Treatment Modalities for Small Saphenous Vein Insufficiency: Systematic Review and Meta-analysis.

PURPOSE: To investigate and compare the anatomical success rates and complications of the treatment modalities for small saphenous vein (SSV) incompetence. METHODS: A systematic literature search was performed in PubMed, EMBASE, and the Cochrane Library on the following therapies for incompetence of SSVs: surgery, endovenous laser ablation (EVLA), radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (UGFS), steam ablation, and mechanochemical endovenous ablation (MOCA). The search found 49 articles (5 randomized controlled trials, 44 cohort studies) reporting on the different treatment modalities: surgery (n=9), EVLA (n=28), RFA (n=9), UGFS (n=6), and MOCA (n=1). A random-effects model was used to estimate the primary outcome of anatomical success, which was defined as closure of the treated vein on follow-up duplex ultrasound imaging. The estimate is reported with the 95% confidence interval (CI). Secondary outcomes were technical success and major complications [paresthesia and deep vein thrombosis (DVT)], given as the weighted means. RESULTS: The pooled anatomical success rate was 58.0% (95% CI 40.9% to 75.0%) for surgery in 798 SSVs, 98.5% (95% CI 97.7% to 99.2%) for EVLA in 2950 SSVs, 97.1% (95% CI 94.3% to 99.9%) for RFA in 386 SSVs, and 63.6% (95% CI 47.1% to 80.1%) for UGFS in 494 SSVs. One study reported results of MOCA, with an anatomical success rate of 94%. Neurologic complications were most frequently reported after surgery (mean 19.6%) and thermal ablation (EVLA: mean 4.8%; RFA: mean 9.7%). Deep venous thrombosis was a rare complication (0% to 1.2%). CONCLUSION: Endovenous thermal ablation (EVLA/RFA) should be preferred to surgery and foam sclerotherapy in the treatment of SSV incompetence. Although data on nonthermal techniques in SSV are still sparse, the potential benefits, especially the reduced risk of nerve injury, might be of considerable clinical importance.

Beware of false-negative CT scan for anastomotic leakage after colonic surgery.

BACKGROUND: Anastomotic leakage is one of the most life-threatening complications after colonic surgery. Correct diagnosis and treatment is important to reduce morbidity and mortality. An abdominal CT scan is one of the main diagnostic tools in diagnosing anastomotic leaks. The aim of this study was to examine the accuracy of abdominal CT scanning to detect anastomotic leakage and to evaluate the consequences of a false-negative CT outcome. METHODS: All consecutive patients who underwent colonic resection for malignant disease between 2009 and 2011 or for benign disease in 2010 were reviewed. Patients in whom a postoperative abdominal CT scan was performed to detect anastomotic leakage were included. RESULTS: In 97 of 524 patients who underwent colonic surgery, an abdominal CT scan was performed for the suspicion of anastomotic leakage. Overall leakage rate was 10.9 % (n = 57). Mortality rate after leakage was 21.1 % (n = 12). Results from all abdominal CT scans revealed an overall sensitivity of 0.59 (95 % CI 0.43-0.73), a specificity of 0.88 (95 % CI 0.75-0.95), positive predictive value 0.82 (95 % CI 0.64-0.92), negative predictive value 0.70 (95 % CI 0.57-0.81), and an accuracy of 74 %. Delayed reintervention for anastomotic leakage due to a false-negative CT outcome resulted in death in 62.5 % (n = 5). CONCLUSION: The sensitivity of abdominal CT scanning after colonic surgery is relatively low. A negative CT scan does not rule out anastomotic leakage. Even with a negative CT scan, we should remain equally alert at clinical deterioration as an argument for timely intervention.

Compromised visceral circulation does not affect the outcome of colorectal surgery.

PURPOSE: Anastomotic leakage is a serious complication after colorectal surgery, and many risk factors for this problem have so far been identified. The aim of this study was to assess the association between visceral arterial occlusive disease and anastomotic leakage. METHODS: The preoperative abdominal computed tomography scans from all consecutive patients who underwent colorectal surgery with anastomosis in 2010 were retrospectively analyzed. RESULTS: A total of 242 patients were included, with a median age of 65 years (interquartile range 55-74). Anastomotic leakage occurred in 14 % of cases (n = 34). The mortality rate was 3 % (n = 8). There was no association between atherosclerosis of the visceral or iliac arteries and anastomotic leakage. There was also no association between right-sided or left-sided resections and total occlusion of the superior or inferior mesenteric artery, respectively. CONCLUSION: Asymptomatic visceral artery occlusive disease is not a risk factor for anastomotic leakage after colorectal surgery, and additional radiological imaging or percutaneous transluminal angioplasty for occluded visceral vessels is not indicated prior to colorectal surgery.

Systematic review on the value of CT scanning in the diagnosis of anastomotic leakage after colorectal surgery.

