Complications in surgery for Crohn's disease after preoperative antitumour necrosis factor therapy.

BACKGROUND: The use of biological therapy (biologicals) is established in the treatment of Crohn's disease. This study aimed to determine whether preoperative treatment with biologicals is associated with an increased rate of complications following surgery for Crohn's disease with intestinal anastomosis. METHODS: All patients receiving biologicals and undergoing abdominal surgery with anastomosis or strictureplasty were identified at six tertiary referral centres. Demographic data, and preoperative, operative and postoperative details were registered. Patients who were treated with biologicals within 2 months before surgery were compared with a control group who were not. Postoperative complications were classified according to anastomotic, infectious or other complications, and graded according to the Clavien-Dindo classification. RESULTS: Some 111 patients treated with biologicals within 2 months before surgery were compared with 187 patients in the control group. The groups were well matched. There were no differences between the treatment and control groups in the rate of complications of any type (34·2 versus 28·9 per cent respectively; P = 0·402), anastomotic complications (7·2 versus 8·0 per cent; P = 0·976) and non-anastomotic infectious complications (16·2 versus 13·9 per cent; P = 0·586). In univariable regression analysis, biologicals were not associated with an increased risk of any complication (odds ratio (OR) 1·33, 95 per cent confidence interval 0·81 to 2·20), anastomotic complication (OR 0·89, 0·37 to 2·17) or infectious complication (OR 1·09, 0·62 to 1·91). CONCLUSION: Treatment with biologicals within 2 months of surgery for Crohn's disease with intestinal anastomosis was not associated with an increased risk of complications.

Cardiopulmonary exercise testing provides a predictive tool for early and late outcomes in abdominal aortic aneurysm patients.

INTRODUCTION: The aim of this study was to determine if cardiopulmonary exercise testing (CPET) predicts 30-day and mid-term outcomes when assessing suitability for abdominal aortic aneurysm (AAA) repair. METHODS: Since July 2006 consecutive patients from a single centre identified with a large (≥5.5 cm) AAA were sent for CPET. Follow-up was completed on 1 August 2009. Univariate logistical regression was used to compare CPET parameters with the Detsky score, the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (VPOSSUM) in predicting predefined early and late outcome measures. RESULTS: Full data were available for 102 patients (93% male, median age: 75 years, interquartile range (IQR): 70-80 years, median follow up: 28 months, IQR: 18-33 months). Ventilatory equivalents for oxygen and APACHE II predicted postoperative inotrope requirement (p=0.018 and p=0.019 respectively). The Detsky score predicted the length of stay in the intensive care unit (p=0.008). Mid-term (30-month) survival was predicted by the anaerobic threshold (p=0.02). CONCLUSIONS: CPET provided the only means in this study of predicting both 30-day outcome and 30-month mortality. CPET could therefore become an increasingly important tool in determining the optimum management for AAA patients.

Development of a pouch functional score following restorative proctocolectomy.

BACKGROUND: The influence of function on quality of life after primary restorative proctocolectomy (RPC) was determined with the aim of developing a pouch functional score. METHODS: The Cleveland Global Quality of Life (CGQL) score was determined in 4013 patients undergoing RPC between 1977 and 2005 (mean(s.d.) follow-up 7.0(5.1) years; 13 105 follow-up episodes). Linear regression analysis was used to identify independent symptom domains of function as possible predictors of quality of life to develop and validate a pouch functional score. RESULTS: CGQL scores at 1, 5, 10, 15 and 20 years were 85.0, 87.5, 87.5, 85.0 and 82.5 respectively (P = 0.001). On multivariable analysis, the symptom domains of stool frequency (24 h, nocturnal), urgency, incontinence and medication (antidiarrhoeals, antibiotics) were independently associated with CGQL (P < 0.001). The beta coefficients within each symptom domain were then adjusted to create a scale of 0-30 for practical use, the Pouch Functional Score (PFS), which correlated with the CGQL score (r(s) = -0.47, P < 0.001). CONCLUSION: Stool frequency, urgency, incontinence and need for medication are major determinants of quality of life following RPC. The PFS demonstrated good correlation with CGQL.

