Definition and reporting of lymphadenectomy and complete mesocolic excision for radical right colectomy: a systematic review.

BACKGROUND: Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation. METHODS: PRISMA-compliant systematic literature review to identify the definitions of RRC. Primary aims were to identify surgical steps and different nomenclature for RRC. Secondary aims were description of heterogeneity and overlap among different RRC techniques. RESULTS: Ninety-nine articles satisfied inclusion criteria. Eight surgical steps were identified and recorded as specific to RRC: Central arterial ligation was described in 100% of the included studies; preservation of mesocolic integrity in 73% and dissection along the SMV plane in 67%. Other surgical steps were inconstantly reported. Six differently named techniques for RRC have been identified. There were 35 definitions for the 6 techniques and 40% of these were used to identify more than one technique. CONCLUSIONS: The only universally adopted surgical step for RRC is central arterial ligation. There is great heterogeneity and consistent overlap among definitions of all RRC techniques. This is likely to jeopardise the interpretation of the outcomes of studies on the topic. Consistent use of definitions and reporting of procedures are needed to obtain reliable conclusions in future trials. PROSPERO CRD42021241650.

The hamletic dilemma of patients waiting for kidney transplantation during the COVID-19 pandemic: To accept or not to accept (an organ offer)?

The outbreak of COVID-19 led to a reduction in the number of organ transplant interventions in most Countries. In April 2020, at the Tor Vergata University in Rome, Italy, two patients on the waiting list for kidney transplantation (KT) declined a deceased donor's kidney offer. Therefore, between April 20 and 25, 2020, we conducted a telephone survey among our 247 KT waitlist patients. Our aim was to explore: (a) the COVID-19 diffusion among them and (b) their current willingness to be transplanted in case of a kidney offer from a deceased donor. Two hundred and forty-three patients participated in a phone interview. One patient had died from COVID-19. Eighty-five (35%) KT candidates would decline any kidney offer, in most cases until the end of the COVID-19 pandemic. Upon a multivariate analysis, female gender (OR = 2.25, 95% CI = 1.26-4.03, P = .006), high cardiovascular risk (OR = 2.33, 95% CI = 1.06-5.08, P = .034), a waiting list time <3 years (OR = 0.375, 95% CI = 0.15-0.95, P = .04), and the need to be transferred to another hospital for HD (OR = 2.56, 95% CI = 1.10-5.9, P = .03) were associated with such refusal. The COVID-19 pandemic led to a fear of transplantation in a third of the KT candidates. Proactive educational webinars could be a useful tool to remove, or at least lessen, any doubts on the part of KT candidates and to avoid losing the opportunity to quit dialysis.

Sensitivity and specificity of diagnostic modalities in pouchitis: a systematic review and meta-analysis.

Restorative proctocolectomy (RPC) is the most common surgical procedure to restore gastrointestinal continuity after surgical resection of the colon and rectum. Pouchitis is a common complication with several different modalities that can be used to aid diagnosis. This systematic review and meta-analysis aimed at exploring the sensitivity and specificity these diagnostic modalities. The medical literature was searched using MEDLINE, EMBASE and EMBASE classic and PubMed from 1978 to June 2022. We calculated descriptive statistics using sensitivity, specificity, and false-positive rate of the primary studies and also their positive and negative likelihood ratios, and their diagnostic odds ratios. The screen found 5477 records with 13 studies being included. Faecal lactoferrin was found to have the highest pooled sensitivity and specificity of 98% and 88% respectively with imaging modalities coming in second and faecal calprotectin third with pooled sensitivities and specificities of 87% and 79% and 74% and 81% respectively. Faecal biomarkers particularly lactoferrin and imaging modalities may have an important role to play in diagnosing pouchitis. Importantly due to delays in availability of pouchoscopy, our data supports early ordering of these tests to help delineate from other causes. Further studies are required with larger cohort sizes to further validate these tests.

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes.

BACKGROUND: Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure. AIMS: To assess the incidence of PRF and to report on the outcomes of available surgical treatments. METHODS: A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020. RESULTS: 34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +). CONCLUSION: PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

Ileoanal pouch cancers in ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis.

INTRODUCTION: Restorative proctocolectomy results in the formation of a pouch that adapts to a more colonic phenotype. The incidence of cancer of the pouch is thought to be low with most societal guidelines differing on their recommendations for surveillance. AIMS: We conducted a systematic review with meta-analysis to report the incidence of cancer in all pouch patients. METHODS: The Embase, Embase classic and PubMed databases were searched between June 1979- June 2021. A random effects model was performed to find the pooled incidence of pouch cancer. In addition, we also looked for risk factors for pouch cancers. RESULTS: Forty-six studies were included. In 19,964 patients with Ulcerative Colitis (UC) the pooled incidence of pouch cancer was 0.0030 (95% CI: 0.0016 -0.0055). In 3741 patients with Familial Adenomatous Polyposis (FAP) the pooled incidence of pouch cancer was 0.01 (95% CI: 0.01 - 0.02). In UC most pouch cancers were found to occur in the pouch body (0.59 (95% CI: 0.29-0.84)). CONCLUSIONS: The findings suggest that the pooled incidence of pouch cancer in UC is similar to that which was previously published, and this is the first meta-analysis to report a pooled incidence for pouch cancer in FAP.

