A meta-analysis of laparoscopic versus ultrasound-guided transversus abdominis plane block in laparoscopic colorectal surgery.

BACKGROUND: Enhanced recovery programmes in laparoscopic colorectal surgery (LCS) employ combined approaches to achieve postoperative analgesia. Transversus abdominis plane (TAP) block is a locoregional anaesthetic technique that may reduce postoperative pain. AIMS: To perform a systematic review and meta-analysis to compare the effectiveness of laparoscopic- versus ultrasound-guided TAP block in LCS. METHODS: Databases were searched for relevant articles from inception until March 2022. All randomised controlled trials (RCTs) that compared laparoscopic (LTB) versus ultrasound-guided (UTB) TAP blocks in LCS were included. The primary outcome was narcotic consumption at 24 h postoperatively, whilst secondary outcomes included pain scores at 24 h postoperatively, operative time, postoperative nausea and vomiting (PONV) and complication rates. Random effects models were used to calculate pooled effect size estimates. RESULTS: Three RCTs were included capturing 219 patients. Studies were clinically heterogenous. On random effects analysis, LTB was associated with significantly lower narcotic consumption (SMD - 0.30 mg, 95% CI = - 0.57 to - 0.03, p = 0.03) and pain scores (SMD - 0.29, 95% CI = - 0.56 to - 0.03, p = 0.03) at 24 h. However, there were no differences in operative time (SMD - 0.09 min, 95% CI = - 0.40 to 0.22, p = 0.56), PONV (OR = 0.97, 95% CI = 0.36 to 2.65, p = 0.96) or complication (OR = 1.30, 95% CI = 0.64 to 2.64, p = 0.47) rates. CONCLUSIONS: LTB is associated with significantly less narcotic usage and pain at 24 h postoperatively but similar PONV, operative time and complication rates, compared to UTB. However, the data were inconsistent, and our findings require further investigation. LTB obviates the need for ultrasound devices whilst also decreasing procedure logistical complexity.

Anastomotic Leak after Ileal Pouch-Anal Anastomosis.

There are special considerations when treating anastomotic leak after restorative proctocolectomy and ileal pouch-anal anastomosis. The epidemiology, risk factors, anatomic considerations, diagnosis and management, as well as the short- and long-term consequences to the patient are unique to this patent population. Additionally, there are specific concerns such as "tip of the J" leaks, transanal management of anastomotic leak/presacral sinus, functional outcomes after leak, and considerations of redo pouch procedures.

Increasing Incidence of Left-Sided Colorectal Cancer in the Young: Age Is Not the Only Factor.

BACKGROUND: Recent single-institution studies have shown that colorectal cancer (CRC) in patients < 50 is predominantly left-sided. The aims of this study were to 1 compare the incidence of left-sided CRC in patients under and over 50, 2 investigate this trend over time, and 3 examine whether racial differences exist in the anatomical distribution of CRC. METHODS: We used the Nationwide Inpatient Sample to identify all patients with colon or rectal cancer who underwent a resection from 2000 to 2014. Logistic regression models were used to determine the odds of a patient having a left-sided CRC based on age and race. RESULTS: A total of 1,547,589 patients underwent resection, with a mean age of 68.6. Overall, 65.1% of patients < 50 had a left-sided CRC compared with 47.2% of patients ≥ 50 (OR = 2.1; 95% CI 2.0, 2.1). The difference was greater as patients became older with 39.9% of patients > 70 having a left-sided CRC (< 50 vs ≥ 70; OR = 2.8; 95% CI 2.7, 2.9). The incidence of CRC in those under 50 increased over the study period due to an increase in left-sided tumors. The distribution of CRC varied with race, with African-Americans having a lower odds for left-sided CRC (OR = 0.89; 95% CI 0.87, 0.91) and Asians/Pacific Islanders having a higher odds (OR = 1.8; 95% CI 1.7, 1.9). CONCLUSION: In the < 50 age group, the incidence of CRC is increasing, with majority of these tumors left-sided. Tumor location varies with both age and race.

Diffuse large B-cell lymphoma of the rectum in a patient with Crohn's disease.

