners. In included trials the clinical success rate was significantly higher in the emergency surgery group (99%) compared with the stent group (52.5%) (p < 0.00001). There was no difference in the overall complication rate in the stent group (48.5%) vs emergency surgery group (51%) (p = 0.86). There was no difference in 30-days postoperative mortality (p = 0.97). The overall survival was analyzed in none trial. When used as a bridge to surgery, colorectal stents provide some advantages: the primary anastomosis rate was significantly higher in the stent group (64.9%) vs emergency surgery group (55%) (p = 0.003); the overall stoma rate was significantly lower in the stent group (45.3%) compared with the emergency surgery group (62%) (p = 0.02). There were no significant differences between the two groups as to permanent stoma rate (46.7% in stent group vs 51.8% in surgical group, p = 0.56), anastomotic leakage rate (9% in stent group vs 3.7% in surgical group, p = 0.35) and intra-abdominal abscess rate (5.1% in stent group vs 4.9% in surgical group, p = 0.97). CONCLUSION: Although colonic stenting appears to be an effective treatment of malignant large bowel obstruction, the clinical success resulted significantly higher in the emergency surgery group without any advantages in terms of overall complication rate and 30-days postoperative mortality. On the other hand, the colonic stenting as a bridge to surgery provides surgical advantages, as higher primary anastomosis rate and a lower overall stoma rate, without increasing the risk of anastomotic leak or intra-abdominal abscess. However, these results should be interpreted with caution because few studies reported data on these outcomes. Due to the small and variable sample size of the included trials, further RCTs are needed including a larger number of patients and evaluating long term results (overall survival and quality of life) and cost-effectiveness analysis.

High tie versus low tie of the inferior mesenteric artery in colorectal cancer: a RCT is needed.

Nowadays left colon and rectal cancer treatment has been well standardized in both open and laparoscopy. Nevertheless, the level of the ligation of the inferior mesenteric artery (IMA), at the origin from the aorta (high tie) or below the origin of the left colic artery (low tie), is still debated. The objective of the systematic review is to evaluate the current scientific evidence of high versus low tie of the IMA in colorectal cancer surgery. The outcomes considered were overall 30-days postoperative morbidity, overall 30-days postoperative mortality, anastomotic leakage, 5-years survival rate, and overall recurrence rate. A total of 8.666 patients were included in our analysis, 4.281 forming the group undergoing high tie versus 4.385 patients undergoing low tie. Neither the high tie nor the low tie strategy showed an evidence based success, as no statistically significant differences were identified for all outcomes measured. Future high powered and well designed randomized clinical trials are needed to draw definitive conclusion on this dilemma.

Surgical treatment of primitive gastro-intestinal lymphomas: a systematic review.

Primitive Gastrointestinal Lymphomas (PGIL) are uncommon tumours, although time-trend analyses have demonstrated an increase. The role of surgery in the management of lymphoproliferative diseases has changed over the past 40 years. Nowadays their management is centred on systemic treatments as chemo-/radiotherapy. Surgery is restricted to very selected indications, always discussed in a multidisciplinary setting. The aim of this systematic review is to evaluate the actual role of surgery in the treatment of PGIL. A systematic review of literature was conducted according to the recommendations of The Cochrane Collaboration. Main outcomes analysed were overall survival (OS) and disease free survival (DFS). There are currently 1 RCT and 4 non-randomised prospective controlled studies comparing surgical versus medical treatment for PGIL. Seven hundred and one patients were analysed, divided into two groups: 318 who underwent to surgery alone or associated with chemotherapy and/or radiotherapy (surgical group) versus 383 who were treated with chemotherapy and/or radiotherapy (medical group). Despite the OS at 10 years between surgical and medical groups did not show relevant differences, the DFS was significantly better in the medical group (P=0.00001). Accordingly a trend was noticed in the recurrence rate, which was lower in the medical group (6.06 vs. 8.57%); and an higher mortality was revealed in the surgical group (4.51% vs. 1.50%).The chemotherapy confirms its primary role in the management of PGIL as part of systemic treatment in the medical group. Surgery remains the treatment of choice in case of PGIL acutely complicated, although there is no evidence in literature regarding the utility of preventive surgery.

High tie versus low tie of the inferior mesenteric artery: a protocol for a systematic review.

In anterior resection of rectum, the section level of inferior mesenteric artery is still subject of controversy between the advocates of high and low tie. The low tie is the division and ligation to the branching of the left colic artery and the high tie is the division and ligation at its origin at the aorta. We intend to assess current scientific evidence in literature and to establish the differences comparing technique, anatomy and physiology. The aim of this protocol is to achieve a meta-analysis that tests safety and feasibility of the two procedures with several types of outcome measures.

