Undiagnosed Primary Hyperparathyroidism and Recurrent Miscarriage: The First Prospective Pilot Study.

BACKGROUND: Primary hyperparathyroidism (pHPT) in pregnancy is reported to be associated with significant maternal and foetal complications and an up to threefold increase in the risk of miscarriage. However, the true incidence of pHPT in pregnancy, complete and miscarried, is unknown and there are no data on the prevalence of undiagnosed pHPT in recurrent miscarriage (RM) (≥3 consecutive miscarriages under 24-week gestation). This is the first prospective study aiming to establish the prevalence of undiagnosed pHPT in RM. METHODS: Following UK National ethics committee approval, women who had experienced 3 or more consecutive miscarriages were recruited from a nationwide RM clinic. Serum corrected calcium, phosphate, PTH and vitamin D were evaluated. Patients with raised serum calcium and/or PTH were recalled for confirmatory tests. Power calculations suggested that a minimum of 272 patients were required to demonstrate a clinically significant incidence of pHPT. RESULTS: Three hundred women were recruited, median age 35 years (range 19-42). Eleven patients had incomplete data, leaving 289 patients suitable for analysis; 50/289 patients (17%) with abnormal tests were recalled. The prevalence of vitamin D deficiency (<25 nmol/l) and insufficiency (25-75 nmol/l) was 8.7 and 67.8%, respectively. One patient was diagnosed with pHPT (0.34%) and underwent successful parathyroidectomy. CONCLUSIONS: The prevalence of undiagnosed pHPT (0.34%) in RM in this study appears to be many times greater than the 0.05% expected in this age group. The findings of this pilot study merit follow-up with a larger-scale study. Routine serum calcium estimation is not currently undertaken in RM and should be considered.

Learning curve of vessel cannulation in rats using cumulative sum analysis.

BACKGROUND: Intravascular access routes are widely used for administering agents or taking blood samples in rodents. Vessel cannulation in rats is a technically challenging procedure with a risk for significant complications. The use of cumulative sum (CUSUM) analysis allows continuous monitoring of the performer's outcomes to evaluate the learning curve for a particular procedure. The aim of the present study was to assess a researcher's learning curve in the cannulation of the jugular and femoral vein in rats using CUSUM analysis. MATERIALS AND METHODS: A single researcher performed two hundred microsurgical operations between September 2012 and September 2013. The animals (male Wistar rats) were anesthetized with isoflurane whereas the right jugular vein and the left femoral vein were catheterized. Prospective data were collected and analyzed using CUSUM analysis. For the purposes of the study, the rat population was divided in four groups based on the order of studies; group 1 represents the first 50 animals cannulated, group 2 the next batch of 50 animals, and so forth. RESULTS: The operating times required for cannulation of the jugular vein for groups 1, 2, 3, and 4 were 24.6 ± 4.8, 15.9 ± 2.5, 15.2 ± 3.2, and 15.7 ± 3.3 min, respectively. Group 1's operating time was significantly longer than all the other groups (P < 0.001 compared with all other groups). The operating times for groups 2, 3, and 4 did not differ significantly (P > 0.05). The cannulation of the femoral vein required a mean of 32 ± 5.3 min for group 1, 24.9 ± 5.7 min for group 2, 18.4 ± 4 min for group 3, and 17.2 ± 3.4 min for group 4. The operating time of group 1 was significantly longer when compared with all groups (P < 0.001 for all groups). Group 2 also had a longer operating time than groups 3 and 4 (P < 0.001 compared with both groups). Groups 3 and 4 did not show any statistical significant difference when their operating time was compared (P > 0.05). CUSUM analysis suggested that the number of cases required to achieve the required experience to most effectively cannulate the jugular and femoral vein is approximately 50 and 100 cases, respectively. The adverse effects of the procedure included two unexpected deaths, both of which occurred in group 1 (0.5% in total). CONCLUSIONS: The authors' experience regarding the learning curve of the cannulation of the femoral and jugular vein in rats from 200 animals operated over a period of 1 y for the evaluation of the pharmacokinetic properties of drug candidates suggests significant experience is required to optimize the operating time required for the procedure.

Retroperitoneoscopic or laparoscopic adrenalectomy? A single-centre UK experience.