Inflammatory Bowel Diseases Benefit from Enhanced Recovery After Surgery [ERAS] Protocol: A Systematic Review with Practical Implications.

BACKGROUND: Enhanced Recovery After Surgery [ERAS] is widely adopted in patients undergoing colorectal surgery, with demonstrated benefits. Few studies have assessed the feasibility, safety, and effectiveness of ERAS in patients with inflammatory bowel diseases [IBD]. The aim of this study was to investigate the current adoption and outcomes of ERAS in IBD. METHODS: This PRISMA-compliant systematic review of the literature included all articles reporting on adult patients with IBD who underwent colorectal surgery within an ERAS pathway. PubMed/MEDLINE, Cochrane Library, and Web of Science were searched. Endpoints included ERAS adoption, perioperative outcomes, and ERAS items more consistently reported, with associated evidence levels [EL] [PROSPERO CRD42021238653]. RESULTS: Out of 217 studies, 16 totalling 2347 patients were included. The median number of patients treated was 50.5. Malnutrition and anaemia optimisation were only included as ERAS items in six and four articles, respectively. Most of the studies included the following items: drinking clear fluids until 2 h before the surgery, fluid restriction, nausea prophylaxis, early feeding, and early mobilisation. Only two studies included postoperative stoma-team and IBD-team evaluation before discharge. Highest EL were observed for ileocaecal Crohn's disease resection [EL2]. Median in-hospital stay was 5.2 [2.9-10.7] days. Surgical site infections and anastomotic leaks ranged between 3.1-23.5% and 0-3.4%, respectively. Complications occurred in 5.7-48%, and mortality did not exceed 1%. CONCLUSIONS: Evidence on ERAS in IBD is lacking, but this group of patients might benefit from consistent adoption of the pathway. Future studies should define if IBD-specific ERAS pathways and selection criteria are needed.

Abdominal versus perineal approach for external rectal prolapse: systematic review with meta-analysis.

BACKGROUND: External rectal prolapse (ERP) is a debilitating condition in which surgery plays an important role. The aim of this study was to evaluate the outcomes of abdominal approaches (AA) and perineal approaches (PA) to ERP. METHODS: This was a PRISMA-compliant systematic review with meta-analysis. Studies published between 1990 and 2021 were retrieved. The primary endpoint was recurrence at the last available follow-up. Secondary endpoints included factors associated with recurrence and function. All studies were assessed for bias using the Newcastle-Ottawa Scale and Cochrane tool. RESULTS: Fifteen studies involving 1611 patients (AA = 817; PA = 794) treated for ERP were included, three of which were randomized controlled trials (RCTs; 114 patients (AA = 54; PA = 60)). Duration of follow-up ranged from 12 to 82 months. Recurrence in non-randomized studies was 7.7 per cent in AA versus 20.1 per cent in PA (odds ratio (OR) 0.29, 95 per cent confidence interval (c.i.) 0.17 to 0.50; P < 0.001, I2 = 45 per cent). In RCTs, there was no significant difference (9.8 per cent versus 16.3 per cent, AA versus PA (OR 0.82, 95 per cent c.i. 0.29 to 2.37; P = 0.72, I2 = 0.0 per cent)). Age at surgery and duration of follow-up were risk factors for recurrence. Following AA, the recurrence rates were 10.1 per cent and 6.2 per cent in patients aged 65 years and older and less than 65 years of age, respectively (effect size [e.s.] 7.7, 95 per cent c.i. 4.5 to 11.5). Following PA, rates were 27 per cent and 16.3 per cent (e.s. 20.1, 95 per cent c.i. 13 to 28.2). Extending follow-up to at least 40 months increased the likelihood of recurrence. The median duration of hospital stay was 4.9 days after PA versus 7.2 days after AA. Overall, incontinence was less likely after AA (OR 0.32), but constipation occurred more frequently (OR 1.68). Most studies were retrospective, and several outcomes from RCTs were not consistent with those observed in non-RCTs. CONCLUSION: The overall risk of recurrence of ERP appears to be higher with PA versus AA. Incontinence is less frequent after AA but at the cost of increased constipation. Age at surgery and duration of follow-up are associated with increased risk of recurrence, which warrants adequate reporting of future studies on this topic.

Perforated gastric cancer: a critical appraisal.