Long-term failure and function after restorative proctocolectomy - a multi-centre study of patients from the UK National Ileal Pouch Registry.

OBJECTIVE: There is little information on the long-term failure and function after restorative proctocolectomy (RPC). The results of data submitted to a national registry were analysed. METHOD: The UK National Pouch Registry was established in 2004. By 2006, it comprised data collected from ten centres between 1976 and 2006. The long-term failure and functional outcome were determined. Trends over time were assessed using the gamma statistic or the Kruskal-Wallis statistic wherever appropriate. RESULTS: In all, 2491 patients underwent primary RPC over a median of 54 months (range 1 month to 28.9 years). Of these, 127 (5.1%) underwent abdominal salvage surgery. The incidence of failure (excision or indefinite diversion) was 7.7% following primary and 27.5% following salvage RPC (P < 0.001). The median frequency of defaecation/24 h was five including one at night. Nocturnal seepage occurred in 8% at 1 year, rising to 15.4% at 20 years (P = 0.037). Urgency was experienced by 5.1% of patients at 1 year rising to 9.1% at 15 years (P = 0.022). Stool frequency and the need for antidiarrhoeal medication were greater following salvage RPC. CONCLUSION: In patients retaining anal function after RPC, frequency of defaecation was stable over 20 years. Faecal urgency and minor incontinence worsened with time. Function after salvage RPC was significantly worse.

A comparison of pancreaticoduodenectomy with extended pancreaticoduodenectomy: a meta-analysis of 1909 patients.

AIM: To compare outcomes between pancreaticoduodenectomy (PD) and extended pancreaticoduodenectomy (EPD) from all published comparative studies in the literature. METHODS: Using meta-analytical techniques the present study compared operative details, post-operative adverse events and survival following PD and EPD. Comparative studies published between 1988 and 2005 of PD versus EPD were included. End points were classified into peri-operative details, post-operative complications including 30day mortality, and survival as measured during follow up. A random effect model was employed. RESULTS: Sixteen comparative studies comprising 1909 patients (865 PD and 1044 EPD), including 3 randomized controlled trials with 454 patients (226 PD and 228 EPD) were identified. Tumour size was comparable between the groups (weighted mean difference (WMD) -0.16 cm, p=0.76). Significantly more lymph nodes were harvested from those patients undergoing EPD (WMD p=14 nodes, p< or =0.001). Operative time was longer in EPD (WMD -48.9 min, p<0.001) and there was a trend towards fewer positive resection margins (odds ratio (OR) 1.78, p=0.080). Peri-operative adverse events were similar between the groups with only delayed gastric emptying (OR 0.59, p=0.030) occurring less frequently in the PD group. Peri-operative mortality (OR 1.48, p=0.180) and long-term survival (hazard ratio 0.77, p=0.100) showed a non-significant trend favouring EPD. CONCLUSIONS: EPD is associated with a greater nodal harvest and fewer positive resection margins than PD. However, the risk of delayed gastric emptying is increased and no significant survival benefit has been shown. Better designed, adequately powered studies are required to settle this question.

A meta-analysis of 21,178 patients undergoing open or endovascular repair of abdominal aortic aneurysm.

