Prophylactic PPI help reduce marginal ulcers after gastric bypass surgery: a systematic review and meta-analysis of cohort studies.

BACKGROUND: Marginal ulceration after gastric bypass surgery is a recognized complication and has been reported in 1-16% of patients. There is evidence that acidity may play a role in the disease pathophysiology and it is a common practice for bariatric surgeons to begin a prophylactic course of proton pump inhibitors (PPI), postoperatively. METHODS: MEDLINE, EMBASE, CINAHL, and the Cochrane Controlled Trials Register were searched using the most comprehensive timeline for each database up to January 2012. Studies that included patients undergoing gastric bypass who received a prophylactic course of PPI postoperatively were eligible. Two reviewers independently selected trials and extracted data. The primary outcome was the incidence of marginal ulcers diagnosed on the basis of endoscopic findings. Inverse variance random effects models were used to estimate odds ratio (OR) and weighted proportion of ulcers. Odds ratio and weighted pooled proportion with corresponding 95% confidence intervals (CI) are reported. RESULTS: The strategic search identified 167 citations. A total of seven studies involving 2,917 participants were eligible for inclusion and 2,114 were used for analysis. The weighted pooled proportion of ulcer formation in PPI groups including all seven studies (four single group cohort studies and PPI arm of three cohort studies) was 5.0% [95% CI 2-10%] (N = 1,407). The OR of marginal ulcer formation comparing PPI to no PPI for three comparative cohort studies was 0.50 [95% CI 0.28-0.90, p = 0.02] (N = 1,022) with low heterogeneity (I(2) = 12%) showing that the PPI group significantly experienced twice less ulceration with PPI treatment compared to no PPI treatment. CONCLUSION: This finding suggests a significant incremental benefit of prophylactic PPI in reducing marginal ulcer after gastric bypass surgery. Prospective randomized trials are needed to further define the role of PPI following gastric bypass surgery.

Pneumonectomy: the burden of death after discharge and predictors of surgical mortality.

BACKGROUND: Pneumonectomy has the highest mortality rate among resections for lung cancer, with limited literature differentiating predictors of postpneumonectomy in-hospital mortality (IHM) from early postdischarge mortality (PDM). This study aims to examine the burden of death over time and to identify potential predictive factors, including patient comorbidities and hospital and surgeon volumes. METHODS: Data were abstracted from an Ontario population-based linked database from 2005 to 2011. Proportional mortality and cumulative survival attributable to IHM and 90-day PDM is reported. Logistic and Cox regression analyses examined the role of potential factors related to death. Odds ratios (ORs) and hazard ratios (HRs) and 95% confidence intervals (CIs) were reported. RESULTS: Of 505 patients who underwent pneumonectomy, the median length of stay was 6 days (1-30 days). IHM was 4.4% (2.9%-6.5%), and 90-day PDM was an additional 6.4% (4.6%-9.0%). Logistic regression showed that congestive heart failure (CHF) (OR, 23.5; range, 4.0-136.0), cerebrovascular disease (OR, 12.5; range, 1.2-128.0), renal disease (OR, 8.8; range, 1.3-60.5), and previous myocardial infarction (MI) (OR, 5.4; range, 1.5-20.0) were predictive of IHM, whereas age (HR, 1.4; range, 1.1-1.7) per year and CHF (HR, 18.0; range, 4.0-79.0) were predictive of PDM. All other factors were not significant. CONCLUSIONS: PDM represents a distinct and underrecognized burden of postoperative death. More than half of postpneumonectomy mortality occurred after discharge, and the rate remained unchanged over the study period. Patient factors play a major role in both IHM and PDM, whereas institutional and physician volume do not influence outcome, suggesting the importance of patient selection and the need for continued evaluation of mortality.

The management of postoperative reflux in congenital esophageal atresia-tracheoesophageal fistula: a systematic review.

PURPOSE: Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is associated with postoperative gastroesophageal reflux (GER). We performed a systematic review of the literature regarding routine anti-reflux medication post EA-TEF repair and its impact on postoperative GER and associated complications. METHODS: A comprehensive search was conducted using MEDLINE, EMBASE, CINHAL, CENTRAL (Cochrane library) electronic databases and gray literature. Full-text screening was performed in duplicate. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with anti-reflux medications. RESULTS: Screening of 2,910 articles resulted in 25 articles (1,663 patients) for analysis. Most were single-center studies (92%) and retrospective (76%); there were no randomized control trials. Fifteen studies named the class of anti-reflux agent used, 3 the duration of therapy, and none either the dose prescribed or number of doses. Complications were inconsistently reported. Anti-reflux surgery was performed in 433/1,663 (26.0%) patients. Average follow-up was 53.2 months (14 studies). CONCLUSION: The quality of literature regarding anti-reflux medication for GER post EA-TEF repair is poor. There are no well-outlined algorithms for anti-reflux agents, doses, or duration of therapy. Standardized protocols and reliable reporting are necessary to develop guidelines to better manage postoperative GER in EA-TEF patients.

Indications for surgical management of osteochondritis dissecans of the knee in the pediatric population: a systematic review.

Several case series have been published exploring the surgical management of osteochondritis dissecans (OCD) of the knee in pediatric patients. This systemic review was performed to identify the surgical indications for this condition. A search of the Embase and Ovid Medline databases was performed to identify clinical studies reporting outcomes of surgical management of OCD in the knee in this patient population. A quality assessment of the included articles was conducted independently by two reviewers using a quality assessment tool developed by Yang et al. A total of 25 articles met the eligibility criteria and were reviewed; 40% of studies did not clearly describe their surgical indications. The remainder of the studies had a failure of nonoperative management with or without the concomitant use of imaging as their indication for surgery, or used lesion stability itself as the indication for surgery. This review outlines several surgical indications presented in the literature for the treatment of OCD lesions of the knee in the pediatric population. The most common indication for surgery was a failure of a trial of nonoperative treatment with or without the concomitant use of serial imaging. Although the quality of the case series was high, inconsistencies in reporting radiographic and arthroscopic classification of the OCD lesion were common.