Omentoplasty to reduce anastomotic leak in colorectal surgery: a meta-analysis.

BACKGROUND: Anastomotic leaks (AL) remain a devastating complication following intestinal anastomoses resulting in increased morbidity and mortality. Wrapping the anastomosis with omentum may be protective although data are conflicting. We performed a meta-analysis to assess the effect of omentoplasty on colorectal anastomoses. METHODS: PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until August 2021. All randomized controlled trials (RCT) that reported on the use of omentoplasty in colon and rectal surgery were included. The primary outcome was rate of overall AL while secondary outcomes included clinical and radiological AL, overall reoperation and mortality. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS: Four RCTs were included capturing 1067 patients. The mean (SD) age of the cohort was 61.5 (±14.8) years. On random effects analysis, omentoplasty reduced rate of overall (OR 0.43, 95% CI = 0.21-0.87, p = 0.02) and clinical AL (OR = 0.35, 95% CI = 0.15-0.81, p = 0.01). However, there was no difference in radiological AL (OR = 0.77, 95% CI = 0.40-1.47, p = 0.42), overall reoperations (OR 0.48, 95% CI = 0.18-1.32, p = 0.16) or mortality (OR 0.52, 95% CI = 0.12 to-2.18, p = 0.37). On sensitivity analysis, assessing rectal anastomoses only, the results for overall AL remained similar (OR 0.28, 95% CI = 0.12-0.61, p = 0.002). CONCLUSION: Although omentoplasty appears to reduce the rate of overall and clinical AL, the heterogeneity in the data prevents definitive recommendations from being made. Further well-designed trials are needed to investigate this technique.

Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis.

BACKGROUND: Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention. METHODS: PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS: Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20). CONCLUSION: PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.

Post-operative Glycaemic Control Using an Insulin Infusion is Associated with Reduced Surgical Site Infections in Colorectal Surgery.

BACKGROUND: The incidence of surgical site infection (SSI) in colorectal surgery (CRS) is higher than other forms of general surgery. Post-operative hyperglycaemia causes increased SSI in CRS. Post-operative hyperglycaemia control in cardiac surgery reduces SSI. The aim was to evaluate using a cohort comparison the effect of post-operative glycaemic control using an insulin infusion on SSI in CRS. METHODS: Collection of data for the ACS-NSQIP was commenced in 2015. The CRS unit added post-operative glycaemic control to the SSI bundle in late 2016. The intervention was an insulin infusion to titrate blood glucose between 135 and 180 mg/Dl (7.5 and 10 mmol/l). The effect of glycaemic control on SSI was assessed comparing ACS-NSQIP raw data prior and after the intervention was commenced. RESULTS: The NSQIP data from July 2015 to June 2016 revealed the incidence of SSI were 25%. From January 2017 to December 2017, there was a significant reduction in SSI to 6.1% (OR = 517 Cl = 1.92-16.08, p < 0.001). The incidence of organ/space SSI fell significantly from 13% to 1.0% (OR = 11.35, Cl = 1.62-488.7, p < 0.001). There was non-significant reduction in superficial SSI from 11 to 4.0% (OR = 2.93, Cl = 0.68-13.03, p = 0.06). There was no significant difference in other factors associated with SSI in CRS. CONCLUSION: Post-operative glycaemic control in CRS reduces the rate of SSI. Post-operative glycaemic control should be included in SSI bundles for CRS and may be of benefit in other surgical specialties.