Risk of Cesarean Delivery Among People With Inflammatory Bowel Disease According to Disease Characteristics: A Population-Based Study.

OBJECTIVES: It is unclear if use of cesarean delivery in people with inflammatory bowel disease (IBD) is guideline-concordant. We compared the odds of cesarean delivery among primiparous individuals with IBD versus without, overall, and by disease characteristics, as well as time to subsequent delivery. METHODS: Retrospective matched population-based cohort study between 1 April 1994 and 31 March 2020. Primiparous individuals aged 15-55 years with IBD were matched to those without IBD on age, year, hospital, and number of newborns delivered. Primary outcome was cesarean delivery versus vaginal delivery. Multivariable conditional logistic regression analyses were performed to estimate the odds of cesarean delivery among individuals with and without IBD as a binary exposure, and a categorical exposure based on IBD-related indications for cesarean delivery. Time to subsequent delivery was evaluated using a Cox proportional hazard model. RESULTS: We matched 7472 individuals with IBD to 37 360 individuals without (99.02% match rate). Individuals with IBD were categorised as having perianal (PA) disease (IBD-PA, n = 764, 10.2%), prior ileal pouch-anal anastomosis (n = 212, 2.8%), or IBD-Other (n = 6496, 86.9%). Cesarean delivery rates were 35.4% in the IBD group versus 30.4% in their controls (adjusted odds ratio 1.27; 95% CI 1.20-1.34). IBD-ileal pouch-anal anastomosis had a cesarean delivery rate of 66.5%, compared to 49.9% in IBD-PA and 32.7% in IBD-Other. There was no significant difference in the rate of subsequent delivery in those with and without IBD (adjusted hazard ratio 1.03; 95% CI 1-1.07). CONCLUSIONS: The higher risk of cesarean delivery in people with IBD reflects guideline-concordant use. Individuals with and without IBD were equally likely to have a subsequent delivery with similar timing.

A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits.

BACKGROUND: Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients. METHODS: We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1-Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11-June 30, 2020), compared with a historical control period (Jan. 1-July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes. RESULTS: Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61-0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions. INTERPRETATION: Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.

Sedation practices for routine gastrointestinal endoscopy: a systematic review of recommendations.

BACKGROUND: Sedation is commonly used in gastrointestinal endoscopy; however, considerable variability in sedation practices has been reported. The objective of this review was to identify and synthesize existing recommendations on sedation practices for routine gastrointestinal endoscopy procedures. METHODS: We systematically reviewed guidelines and position statements identified through a search of PubMed, guidelines databases, and websites of relevant professional associations from January 1, 2005 to May 10, 2019. We included English-language guidelines/position statements with recommendations relating to sedation for adults undergoing routine gastrointestinal endoscopy. Documents with guidance only for complex endoscopic procedures were excluded. We extracted and synthesized recommendations relating to: 1) choice of sedatives, 2) sedation administration, 3) personnel responsible for monitoring sedated patients, 4) skills and training of individuals involved in sedation, and 5) equipment required for monitoring sedated patients. We assessed the quality of included documents using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool. RESULTS: We identified 19 guidelines and 7 position statements meeting inclusion criteria. Documents generally agreed that a single, trained registered nurse can administer moderate sedation, monitor the patient, and assist with brief, interruptible tasks. Documents also agreed on the routine use of pulse oximetry and blood pressure monitoring during endoscopy. However, recommendations relating to the drugs to be used for sedation, the healthcare personnel capable of administering propofol and monitoring patients sedated with propofol, and the need for capnography when monitoring sedated patients varied. Only 9 documents provided a grade or level of evidence in support of their recommendations. CONCLUSIONS: Recommendations for sedation practices in routine gastrointestinal endoscopy differ across guidelines/position statements and often lack supporting evidence with potential implications for patient safety and procedural efficiency.

Improving the reporting of non-inferiority trials by incorporating non-efficacy benefits: not all non-inferiority trials are created equal.

Non-inferiority trials are used to test if a novel intervention is not worse than a standard treatment by more than a prespecified amount, the non-inferiority margin (ΔNI). The ΔNI indicates the amount of efficacy loss in the primary outcome that is acceptable in exchange for non-efficacy benefits in other outcomes. However, non-inferiority designs are sometimes used when non-efficacy benefits are absent. Without non-efficacy benefits, loss in efficacy cannot be easily justified. Further, non-efficacy benefits are scarcely defined or considered by trialists when determining the magnitude of and providing justification for the non-inferiority margin. This is problematic as the importance of a treatment's non-efficacy benefits are critical to understanding the results of a non-inferiority study. Here we propose the routine reporting in non-inferiority trial protocols and publications of non-efficacy benefits of the novel intervention along with the reporting of non-inferiority margins and their justification. The justification should include the specific trade-off between the accepted loss in efficacy (ΔNI) and the non-efficacy benefits of the novel treatment and should describe whether patients and other relevant stakeholders were involved in the definition of the ΔNI.