BACKGROUND: Laparoscopic adrenalectomy (LA) is the "gold standard" approach to benign adrenal tumours. Retroperitoneoscopic adrenalectomy (RA) is an increasingly popular alternative. The purpose of this study was to compare our preliminary experience with RA to the more established LA. METHODS: Data on patients undergoing adrenalectomy over a 2-year period from 2010 were reviewed. Patients undergoing open adrenalectomy, bilateral adrenal surgery, or paraganglioma resection were excluded. The LA and RA patients were compared according to their operative time, time to first oral intake, complications, analgesic requirements, and length of hospital stay. Further analysis was performed on patients matched for all patient and disease-related criteria. Statistical analysis was performed using the χ (2) test and the Mann-Whitney U test as appropriate. RESULTS: A total of 71 adrenalectomies that fit the inclusion criteria were performed during the period studied of which 36 patients underwent LA and 35 patients underwent RA. Mean tumour size differed between the two groups (2.83 cm in RA group vs. 4.1 cm in LA group; p = 0.033). Operative time, time to first oral intake, analgesic requirements, length of hospital stay, and postoperative complications were all significantly lower in the RA group. Analysis of matched patients showed a significant difference between RA and LA in analgesia requirements (5 vs. 8 paracetamol doses, p = 0.014; 2 vs. 10 tramadol doses, p = 0.042) as well as in the length of hospital stay (1.58 vs. 3.58 days, p = 0.038). CONCLUSIONS: RA may be associated with reduced postoperative pain and length of hospital stay. It is a valuable alternative to LA in smaller tumours where it may prove to be superior.

Advances in Molecular Profiling and Their Potential Influence on the Extent of Surgery in Well-Differentiated Thyroid Carcinoma (WDTC).

Thyroid cancer surgery has evolved dramatically with advances in our understanding of the biological behaviour of WDTC. Molecular profiling is shedding light on the subset that may behave aggressively. In an era when thyroid cancer management is becoming increasingly conservative, decision making regarding the extent of surgery must be objectively guided by molecular markers. The aim of the present article is to summarise the current published literature and provide possible practice recommendations. An online search for relevant published articles was performed using several databases. Title, abstract, and full-text screening, along with data extraction, was performed by two independent reviewers after the inclusion and exclusion criteria were defined. A total of 1241 articles were identified, and 82 relevant articles were extracted and scrutinised. BRAF V600E and TERT promoter mutations were found to be associated with an increased risk of disease recurrence and distant metastases. Several other mutations have been identified that enhance disease aggressiveness (such as RET/PTC, PTEN, and TP53). One of the most important determinants of the outcome in WDTC is the extent of surgical resection. The evolution of molecular testing has reached a stage of personalised incorporation into surgical practice. Guidelines for molecular testing and surgery in WDTC will need to be clearly defined, arguably representing the next chapter in the management of the disease.

Triple water clear cell parathyroid adenomas: a rare cause of primary hyperparathyroidism.

A man in his 70s was referred to the endocrine surgery department after incidental finding of hypercalcaemia during preoperative work-up for abdominal aortic aneurysm repair. The patient reported severe fatigue and malaise with no previous history of nephrolithiasis or osteoporosis. After biochemical confirmation of primary hyperparathyroidism, localisation studies suggested multiple gland disease. Intraoperatively, three enlarged parathyroid adenomas were found and excised. Histopathological and immunohistochemical examination revealed triple water clear cell (WCC) parathyroid adenomas. Adenomas being entirely composed of WCCs are rare. In addition, triple adenomas are so rare that their existence is disputed by some authors. The present paper reports on an extremely rare case of a patient suffering from triple parathyroid adenomas composed entirely of WCCs. To our knowledge, this is the first such reported case in the English language literature.

Microcalcifications without a thyroid nodule as the sole sign of papillary thyroid carcinoma.

