Is early bowel resection better than medical therapy for ileocolonic Crohn's disease? A systematic review and meta-analysis.

AIM: There is emerging evidence supporting early bowel resection (EBR) for ileocaecal Crohn's disease (CD) as an alternative to conventional escalation of medical therapy (MT). Here, we present a systematic review and meta-analysis of studies comparing the outcomes of EBR with those of MT in ileocolonic CD, with a focus on ileocaecal disease. METHODOLOGY: The MEDLINE, Embase, CINAHL and Cochrane Central Register of Controlled Trials databases were searched for studies reporting the outcomes of EBR versus MT for ileocolonic CD. The Cochrane tools for assessment of risk of bias were used to assess the methodological quality of studies. RESULTS: Nine records (from 8 studies, with a total of 1867 patients) were included in the analysis. Six studies were observational and two were randomised controlled trials. There was a reduced need for drug therapy in the EBR arm. The rate of intestinal resection at 5 years was 7.8% in the EBR arm and 25.4% in the MT group with a pooled OR of 0.32 (95% CI 0.19, 0.54; p < 0.0001). The EBR group had a longer resection-free survival (HR 0.56, 95% CI 0.38, 0.83; p = 0.004). These outcomes were consistent in a subgroup analysis of patients with ileocaecal disease. Morbidity and quality of life scores were similar across the two groups. CONCLUSION: EBR is associated with a more stable remission compared to initial MT for ileocolonic Crohn's disease. There is enough evidence to support EBR as an alternative to escalation of MT in selected patients with limited ileocaecal disease.

A review of forehead lipomas: Important tips for the training surgeon.

BACKGROUND: Forehead swellings can be caused by a variety of different pathologies, including lipomas. These benign lesions are composed of mature fat cells and often result in a poor cosmetic appearance causing significant psychosocial distress. Surgical removal is therefore frequently requested and they are often listed on a training local anaesthetic list. Thus, it is essential that trainees understand the nature of these lesions, their anatomical location and management, as well as differential diagnoses. METHODS: A review of the available literature on forehead lipomas and their management was performed. Searches of both MEDLINE and EMBASE were conducted, with all full text articles published in English being included for analysis. RESULTS: 14 papers were included for analysis. Forehead lipomas are slow growing lesions with 100% presenting as a solitary swelling. They are more prevalent in males with mean age at presentation being 48 years. Their aetiology is unknown, however, blunt trauma has been postulated to contribute to their formation. Differential diagnoses include cysts and extension of intracranial lesions. Surgical intervention is the only recognised treatment, with a transverse, forehead-crease incision most commonly being adopted under local anaesthetic. Exploration beneath the frontalis muscle is often required in order to achieve their excision. CONCLUSION: Important differential diagnoses must be excluded prior to attempted surgical excision of forehead lipomas. Surgeons must also be aware that the correct anatomical plane for these lesions is often beneath the frontalis muscle.

Therapeutic targets in the management of striae distensae: A systematic review.

BACKGROUND: Striae distensae are permanent dermal lesions that can cause significant psychosocial distress. A detailed understanding of the numerous treatment modalities available is essential to ensuring optimal patient outcomes. OBJECTIVE: Our objective was to evaluate and summarize the different treatment methods for striae distensae by linking their proposed modes of action with the histopathogenesis of the condition to guide patient treatment. METHODS: A systematic review of the literature was performed with no limits placed on publication date. Relevant studies were assigned a level of evidence by the authors. RESULTS: Ninety-two articles were identified, with 74 being eligible for quality assessment. The majority of treatments aim to increase collagen production. The use of vascular lasers can reduce erythema in striae rubrae by targeting hemoglobin, whereas increasing melanin through methods such as ultraviolet light is a major focus for treatment of striae albae. Despite some topical treatments being widely used, uncertainty regarding their mode of action remains. No treatment has proved to be completely effective. LIMITATIONS: Limitations of the study include low-quality evidence, small sample sizes, and varying treatment protocols and outcome measures, along with concerns regarding publication bias. CONCLUSIONS: Further randomized, controlled trials are needed before definitive conclusions and recommendations can be made.

Role of compression therapy in pathophysiology of the venous system in lower limbs.

The management of varicose veins and their sequelae are estimated to cost the NHS approximately £400-600 m annually. Along with interventional procedures, the National Institute for Health and Care Excellence (NICE) also recommends the use of compression therapy. With the vast array of different compression therapies available, prescribing the correct method can be challenging, with patients receiving incorrect compression being a matter of concern. This review summarises the key principles underpinning the management of these patients with particular emphasis on the pathophysiology and different classes of compression.

Management of novel oral anticoagulants in emergency and trauma surgery.