BACKGROUND: Timely diagnosis of anastomotic leakage after colorectal surgery and adequate treatment is important to reduce morbidity and mortality. Abdominal computed tomography (CT) scanning is the diagnostic tool of preference, but its value may be questionable in the early postoperative period. The accuracy of CT scanning for the detection of anastomotic leakage and its role in timing of intervention was evaluated. METHODS: A systematic literature search was performed. Relevant publications were identified from four electronic databases between 1990 and 2011. Inclusion criteria were human studies, studies published in English or Dutch, colorectal surgery with primary anastomosis, and abdominal CT scan with reported outcome for the detection of anastomotic leakage. Exclusion criteria were cohort of fewer than five patients, other gastrointestinal surgery, no anastomosis, and radiological imaging other than CT. RESULTS: Eight studies, including 221 abdominal CT scans, fulfilled the inclusion criteria. Overall, the methodological quality of the studies was poor. The overall sensitivity of CT scanning to diagnose leakage was 0.68 (95 % confidence interval 0.59-0.75) for colonic resection. Data on the sequelae of false-negative CT scanning was not available. CONCLUSION: There is limited good-quality evidence to determine the value of CT scans in the detection of anastomotic leakage. To prevent delay in diagnosis and appropriate treatment of anastomotic leakage, the relatively low sensitivity of CT scanning must be taken into account.

The First Year After Colorectal Surgery in the Elderly.

PURPOSE: Surgery for colorectal malignancy is increasingly being performed in the elderly. Little is known about the impact of complications on late mortality. This study aimed to analyze whether a complicated postoperative course affects the 1-year survival in elderly patients. METHODS: All consecutive patients older than 75 years of age who underwent colorectal cancer surgery between January 2009 and April 2013 were included in this study. The main outcome was mortality at 1 year after surgery. Logistic regression analyses were performed to determine risk factors for a poor outcome (mortality) after survival of the early postoperative course of surgery at 1-year follow-up. Patients who died within 30 days postoperatively were excluded from analysis. RESULTS: The early mortality rate was 6.3% (n = 15), and 2 patients died during follow-up as a result of complications after a second surgery. A total of 223 patients survived the perioperative period and were included in this study. Twenty-two patients (9.9%) died during the first year of follow-up. Stage IV disease (P = 0.002), complications of primary surgery (P = 0.016), and comorbidity (P = 0.050) were risk factors for 1-year mortality. Intensive care unit stay, reoperation and readmission were not associated with a worse 1-year outcome. CONCLUSION: Elderly patients with stage IV disease at the time of surgery, comorbidity, and postoperative complications are at risk for mortality during the first year after surgery. A patient-tailored approach with special attention to perioperative care should be considered in the elderly.

Quality of Life After a Low Anterior Resection for Rectal Cancer in Elderly Patients.

PURPOSE: Fecal incontinence is a major concern, and its incidence increases with age. Quality of life may decrease due to fecal incontinence after both sphincter-saving surgery and a rectal resection with a permanent stoma. This study investigated quality of life, with regard to fecal incontinency, in elderly patients after rectal-cancer surgery. METHODS: All patients who underwent elective rectal surgery with anastomosis for rectal cancer between December 2008 and June 2012 at two Dutch hospitals were eligible for inclusion. The Wexner and the fecal incontinence quality of life (FIQoL) scores were collected. Young (<70 years of age) and elderly (≥70 years of age) patients were compared. RESULTS: Seventy-nine patients were included, of whom 19 were elderly patients (24.1%). All diverting stomas that had been placed (n = 60, 75.9%) had been closed at the time of the study. There were no differences in Wexner or FIQoL scores between the young and the elderly patients. Also, there were no differences between patients without a diverting stoma and patients in whom bowel continuity had been restored. Elderly females had significantly worse scores on the FIQoL subscales of coping/behavior (P = 0.043) and depression/self-perception (P = 0.004) than young females. Elderly females scored worse on coping/behavior (P = 0.010) and depression/self-perception (P = 0.036) than elderly males. Young and elderly males had comparable scores. CONCLUSION: Quality of life with regard to fecal incontinency is worse in elderly females after sphincter-preserving surgery for rectal cancer. Patients should be informed of this impact, and a definite stoma may be considered in this patient group.

Predictors of fecal incontinence and related quality of life after a total mesorectal excision with primary anastomosis for patients with rectal cancer.

