Post-injury born oligodendrocytes incorporate into the glial scar and contribute to the inhibition of axon regeneration.

Failure of central nervous system projection neurons to spontaneously regenerate long-distance axons underlies irreversibility of white matter pathologies. A barrier to axonal regenerative research is that the axons regenerating in response to experimental treatments stall growth before reaching post-synaptic targets. Here, we test the hypothesis that the interaction of regenerating axons with live oligodendrocytes, which were absent during developmental axon growth, contributes to stalling axonal growth. To test this hypothesis, first, we used single cell RNA-seq (scRNA-seq) and immunohistology to investigate whether post-injury born oligodendrocytes incorporate into the glial scar after optic nerve injury. Then, we administered demyelination-inducing cuprizone and stimulated axon regeneration by Pten knockdown (KD) after optic nerve crush. We found that post-injury born oligodendrocyte lineage cells incorporate into the glial scar, where they are susceptible to the demyelination diet, which reduced their presence in the glial scar. We further found that the demyelination diet enhanced Pten KD-stimulated axon regeneration and that localized cuprizone injection promoted axon regeneration. We also present a resource for comparing the gene expression of scRNA-seq-profiled normal and injured optic nerve oligodendrocyte lineage cells.

Caution Influences Avoidance and Approach Behaviors Differently.

While conflict between incompatible goals has well-known effects on actions, in many situations the same action may produce harmful or beneficial consequences during different periods in a nonconflicting manner, e.g., crossing the street during a red or green light. To avoid harm, subjects must be cautious to inhibit the action specifically when it is punished, as in passive avoidance, but act when it is beneficial, as in active avoidance or active approach. In mice of both sexes performing a signaled action to avoid harm or obtain reward, we found that addition of a new rule that punishes the action when it occurs unsignaled delays the timing of the signaled action in an apparent sign of increased caution. Caution depended on task signaling, contingency, and reinforcement type. Interestingly, caution became persistent when the signaled action was avoidance motivated by danger but was only transient when it was approach motivated by reward. Although caution is represented by the activity of neurons in the midbrain, it developed independent of frontal cortex or basal ganglia output circuits. These results indicate that caution disrupts actions in different ways depending on the motivational state and may develop from unforeseen brain circuits.SIGNIFICANCE STATEMENT Actions, such as crossing the street at a light, can have benefits during one light signal (getting somewhere) but can be harmful during a different signal (being run over). Humans must be cautious to cross the street during the period marked by the appropriate signal. In mice performing a signaled action to avoid harm or obtain reward, we found that addition of a new rule that punishes the action when it occurs unsignaled, delays the timing of the signaled action in an apparent sign of increased caution. Caution became persistent when the signaled action was motivated by danger, but not when it was motivated by reward. Moreover, the development of caution did not depend on prototypical frontal cortex circuits.

Comprehensive systematic review on the self-gripping mesh vs sutured mesh in inguinal hernia repair.

Objective: The objective of this systematic review is to analyse the randomised control trials (RCTs) comparing the self-gripping mesh (SGM) with sutured mesh fixation (SMF) in open inguinal hernia repair. Materials and methods: RCTs comparing SGM with SMF in open inguinal hernia repair were selected from medical electronic databases and analysis was performed using the principles of meta-analysis with RevMan version 5 statistical software. Results: Seventeen RCTs involving 3863 patients were used for the final analysis. In the random effect model analysis, the operative time [mean difference - 7.72, 95 %, CI (-9.08, -6.35), Z = 11.07, P = 0.00001] was shorter for open inguinal hernia repair with SGM. However, there was noteworthy heterogeneity (Tau2 = 4.24; Chi2 = 1795.04, df = 12; (P = 0.00001; I2 = 99 %) among the included studies. The incidence of chronic groin pain [odds ratio 1.17, 95 %, CI (0.88, 1.54), Z = 1.09, P = 0.28], postoperative complications [odds ratio 0.92, 95 %, CI (0.73, 1.16), Z = 0.71, P = 0.48] and recurrence [odds ratio 1.31, 95 %, CI (0.80, 2.12), Z = 1.08, P = 0.28] were statistically similar between both groups, without heterogeneity. Conclusion: SGM failed to demonstrate a clinical advantage over SMF in terms of perioperative outcomes although the duration of surgery was shorter in SGM.

Laparoscopic versus robotic cholecystectomy: a systematic review with meta-analysis to differentiate between postoperative outcomes and cost-effectiveness.

Background: Robotic cholecystectomy (RC) has shown promising outcomes in multiple studies when compared with the gold standard laparoscopic cholecystectomy (LC). The objective of this study is to compare the postoperative surgical outcomes and cost in patients undergoing RC versus LC. Methods: Studies reporting postoperative outcomes and costs in patients undergoing RC versus LC were selected from medical electronic databases and analysis was conducted by the values of systematic review on the statistical software RevMan version 5. Results: Six trials on 1,013 affected individuals for post-operative outcomes and cost comparison were used. Random effect model analysis was used in the analysis. Duration of operation (mean difference: -10.23, 95% CI: -16.23 to -4.22, Z=3.34, P=0.0008) was shorter in the LC group with moderate heterogeneity. Bile leak (odds ratio: 3.34, 95% CI: 0.85 to 13.03, Z=1.73, P=0.08) and no heterogeneity was seen, Postoperative complications (odds ratio: 1.49, 95% CI: 0.50 to 4.46, Z=0.72, P=0.47) with moderate heterogeneity. Both were statistically similar. LC had reduced cost (standardised mean difference: -7.42, 95% CI: -13.10 to -1.74, Z=2.56, P=0.01) with significant heterogeneity. Conclusions: RC failed to prove any clinical advantage over LC for postoperative outcomes including longer duration of operation moreover LC was more cost effective. Due to the paucity of randomised control trial (RCT) and significant heterogeneity, a major multicentre RCT is required to strengthen and validate the findings.