BACKGROUND: Several studies have compared outcomes after elective open and endovascular approaches to abdominal aortic aneurysm (AAA) surgery, with varying results. METHODS: A random-effects meta-analysis was undertaken to compare operative outcomes, postoperative complications, 30-day mortality and long-term patient survival after surgery. Endpoints were compared using odds ratios (ORs), weighted mean differences (WMDs) or log hazard ratios (HRs) as appropriate. RESULTS: Forty-two studies comprising 21,178 patients (10,855 open; 10,323 endovascular) were included. In the elective setting (20,715 patients), the endovascular method was associated with a shorter stay in intensive care (WMD--36 h; P < 0.001) and a shorter total postoperative stay (WMD--5.4 days; P < 0.001). Cardiac (OR 1.76; P = 0.002) and respiratory (OR 4.01; P < 0.001) complications were more common after open surgery. In the endovascular group, 30-day mortality was lower (OR 0.46; P < 0.001). Endovascular surgery was also associated with an improved long-term aneurysm-related mortality (HR 0.39; P < 0.001). For ruptured AAA (463 patients), the less invasive operation was associated with a reduced stay in intensive care (WMD--100.4 h; P = 0.005) and a significantly lower 30-day mortality (OR 0.45; P = 0.005). CONCLUSIONS: The endovascular repair of AAA offers a clear benefit in terms of reduction in postoperative adverse events and 30-day mortality. In the longer term, it is also associated with a reduction in aneurysm-related mortality, but not in all-cause mortality.

Endovascular and open approaches to non-thrombosed popliteal aneurysm repair: a meta-analysis.

OBJECTIVE: Endovascular repair of popliteal artery aneurysms is a relatively new technique that is still undergoing evaluation. The aim of this study was to compare outcomes following open and endovascular approaches. METHODS: All published studies comparing outcomes following open and endovascular popliteal aneurysm were included. Endpoints included operative duration, length of stay, and postoperative complications including short-term patency rates. Outcomes were combined using a random-effects meta-analytical technique and differences assessed using odds ratios (OR), weighted mean difference (WMD) and log hazards ratio (HR). RESULTS: Three studies comprising 141 patients (37 endovascular; 104 open) were included. No significant differences in patient characteristics were seen. Operative duration was significantly longer for endovascular repair (WMD 120 minutes, p<0.001). Thirty day graft thrombosis (OR 5.05, p=0.06) and reintervention (OR 18.80, p=0.03) were more likely following endovascular repairs. Postoperative length of stay was shorter in the endovascular group (WMD--3.9 days, p<0.001). There was no significant difference in long-term primary patency rates (HR 1.70, p=0.53). CONCLUSIONS: Endovascular repair of popliteal artery aneurysms offers similar medium-term benefits as an open repair. However, short-term graft thrombosis and reintervention rates are significantly greater. With the current technology it is difficult to justify endovascular treatment of popliteal aneurysms.

A selective approach to restorative proctocolectomy without ileostomy: a single centre experience.

OBJECTIVE: A single surgeon series on complications and functional outcomes following restorative proctocolectomy (RPC) is presented. METHOD: An ethically-approved database was used to collect data on all patients undergoing RPC at a single institution. Patient demographics, operative details, complications and functional outcomes were assessed. The impact of ileostomy omission on outcomes was also assessed. RESULTS: Two hundred patients undergoing RPC between 1987 and 2006 were included. There were 122 (61.0%) males and the mean age at surgery was 37.6 years. A J pouch was constructed in 199 (99.5%) patients and an ileostomy omitted in 160 (80.0%). Since adopting a selective policy after the 36th consecutive patient in the series, only 9 (5.5%) patients have had an ileostomy constructed at the time of pouch construction. Complications occurred in 112 (56.3%) patients, with anastomotic stricture (20.6%) and pouchitis (28.6%) being the most common. Anastomotic stricture was more common in those patients receiving an ileostomy (43.6%vs 15.0%, P < 0.001), as were pouch-cutaneous fistulae (5.1%vs 0.6%, P = 0.039) and pelvic sepsis (15.4%vs 5.0%, P = 0.023). Functional outcomes were good, with median 24-h stool frequency of five motions at 1 year. There was increased urgency to defaecate which in part may be due to a significant decline in the use of antidiarrhoeal medication during follow up. CONCLUSIONS: Selective omission of a covering ileostomy in most cases can produce good results following RPC with no increase in the risk of septic complications or pouch failure, and a decreased risk of anastomotic stricture, with maintenance of good function in the majority.