Clinical and endoscopist factors associated with post-colonoscopy colorectal cancer in a population-based sample.

AIM: Factors associated with verified post-colonoscopy colorectal cancers (PCCRC) have not been well defined and survival for these patients is not well described. We aimed to assess the association of patient, tumour and endoscopist characteristics with PCCRC. METHODS: Using population-based data, we identified individuals diagnosed with CRC from 1 January 2000 to 31 December 2005 who underwent a colonoscopy within 3 years prior to diagnosis. Detected cancers were those diagnosed ≤6 months following colonoscopy; PCCRC were diagnosed >6 months to ≤3 years following colonoscopy. Post-colonoscopy and detected cancers were verified through chart review using a hospital-based simple random sampling frame. We used multivariable conditional logistic regression to determine the association of patient, tumour and endoscopist factors with PCCRC and compared overall survival using Cox proportional hazard models. RESULTS: Using the random sampling frame, we identified 498 patients with PCCRC and 498 with detected CRC; we obtained records and confirmed 367 patients with PCCRC and 412 with detected cancers. In multivariable analysis, patient age (OR 1.01; 95% CI 1.00-1.03) and tumour location (distal vs. proximal OR 0.36; 95% CI 0.25-0.53) were associated with PCCRC; endoscopist quality measures were not significantly associated with PCCRC. We did not find significant differences in overall survival between PCCRC and detected cancers (hazard ratio 1.12; 95% CI 0.92-1.32). CONCLUSION: Although endoscopic quality measures are important for CRC prevention, endoscopist factors were not associated with PCCRC. This study highlights the need for further research into the role of tumour biology in PCCRC development.

Social Media and mHealth Technology for Cancer Screening: Systematic Review and Meta-analysis.

BACKGROUND: Cancer is a leading cause of death, and although screening can reduce cancer morbidity and mortality, participation in screening remains suboptimal. OBJECTIVE: This systematic review and meta-analysis aims to evaluate the effectiveness of social media and mobile health (mHealth) interventions for cancer screening. METHODS: We searched for randomized controlled trials and quasi-experimental studies of social media and mHealth interventions promoting cancer screening (breast, cervical, colorectal, lung, and prostate cancers) in adults in MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Communication & Mass Media Complete from January 1, 2000, to July 17, 2020. Two independent reviewers screened the titles, abstracts, and full-text articles and completed the risk of bias assessments. We pooled odds ratios for screening participation using the Mantel-Haenszel method in a random-effects model. RESULTS: We screened 18,008 records identifying 39 studies (35 mHealth and 4 social media). The types of interventions included peer support (n=1), education or awareness (n=6), reminders (n=13), or mixed (n=19). The overall pooled odds ratio was 1.49 (95% CI 1.31-1.70), with similar effect sizes across cancer types. CONCLUSIONS: Screening programs should consider mHealth interventions because of their promising role in promoting cancer screening participation. Given the limited number of studies identified, further research is needed for social media interventions. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42019139615; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139615. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-035411.

A Systematic Review of Behavioral Interventions to Decrease Opioid Prescribing After Surgery.

OBJECTIVE: The aim of this study was to summarize strategies to reduce postsurgical opioid prescribing at discharge. SUMMARY BACKGROUND DATA: Current practices for the prescription of opioids at discharge after surgery are highly variable and often excessive. We conducted a systematic review to identify behavioral interventions designed to improve these practices. METHODS: We searched MEDLINE, EMBASE, CINAHL, and PsycINFO until December 14, 2018 to identify studies of behavioral interventions designed to decrease opioid prescribing at discharge among adults undergoing surgery. Behavioral interventions were defined according to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We assessed the risk of bias of included studies using criteria suggested by Cochrane EPOC and the Newcastle-Ottawa scale. RESULTS: Of 8048 citations that were screened, 24 studies were included in our review. Six types of behavioral interventions were identified: local consensus-based processes (18 studies), patient-mediated interventions (2 studies), clinical practice guidelines (1 study), educational meetings (1 study), interprofessional education (1 study), and clinician reminder (1 study). All but one study reported a statistically significant decrease in the amount of opioid prescribed at discharge after surgery, and only 2 studies reported evidence of increased pain intensity. Reductions in prescribed opioids ranged from 34.4 to 212.3 mg morphine equivalents. All studies were found to have medium-to-high risks of bias. CONCLUSIONS: We identified 6 types of behavioral strategies to decrease opioid prescription at discharge after surgery. Despite the risk of bias, almost all types of intervention seemed effective in reducing opioid prescriptions at discharge after surgery without negatively impacting pain control.