Gastric cancer perforation is a life-threatening condition that accounts for less than 5% of all gastric cancer patients and typically requires emergency surgery. However, preoperative diagnosis is difficult and management has a dual purpose: to treat peritonitis and to achieve a curative resection. The optimal surgical strategy is still unclear and prognosis remains poor. A search of the literature was performed using MEDLINE databases (Pubmed, EMBASE, Web of Science and Cochrane) using terms such as "perforated gastric cancer", "perforated gastric cancer and surgery", "perforated gastric tumour" and "gastric cancer perforated". Case reports, other reviews, non-english written papers and papers written before 2010 were excluded. Eight articles published between 2010 and 2020 matched the inclusion criteria for this review. Perforated gastric cancer was more prevalent in elderly males. Distal stomach was most frequently involved. Preoperative diagnosis was uncommon. Mortality rates ranged from 2 to 46%. Patients able to receive an R0 resection demonstrated better long-term survival compared with patients who had simple closure procedures. Laparoscopic procedure was mentioned only in one study. In an emergency situation, curative RO resection should always be offered in patients without multiple adverse factors. A surgical strategy using laparoscopic local repair as first step of surgery to resolve the peritonitis followed by a radical open or laparoscopic gastrectomy with lymphadenectomy could be considered. A balance between emergency and oncological needs should drive the surgical choice on a case by case basis.

Role of Breast-Conserving Surgery on the National Health System Economy From and to SARS-COVID-19 Era.

Day surgery breast-conserving surgery (DS-BCS) is a surgical approach applied in many specialized breast surgery departments. This study demonstrates the benefits of this approach from the perspectives of patients and of the Hospital/National Health System compared to ordinary breast-conserving surgery (ORD-BCS) under general anesthetic. A comparison of costs and diagnosis-related group (DRG) reimbursement demonstrated improved cost-effectiveness in DS-BCS compared to ORD-BCS.

Complete mesocolic excision and central vascular ligation in colorectal cancer in the era of minimally invasive surgery.

Since the 19th century, appropriate lymphadenectomy has been considered a cornerstone of oncologic surgery and one of the most important prognostic factors. This approach can be applied to any surgery for gastrointestinal cancer. During surgery for colon and rectal cancer, an adequate portion of the mesentery is removed together with the segment of bowel affected by the disease. The adequate number of lymph nodes to be removed is standardized and reported by several guidelines. It is mandatory to determine the appropriate extent of lymphadenectomy and to balance its oncological benefits with the increased morbidity associated with its execution in cancer patients. Our review focuses on the concept of "complete mesenteric excision (CME) with central vascular ligation (CVL)," a radical lymphadenectomy for colorectal cancer that has gained increasing interest in recent years. The aim of this study was to evaluate the evolution of this approach over the years, its potential oncologic benefits and potential risks, and the improvements offered by laparoscopic techniques. Theoretical advantages of CME are improved local-relapse rates due to complete removal of the intact mesocolic fascia and improved distance recurrence rates due to ligation of vessels at their origin (CVL) which guarantees removal of a larger number of lymph nodes. The development and worldwide diffusion of laparoscopic techniques minimized postoperative trauma in oncologic surgery, providing the same oncologic results as open surgery. This has been widely applied to colorectal cancer surgery; however, CME entails a technical complexity that can limit its wide minimally-invasive application. This review analyzes results of these procedures in terms of oncological outcomes, technical feasibility and complexity, especially within the context of minimally invasive surgery.

Long-Term Bowel Function and Fate of the Ileal Pouch After Restorative Proctocolectomy in Patients With Crohn's Disease: A Systematic Review With Meta-Analysis and Metaregression.

BACKGROUND AND AIMS: Debate exists on whether ileal pouch anal anastomosis [IPAA] can be safely offered to patients diagnosed with Crohn's disease [CD]. Our aim was to assess the outcome of IPAA for CD vs ulcerative colitis [UC]. METHODS: We used a PRISMA/MOOSE-compliant meta-analysis. Studies published between 1993 and 2018 were retrieved. Primary end points included complications. Secondary endpoints included functional outcome. The time of CD diagnosis was considered [intentional vs incidental IPAA]. RESULTS: Eleven studies comprising 6770 patients [CD = 352, UC = 6418] were included, with 44-120 months of follow-up. Pouch fistulae were more common in CD (CD vs UC; odds ratio (OR) 6.08; p = 0.0003, GRADE+++), as were strictures [OR 1.82; p = 0.02, GRADE+++] and failure [OR 5.27; p < 0.0001, GRADE++++]. Compared with UC, postoperative CD diagnosis was associated with a much higher risk of fistulae [OR 6.23; p = 0.006, GRADE+++] and failure [OR 8.53; p < 0.0001, GRADE++++] than intentional IPAA in CD [fistula: OR 4.17; p = 0.04, GRADE+++; failure: OR 2.48; p = 0.009, GRADE++++]. Age at surgery was positively associated with failure in CD [p = 0.007]. Obstruction was more common after intentional IPAA for CD. The risk of pouchitis did not differ between CD and UC [OR 1.07, p = 0.76, GRADE+++]. CD patients were at a higher risk of seepage [OR 2.27; p = 0.010, GRADE++]. CONCLUSIONS: Patients with CD have 5-fold higher risk of failure, and a 2-fold risk of strictures after IPAA compared with UC. The risk is much higher if diagnosis is performed after IPAA. Function in those who retain the pouch seemed similar to that of patients with UC. CD does not increase the risk of pouchitis. IPAA could be offered to a selected population of CD patients after proper preoperative counselling.[PROSPERO registry 116811].