A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: a meta-analysis of 2822 patients.

BACKGROUND: The gold-standard for surgical excision of peri-ampullary tumours has not been established despite numerous studies, due to conflicting outcomes. AIM: To consolidate the published evidence and compare outcomes between pancreaticoduodenectomy (PD) and pylorus preserving pancreaticoduodenectomy (PPPD) across all published comparative studies. METHODS: Using meta-analytical techniques the study compared: operative details, post-operative adverse events and survival following PD and PPPD. Comparative studies published between 1986 and 2005 of PD versus PPPD were included. A random effect model was employed, with significance reported at the 5% level. RESULTS: 32 studies comprising 2822 patients (1335 PD and 1487 PPPD), including 5 randomized controlled trials with 421 patients (215 PD and 206 PPPD) were included. Patients undergoing PPPD were found to have smaller tumours (weighted mean difference (WMD) -0.54 cm, p=0.030), although no significant difference in the number of patients with stage III or IV disease existed between the groups (odds ratio, OR 1.55, p=0.320). Decreased operating times (WMD -41.3 min, p=0.010) and fewer blood transfusions (WMD -0.9 units, p<0.001) were observed in the PPPD group. There was no difference in post-operative complications, including pancreatic and biliary leaks or fistulae, between the two groups. It was suggested that peri-operative mortality was decreased in the PPPD group (OR 1.7, p=0.040), and overall survival was better (hazard ratio (HR) 0.66, p=0.02), although this did not remain significant on subgroup analysis. CONCLUSIONS: Both PD and PPPD had similar peri-operative adverse events, however, in overall analysis PPPD has lower mortality and improved long-term patient survival, although this was not reflected in the sub-group analysis.

Comparison of outcomes of ileal pouch-anal anastomosis for familial adenomatous polyposis with and without previous ileorectal anastomosis.

BACKGROUND: It is reported that previous colectomy and ileorectal anastomosis (IRA) has no effect on postoperative complications and functional outcomes of secondary proctectomy and ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP). This retrospective study re-examined the question in a single centre. METHODS: Some 185 patients were grouped by either IPAA as the initial prophylactic surgical procedure (primary IPAA) or IPAA preceded by IRA (secondary IPAA). Data on functional outcomes were available for 104, 83 and 56 patients at years 1, 5 and 10 respectively. RESULTS: The 78 patients who had secondary IPAA were older at the time of operation than the 107 who underwent primary IPAA (35.7 versus 29.2 years; P < 0.001). Six (8 per cent) of the secondary IPAA procedures could not be completed. Otherwise, apart from more wound infections in the secondary IPAA group (9 versus 0.9 per cent in the primary IPAA group; P = 0.012), there were no significant differences in rates of complications, functional outcomes, desmoid disease or pouch failure. CONCLUSION: Conversion from IRA to IPAA may not be possible in patients with FAP. Where conversion is successful, pouch outcomes are similar but wound infections are more frequent.

Meta-analysis of short-term and long-term outcomes of J, W and S ileal reservoirs for restorative proctocolectomy.

OBJECTIVE: The choice of ileal pouch reservoir has been a contentious subject with no consensus as to which technique provides better function. This study aimed to compare short- and long-term outcomes of three ileal reservoir designs. METHOD: Comparative studies published between 1985 and 2000 of J, W and S ileal pouch reservoirs were included. Meta-analytical techniques were employed to compare postoperative complications, pouch failure, and functional and physiological outcomes. Quality of life following surgery was also assessed. RESULTS: Eighteen studies, comprising 1519 patients (689 J pouch, 306 W pouch and 524 S pouch) were included. There was no significant difference in the incidence of early postoperative complications between the three groups. The frequency of defecation over 24 h favoured the use of either a W or S pouch [J vs S: weighted mean difference (WMD) 1.48, P < 0.001; J vs W: WMD 0.97, P = 0.01]. The S pouch was associated with an increased need for pouch intubation (S vs J: OR 6.19, P = 0.04). The use of a J pouch was associated with a significantly higher prevalence of use of anti-diarrhoeal medication (J vs S: OR 2.80, P = 0.01; J vs W: OR 3.55, P < 0.001). CONCLUSION: All three reservoirs had similar perioperative complication rates. The S pouch was associated with the need for anal intubation. There was less frequency and less need for antidiarrhoeal agents with the W rather than the J pouch.