PURPOSE: After total mesorectal excision (TME) with primary anastomosis for patients with rectal cancer, the quality of life (QoL) may be decreased due to fecal incontinence. This study aimed to identify predictors of fecal incontinence and related QoL. METHODS: Patients who underwent TME with primary anastomosis for rectal cancer between December 2008 and June 2012 completed the fecal incontinence quality of life scale (FIQoL) and Wexner incontinence score. Factors associated with these scores were identified using a linear regression analysis. RESULTS: A total of 80 patients were included. Multivariate analysis identified a diverting ileostomy (n = 58) as an independent predictor of an unfavorable outcome on the FIQoL subscale coping/behavior (P = 0.041). Ileostomy closure within and after 3 months resulted in median Wexner scores of 5.0 (interquartile range [IQR], 2.5-8.0) and 10.5 (IQR, 6.0-13.8), respectively (P < 0.001). The median FIQoL score was 15.0 (IQR, 13.1-16.0) for stoma closure within 3 months versus 12.0 (IQR, 10.5-13.9) for closure after 3 months (P = 0.001). CONCLUSION: A diverting ileostomy is a predictor for an impaired FIQoL after a TME for rectal cancer. Stoma reversal within 3 months showed better outcomes than reversal after 3 months. Patients with a diverting ileostomy should be informed about the impaired QoL, even after stoma closure.

Erratum.

[This corrects the article on p. 23 in vol. 31, PMID: 25745623.].

Unique case of pneumomediastinum due to penetrating injury to the mediastinum.

Pneumomediastinum is a rare condition, and mostly occurs following traumatic or iatrogenic tracheal and oesophageal perforation, but spontaneous pneumomediastinum has also been described. We report a case of a 17-year-old woman who presented with a penetrating neck wound after a fall down the stairs. She had an extensive pneumomediastinum without signs of tracheal or oesophageal laceration, rib fractures, pneumothorax or haematothorax. The contaminated wound was surgically explored and extensively lavaged. Prophylactic antibiotic treatment was given and the patient recovered without complications. Direct perforating trauma to the mediastinum is a severe entity, but can be treated by lavage and prophylactic antibiotic therapy.

The new Body Mass Index as a predictor of postoperative complications in elective colorectal cancer surgery.

BACKGROUND & AIMS: A new Body Mass Index (BMI) formula has been developed for a better approximation of under and overweight. The aim of this study was to investigate the predictive value of this newly proposed BMI formula for postoperative complications in elective colorectal cancer surgery compared with the conventional BMI formula. METHODS: A digital database of patients undergoing elective colorectal cancer surgery was prospectively maintained in three centers and retrospectively analyzed. Data consisted of patient characteristics, surgical procedure, length of hospital stay (LOS), postoperative complications, mortality, reoperation and readmission. The BMI was calculated using both the conventional and new BMI formula. Patients were divided into four groups (BMI <20, 20-25, 25-30, ≥30 kg/m(2)). RESULTS: A total of 1614 patients were included. There was no significant difference in mean BMI between males and females using the conventional BMI formula (26.0 versus 26.2, p = 0.347), whereas a trend was observed using the new BMI formula (26.3 versus 25.6, p = 0.071). The proportion of overweight (BMI ≥25) male patients was significantly higher compared with the proportion of overweight female patients using the conventional formula (58.9% versus 51.0%, p = 0.021), whereas a non-significant difference was observed using the new formula (51.7% versus 53.4%, p = 0.515). Neither the conventional nor the new BMI were associated with postoperative complications and LOS. Higher age, higher ASA classification, male gender, and conventional surgery were independent predictors of the occurrence of postoperative complications. A longer LOS was also independently predicted by higher age, higher ASA classification and conventional surgery. CONCLUSIONS: This study showed no superiority of the new BMI formula in predicting postoperative complications after colorectal cancer surgery. Confirmation of the results in a larger cohort is desirable.

Increasing duration of circulatory arrest, but not antegrade cerebral perfusion, prolongs postoperative recovery after neonatal cardiac surgery.

OBJECTIVE: Deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP) are 2 cardiopulmonary bypass techniques applied in aortic arch repair. In recent literature, cerebral effects of both techniques have received most attention, whereas the consequences for other organs have not been thoroughly investigated. Therefore, in this study, the impact of duration of DHCA and ACP on postoperative recovery was analyzed in a cohort of neonates undergoing aortic arch reconstruction. METHODS: All consecutive neonates who underwent aortic arch reconstruction from 2004 to 2009 were included in this retrospective study. Length of stay on the intensive care unit (ICU-LOS), duration of mechanical ventilation, inotrope score, and areas under the curve (AUC) for lactate and creatinine were compared with respect to durations of DHCA and ACP, respectively. Correction for confounders was performed using multivariable linear regression. RESULTS: Eighty-three neonates were included, with a 30-day mortality of 4.8%. Longer duration of DHCA was associated with longer ICU-LOS both in univariable and multivariable analyses. Similarly, duration of mechanical ventilation and lactate and creatinine AUCs increased with duration of DHCA. Inotrope score was only associated with DHCA duration in univariable analysis. Duration of ACP did not affect any of the outcome parameters. CONCLUSIONS: Increasing duration of DHCA, but not ACP, during neonatal aortic arch reconstruction prolongs short-term postoperative recovery. This suggests all efforts should be made to reduce the duration of DHCA to the shortest period possible, which may be achieved by exclusive use of ACP or a combination of the 2 perfusion techniques.