BACKGROUND: The compelling safety, efficacy and predictable effect of novel oral anticoagulants (NOACs) is driving a rapid expansion in their therapeutic indications. Management of the increasing number of patients on those new agents in the setting of emergency or trauma surgery can be challenging and the absence of specific reversal agents has been a matter of concern. This review summarises the key principles that underpin the management of those patients with a particular emphasis on the recent development of specific antidotes. FINDINGS: As of 2015, a new line of antidotes, specific for these drugs, are at different stages of their development with their release imminent. However, as NOACs are innately reversible due to their short half-life, the use of reversal agents will probably be restricted to a few exceptional cases. Post-marketing surveillance will be paramount to better clarify the role of these promising drugs. CONCLUSIONS: Management of patients on NOACs in the context of emergency or trauma surgery relies on best supportive care in combination with the blood products and/or specific antidotes as required. Familiarity with the new reversal agents is essential but further evidence on their indications, safety and efficacy as well as consensus guidelines are warranted prior to widespread adoption.

Multi-nodal basin drainage in lower limb melanoma.

Lymph node status is an important factor that influences outcomes in melanoma. Whilst certain anatomical areas have multiple-nodal basin drainage, limb melanomas are thought to have more predictable lymphatic drainage patterns, with lower limb melanomas reliably draining to the corresponding ipsilateral inguinal lymph node basin with occasional popliteal drainage. Here we share our unique experience of a patient with a lower limb melanoma demonstrating sentinel lymph nodes, and subsequent metastatic spread, in both the ipsilateral and contralateral inguinal lymph node basins, highlighting an important learning point with respect to our clinical examination of melanoma patients.

Facial Cartilaginous Reconstruction-A Historical Perspective, State-of-the-Art, and Future Directions.

Importance: Reconstruction of facial deformity poses a significant surgical challenge due to the psychological, functional, and aesthetic importance of this anatomical area. There is a need to provide not only an excellent colour and contour match for skin defects, but also a durable cartilaginous structural replacement for nasal or auricular defects. The purpose of this review is to describe the history of, and state-of-the-art techniques within, facial cartilaginous surgery, whilst highlighting recent advances and future directions for this continually advancing specialty. Observations: Limitations of synthetic implants for nasal and auricular reconstruction, such as silicone and porous polyethylene, have meant that autologous cartilage tissue for such cases remains the current gold standard. Similarly, tissue engineering approaches using unrelated cells and synthetic scaffolds have shown limited in vivo success. There is increasing recognition that both the intrinsic and extrinsic microenvironment are important for tissue engineering and synthetic scaffolds fail to provide the necessary cues for cartilage matrix secretion. Conclusions and Relevance: We discuss the first-in-man studies in the context of biomimetic and developmental approaches to engineering durable cartilage for clinical translation. Implementation of engineered autologous tissue into clinical practise could eliminate donor site morbidity and represent the next phase of the facial reconstruction evolution.

After you Roux, what do you do? A systematic review of most successful advanced assisted ERCP techniques in patients with various altered upper gastrointestinal surgical anatomical reconstructions with particular focus on RYGB (last 10 years).

Access to the Common Bile Duct in patients with surgically altered UGI anatomy such as RYGB is exceptionally challenging. Previously, these patients could only be treated by open surgery; however, multiple new advanced assisted ERCP techniques such as EDGE, LA-ERCP, and DEA-ERCP have now been developed and indeed successfully used to treat these patients. Despite growing experience, these techniques have yet to become part of our mainstream practice and many clinicians remain unfamiliar or even unaware of them; as a result, they are unfortunately often overlooked. We conducted this systematic review to try and shed more light on them and understand which of these techniques resulted in the best patient outcomes. We conducted a systematic review of PubMed database publications between December 2008 and December 2018. Keyword variants of "EDGE, Enteroscopy-assisted & laparoscopy-assisted ERCP" and "altered surgical anatomy" were combined to identify relevant papers for inclusion. We identified 34 studies, comprising a total of 1848 advanced assisted ERCPs in patients with altered UGI anatomy from 12 different countries. These papers were critically appraised, summarised, and presented in table format. EDGE and LA-ERCP were associated with both the highest overall combined CBD cannulation rates (99.3% for both vs 74.6% for DEA-ERCP) and ERCP interventional success (98.3% for EDGE vs 97.4% for LA-ERCP and 67.6% for DEA-ERCP). Advanced ERCP is associated with excellent success rates and a higher safety profile than surgery; however, patient selection and identification of the exact surgical anatomy are key.

Severe lower limb lymphoedema successfully treated with a two-stage debulking procedure: a case report.

Lymphoedema is a chronic condition that has significant functional and psychosocial morbidity. We report a case of severe lower limb lymphoedema successfully treated with a two-stage debulking procedure, highlighting the significant improvements in function and quality of life this operation can have with the appropriate multidisciplinary support.