Comparison of colonic stenting and open surgery for malignant large bowel obstruction.

BACKGROUND: Colonic stents potentially offer effective palliation for those with bowel obstruction attributable to incurable malignancy, and a "bridge to surgery" for those in whom emergency surgery would necessitate a stoma. The current study compared the outcomes of stents and open surgery in the management of malignant large bowel obstruction. METHODS: A literature search of the Medline, Ovid, Embase and Cochrane databases was performed to identify comparative studies reporting outcomes on colonic stenting and surgery for large bowel obstruction. Random effects meta-analytical techniques were applied to identify differences in outcomes between the two groups. Sensitivity analysis of high quality studies, those reporting on more than 35 patients, those solely concerning colorectal cancer and studies performing intention to treat analysis was undertaken to evaluate the study heterogeneity. RESULTS: A total of 10 studies satisfied the criteria for inclusion, with outcomes reported for 451 patients. Stent insertion was attempted for 244 patients (54.1%), and proved successful for 226 (92.6%). The length of hospital stay was shorter by 7.72 days in the stent group (p < 0.001), which also had lower mortality (p = 0.03) and fewer medical complications (p < 0.001). Stoma formation at any point during management was significantly lower than in the stent group (odds ratio, 0.02; p < 0.001), and "bridging to surgery" did not adversely influence survival. CONCLUSIONS: Colonic stenting offers effective palliation for malignant bowel obstruction, with short lengths of hospital stay and a low rate for stoma formation, but data on quality of life and economic evaluation are limited. There is no evidence of differences in long-term survival between those who have stents followed by subsequent resection and those undergoing emergency bowel resection.

Laparoscopic vs open subtotal colectomy for benign and malignant disease.

AIM: The present meta-analysis aims to compare short-term and long-term outcomes in patients undergoing laparoscopic or open subtotal colectomy for benign and malignant disease. METHODS: A literature search of Medline, Ovid, Embase and Cochrane databases was performed to identify studies published between 1992 and 2005, comparing laparoscopic (LSC) and open (OSC) subtotal colectomy. A random effect meta-analytical technique was used and sensitivity analysis performed on studies published since the beginning of 2000, higher quality papers, those reporting on more than 40 patients, and those studies reporting on adult cases or acute colitis. RESULTS: A total of eight studies satisfied the criteria for inclusion. These included outcomes on 336 patients, 143 (42.6%) of whom had undergone laparoscopic resection, with an overall conversion rate to open surgery of 5% (range 0-11.8%). Operative time was significantly longer in the laparoscopic group by 86.2 min (P < 0.001) and throughout subgroup analysis, although it was only in patients with acute colitis that this finding was without significant heterogeneity. Operative blood loss was less in the laparoscopic group by 57.5 millilitres in high quality and studies published since 2000, and 65.3 millilitres in those reporting on more than 40 patients. There was no significant difference in early or long-term complications between the groups. A statistically significant reduction in length of postoperative stay was observed in the laparoscopic groups by 2.9 days (P < 0.001). CONCLUSION: Laparoscopic subtotal colectomy was associated with longer operating times but a reduced length of stay compared to open surgery. Although short-term outcomes were equivalent in both groups, the suggested benefits in terms of reduced long-term obstructive complications were not supported by this meta-analysis.