A 62-year-old man presented to our institute with diarrhoea and dysuria on a background of subtotal colectomy and end ileostomy and biological therapy for Crohn's disease. He was diagnosed with urinary tract infection and acute kidney injury (AKI). Renal ultrasound suggested left hydronephrosis, with renal protocol computed tomography (CT) showing a large pelvic mass. Magnetic resonance imaging (MRI) of the pelvis demonstrated a rectal tumour invading the bladder and compressing both ureters. He underwent cystoscopy, flexible sigmoidoscopy and positron emission tomography-CT and was diagnosed with stage IV non-Hodgkin's diffuse large B-cell lymphoma. He was treated primarily with rituximab, cyclophosphamide, hydroxydaunomycin, oncovin and prednisolone chemotherapy regimen. He had ongoing urosepsis before admission for pelvic exenteration. He underwent cystoprostatectomy, excision of rectal stump and formation of ileal conduit. Histology showed no signs of residual malignancy. One year later, the patient was admitted to the intensive care unit with aspiration pneumonia, urosepsis and AKI. Despite maximal therapy, he developed multiorgan failure and passed away.

Excisional Hemorrhoidectomy: Safe in Patients With Crohn's Disease?

INTRODUCTION: Due to concerns over wound healing, hemorrhoidectomy in patients with Crohn's disease (CD) remains controversial. We sought to ascertain safety and efficacy of excisional hemorrhoidectomy in CD. METHODS: A retrospective review of all adult CD patients undergoing excisional hemorrhoidectomy between January 1, 1995, and January 1, 2019, at 2 IBD referral centers was performed. Data collected included patient demographics, clinical characteristics of CD (anorectal symptoms; prior nonoperative hemorrhoidal therapy; presence of other perianal disease; and activity, duration, and anatomic location of CD), and postoperative complications including bleeding, wound healing, and need for further therapy or surgical intervention after surgery. RESULTS: A total of 36 adult patients with Crohn's disease with symptomatic hemorrhoidal disease were included. The study cohort included 16 males (44%), and median age was 49 (range, 21 to 77) years. Predominant symptoms included pain (n = 16; 44%), prolapse (n = 8; 22%), and bleeding (n = 12; 33%). Sixteen patients (44%) had nonoperative therapy before surgery. Twenty-four patients (67%) had other perianal disease. At the time of hemorrhoidectomy, 9 patients (25%) were exposed to corticosteroids, 8 patients (25%) to immunomodulators, and 9 patients (25%) to biologics. During a median follow-up time of 31.5 (range, 1 to 255) months after hemorrhoidectomy, 4 patients (11%) had complications (1 developed a stricture, 1 developed a perianal abscess/fistula, 1 had a nonhealing wound, and 1 had hemorrhoidal recurrence). CONCLUSION: Our data suggest that excisional hemorrhoidectomy may be performed safely in CD patients who have failed nonoperative hemorrhoidal therapy without concern for de novo perianal disease or need for proctectomy.Hemorrhoidal disease is common in patients with Crohn's disease. This study sought to understand the outcomes of surgically treating hemorrhoids in patients with Crohn's disease.

Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis.

Despite widespread scientific and popular interest in mindfulness-based interventions, questions regarding the empirical status of these treatments remain. We sought to examine the efficacy of mindfulness-based interventions for clinical populations on disorder-specific symptoms. To address the question of relative efficacy, we coded the strength of the comparison group into five categories: no treatment, minimal treatment, non-specific active control, specific active control, and evidence-based treatment. A total of 142 non-overlapping samples and 12,005 participants were included. At post-treatment, mindfulness-based interventions were superior to no treatment (d=0.55), minimal treatment (d=0.37), non-specific active controls (d=0.35), and specific active controls (d=0.23). Mindfulness conditions did not differ from evidence-based treatments (d=-0.004). At follow-up, mindfulness-based interventions were superior to no treatment conditions (d=0.50), non-specific active controls (d=0.52), and specific active controls (d=0.29). Mindfulness conditions did not differ from minimal treatment conditions (d=0.38) and evidence-based treatments (d=0.09). Effects on specific disorder subgroups showed the most consistent evidence in support of mindfulness for depression, pain conditions, smoking, and addictive disorders. Results support the notion that mindfulness-based interventions hold promise as evidence-based treatments.

Assessing the impact of neoadjuvant chemotherapy on the management of the breast and axilla in breast cancer.