Comparing Observation, Axillary Radiotherapy, and Completion Axillary Lymph Node Dissection for Management of Axilla in Breast Cancer in Patients with Positive Sentinel Nodes: A Systematic Review.

PURPOSE: Several randomized controlled trials (RCTs) have investigated observation or axillary radiotherapy (ART) in place of completion axillary lymph node dissection (cALND) for management of positive sentinel nodes (SNs) in clinically node-negative women with breast cancer. The optimal treatment strategy for this population is not known. METHODS: MEDLINE, Embase, and EBM Reviews-NHS Economic Evaluation Database were searched from inception until July 2019. A systematic review and narrative summary was performed of RCTs comparing observation or ART versus cALND in clinically node-negative female breast cancer patients with positive SNs. The Cochrane risk of bias tool for RCTs was used to assess risk of bias. Outcomes of interest included overall survival (OS), disease-free survival (DFS), axillary recurrence, and axillary surgery-related morbidity. RESULTS: Three trials compared observation with cALND, and two trials compared ART with cALND. No studies blinded participants or personnel, and there was heterogeneity in inclusion criteria, study design, and follow-up. Neither observation nor ART resulted in statistically inferior 5- or 8-year OS or DFS compared with cALND. There was also no statistically significant increase in axillary recurrences associated with either approach. Four trials reported morbidity outcomes, and all showed cALND was associated with significantly more lymphedema, paresthesia, and shoulder dysfunction compared with observation or ART. CONCLUSIONS: Women with clinically node-negative breast cancer and positive SNs can safely be managed without cALND.

Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes.

BACKGROUND AND AIMS: Propofol is increasingly being used for sedation in colonoscopy; however, its benefits over midazolam (± short-acting opioids) are not well quantified. The objective of this study was to compare safety, satisfaction, and efficiency outcomes of propofol versus midazolam (± short-acting opioids) in patients undergoing colonoscopy. METHODS: We systematically searched Medline, Embase, and the Cochrane library (to July 30, 2018) for randomized controlled trials of colonoscopies performed with propofol versus midazolam (± short-acting opioids). We pooled odds ratios for cardiorespiratory outcomes using mixed-effects conditional logistic models. We pooled standardized mean differences (SMDs) for patient and endoscopist satisfaction and efficiency outcomes using random-effects models. RESULTS: Nine studies of 1427 patients met the inclusion criteria. There were no significant differences in cardiorespiratory outcomes (hypotension, hypoxia, bradycardia) between sedative groups. Patient satisfaction was high in both groups, with most patients reporting willingness to undergo a future colonoscopy with the same sedative regimen. In the meta-analysis, patients sedated with propofol had greater satisfaction than those sedated with midazolam (± short-acting opioids) (SMD, .54; 95% confidence interval [CI], .30-.79); however, there was considerable heterogeneity. Procedure time was similar between groups (SMD, .15; 95% CI, .04-.27), but recovery time was shorter in the propofol group (SMD, .41; 95% CI, .08-.74). The median difference in recovery time was 3 minutes, 6 seconds shorter in patients sedated with propofol. CONCLUSIONS: Both propofol and midazolam (± short-acting opioids) result in high patient satisfaction and appear to be safe for use in colonoscopy. The marginal benefits to propofol are small improvements in satisfaction and recovery time.

Optimal Operative Strategy for Hinchey III Sigmoid Diverticulitis: A Decision Analysis.

