Effect of Alvimopan on Postoperative Ileus and Length of Hospital Stay in Patients Undergoing Bowel Resection: A Systematic Review and Meta-Analysis.

AIMS: The aim is to investigate the effect of alvimopan on postoperative ileus and length of hospital stay in patients undergoing bowel resection. METHODS: The PRISMA statement standards were followed to conduct a systematic review and meta-analysis. The available literature was searched to identify all studies comparing alvimopan with no alvimopan in patients undergoing bowel resection. Postoperative ileus and length of hospital stay were the primary outcomes, and time to first bowel motion was the secondary outcome. Random-effects modeling was applied for analyses. RESULTS: Analysis of 94 833 patients from 26 studies showed that alvimopan was associated with lower risk of postoperative ileus (OR: .57, 95% CI .48 to .67, P <.00001; high GRADE certainty), shorter length of hospital stay (MD: -1.08 day, 95% CI -1.36 to -.81, P < .00001; moderate GRADE certainty), and shorter time to first bowel motion (MD: -.43 day, 95% CI -.58 to -.28, P < .00001; moderate GRADE certainty). Separate analyses of randomized controlled trials and observational studies showed similar findings. Subgroup analyses suggested consistent findings in patients undergoing elective bowel resection, emergency bowel resection, and open surgery; however, alvimopan did not improve the outcomes in patients undergoing minimally invasive surgery. CONCLUSION: Robust evidence supports the routine use of alvimopan in patients undergoing open bowel resection as indicated by lower risk of postoperative ileus and shorter length of hospital stay. We support incorporation of alvimopan into enhanced recovery after surgery programs for the procedures involving open bowel resection. The role of alvimopan in minimally invasive bowel resection needs more research.

Predictive Significance of Tumour Size in Patients Undergoing Curative Surgery for Colorectal Cancer: A Retrospective Cohort Study.

Objectives To evaluate the predictive significance of tumour size in patients undergoing curative surgery for colorectal cancer (CRC). Methods All patients undergoing curative surgery for colon or rectum cancer performed by a single colorectal surgeon between January 2013 and January 2020 were considered eligible for inclusion. Linear and binary logistic regression analyses were modelled to assess whether colonic or rectal tumour size could predict R0 resection, specimen length, number of harvested and positive lymph nodes, lymphocytic infiltration, venous invasion, and overall survival. Results A total of 192 patients were eligible for inclusion. In patients with colon cancer, tumour size was the independent predictor of the number of harvested lymph nodes (P<0.001), the number of positive lymph nodes (P=0.001), and lymphocytic infiltration (P=0.009). However, it did not predict R0 resection (P=0.563), specimen length (P=0.111), specimen length >120 mm (P=0.186), >12 harvested lymph nodes (P=0.145), venous invasion (P=0.103), and five-year overall survival (P=0.543). In patients with rectal cancer, tumour size was the independent predictor of the number of harvested lymph nodes (P<0.001) and the number of positive lymph nodes (P<0.001). However, it did not predict R0 resection (P=0.108), specimen length (P=0.774), specimen length >120 mm (P=0.405), >12 harvested lymph nodes (P= 0.069), lymphocytic infiltration (P=0.912), venous invasion (P= 0.105), and five-year overall survival (P=0.413). Conclusions The results of the current study suggest that tumour size on its own may not have a significant predictive value in oncological or survival outcomes in patients undergoing curative surgery for colon or rectum cancer.

Absorbable versus non-absorbable tacks for mesh fixation in laparoscopic ventral hernia repair: A systematic review and meta-analysis.

OBJECTIVES: To investigate the outcomes of absorbable versus non-absorbable tacks in patients undergoing laparoscopic ventral hernia repair. METHODS: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; and ISRCTN Register, and bibliographic reference lists to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of absorbable versus non-absorbable tacks for mesh fixation in patients undergoing laparoscopic ventral hernia repair. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Fixed-effect or random-effects models were applied to calculate pooled outcome data. RESULTS: We identified three RCTs and two observational studies enrolling a total of 1149 patients. The included patients were comparable in terms of age [Mean difference (MD) 0.28, 95% confidence intervals (CI) -1.45-2, P = 0.75], male gender (MD 0.81, 95% CI 0.63-1.04, P = 0.10), body mass index (MD -041, 95% CI -1.28-0.46, P = 0.36) and hernia defect size (MD 0.12, 95% CI -0.26-0.49, P = 0.54). The mean and median follow-up period was 30 months and 13 months, respectively There was no difference between the two mesh fixation techniques in terms of recurrence [Risk difference (RD) 0.03, 95% CI -0.04, 0.09, P = 0.47], chronic pain [Odds ratio (OR) 0.91, 95% CI 0.62-1.33, P = 0.64], seroma (OR 0.98, 95% CI 0.37-2.60, P = 0.96), haematoma (RD -0.00, 95% CI -0.04- 0.04, P = 0.99), prolonged ileus (OR 0.99, 95% CI 0.24-4.03, P = 0.99), length of hospital stay (MD 0.10, 95% CI -0.36-0.56, P = 0.68) and port-site hernia (OR 0.98, 95% CI 0.13-7.16, P = 0.98). The operative time was longer in absorbable tack group (MD 7.53, 95% CI 1.49-13.58, P = 0.01). The results remain consistent when randomised trials were analysed separately. CONCLUSIONS: We found no difference in clinical outcomes between absorbable and non-absorbable tacks for mesh fixation in patients undergoing laparoscopic ventral hernia repair. The quality of the available evidence is moderate with a possibility of type 2 error. High quality RCTs with adequate statistical power are required to provide more robust basis for definite conclusions. Considering the similarity of both techniques in terms of clinical outcomes, the cost-effectiveness of each technique would be an important outcome determining which technique should be used; this needs to be considered as an outcome of interest in future studies.

Admission levels of serum amyloid a and procalcitonin are more predictive of the diagnosis of acute appendicitis compared with C-reactive protein.

BACKGROUND: Acute appendicitis is the commonest surgical emergency, but its diagnosis can be elusive with a negative appendicectomy rate of 20%. The aims of this study were to investigate the potential value of the markers of acute inflammation, serum amyloid A (SAA), and serum procalcitonin (ProCT), in the diagnosis of acute appendicitis in adults and to compare that with the commonly used serum C-reactive protein (CRP). METHODS: Adult patients presenting with acute right lower abdominal pain and a clinical suspicion of acute appendicitis were included. Blood samples were obtained within 6 hours of admission for rapid serum CRP assay and for end-of-recruitment batch analysis of SAA and serum ProCT concentrations. RESULTS: A total of 147 patients (81 males) with a mean (±SD) age of 36 (±17) years were recruited. Appendicitis was confirmed histologically in 61 of 72 patients (84.7%) who underwent appendicectomy. A post hoc analysis revealed a diagnostic sensitivity and specificity for SAA of 92% and 72%, ProCT of 85% and 74%, and CRP of 75% and 72%, respectively. The receiver operator characteristics for the area under the curves showed that SAA (P=0.011) and ProCT (P=0.037) significantly exceeded CRP in the prediction of acute appendicitis on admission. CONCLUSIONS: The measurement of SAA and serum ProCT on admission in patients with clinically suspected acute appendicitis seems to outperform serum CRP in aiding that diagnosis.