SUMMARY: Our objective is to demonstrate the importance of considering microcalcifications even without evidence of nodules as a potential sign of malignancy. Current guidelines, such as those of the British Thyroid Association, acknowledge the clinical significance of microcalcifications only when found within nodules. In this case, they are considered a suspicious feature, classifying the nodules as U5 (i.e. high risk) where fine-needle aspiration biopsy (FNAB) is warranted, following the high likelihood of cancer in these nodules. In addition, there is a dearth of evidence of ultrasound scan (USS) detection of microcalcifications in the thyroid gland outside of nodules, along with their associated clinical implications. Yet, this clinical manifestation is not so infrequent considering that we do encounter patients in the clinic showing these findings upon ultrasound examination. Three patients who presented to our clinic with thyroid-related symptoms were shown to have areas of microcalcifications without a nodule upon sonographic evaluation of their thyroid gland. These incidentally detected hyperechoic foci were later confirmed to correspond to areas of papillary thyroid carcinoma (PTC) on histopathological examination of resected tissue following thyroidectomy. Four more cases were identified with sonographic evidence of microcalcifications without nodules and given their clinical and other sonographic characteristics were managed with active surveillance instead. LEARNING POINTS: Echogenic foci known as microcalcifications may be visible without apparent association to nodular structures. Microcalcifications without nodules may not be an infrequent finding. Microcalcifications are frequently indicative of malignancy within the thyroid gland even without a clearly delineated nodule. Empirically, the usual guidelines for the management of thyroid nodules can be applied to the management of microcalcifications not confined to a nodule, but such a finding per se should be classified as a 'high-risk' sign.

Clinicopathological factors and survival outcomes of signet-ring cell and mucinous carcinoma versus adenocarcinoma of the colon and rectum: a systematic review and meta-analysis.

BACKGROUND: Histological subtypes of colorectal cancer may be associated with varied prognostic features. This systematic review and meta-analysis aimed to compare clinicopathological characteristics, recurrence and overall survival between colorectal signet-ring cell (SC) and mucinous carcinoma (MC) to conventional adenocarcinoma (AC). METHODS: A literature search of MEDLINE, EMBASE, Ovid and Cochrane Library was performed for studies that reported data on clinicopathological and survival outcomes on SC and/or MC versus AC from January 1985 to May 2020. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. RESULTS: Thirty studies of 1,087,055 patients were included: 11,510 (1.06%) with SC, 110,179 (10.13%) with MC and 965,366 (88.81%) with AC. Patients with SC were younger than patients with AC (WMD - 0.47; 95% CI - 0.84 to -0.10; I2 88.6%; p = 0.014) and more likely to have right-sided disease (OR 2.12; 95% CI 1.72-2.60; I2 82.9%; p < 0.001). Locoregional recurrence at 5 years was more frequent in patients with SC (OR 2.81; 95% CI 1.40-5.65; I2 0.0%; p = 0.004) and MC (OR 1.92; 95% CI 1.18-3.15; I2 74.0%; p = 0.009). 5-year overall survival was significantly reduced when comparing SC and MC to AC (HR 2.54; 95% CI 1.98-3.27; I2 99.1%; p < 0.001 and HR 1.38; 95% CI 1.19-1.61; I2 98.6%; p < 0.001, respectively). CONCLUSION: SC and MC are associated with right-sided lesions, advanced stage at presentation, higher rates of recurrence and poorer overall survival. This has strong implications towards surgical and oncological management and surveillance of colorectal cancer.

Lymph Node Metastasis and Extrathyroidal Extension in Papillary Thyroid Microcarcinoma in Cyprus: Suspicious Subcentimeter Nodules Should Undergo FNA When Multifocality is Suspected.

OBJECTIVE: To determine the prevalence of lymph node (LN) metastasis and extrathyroidal extension (ETE) in patients with papillary thyroid microcarcinoma (PTMC) in Cyprus and to evaluate the role of preoperative ultrasound (U/S) examination. METHODS: A retrospective study of 102 patients who underwent thyroidectomy for PTMC in a 2-year period. Preoperatively, all patients had a thyroid and neck U/S examination with LN mapping. Tumor size according to the largest diameter, number of foci, LN metastasis, and ETE data was collected from the histopathological report and was compared to the preoperative U/S reports. RESULTS: LN metastasis was present in 23.5% of patients. 15.7% had central, 3.9% had lateral, and 3.9% had both central and lateral LN metastasis. ETE was present in 27.5% of patients. 21.6% had multifocal disease, and in this group, 40.9% had LN metastasis and 36.4% had ETE. Multifocality (p = 0.03), size of tumor (p = 0.05), and ETE (p ≤ 0.001) were significantly associated with LN metastasis. The prevalence of LN metastasis in multifocal PTMC ≤5 mm was the same with multifocal PTMC >5 mm. The preoperative U/S sensitivity for the suspicious lateral neck and central LN was 100%, and the specificity was 100%. The preoperative U/S sensitivity for nodules suspicious for ETE was 53.6%, and the specificity was 100%. CONCLUSION: The presence of LN metastasis and ETE in our PTMC patients in Cyprus is frequent. Neck U/S mapping is a highly reliable and accurate tool in identifying metastatic nodes. LN metastasis is associated with ETE and multifocality. Suspicious subcentimeter nodules should undergo FNA irrespective of size when multifocality is suspected.