BACKGROUND: Operative approaches for Hinchey III diverticulitis include the Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage. Several randomized controlled trials and meta-analyses have compared these approaches; however, results are conflicting and previous studies have not captured the complexity of balancing surgical risks and quality of life. OBJECTIVE: This study aimed to determine the optimal operative strategy for patients with Hinchey III sigmoid diverticulitis. DESIGN: We developed a Markov cohort model, incorporating perioperative morbidity/mortality, emergency and elective reoperations, and quality-of-life weights. We derived model parameters from systematic reviews and meta-analyses, where possible. We performed a second-order Monte Carlo probabilistic sensitivity analysis to account for joint uncertainty in model parameters. SETTING: This study measured outcomes over patients' lifetime horizon. PATIENTS: The base case was a simulated cohort of 65-year-old patients with Hinchey III diverticulitis. A scenario simulating a cohort of highly comorbid 80-year-old patients was also planned. INTERVENTIONS: Hartmann procedure, primary resection and anastomosis (with or without diverting ileostomy), and laparoscopic lavage were performed. MAIN OUTCOME MEASURES: Quality-adjusted life years were the primary outcome measured. RESULTS: Following surgery for Hinchey III diverticulitis, 39.5% of patients who underwent the Hartmann procedure, 14.3% of patients who underwent laparoscopic lavage, and 16.7% of patients who underwent primary resection and anastomosis had a stoma at 12 months. After applying quality-of-life weights, primary resection and anastomosis was the optimal operative strategy, yielding 18.0 quality-adjusted life years; laparoscopic lavage and the Hartmann procedure yielded 9.6 and 13.7 fewer quality-adjusted life months. A scenario analysis for elderly, highly comorbid patients could not be performed because of a lack of high-quality evidence to inform model parameters. LIMITATIONS: This model required assumptions about the long-term postoperative course of patients who underwent laparoscopic lavage because few long-term data for this group have been published. CONCLUSIONS: Although the Hartmann procedure is widely used for Hinchey III diverticulitis, when considering both surgical risks and quality of life, both laparoscopic lavage and primary resection and anastomosis provide greater quality-adjusted life years for patients with Hinchey III diverticulitis, and primary resection and anastomosis appears to be the optimal approach. See Video Abstract at http://links.lww.com/DCR/B223. ESTRATEGIA OPERATIVA ÓPTIMA EN DIVERTICULITIS HINCHEY III DE SIGMOIDES: UN ANÁLISIS DE DECISION: Los enfoques quirúrgicos para la diverticulitis Hinchey III incluyen el procedimiento de Hartmann, la resección primaria y anastomosis, y el lavado laparoscópico. Varios ensayos controlados aleatorios y metanálisis han comparado estos enfoques; sin embargo, los resultados son contradictorios y los estudios previos no han captado la complejidad de equilibrar los riesgos quirúrgicos y la calidad de vida.Determinar la estrategia operativa óptima para pacientes con diverticulitis Hinchey III de sigmoides.Desarrollamos un modelo de cohorte de Markov, incorporando morbilidad / mortalidad perioperatoria, reoperaciones electivas y de emergencia, y pesos de calidad de vida. Derivamos los parámetros del modelo de revisiones sistemáticas y metaanálisis, cuando fue posible. Realizamos un análisis de sensibilidad probabilístico Monte Carlo de segundo orden para tener en cuenta la incertidumbre conjunta en los parámetros del modelo.Seguimiento de por vida.El caso base fue una cohorte simulada de pacientes de 65 años con diverticulitis de Hinchey III. También se planeó un escenario que simulaba una cohorte de pacientes de 80 años altamente comórbidos.Procedimiento de Hartmann, resección primaria y anastomosis (con o sin desviación de ileostomía) y lavado laparoscópico.Años de vida ajustados por calidad.Después de la cirugía para la diverticulitis de Hinchey III, el 39.5% de los pacientes que se sometieron al procedimiento de Hartmann, el 14.3% de los pacientes que se sometieron a un lavado laparoscópico, y el 16.7% de los pacientes que se sometieron a resección primaria y anastomosis tuvieron un estoma a los 12 meses. Después de aplicar el peso de la calidad de vida, la resección primaria y la anastomosis fueron la estrategia operativa óptima, que dio como resultado 18.0 años de vida ajustados en función de la calidad; el lavado laparoscópico y el procedimiento de Hartmann arrojaron 9.6 y 13.7 meses de vida ajustados en función de la calidad, respectivamente. No se pudo realizar un análisis de escenarios para pacientes de edad avanzada altamente comórbidos debido a la falta de evidencia de alta calidad para informar los parámetros del modelo.Este modelo requirió suposiciones sobre el curso postoperatorio a largo plazo de pacientes que se sometieron a lavado laparoscópico, ya que se han publicado pocos datos a largo plazo para este grupo.Aunque el procedimiento de Hartmann se usa ampliamente para la diverticulitis de Hinchey III, cuando se consideran tanto los riesgos quirúrgicos como la calidad de vida, tanto el lavado laparoscópico como la resección primaria y la anastomosis proporcionan una mayor calidad de años de vida ajustada para los pacientes con diverticulitis de Hinchey III y la resección primaria y anastomosis parece ser el enfoque óptimo. Consulte Video Resumen en http://links.lww.com/DCR/B223.

Ileorectal Anastomosis Versus IPAA for the Surgical Treatment of Ulcerative Colitis: A Markov Decision Analysis.