BACKGROUND: Nodal status is a sensitive prognostic indicator in breast cancer. Axillary metastases may be an indication for neoadjuvant systemic therapy. The aims of this study were to compare pathologic response rates to neoadjuvant chemotherapy (NAC) in the breast and axilla across different molecular subtypes of breast cancer and to compare the predictive value of axillary assessment before and after chemotherapy in determining final nodal status in this cohort of patients. PATIENTS AND METHODS: The cohort comprised patients undergoing NAC from 2003 to November 2012. Data regarding patient and tumor characteristics, management, and outcomes were obtained from a prospectively maintained database and analyzed using PASW Statistics, version 18 (SPSS Inc, Chicago, IL). RESULTS: Two hundred two cancers were identified in 196 patients. One hundred thirty-one (65%) diagnostic axillary procedures were performed, 105 (80%) before NAC, of which 93 (89%) were positive. In 28 (30%), downstaging was noted before NAC. Human epidermal growth factor receptor 2 (HER2) subtypes had the highest rate of complete pathologic response (n = 11 [61%]) and negative axillary clearance (AXCn) (n = 11 [69%]). Of 177 AXCns, 68 (38%) were negative before NAC. CONCLUSION: AXCn in patients undergoing NAC remains controversial. HER2 subtypes are less likely to have axillary involvement after NAC and may demand different management.

Temporal artery biopsy is not required in all cases of suspected giant cell arteritis.

BACKGROUND: Temporal artery biopsy (TAB) is performed during the diagnostic workup for giant cell arteritis (GCA), a vasculitis with the potential to cause irreversible blindness or stroke. However, treatment is often started on clinical grounds, and TAB result frequently does not influence patient management. The aim of this study was to assess the need for TAB in cases of suspected GCA. METHODS: We performed a retrospective review of 185 TABs performed in our institution from 1990 to 2010. Patients were identified through the Hospital In-Patient Enquiry database and theater records. Clinical findings, erythrocyte sedimentation rate, steroid treatment preoperatively, American College of Rheumatology (ACR) criteria for GCA score, biopsy result, and follow-up were recorded. RESULTS: Fifty-eight (31.4%) biopsies were positive for GCA. Presence of jaw claudication (P = 0.001), abnormal fundoscopy (P = 0.001), and raised erythrocyte sedimentation rate (P = 0.001) were significantly associated with GCA. The strongest association with positive biopsy was seen with the prebiopsy ACR score (P < 0.001). Twenty-four (13.7%) patients had undergone biopsy, despite no potential for meeting ACR criteria preoperatively. None of these were positive. Overall, 29 (16.4%) patients had management altered by TAB result. CONCLUSIONS: Our results confirm that TAB does not affect management in the majority of patients with suspected GCA. We conclude that TAB has benefit only for patients who score 2 or 3 on the ACR criteria for GCA without biopsy.

A randomized controlled trial of gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding.

GOALS: We hypothesized that large volume gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding would improve the quality of endoscopic examination. BACKGROUND: Blood retained in the stomach can impair visualization during esophagogastroduodenoscopy. Patients with acute upper gastrointestinal bleeding and a retained gastric fundic pool during endoscopy may have worse outcomes than patients without a retained fundic pool. No trials to date have evaluated if large volume gastric lavage prior to endoscopy improves visualization during acute upper gastrointestinal bleeding. STUDY METHODS: Patients with acute upper gastrointestinal bleeding were randomized to esophagogastroduodenoscopy alone or large volume tap water gastric lavage prior to esophagogastroduodenoscopy. The quality of endoscopic visualization was assessed using a 5-point scale. Clinical outcomes were compared for lavaged and nonlavaged patients. RESULTS: A total of 39 patients were randomized. In 1 patient, lavage was unsuccessful. The quality of visualization was not significantly different between groups for the esophagus, gastric antrum, or duodenum but was significantly better for the gastric fundus for patients randomized to lavage (P = 0.02). There was no significant difference between groups for ability to define a bleeding source, achieve hemostasis, recurrent bleeding, need for repeat endoscopy, and length of stay or death. There were no complications. CONCLUSIONS: Large volume gastric lavage prior to esophagogastroduodenoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus.

The effect of a Helicobacter pylori treatment strategy on health care expenditures in patients with peptic ulcer disease and dyspepsia.