Association Between hsa-miR-30e Polymorphisms and Sporadic Primary Hyperparathyroidism Risk.

BACKGROUND/AIM: Almost 15% of patients with sporadic primary hyperparathyroidism (sPHPT) present with multiple gland disease (MGD). The aim of this study was to investigate the potential role of two polymorphisms of the hsa-miR-30e, in sPHPT tumorigenesis. PATIENTS AND METHODS: One-hundred twenty sPHPT patients, 77 presenting a single adenoma and 43 with MGD, and 54 healthy controls were genotyped. The SNPs were identified using the allele-specific PCR methodology, while the hsa-miR-30e expression was analyzed by real-time quantitative reverse transcriptase PCR. RESULTS: Hsa-miR-30e expression was found to be significantly higher in patients with MGD compared to patients with single adenomas (p=0.0019), but no differences were found regarding specific genotype carriers. The genotype frequencies for ss178077483 and rs7556088 were significantly different between patients and healthy controls. CONCLUSION: Although the polymorphisms cannot be used as biomarkers for the differential diagnosis of MGD, hsa-miR-30e expression could potentially serve as a biomarker for this purpose.

Is rectal washout effective for preventing localized recurrence after anterior resection for rectal cancer?

PURPOSE: The present study evaluated the effect of rectal washout in reducing local recurrence after resection for rectal cancer. METHODS: A literature search was performed on studies published since 1989 that compared rectal washout to no washout for rectal cancer resection. Primary end point was local cancer recurrence. Random-effect meta-analysis was used and subgroup analysis was performed. RESULTS: Five studies matched the selection criteria, and reported on 176 patients who underwent rectal washout and 256 who did not undergo washout. Different washout solutions were used in every study, and total mesorectal excision was not universally applied. Overall local recurrence rate was 8 percent (33/432). Local recurrence rate for rectal washout patients was 4.8 percent compared with 10.2 percent for patients who did not undergo rectal washout, a difference that was not statistically significant (odds ratio = 0.64; 95 percent confidence interval = 0.2-2.04). When only studies using total mesorectal excision were considered, there was no significant difference between the two groups (odds ratio = 1.21; 95 percent confidence interval = 0.37-3.92). CONCLUSIONS: Although no definitive conclusions may be drawn because of the nonrandomized nature of the included studies, rectal washout is relatively risk-free and adds little to the operative time. This may be performed until a randomized, controlled trial is undertaken to resolve this contentious issue.

Florid hyperandrogenism due to a benign adrenocortical adenoma.

A 26-year-old woman with a history of polycystic ovarian syndrome presented with secondary amenorrhea, worsening hirsutism, acne, deepening of voice and unexplained 10-20 kg weight gain. Her Ferriman-Gallway hirsutism score was 12 with cystic facial acne and increased masculine phenotype. Urine Beta-Human Chorionic Gonadotropins (bHCG) was negative. She had elevated serum testosterone of 551 ng/dL, androstenedione at 7.46 ng/mL and dehydroepiandrosterone sulfate (DHEAS) at 4243 µg/L. Overnight dexamethasone suppression test showed mildly unsuppressed cortisol (2.89 µg/dL). Urinary free cortisol along with paired serum cortisol and adrenocorticotrophic hormone (ACTH) tests were normal (55.4 µg/24 hours, 13.44 mcg/dL, 30.4 pg/mL respectively). Her leutinizing hormone (LH) was low(<0.1 mIU/mL), follicle stimulating hormone (FSH) low/normal (1.41 mIU/mL) with sex hormone binding globulin (SHBG) level 45nmol/L and the rest of the pituitary and adrenal workup was unremarkable. Thyroid stimulating hormone (TSH) was 2.15mU/mL. MRI revealed a 3.1 cm, indeterminate but well-defined left adrenal lesion and polycystic ovaries without abdominal lymphadenopathy. Given radiological appearances and despite biochemical concerns for adrenocortical malignancy, a multidisciplinary team meeting decision was made to proceed with laparoscopic adrenalectomy. Histology was consistent with a benign adenoma. Postoperatively, there was clinical and biochemical resolution of the disease.