BACKGROUND: Ileorectal anastomosis in patients with ulcerative colitis results in decreased postoperative morbidity and better functional outcome but leads to increased risk for rectal cancer compared with IPAA. OBJECTIVE: This study aims to compare ileorectal anastomosis with IPAA in ulcerative colitis by using a decision model. DESIGN: A Markov simulation model was designed to simulate clinical events of ileorectal anastomosis and IPAA over a time horizon of 40 years with time cycles of 1 year. All probabilities and utilities were derived from observational studies, identified after a systematic literature search using MEDLINE. Primary outcomes were life-years and quality-adjusted life-years. Deterministic and probabilistic sensitivity analyses were performed. SETTINGS: A decision model using Markov simulation was designed. PATIENTS: The base case was a 35-year-old patient with ulcerative colitis and a relatively preserved rectum. MAIN OUTCOMES MEASURES: The primary outcome measures were (quality-adjusted) life-years. RESULTS: The model resulted in lower life-years (36.22 vs 37.02) and higher quality-adjusted life-years (33.42 vs 31.57) for ileorectal anastomosis. This was confirmed after probabilistic sensitivity analysis. The model was sensitive to the utility of ileorectal anastomosis, IPAA, and end-ileostomy. A higher proportion of patients with ileorectal anastomosis will develop rectal cancer (7.6% vs 3.2%) and 43.5% of all patients with ileorectal anastomosis will end with an ileostomy as opposed to 23.0% of all patients with IPAA. LIMITATIONS: The study was limited by characteristics inherent to modeling studies, including assumptions necessary to build the model, data input based on best available but often limited evidence, and unavoidable extra- and interpolation of data. CONCLUSIONS: Ileorectal anastomosis was the preferred treatment option when quality-adjusted life-years were the outcome, with higher life-years for IPAA. This model highlights that both surgical strategies are useful in patients who have ulcerative colitis with a relatively spared rectum. See Video Abstract at http://links.lww.com/DCR/B249. ANASTOMOSIS ILEORRECTAL VERSUS ANASTOMOSIS ANAL CON RESERVORIO ILEAL EN EL TRATAMIENTO QUIRÚRGICO DE LA COLITIS ULCEROSA: ANÁLISIS DE DECISIÓN DE MARKOV: Las anastomosis ileorrectales en pacientes con colitis ulcerosa se encuentran asociadas con la disminución de la morbilidad postoperatoria y un mejor resultado funcional, pero conducen a un mayor riesgo de cáncer de recto cuando se las compara con casos de confección de un reservorio íleo-anal.Comparar las anastomosis ileorrectales con la anastomosis de un reservorio íleo-anal en casos de colitis ulcerosa, utilizando un modelo de procesos de decisión.Se diseñó un modelo de proceso de Markov para simular eventos clínicos en casos de anastomosis ileorrectales y anastomosis de reservorios íleo-anales en un horizonte temporal de 40 años comprendiendo ciclos temporales de 1 año. Todas las probabilidades y utilidades se derivaron de estudios observacionales, identificados después de una búsqueda sistemática de literatura usando MEDLINE. Los resultados primarios fueron años de vida y los años ajustados a la calidad de vida. Se realizaron los análisis de sensibilidad determinada y de probabilística.Se diseñó un modelo de decisión utilizando el proceso de simulación de Markov.El caso base fue el de un paciente de 35 años con colitis ulcerosa y con un recto relativamente sano.El resultado principal fué la medida de los años de vida (con ajuste en la calidad de vida).El modelo resultó en menos años de vida (36.22 frente a 37.02) y años de vida de menor calidad (33.42 frente a 31.57) para los casos de anastomosis ileorrectales. Esto se confirmó después del análisis de sensibilidad probabilística. El modelo era sensible a la utilidad de la anastomosis ileorrectal, la anastomosis del reservorio íleo-anal y la ileostomía terminal. Una mayor proporción de pacientes con anastomosis ileorectales desarrollarán cáncer de recto (7,6% frente a 3,2%) y el 43,5% de todos los pacientes con anastomosis ileorrectales terminarán con una ileostomía en comparación con el 23,0% de todos los pacientes con un reservorio íleo-anal.El analisis estuvo limitado por las características inherentes a los estudios de modelado, incluidas las suposiciones necesarias para construir el modelo, la entrada de datos basada en la mejor evidencia disponible pero a menudo limitada y la extrapolación e interpolación inevitable de datos.Las anastomosis ileorrectales fueron la opción de tratamiento preferida cuando el resultado fue ajustado en años con calidad de vida, con años de vida más larga para la anastomosis de reservorios íleo-anales. Este modelo destaca que ambas estrategias quirúrgicas son útiles en pacientes con colitis ulcerosa con rectos relativamente sanos. Consulte Video Resumen en http://links.lww.com/DCR/B249.

Association Between Preoperative Oral Antibiotics and the Incidence of Postoperative Clostridium difficile Infection in Adults Undergoing Elective Colorectal Resection: A Systematic Review and Meta-analysis.