OBJECTIVE: The aim of this study was to determine whether treatment for Helicobacter pylori (H. pylori) for patients with dyspepsia or a history of peptic ulcer decreases hospital expenditures. METHODS: Patients receiving acid suppressive medications were interviewed. Those with a documented ulcer, a self-reported ulcer, or dyspepsia were tested for H. pylori and treated with antibiotics if seropositive. Acid suppressive medications were stopped on completion of H. pylori therapy unless there was a history of gastroesophageal reflux disease (GERD) or Barrett's esophagus, and were started again at the discretion of primary care providers. Total hospital costs and GI medication costs in the 12 months before H. pylori treatment were compared to costs 12 months after H. pylori treatment. RESULTS: A total of 432 consecutive patients were treated for H. pylori. Of the patients, 125 (29%) had dyspepsia, 45 (10%) documented peptic ulcer, and 262 (61%) self-reported peptic ulcer. Total costs (mean 327 US dollars +/- 349 vs 291 USA dollars +/- 362, p = 0.06) and medication costs (mean 207 US dollars +/- 237 vs 224 US dollars +/- 277, p = 0.38) were not significantly different after treatment versus before treatment. A significant decrease in expenditures was limited to patients chronically on acid suppressive medications who had documented peptic ulcers and no history of GERD or Barrett's esophagus (mean 482 US dollars +/- 274 vs 282 US dollars +/- 218, p = 0.03). CONCLUSIONS: Treatment of H. pylori for patients with chronic dyspepsia or self-reported peptic ulcer does not reduce expenditures over 1 yr of follow up. H. pylori treatment for patients chronically receiving acid suppressive treatment with a prior documented ulcer significantly reduces expenditures if GERD and Barrett's esophagus are absent.

A case-control study of endoscopy and mortality from adenocarcinoma of the esophagus or gastric cardia in persons with GERD.

BACKGROUND: This study assessed whether EGD reduces mortality from adenocarcinoma of the esophagus or gastric cardia for patients with gastroesophageal reflux. METHODS: A case-control study was performed. A total of 245 incident cases of death caused by adenocarcinoma of the esophagus or gastric cardia (1995-1999) in which reflux was present were identified using Veterans Health Administration databases. A total of 980 controls with reflux but no death from adenocarcinoma were frequency matched for age, gender, and race. The occurrences of EGD from 1990 onward were compared for cases and controls. Logistic regression analysis with adjustment for potential confounding factors was performed. RESULTS: All the subjects were men. Cases were significantly less likely to have had an EGD in the time period of interest as compared with controls (adjusted odds ratio 0.66: 95% CI [0.45, 0.96], p = 0.03). This negative association was as strong for any EGD performed within 1 to 8 years before diagnosis as for a more recent EGD. However, there were no controls that included esophagectomy and no controls with a nonfatal diagnosis of adenocarcinoma, raising the question of whether EGD and reduced mortality are causally linked. The risk of dying from adenocarcinoma was significantly lower for men with a diagnosis of GERD as an inpatient relative to men in whom the diagnosis was made as an outpatient (adjusted odds ratio 0.21: 95% CI [0.15, 0.31], p < 0.01). CONCLUSIONS: For patients with GERD, performing an EGD is associated with reduced mortality from adenocarcinoma of the esophagus or gastric cardia, but whether this is a causative association remains unclear.

Conformal high dose rate brachytherapy improves biochemical control and cause specific survival in patients with prostate cancer and poor prognostic factors.

PURPOSE: To improve outcome for patients with prostate cancer with poor prognostic factors higher than conventional radiation doses are required. To achieve this outcome a brachytherapy boost was given. We report the results of the first high dose rate dose-escalation brachytherapy trial. MATERIALS AND METHODS: Between 1991 and 2000, 207 patients were prospectively enrolled in a dose escalation trial including pelvic radiotherapy and conformal high dose rate prostate brachytherapy boost. The dose was increased from 5.5 to 11.5 Gy. per implant. Patient eligibility for the study included pretreatment prostate specific antigen 10 or greater, Gleason 7 or greater or clinical stage T2b or higher. No patient received hormonal therapy. The American Society for Therapeutic Radiology and Oncology consensus panel definition of biochemical failure was applied. RESULTS: Median patient age was 69 years. Mean followup was 4.7 years (range 0.6 to 10.4). The 5-year actuarial biochemical control rate was 74%. The 5-year biochemical control was 85% for 1 poor prognostic factor, 75% for 2 and 50% for all 3 (p = 0.001). On Cox regression multivariate analysis lower brachytherapy dose, and higher Gleason and nadir value were associated with biochemical failure. The 5-year actuarial overall survival was 92%, cause specific survival 98% and disease-free survival 68%. The 5-year actuarial rates of complications were 8% and 0% for grades 3 and 4 genitourinary, and 0.5% and 0.5% for grades 3 and 4 gastrointestinal, respectively. The 5-year actuarial impotence rate was 51%. CONCLUSIONS: For patients with poor prognostic factors external beam radiation therapy with conformal high dose rate brachytherapy boost improved biochemical control, resulting in a high cause specific survival rate with low toxicity. Another important advantage is that the patient is not radioactive after the high dose rate implant.