Laparoscopic versus open hepatic resections for benign and malignant neoplasms--a meta-analysis.

BACKGROUND: Laparoscopic surgery for hepatic neoplasms aims to provide curative resection while minimizing complications. The present study compared laparoscopic versus open surgery for patients with hepatic neoplasms with regard to short-term outcomes. METHODS: Comparative studies published between 1998 and 2005 were included. Evaluated endpoints were operative, functional, and adverse events. A random-effects model was used and sensitivity analysis performed to account for bias in patient selection. RESULTS: Eight nonrandomized studies were included, reporting on 409 resections of hepatic neoplasms, of which 165 (40.3%) were laparoscopic and 244 (59.7%) were open. Operative blood loss (weighted mean difference = -123 mL; confidence interval = -179, -67 mL) and duration of hospital stay (weighted mean difference = -2.6 days; confidence interval = -3.8, -1.4 days) were significantly reduced after laparoscopic surgery. These findings remained consistent when considering studies matched for the presence of malignancy and segment resection. There was no difference in postoperative adverse events and extent of oncologic clearance. CONCLUSIONS: Laparoscopic resection results in reduced operative blood loss and earlier recovery with oncologic clearance comparable with open surgery. When performed by experienced surgeons in selected patients it may be a safe and feasible option. Because of the potential of significant bias arising from the included studies, further randomized controlled trials should be undertaken to confirm this bias and to assess long-term survival rates.

Can Total Thyroidectomy Be Safely Performed by Residents?: A Comparative Retrospective Multicenter Study.

This retrospective comparative multicenter study aims to analyze the impact on patient outcomes of total thyroidectomy (TT) performed by resident surgeons (RS) with close supervision and assistance of attending surgeons (AS).All patients who underwent TT between 2009 and 2013 in 10 Units of endocrine surgery (8 in Italy, 1 in France, and 1 in UK) were evaluated. Demographic data, preoperative diagnosis, extension of goiter, type of surgical access, surgical approach, operative time, use and duration of drain, length of hospitalization, histology, and postoperative complications were recorded. Patients were divided into 3 groups: A, when treated by an AS assisted by an RS; B and C, when treated by a junior and a senior RS, respectively, assisted by an AS.The 8908 patients (mean age 51.1 ±â€Š13.6 years), with 6602 (74.1%) females were enrolled. Group A counted 7092 (79.6%) patients, Group B 261 (2.9%) and Group C 1555 (17.5%). Operative time was significantly greater (P < 0.001) in B (101.3 ±â€Š43.0 min) vs A (71.8 ±â€Š27.6 min) and C (81.2 ±â€Š29.9 min). Duration of drain was significantly lower (P < 0.001) in A (47.4 ±â€Š13.2 h) vs C (56.4 ±â€Š16.5 h), and in B (42.8 ±â€Š14.9 h) vs A and C. Length of hospitalization was significantly longer (P < 0.001) in C (3.8 ±â€Š1.8 days) vs B (2.4 ±â€Š1.0 days) and A (2.6 ±â€Š1.5 days). No mortality occurred. Overall postoperative morbidity was 22.3%: it was significantly higher in B vs A (29.5% vs 22.3%; odds ratio [OR] 1.46, 95% confidence interval [CI] 1.11-1.92, P = 0.006) and C (21.3%; OR 1.55, 95% CI 1.15-2.07, P = 0.003). No differences were found for recurrent laryngeal nerve palsy, hypoparathyroidism, hemorrhage, and wound infection. The adjusted ORs in multivariate analysis showed that overall morbidity remained significantly associated with Group B vs A (OR 1.48, 95% CI 1.12-1.96, P = 0.005) and vs C (OR 1.60, 95% CI 1.19-2.17, P = 0.002), while no difference was observed in Group A vs B + C.TT can be safely performed by residents correctly supervised. Innovative gradual training in dedicated high-volume hospitals should be proposed in order to allow adequate autonomy for the RS and safeguard patient outcome.

Diagnostic accuracy and value of magnetic resonance imaging (MRI) in planning exenterative pelvic surgery for advanced colorectal cancer.