BACKGROUND: The risk of postoperative Clostridium difficile infection in patients receiving preoperative oral antibiotics remains controversial and a potential barrier for implementation. OBJECTIVE: The purpose of this study was to determine the association between preoperative oral antibiotics and the incidence of postoperative C difficile infection in patients undergoing colorectal surgery. DATA SOURCES: Medline, PubMed (not Medline), Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science were searched for articles published up to September 2018. STUDY SELECTION: Randomized controlled trials and observational studies that compared bowel preparation regimens in adult patients who underwent colorectal surgery were selected. MAIN OUTCOME MEASURE: The incidence of postoperative C difficile infection in adults receiving oral antibiotics versus no oral antibiotics was used as the primary outcome. ORs were pooled using generalized linear/mixed effects models. RESULTS: Fourteen randomized controlled trials and 13 cohort studies comparing bowel preparation with oral antibiotics to those without oral antibiotics were identified. The pooled OR from 4 eligible randomized controlled trials was suggestive of a greater odds of C difficile infection in the oral antibiotic group (OR = 4.46 (95% CI, 0.96-20.66)); however, the absolute incidence of C difficile infection was extremely low (total 11 events among 2753 patients). The pooled OR from 6 eligible cohort studies did not demonstrate a significant difference in the odds of C difficile infection (OR = 0.88 (95% CI, 0.51-1.52)); again, a very low absolute incidence of C difficile infection was identified (total 830 events among 59,960 patients). LIMITATIONS: This meta-analysis was limited by the low incidence of C difficile infection reported in the studies and the low number of randomized controlled trials included. CONCLUSIONS: The incidence of C difficile infection in patients who undergo colorectal surgery is very low, regardless of bowel preparation regimen used. Considering the beneficial role of oral antibiotics in reducing surgical site infection, the fear for C difficile infection is not sufficient to omit oral antibiotics in this setting. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO - IDCRD42018092148.

Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database.

PURPOSE: The safety of immediate breast reconstruction (IBR) in older women is largely unknown. This study aimed to determine the 30-day postoperative complication rates following IBR (implant-based or autologous) in older women (≥ 70 years) with breast cancer and to compare them to younger women (18-69 years). METHODS: The National Surgical Quality Improvement Program (NSQIP) database was used to identify women with in situ or invasive breast cancer who underwent IBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality, which were compared across age groups stratified by type of reconstruction. RESULTS: Of 28,850 women who underwent implant-based and 9123 who underwent autologous reconstruction, older women comprised 6.5% and 5.7% of the sample, respectively. Compared to younger women, older women had more comorbidities, shorter operative times, and longer length of hospital stay. In the implant-based reconstruction group, the 30-day morbidity rate was significantly higher in older women (7.5% vs 5.3%, p < 0.0001) due to higher rates of infectious, pulmonary, and venous thromboembolic events. Wound morbidity and prosthesis failure occurred equally among age groups. In the autologous reconstruction group, there was no statistically significant difference in the 30-day morbidity rates (older 9.5% vs younger 11.6%, p = 0.15). Both wound morbidity and flap failure rates were similar between the two age groups. For both reconstruction techniques, mortality within 30 days of breast surgery was rare. CONCLUSION: Immediate breast reconstruction is safe in older women. These data support the notion that surgeons should discuss IBR as a safe and integral part of cancer treatment in well-selected older women.

Management and surveillance of non-functional pancreatic neuroendocrine tumours: Retrospective review.

BACKGROUND: /Objective. To determine the outcomes of a non-operative management approach for sporadic, small, non-functional pancreatic neuroendocrine tumours. METHODS: A retrospective chart review of patients with non-functional pancreatic neuroendocrine tumours initially managed non-operatively at a single institution was performed. Patients were identified through a search of radiologic reports, and individuals with ≥2 cross-sectional imaging studies performed >6 months apart from Jan. 1, 2000 to Dec. 31, 2013 were included. Data on tumour size, radiologic characteristics at diagnosis, interval radiologic growth, and surgical outcomes were recorded. RESULTS: Over the thirteen-year study period, 95 patients met inclusion criteria and were followed radiologically for a median of 36 months (18-69 months). Median initial tumour size on first imaging was 14.0 mm (IQR 10-19 mm). Median overall tumour growth rate was 0.03 mm/month (IQR: 0.00-0.14 mm/month). There was no significant relationship between initial tumour size and growth rate for tumours ≤ 2 cm or for lesions between 2 and 4 cm. Thirteen (14%) patients initially managed non-operatively underwent resection during the follow-up period. Reasons for surgery included interval tumour growth, patient anxiety or preference, or diagnostic uncertainty. Median time to surgery was 14 months (IQR 8-19 months). No patients progressed beyond resectability or developed metastatic disease during the observation period. CONCLUSION: For patients with sporadic, small, non-functional pancreatic neuroendocrine tumours, radiologic surveillance appears to be a safe initial approach to management.

Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer.

