EAES, SAGES, and ESCP rapid guideline: bowel preparation for minimally invasive colorectal resection.

BACKGROUND: Variation exists in practice pertaining to bowel preparation before minimally invasive colorectal surgery. A survey of EAES members prioritized this topic to be addressed by a clinical practice guideline. OBJECTIVE: The aim of the study was to develop evidence-informed clinical practice recommendations on the use of bowel preparation before minimally invasive colorectal surgery, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders. METHODS: This is a collaborative project of EAES, SAGES, and ESCP. We updated a previous systematic review and performed a network meta-analysis of interventions. We appraised the certainty of the evidence for each comparison, using the GRADE and CINeMA methods. A panel of general and colorectal surgeons, infectious diseases specialists, an anesthetist, and a patient representative discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost, and use of resources, moderated by a GIN-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey. RESULTS: The panel suggests either oral antibiotics alone prior to minimally invasive right colon resection or mechanical bowel preparation (MBP) plus oral antibiotics; MBP plus oral antibiotics prior to minimally invasive left colon and sigmoid resection, and prior to minimally invasive right colon resection when there is an intention to perform intracorporeal anastomosis; and MBP plus oral antibiotics plus enema prior to minimally invasive rectal surgery (conditional recommendations); and recommends MBP plus oral antibiotics prior to minimally invasive colorectal surgery, when there is an intention to localize the lesion intraoperatively (strong recommendation). The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/LwvKej . CONCLUSION: This guideline provides recommendations on bowel preparation prior to minimally invasive colorectal surgery for different procedures, using highest methodological standards, through a structured framework informed by key stakeholders. Guideline registration number PREPARE-2023CN045.

Loco-regional versus general anaesthesia for elective endovascular aneurysm repair - results of a cohort study and a meta-analysis.

BACKGROUND: The aim of this study was to investigate whether patients undergoing elective endovascular aneurysm repair (EVAR) with loco-regional anaesthetic techniques have better outcomes than those treated with general anaesthesia (GA). PATIENTS AND METHODS: We retrospectively evaluated outcomes of EVAR performed with regional anaesthesia (RA) or GA over a five-year period. Furthermore, we searched electronic bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) to identify studies comparing different anaesthetic methods in EVAR. We defined perioperative mortality and morbidity as well as length of hospital stay (LOS) as the primary outcome measures. Pooled effect estimates were calculated using fixed-effect or random-effects models. Results are reported as the odds ratio (OR) or mean difference (MD) and 95 % confidence interval (CI). RESULTS: Three hundred and fifty-five patients underwent standard EVAR over the study period (RA, 215 patients; GA 140 patients). Patients in both groups had comparable baseline demographics and clinical characteristics. Perioperative mortality was significantly lower in the RA group (0.5 % vs. 4.3 %, P = 0.017). No difference was found in perioperative morbidity (P = 0.370), LOS (P = 0.146), postoperative destination (P = 0.799), reoperation (P = 0.355) or readmission within 30 days (P = 0.846). Meta-analysis of data on 15,472 patients from 15 observational studies found a significantly lower perioperative mortality (OR 0.70, 95 % CI 0.52-0.95, P = 0.02) and morbidity (OR 0.73, 95 % CI 0.55-0.96, P = 0.02) in patients treated with loco-regional anaesthetic techniques compared to those treated with GA. Our sub-group analysis demonstrated that both local anaesthesia (LA) (P = 0.003) and RA (P < 0.0001) were associated with a significantly shorter LOS compared to GA. CONCLUSIONS: Local and/or regional anaesthetic techniques may be advantageous over GA in elective EVAR, as indicated by reduced perioperative mortality and morbidity and a shorter hospital stay. Considering the current level of evidence, LA or RA should be considered in selected patients. Further clinical research is required to provide high level evidence on the optimal anaesthetic technique in EVAR.

Endoscopic full-thickness plication versus laparoscopic fundoplication: a prospective study on quality of life and symptom control.

BACKGROUND: Endoscopic antireflux techniques have emerged as alternative therapies for gastroesophageal reflux disease (GERD). Endoscopic plication receives continuing interest as an effective and safe procedure. This treatment option has not been the subject of comparison with well-established operative therapies to date. The present study aimed at comparatively evaluating the effectiveness of endoscopic plication and laparoscopic fundoplication in terms of quality of life and symptom control. METHODS: Between October 2006 and April 2010, 60 patients with documented GERD were randomly assigned to undergo either endoscopic plication or laparoscopic fundoplication. Quality-of-life scores and symptom grading were recorded before treatment and at 3- and 12-month follow-up. Outcomes were compared with the statistical significance set at a p value of 0.05. RESULTS: Twenty-nine patients from the endoscopic group and 27 patients from the operative group were available at follow-up. Quality-of-life scores showed a substantial and similar increase for both groups after treatment. Symptoms of heartburn (p < 0.02), regurgitation (p < 0.004), and asthma (p = 0.03) were significantly improved in the endoscopic group, whereas laparoscopic fundoplication was more effective in controlling symptoms of heartburn (p < 0.01) and regurgitation (p < 0.05) compared to the endoscopic procedure. CONCLUSIONS: Endoscopic plication and laparoscopic fundoplication resulted in significant symptom improvement with similar quality-of-life scores in a selected patient population with GERD, whereas operative treatment was more effective in the relief of heartburn and regurgitation at the expense of higher short-term dysphagia rates.