Surgical Management of Hemorrhoidal Disease in Inflammatory Bowel Disease: A Systematic Review with Proportional Meta-Analysis.

Surgical treatment of hemorrhoidal disease (HD) in inflammatory bowel disease (IBD) has been considered to be potentially harmful, but the evidence for this is poor. Therefore, a systematic review of the literature was undertaken to reappraise the safety and effectiveness of surgical treatments in this special circumstance. A MEDLINE, Web of Science, Scopus, and Cochrane Library search was performed to retrieve studies reporting the outcomes of surgical treatment of HD in patients with Crohn's disease (CD) and ulcerative colitis (UC). From a total of 2072 citations, 10 retrospective studies including 222 (range, 2-70) patients were identified. Of these, 119 (54%) had CD and 103 (46%) UC. Mean age was between 41 and 49 years (range 14-77). Most studies lacked information on the interval between surgery and the onset of complications. Operative treatments included open or closed hemorrhoidectomy (n = 156 patients (70%)), rubber band ligation (n = 39 (18%)), excision or incision of thrombosed hemorrhoid (n = 14 (6%)), and doppler-guided hemorrhoidal artery ligation (DG-HAL, n = 13 (6%)). In total, 23 patients developed a complication (pooled prevalence, 9%; (95%CI, 3-16%)), with a more than two-fold higher rate in patients with CD compared to UC (11% (5-16%) vs. 5% (0-13%), respectively). Despite the low quality evidence, surgical management of HD in IBD and particularly in CD patients who have failed nonoperative therapy should still be performed with caution and limited to inactive disease. Further studies should determine whether advantages in terms of safety and effectiveness with the use of non-excisional techniques (e.g., DG-HAL) can be obtained in this patient population.

Mixed adenoneuroendocrine carcinoma (MANEC) of the lower gastrointestinal tract: A systematic review with Bayesian hierarchical survival analysis.

BACKGROUND: Mixed adeno-neuroendocrine carcinomas (MANEC) are a subgroup of mixed neuroendocrine non-neuroendocrine neoplasms (MiNEN) described as mixed neoplasms containing dual neuroendocrine and non-neuroendocrine components. The aim of this study was to appraise the prevalence of MANEC in the lower gastrointestinal (GI) tract and provide reliable estimates of survival. METHOD: A systematic review was undertaken in accordance with PRISMA guidelines using PubMed, Embase, Cochrane Library of Systematic Review, Web of Science, and Scopus databases, and a Bayesian hierarchical survival pooled analysis was performed. RESULTS: Of 182 unique records identified, 71 studies reporting on 752 patients met the inclusion criteria. Mean age was 64.2 ± 13.6, with a male-to-female ratio of 1.25. Overall, 60.3% of MANEC were located in the appendix, 29.3% in the colon, and 10.4% in the anorectum. More than a quarter (29%) of patients had stage IV disease at diagnosis, with higher prevalence in appendiceal than colonic and anorectal primaries. More than 80% had a high-grade (G3) endocrine component. Of the 152 patients followed up for a median of 20 months (interquartile range limits, 16.5-32), median overall survival was 12.3 months (95% credible interval [95%CrI], 11.3-13.7), with a 1.12 [95%CrI, 0.67-1.83] age-adjusted hazard ratio between metastatic and non-metastatic MANEC. Stage IV disease at diagnosis was more prognostically unfavorable in cases of colonic compared to anorectal origin. CONCLUSION: MANEC is a clinically aggressive pathological entity. The results of this study provide new insights for the understanding of tumor location within the lower GI tract and its prognosis in terms of overall survival.

Neoadjuvant treatment in pancreatic cancer: Evidence-based medicine? A systematic review and meta-analysis.