PURPOSE: To assess the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting colorectal tumour invasion according to seven intrapelvic compartments for planning exenterative pelvic surgery. METHOD: Sixty-three consecutive patients underwent preoperative MRI planning for exenterative surgery, defined as operative excision beyond conventional mesenteric planes for locally advanced (n=23) and recurrent (n=41) pelvic colorectal cancer. The institutional research committee approved of the study and waived the need for a consent form as the images were retrospectively assessed. Two radiologists reported tumour invasion for each of seven anatomic surgical resection compartments, blinded to histopathology and the intraoperative findings. Sensitivity, specificity and predictive values were calculated for the seven intrapelvic compartments. Cox regression analysis was used to calculate the risk of death and recurrence. Overall interobserver agreement was assessed using Cohen's Kappa coefficient (k). RESULTS: The sensitivity of MRI was ≥93.3% in all but the lateral compartment where it was 89.3%. Specificity for the posterior (82.2%) and anterior compartments below the peritoneal reflection (86.4%) was lower compared to the other compartments. Agreement between the two radiologists was found to be good or very good for all compartments (k>0.72). An MRI diagnosis of tumour invasion in the anterior compartment above the peritoneal reflection was associated with a poorer survival (p=0.012). CONCLUSION: MRI is accurate in predicting the extent of colorectal tumour within the pelvis and therefore can be used to determine the type of surgery required for curative resection. It should always be used to stage patients with advanced colorectal pelvic cancer.

The role of laparoscopy and laparoscopic ultrasound in the preoperative staging of patients with resectable colorectal liver metastases: a meta-analysis.

BACKGROUND: The role of staging laparoscopy (SL) with laparoscopic ultrasound (LUS) in patients with resectable colorectal liver metastases (CRLM) remains controversial. METHODS: A meta-analysis of all studies (from 1998 to the present) on the effect of SL/LUS in patients with potentially resectable CRLM with respect to alteration in surgical management was performed. RESULTS: Twelve studies satisfied the inclusion criteria. A total of 1,047 patients underwent SL/LUS. The true yield of SL/LUS for CRLM was 19% (95% confidence interval [CI], 16%-22%), with a diagnostic odds ratio of 132 (95% CI, 56-310) and an overall sensitivity of 59% (95% CI, 53%-65%). Subgroup analysis for detection of other liver and peritoneal lesions showed a sensitivity of 59% (95% CI, 49%-67%) and 75% (95% CI, 63%-85%) respectively. There was major between-study heterogeneity for all analyses, with no obvious cause revealed by meta-regression. CONCLUSIONS: The true benefit of using SL/LUS universally seems limited. It appears more useful as an adjunct in patients when peritoneal disease is suspected.

A rare complication: lymphocele following a re-operative right thyroid lobectomy for multinodular goitre.

Lymphatic leakage is a rare complication of thyroid surgery, the risk of which increases in the presence of malignancy and correlates with the extent of surgery. Although primarily associated with left-sided thoracic duct injuries, lymphatic leaks may occur following right-sided neck dissections for metastatic thyroid cancer. However, the development of a lymphocele following a right-sided lobectomy for benign disease is exceptionally rare. The authors present the case of a patient who developed a cervical lymphocele 10 days after a re-operative right thyroid lobectomy for a multinodular goitre. The patient was successfully managed conservatively with a combination of dietary modification and high-dose octreotide. The reason for her presentation was most likely the result of an occult injury to a congenitally-aberrant lymphatic duct, brought into the operative field by postsurgical adhesions. The case serves to highlight the importance of subtle variations in lymphatic anatomy in the context of a re-operative thyroidectomy.

The risk of cancer in patients with Crohn's disease.

