Controversies of colonic stenting in obstructive left colorectal cancer: a critical analysis with meta-analysis and meta-regression.

PURPOSE: After almost three decades since the first description of colonic stents, the controversies of its safe application continue to impede the readiness of adoption by clinicians for malignant left bowel obstruction. This review seeks to address some of the controversial aspects of stenting and its impact on surgical and oncological outcomes. METHODS: Medline, Embase, and CNKI were searched for articles employing SEMS for left colonic obstruction. Outcomes analyzed include success rates, complications, and long-term survival. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated. RESULTS: 36 studies were included with 2002 patients across seven randomized controlled trials and 29 observational studies. High technical (92%) and clinical (82%) success rates, and low rates of complications, including perforation (5%), were found. Those with > 8% perforation rates had poorer technical success rates than those with ≤ 8%, but there were no significant differences in 90-day in-hospital mortality and three and 5-year overall and disease-free survival. A significant increase was found in technical (RR = 1.094; CI, 1.041-1.149; p < 0.001) and clinical (RR = 1.158; CI, 1.064-1.259; p = 0.001) success rates when the duration between stenting and surgery was ≥ 2 weeks compared to < 2 weeks, but there were no significant differences in perforation rates, 90-day in-hospital mortality, and long-term survival. CONCLUSIONS: Colonic stenting is safe and effective with high success rates and low complication rates. However, outcomes of higher perforation rates and optimal timing from stent till surgery remain unclear, with only a few studies reporting on these outcomes, leaving areas for future research.

The Impact of Cognitive Impairment on Clinical Outcomes After Transcatheter Aortic Valve Implantation (from a Systematic Review and Meta-Analysis).

This study sought to investigate the impact of pre-existing cognitive impairment on outcomes after transcatheter aortic valve implantation (TAVI). TAVI has been increasingly used in seniors, and evidence suggests better outcomes than surgical aortic valve replacement. Although frailty has been shown to be associated with poorer outcomes after TAVI, the effect of pre-existing cognitive impairment on patient outcomes after TAVI remains unclear. We searched the Medline, Embase, Scopus and Cochrane databases until May 14, 2022. The risk of bias was assessed using the Newcastle-Ottawa scale. The primary outcome was short-term (6 months to 1 year) mortality, and secondary outcomes included long-term (1 year to 3 years) mortality, in-hospital mortality, and postoperative delirium. A total of 14 studies with 32,746 patients (5,098 patients with cognitive impairment at baseline, 27,648 without) were included in our meta-analysis. Among studies that reported the raw proportion of patients with mortality of postoperative delirium, cognitive impairment significantly increased mortality (risk ratio 2.10, 95% confidence intervals [CIs] 1.43 to 3.08, p = 0.0002) and postoperative delirium (risk ratio 2.27, 95% CI 1.76 to 2.93, p <0.0001). Studies which reported the hazards for mortality (pooled hazards ratio 1.97, 95% CI 1.50 to 2.60, p <0.0001) and odds of postoperative delirium (pooled odds ratio 2.40, 95% CI: 1.51 to 3.80, p = 0.0002) yielded results consistent with the primary meta-analysis. In conclusion, pre-existing cognitive impairment is a significant risk factor for poorer outcomes after TAVI and should be carefully considered in this group of patients. Guidelines and future studies should take cognitive impairment into consideration for preoperative risk stratification.