Neoadjuvant treatment in non-metastatic pancreatic cancer (PaC) has the theoretical advantages of downstaging the tumor, sterilizing any present systemic undetectable disease, selecting patients for surgery and administering therapy to each patient. The aim of this systematic review is to analyze the state of the art on neoadjuvant protocols for non-metastatic PaC. A literature search over the last 10 years was conducted, and papers had to be focused on resectable, borderline resectable (BLR) or locally advanced (LA) histo- or cytologically proven PaC; to be prospective studies or prospectively collected databases; to report percentage of protocol achievement and survival data at least in an intention-to-treat (ITT) analysis. Twelve studies were eligible for systematic review. Studies included a total of 624 patients: 248 resectable, 268 BLR, 71 LA and 37 non-specified. All studies were included for meta-analysis. ITT overall survival (OS) was 16.7 months (95% CI 15.16-18.26 months); for resected patients OS was 22.78 months (95% CI 20.42-25.16), and for eventually non-resected patients it was 9.89 months (95% CI 8.84-10.96). Neoadjuvant approaches for resectable, BLR and LA PaC are spreading. Outcomes tend to be better outside an RCT context, but strong evidences are lacking. Actually such treatments should be performed only in a randomized clinical trial setting.

Free peritoneal tumor cells detection in gastric and colorectal cancer patients.

BACKGROUND: Free peritoneal tumor cells (FPTC) derive from the detachment of primary cancer and may result in peritoneal carcinomatosis. Since peritoneal lavage cytology has low sensitivity in detecting FPTC, our aim was to estimate the clinical relevance of FPTC detected using an approach based on multiple molecular techniques. MATERIALS AND METHODS: Samples of peritoneal lavage were collected from 27 gastric and 48 colorectal cancer patients. FPTC recovery and detection from peritoneal washes was performed by cytological examination and immunomagnetic enrichment for epithelial cells followed by immunofluorescence analysis for epithelial marker EpCAM/CD326 and carcinoembryonic antigen (CEA). CEA and CK20 mRNA levels were quantified using a real-time qRT-PCR system. RESULTS: For gastric carcinoma the FPTC positivity rate acquired by cytology, immunofluorescence and qRT-PCR was 14.8%, 14.8%, and 78% and for colorectal carcinoma was 0%, 17%, and 42%, respectively. qRT-PCR positivity was correlated with a poor cancer-specific survival and time-to-recurrence rates in both gastric and colorectal carcinoma. CONCLUSIONS: Epithelial immunoenrichment and immunofluorescence analysis allows unequivocal identification of the FPTC. The real time qRT-PCR showed higher sensitivity for the detection of CEA and CK20 mRNA levels and confirmed its prognostic value in gastrointestinal cancers.

Preoperative brain natriuretic peptide (BNP) is a better predictor of adverse cardiac events compared to preoperative scoring system in patients who underwent abdominal surgery.

BACKGROUND: Cardiovascular disease is the leading cause of perioperative death in surgical patients. A variety of clinical scoring systems have been developed to predict adverse cardiovascular events. B-type natriuretic peptide (BNP) is a sensitive and specific predictor of left ventricular systolic dysfunction and predicts first cardiovascular event and death in the general population. We present a prospective, single-center, observational cohort study of patients undergoing major abdominal surgery and evaluate the role of BNP in predicting adverse cardiac events. METHOD: A total of 205 patients were included in the study. All patients were assessed by a cardiological clinical evaluation, a 12-lead ECG report, and a preoperative and postoperative blood sample for plasmatic BNP assessment. The primary end point was the predictive power of preoperative BNP levels for adverse cardiac events until 30 days after discharge. RESULTS: Thirty-one of 205 (15%) patients had adverse cardiac events in the postoperative period up to 30 days after discharge. Five patients (2.4%) of these died of cardiac events. Preoperative BNP values were significantly increased in the 31 patients compared to the other patients in the postoperative period [mean = 112.93 pg/ml (range = 5-2,080) vs. 178.99 pg/ml (range = 5-3,980); median = 117 vs. 23 pg/ml; 95% CI = 49-181; p < 0.0001]. At logistic regression, a preoperative BNP value of >36 pg/ml was the only effective predictor of adverse cardiac events. CONCLUSION: We have demonstrated that elevated preoperative BNP levels are independent predictors of adverse cardiac events in a cohort of patients undergoing major abdominal surgery in a general surgery department, and this is the first study about this specific cohort of patients.