BACKGROUND: Recent studies demonstrating shorter survival among cervical cancer patients undergoing minimally invasive versus open radical hysterectomy could not account for surgeon volume and require confirmation in other jurisdictions with larger sample sizes, longer follow-up, and data on disease recurrence. OBJECTIVE: To determine if surgical approach is associated with oncologic outcomes in cervical cancer patients undergoing minimally invasive or open radical hysterectomy, while accounting for mechanistic factors including surgeon volume. STUDY DESIGN: We performed a population-based retrospective cohort study of cervical cancer patients undergoing primary radical hysterectomy by a gynecologic oncologist from 2006 to 2017 in Ontario, Canada. A multivariable marginal Cox proportional hazards model and cause-specific hazards model were used to evaluate the association of surgical approach with all-cause death and recurrence respectively, clustering at the surgeon level. We tested for interactions between surgical approach and either pathologic stage or surgeon volume. RESULTS: We identified 958 patients (minimally invasive 475; open 483) with mean age 45.9 and a median follow-up of 6 years. Of minimally invasive procedures, 89.6% were performed laparoscopically and 10.4% robotically. The unadjusted 5-year cumulative incidences of all-cause death (minimally invasive 12.5%; open 5.4%), cervical cancer death (minimally invasive 9.3%; open 3.3%), and recurrence (minimally invasive 16.2%; open 8.4%) were significantly increased for minimally invasive radical hysterectomy in patients with stage IB disease, but not the cohort overall. After adjusting for patient factors and surgeon volume, minimally invasive radical hysterectomy was associated with increased rates of death (hazard ratio [HR], 2.20; 95% confidence interval [CI], 1.15-4.19) and recurrence (HR, 1.97; 95% CI, 1.10-3.50) compared to open radical hysterectomy in patients with stage IB disease (n = 534), but not IA disease (n = 244; HR, 0.73; 95% CI, 0.13-4.01; HR, 0.34; 95% CI, 0.10-1.10). CONCLUSION: Minimally invasive radical hysterectomy is associated with increased rates of death and recurrence in patients with stage IB cervical cancer even after controlling for surgeon volume; open radical hysterectomy should be the recommended approach in this population. Although there may be a subset of patients with microscopic early-stage disease for whom minimally invasive radical hysterectomy remains safe, additional studies are required.

Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications.

OBJECTIVE DATA: Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic and robotic hysterectomy in patients with endometrial cancer and obesity (body mass index, ≥30 kg/m2). STUDY: We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000, to July 18, 2018) for studies of patients with endometrial cancer and obesity (body mass index, ≥30 kg/m2) who underwent primary hysterectomy. STUDY APPRAISAL AND SYNTHESIS METHODS: We determined the pooled proportions of conversion, organ/vessel injury, venous thromboembolism, and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies. RESULTS: We identified 51 observational studies that reported on 10,800 patients with endometrial cancer and obesity (study-level body mass index, 31.0-56.3 kg/m2). The pooled proportions of conversion from laparoscopic and robotic hysterectomy were 6.5% (95% confidence interval, 4.3-9.9) and 5.5% (95% confidence interval, 3.3-9.1), respectively, among patients with a body mass index of ≥30 kg/m2, and 7.0% (95% confidence interval, 3.2-14.5) and 3.8% (95% confidence interval, 1.4-9.9) among patients with body mass index of ≥40 kg/m2. Inadequate exposure because of adhesions/visceral adiposity was the most common reason for conversion for both laparoscopic (32%) and robotic hysterectomy (61%); however, intolerance of the Trendelenburg position caused 31% of laparoscopic conversions and 6% of robotic hysterectomy conversions. The pooled proportions of organ/vessel injury (laparoscopic, 3.5% [95% confidence interval, 2.2-5.5]; robotic hysterectomy, 1.2% [95% confidence interval, 0.4-3.4]), venous thromboembolism (laparoscopic, 0.5% [95% confidence interval, 0.2-1.2]; robotic hysterectomy, 0.5% [95% confidence interval, 0.1-2.0]), and blood transfusion (laparoscopic, 2.8% [95% confidence interval, 1.5-5.1]; robotic hysterectomy, 2.1% [95% confidence interval, 1.6-3.8]) were low and not appreciably different between arms. CONCLUSION: Robotic and laparoscopic hysterectomy have similar rates perioperative complications in patients with endometrial cancer and obesity, but robotic hysterectomy may reduce conversions because of positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population.

Do North American colorectal surgeons use mesh to prevent parastomal hernia? A survey of current attitudes and practice

Background: The use of prophylactic mesh in end colostomy procedures has been shown to reduce the rate of parastomal hernia. However, the degree to which the practice has been adopted clinically remains unknown. We conducted a study to evaluate the current opinions and practice patterns of Canadian and US colorectal surgeons with regard to the use of prophylactic mesh in end colostomy. Methods: Between May and July 2017, we conducted an internet-based survey of colorectal surgeons in Canada and the United States (selected at random). Using a questionnaire designed and tested for this study, we assessed the rate of mesh use, types of mesh and placement techniques, and perceived barriers and facilitators associated with the practice. Results: Forty-eight (51.6%) of 93 invited Canadian surgeons and 253 (16.6%) of 1521 invited US surgeons responded (overall response rate 18.6%). Of the 301 respondents, 32 (10.6%) were currently using mesh, 32 (10.6%) had previously used mesh, and 237 (78.7%) had never used mesh. Of 29 respondents currently using mesh, 12 (41.4%) used it only in selected patients; the majority used a sublay technique (20 [69.0%]) and biologic mesh (17 [58.6%]). Most respondents agreed that parastomal hernias are common and negatively affect quality of life; however, there remained concerns about evidence quality and the perceived risk associated with mesh among those who had never or had previously used mesh. Conclusion: Prophylactic mesh placement remains relatively uncommon; when used, biologic mesh was the most common type. Many surgeons were not convinced of the safety or efficacy of prophylactic mesh placement.