PURPOSE: The risk of cancer in patients with Crohn's disease is not well defined. Using meta-analytical techniques, the present study was designed to quantify the risk of intestinal, extraintestinal, and hemopoietic malignancies in such patients. METHODS: A literature search identified 34 studies of 60,122 patients with Crohn's disease. The incidence and relative risk of cancer were calculated for patients with Crohn's disease and compared with the baseline population of patients without Crohn's disease. Overall pooled estimates, with 95 percent confidence intervals, were obtained, using a random-effects model. RESULTS: The relative risk of small bowel, colorectal, extraintestinal cancer, and lymphoma compared with the baseline population was 28.4 (95 percent confidence interval, 14.46-55.66), 2.4 (95 percent confidence interval, 1.56-4.36), 1.27 (95 percent confidence interval, 1.1-1.47), and 1.42 (95 percent confidence interval, 1.16-1.73), respectively. On subgroup analysis, patients with Crohn's disease had an increased risk of colon cancer (relative risk, 2.59; 95 percent confidence interval, 1.54-4.36) but not of rectal cancer (relative risk, 1.46; 95 percent confidence interval, 0.8-2.55). There was significant association between the anatomic location of the diseased bowel and the risk of cancer in that segment. The risk of small bowel cancer and colorectal cancer was found to be higher in North America and the United Kingdom than in Scandinavian countries with no evidence of temporal changes in the cancer incidence. CONCLUSIONS: The present meta-analysis demonstrated an increased risk of small bowel, colon, extraintestinal cancers, and lymphoma in patients with Crohn's disease. Patients with extensive colonic disease that has been present from a young age should be candidates for endoscopic surveillance; however, further data are required to evaluate the risk of neoplasia over time.

Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann's procedures.

OBJECTIVE: To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmann's procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis. SUMMARY BACKGROUND DATA: The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure. METHODS: Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations. Decision analysis from the patient's perspective was used to calculate the optimal operative strategy and sensitivity analysis performed. RESULTS: A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmann's procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively. CONCLUSION: Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.

Factors affecting circumferential resection margin involvement after rectal cancer excision.

PURPOSE: This study was designed to assess factors affecting rates of circumferential resection margin involvement after rectal cancer excision, the association between circumferential resection margin involvement rates for patients undergoing anterior resection and abdominoperineal excision within the same unit, and trends in outcomes between units. METHODS: Data about patients undergoing rectal cancer excision between 2000 and 2003 were extracted from the Association of Coloproctology of Great Britain and Ireland database. Multivariate logistic regression analysis was used to identify independent predictors of circumferential resection margin involvement. Pearson correlation coefficient was used to evaluate the association between circumferential resection margin involvement for anterior resection and abdominoperineal excision. RESULTS: A total of 1,430 patients satisfied the inclusion criteria. The circumferential resection margin involvement rate for anterior resection (n=794) was 6.7 percent, between hospital variability was 0 to 40 percent, and for abdominoperineal excision (n=521) was 17.6 percent, between hospital variability 0 to 100 percent. Independent predictors of circumferential resection margin involvement were T stage (P<0.001), nodal involvement (P=0.007), and operative procedure (P<0.001). Units with a high circumferential resection margin involvement rate for anterior resection also had a high circumferential resection margin involvement rate for abdominoperineal excision (Pearson correlation=0.349; P=0.01). CONCLUSIONS: Circumferential resection margin involvement is more common in lymph-node-positive tumors and is more common after abdominoperineal excision compared with anterior resection. This relationship was consistent across units irrespective of their individual circumferential resection margin involvement rates.

Comparison of short-term outcomes of laparoscopic vs open approaches to ileal pouch surgery.

AIMS: The present meta-analysis compared short-term outcomes between patients undergoing laparoscopic and open restorative proctocolectomy. METHODS: A literature search of Medical Literature Analysis and Retrieval System Online, Ovid, Excerpta Medica and Cochrane databases was performed to identify studies published between 1990 and 2006 comparing laparoscopic and open restorative proctocolectomy. A random-effect meta-analytical technique was used, and sensitivity analysis was performed on studies published since 2001, higher-quality papers, those reporting on more than 30 patients and those with matching of patient characteristics. RESULTS: Ten studies satisfied the selection criteria, including outcomes on 329 patients, 168 (51.1%) of whom underwent laparoscopic resection. Operative time was significantly longer in the laparoscopic group by 86 min (p<0.001) and throughout the subgroup analysis, but this finding was associated with significant heterogeneity. Operative blood loss was less in the laparoscopic group by 84 ml. There was no significant difference in post-operative adverse events between the groups. A statistically significant reduction in length of post-operative stay was observed for laparoscopic patients in high-quality studies and those reporting on more than 30 patients by 1.1 days (p=0.02 in both subgroups) and studies published in or since 2001 by 3.0 days (p=0.004) but not overall. CONCLUSION: Laparoscopic ileal pouch surgery was associated with longer operative time, lower blood loss, shorter length of hospital stay and similar short-term adverse events compared with open surgery. Comparative data on quality of life and long-term outcomes are currently unavailable. The potential advantage of laparoscopic ileal pouch surgery remains to be established.