Efficacy of surgery and imatinib mesylate in the treatment of advanced gastrointestinal stromal tumor: a systematic review.

AIMS AND BACKGROUND: In patients with localized gastrointestinal stromal tumors, surgery remains the elective treatment. Nowadays, imatinib therapy has been standardized in advanced gastrointestinal stromal tumors, showing continuous improvements in progression-free and overall survival. A combination of imatinib therapy and surgery may also be effective in a subset of patients with metastatic or unresectable gastrointestinal stromal tumors. In this review, the authors analyzed the role of imatinib mesylate associated to surgery in unresectable and/or metastatic gastrointestinal stromal tumors. METHODS AND STUDY DESIGN: We searched for all published and unpublished randomized controlled clinical trials and controlled clinical trials. We conducted the review according to the recommendations of The Cochrane Collaboration. We used Review Manager 5 software for the statistical analysis. RESULTS: There are currently no randomized controlled clinical trials or controlled clinical trials on this issue. We performed a subgroup analysis in the patients preoperatively treated with imatinib mesylate. This subgroup revealed a minor incidence of recurrent or metastatic gastrointestinal stromal tumors and a greater incidence of locally unresectable gastrointestinal stromal tumors in the responsive disease group (P = 0.001). In this patient group, more complete resections were observed (P = 0.00001). Furthermore, in the same patient group we observed a more significant 12 and 24-month disease-free survival after imatinib treatment and complete resection (respectively P= 0.06 and P= 0.003) and also a better 24-month overall survival (P = 0.004). CONCLUSIONS: There is actually only one ongoing European randomized study evaluating surgery of residual disease in patients with metastatic gastrointestinal stromal tumors responding to imatinib mesylate. Imatinib mesylate represents the standard treatment as preoperative supplement for locally unresectable and/or metastatic gastrointestinal stromal tumors, and a trial to compare the approach versus surgery alone is not necessary. For patients responding to imatinib or patients with prolonged stable disease, resection of residual disease should be considered. A phase III randomized study evaluating surgery of residual disease in patients with metastatic gastrointestinal stromal tumor responding to imatinib mesylate, EORTC 62063, has been opened. Moreover, surgery should be considered for patients at higher risk of complications during pharmacological debulking. In advanced gastrointestinal stromal tumors, the advantages of the integrated treatment are significant in the complete or partial response disease group in terms of more complete resections and better disease-free and overall survival.

Covering ileo- or colostomy in anterior resection for rectal carcinoma.

BACKGROUND: Anastomotic leakage is one of the most important complications that occur after surgical low anterior resection for rectal cancer. There are indications that anastomotic leak is associated with increased morbidity, mortality, frequent re-operation or radiological drainage, and prolonged hospital stay. Defunctioning stoma can be useful for patients undergoing a rectal surgery. OBJECTIVES: To determine the efficacy of protective defunctioning stoma in low anterior resection for rectal carcinoma. SEARCH STRATEGY: Searches were conducted November 2009. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1966) and EMBASE (from 1980). SELECTION CRITERIA: We included randomised clinical trials comparing the use of stoma versus "no stoma" in patients that received low anterior resection for rectal cancer. DATA COLLECTION AND ANALYSIS: Six randomised controlled trials were identified and included in this review. Five trials were fully published in peer-reviewed journals. An attempt was made to obtain further information from the authors of the trial that was available only in an abstract form. The studies analysed the following outcomes: clinical anastomotic leakage, urgent reoperation, mortality and length of postoperative hospital stay. Review authors extracted the data independently, the risk ratios (RR) were estimated for the dichotomous outcomes and standardised mean difference were estimated for the continuous outcome MAIN RESULTS: All the trials reported results for clinical anastomotic leakage, urgent reoperation and mortality. Only two trials reported the results for length of postoperative hospital stay.With respect to controls, use of covering stoma was significantly associated with less anastomotic leakage (RR 0.33; 95%CI [0.21, 0.53]) and less urgent reoperation (RR 0.23; 95%CI [0.12, 0.42] ). There was no significant difference in terms of mortality (RR 0.58; 95%CI [0.14, 2.33]). There was no evidence of statistical heterogeneity in any of the comparisons. AUTHORS' CONCLUSIONS: Covering stoma seems to be useful to prevent anastomotic leakage and urgent re-operations in patients receiving low anterior resection for rectal cancer. However, covering stoma does not seems to offer advantage in term of 30 days or long term mortality.

Familial adenomatous polyposis (FAP) and gender. Does gender influence the genetic transmission of FAP?