Contexte: Il a été démontré que la pose d'un treillis prophylactique durant une colostomie terminale réduit le risque de hernie parastomale. On ignore toutefois à quel point cette pratique a été adoptée en contexte clinique. Nous avons mené une étude pour connaître l'opinion et les habitudes des chirurgiens colorectaux canadiens et américains quant à cette intervention. Méthodes: De mai à juillet 2017, nous avons mené un sondage en ligne auprès de chirurgiens colorectaux canadiens et américains sélectionnés aléatoirement. À l'aide d'un questionnaire conçu et validé pour cette étude, nous avons évalué le taux de pose de treillis, le type de treillis et la technique utilisé, ainsi que les facteurs facilitant ou limitant l'intervention. Résultats: Au total, 48 des 93 chirurgiens canadiens (51,6 %) et 253 des 1521 chirurgiens américains (16,6 %) approchés ont répondu au sondage (taux de réponse global : 18,6 %). Sur les 301 répondants, 32 (10,6 %) ont dit qu'ils installent actuellement des treillis, 32 (10,6 %) ont dit en avoir installé, et 237 (78,7 %) ont dit n'en avoir jamais installé. Parmi 29 répondants posant actuellement des treillis, 12 (41,4 %) ont déclaré y avoir recours pour certains patients seulement; la majorité pose les treillis dans l'espace prépéritonéal (20 [69,0 %]) et se sert de treillis biologiques (17 [58,6 %]). La plupart des répondants s'entendaient pour dire que les hernies parastomales sont courantes et ont des répercussions négatives sur la qualité de vie des patients; cependant, les chirurgiens n'ayant jamais installé de treillis ou en ayant seulement installé par le passé se sont dits préoccupés par la qualité des données et les risques perçus associés aux treillis. Conclusion: La pose d'un treillis à des fins prophylactiques demeure relativement rare. Les treillis biologiques étaient les plus fréquemment utilisés par les répondants. Bon nombre des chirurgiens questionnés n'étaient pas convaincus de l'innocuité ou de l'efficacité de l'intervention.

Life After Surgery: Surgeon Assessments of Quality of Life Among Patients With Familial Adenomatous Polyposis.

BACKGROUND: Without prophylactic surgery, patients with familial adenomatous polyposis are at high risk for colorectal cancer development. Various surgical options for prophylaxis are available. Patient decision-making for preventative treatments is often influenced by the preferences of healthcare providers. OBJECTIVE: We determined surgeon preferences for the surgical options available to patients with familial adenomatous polyposis. DESIGN: We obtained preference estimates for postoperative health states from colorectal surgeons who had treated ≥10 patients with familial adenomatous polyposis. SETTINGS: Assessments were made at an annual meeting of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES: Utilities were measured through the time trade-off method. We determined utilities for 3 procedures used for prophylaxis, including total proctocolectomy with permanent ileostomy, colectomy with ileorectal anastomosis, and total proctocolectomy with IPAA. We also assessed utilities for 2 short-term health states: 90 days with a temporary ileostomy and 2 years with a poorly functioning ileoanal pouch. RESULTS: Twenty-seven surgeons who had cared for >1700 patients with familial adenomatous polyposis participated in this study. The highest utility scores were provided for colectomy with ileorectal anastomosis (0.98). Lower utility scores were provided for total proctocolectomy with permanent ileostomy (0.87) and IPAA (0.89). The number of patients with familial adenomatous polyposis who were treated by participating surgeons did not influence these estimates; however, more-experienced surgeons gave lower utility scores for a poorly functioning ileoanal pouch than less-experienced surgeons (0.15, 0.50, and 0.25 for high-, medium-, and low-volume surgeons; p = 0.02). LIMITATIONS: This study was limited by the sample size. CONCLUSIONS: For patients with familial adenomatous polyposis and relative rectal sparing, surgeon preferences are greatest for colectomy with ileorectal anastomosis. Utility estimates provided by this study are important for understanding surgical decision-making and suggest a role for ileorectal anastomosis in appropriately selected patients. See Video Abstract at http://links.lww.com/DCR/A656.