Familial adenomatous polyposis (FAP) is an autosomal dominant syndrome with a penetrance close to 100% at the age of 40 years. The incidence is thought to be equal among both sexes, but we noticed an excess of males undergoing primary surgery for FAP at our institution. The aim of the study is to investigate the hypothesis that FAP patients produce an excess of affected male offspring. We identified all families with known APC mutation in the polyposis registry at St Mark's from its foundation until October 2009. We analysed their pedigrees with respect to gender of the affected individuals with progeny and to the gender and mutation status of their offspring. Only individuals with complete data regarding their offspring (gender and mutation status) were included. We identified 666 (324 males and 342 females) affected individuals with progeny. We analysed the progeny of 368 (182 males, 186 females) affected individuals with complete data on all offspring: 235 (27.5%) affected males, 212 (24.8%) affected females, 207 (24.3%) unaffected males and 200 (23.4%) unaffected females. The overall ratio of affected/unaffected and male/female offspring did not differ from the expected 50%. Further sub-analysis by gender of parents did not show any statistically significant difference in gender and mutation status of offspring. In addition the mean number of children per affected parent did not depend on gender (males 2.34; females 2.30). This study shows that gender does not influence the genetic transmission of FAP. The excess of males undergoing primary surgery at our institution is probably a result of referral bias.

Laparoscopic versus open surgery in small bowel obstruction.

BACKGROUND: Acute intestinal obstruction is one of the most common surgical emergencies. The small bowel obstruction (SBO) is the site of obstruction in most patients (76%) and adhesions are the most common etiology (65%). Laparoscopy in SBO has no clear role yet as it may have a therapeutic and diagnostic function. In some settings laparoscopic or laparoscopy-assisted surgery is considered feasible and convenient more than conventional surgery for SBO; however little is known if laparoscopic or laparoscopy-assisted surgery is more suitable with respect to open surgery for patients with SBO. OBJECTIVES: The aim of this systematic review is to assess whether laparoscopic or laparoscopy-assisted surgery is feasible and safe for acute SBO, and whether laparoscopic and laparoscopy-assisted surgery present advantages compared to open surgery in terms of short-term and long-term outcomes. SEARCH STRATEGY: We searched for published randomised and prospective controlled clinical trials without language restrictions using the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 onwards) and EMBASE (1980 onwards). SELECTION CRITERIA: Randomised controlled trials and non randomised controlled prospective trials evaluating laparoscopic and laparoscopy-assisted surgery versus traditional open surgery for acute SBO were considered. DATA COLLECTION AND ANALYSIS: We conducted the review according to the recommendations of The Cochrane Collaboration and the Cochrane Colorectal Group as well, using Review Manager 5 to conduct the review. MAIN RESULTS: No published or unpublished randomised controlled trials or prospective controlled clinical trials comparing laparoscopy with open surgery for patients with SBO were identified. AUTHORS' CONCLUSIONS: Although data from retrospective clinical controlled trials suggest that laparoscopy seems feasible and better in terms of hospital stay and mortality reduction, high quality randomised controlled trials assessing all clinically relevant outcomes including overall mortality, morbidity, hospital stay and conversion are needed.

The sigmoid volvulus: surgical timing and mortality for different clinical types.

BACKGROUND: In western countries intestinal obstruction caused by sigmoid volvulus is rare and its mortality remains significant in patients with late diagnosis. The aim of this work is to assess what is the correct surgical timing and how the prognosis changes for the different clinical types. METHODS: We realized a retrospective clinical study including all the patients treated for sigmoid volvulus in the Department of General Surgery, St Maria Hospital, Terni, from January 1996 till January 2009. We selected 23 patients and divided them in 2 groups on the basis of the clinical onset: patients with clear clinical signs of obstruction and patients with subocclusive symptoms. We focused on 30-day postoperative mortality in relation to the surgical timing and procedure performed for each group. RESULTS: In the obstruction group mortality rate was 44% and it concerned only the patients who had clinical signs and symptoms of peritonitis and that were treated with a sigmoid resection (57%). Conversely none of the patients treated with intestinal derotation and colopexy died. In the subocclusive group mortality was 35% and it increased up to 50% in those patients with a late diagnosis who underwent a sigmoid resection. CONCLUSIONS: The mortality of patients affected by sigmoid volvulus is related to the disease stage, prompt surgical timing, functional status of the patient and his collaboration with the clinicians in the pre-operative decision making process. Mortality is higher in both obstructed patients with generalized peritonitis and patients affected by subocclusion with late diagnosis and surgical treatment; in both scenarios a Hartmann's procedure is the proper operation to be considered.