Cost-comparison of robotic versus laparoscopic colorectal resections: a mapped systematic review and meta-analysis of published studies.

Background: Robotic colorectal resections (RCR) have been gaining popularity recently due to several advantages in addition to oncological safety. The objective of this review is to evaluate the cost comparison of RCR versus laparoscopic colorectal resections (LCR). Methods: All types of comparative studies reporting the cost of RCR versus LCR were retrieved from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5. Results: The search of medical databases yielded 13 studies (one randomised trial and 12 comparative studies) on 16,082 patients undergoing oncological and non-oncological colorectal resections. Eleven studies reported total cost whereas seven studies reported only operative cost. In the random effects model analysis, LCR was associated with the reduced total cost [standardised mean difference -62.34, 95% confidence interval (CI): -75.14 to -49.54, Z=9.55, P<0.001] as well as reduced operative cost (standardised mean difference -4.60, 95% CI: -5.90 to -3.31, Z=6.96, P<0.001) compared to RCR. However, there was significant heterogeneity [Tau2=346.74, Chi2=29,559.11, df =11 (P<0.001; I2=100%); Tau2=2.73, Chi2=832.21, df =6 (P<0.001; I2=99%)] among included studies. Conclusions: The LCR seems to be more economical as compared to the RCR in terms of operative cost as well as total cost (operative plus in-patient stay). However, due to statistically significant heterogeneity among included studies and paucity of the randomised trials, these findings should be taken cautiously.

Exploring mosquito abundance and Plasmodium infection through nested-PCR: implications for disease surveillance and control.

The Plasmodium is responsible for malaria which poses a major health threat, globally. This study is based on the estimation of the relative abundance of mosquitoes, and finding out the correlations of meteorological parameters (temperature, humidity and rainfall) with the abundance of mosquitoes. In addition, this study also focused on the use of nested PCR (species-specific nucleotide sequences of 18S rRNA genes) to explore the Plasmodium spp. in female Anopheles. In the current study, the percentage relative abundance of Culex mosquitoes was 57.65% and Anopheles 42.34% among the study areas. In addition, the highest number of mosquitoes was found in March in district Mandi Bahauddin at 21 °C (Tmax = 27, Tmin = 15) average temperature, 69% average relative humidity and 131 mm rainfall, and these climatic factors were found to affect the abundance of the mosquitoes, directly or indirectly. Molecular analysis showed that overall, 41.3% of the female Anopheles pools were positive for genus Plasmodium. Among species, the prevalence of Plasmodium (P.) vivax (78.1%) was significantly higher than P. falciparum (21.9%). This study will be helpful in the estimation of future risk of mosquito-borne diseases along with population dynamic of mosquitoes to enhance the effectiveness of vector surveillance and control programs.

Intra-abdominal collections following laparoscopic versus open appendicectomy: an experience of 516 consecutive cases at a district general hospital.

BACKGROUND: The objective of this study is to evaluate the incidence of intra-abdominal collections (IACs) in all patients undergoing laparoscopic (LA) and open appendicectomy (OA) from April 2009 to October 2011 in a district general hospital with expertise in minimally invasive surgery (MIS). METHODS: A retrospective review of all patients undergoing appendicectomy in the specified time period was carried out. IACs were identified from various in-hospital data resources. Severity of appendicitis was assessed from histology reports. RESULTS: 516 patients were identified, of whom 242 (47 %) underwent OA and 274 (53 %) LA. Twenty-six (5 %) patients were found to have IACs postoperatively. Fifteen (5.5 %) IACs were identified in the laparoscopic group and 11 (4.5 %) in the open group. There was no statistically significant difference in the risk of developing IACs in open versus laparoscopic groups [odds ratio (OR) 1.22, confidence interval (CI) 0.55-2.70, P = 0.63]. Patients were twelve times more likely to develop IACs with an appendix identified as being necrotic or perforated on histology (OR 12.24, CI 5.29-28.32, P < 0.0001). There was a trend towards shorter total hospital stay in the LA (3.58 days, CI 3.0-4.1 days) compared with OA (4.31 days, CI 3.7-4.9 days, P = 0.082) group, although this was not statistically significant. CONCLUSIONS: Increased rates of IAC following LA have been identified in some studies. Our series shows that, in a centre with adequate MIS experience, the IAC rate following LA is comparable to that of the open approach and should not deter surgeons with adequate support and resources.

Fibrin glue instillation under skin flaps to prevent seroma-related morbidity following breast and axillary surgery.

BACKGROUND: Fibrin glue (FG) combines fibrinogen and thrombin, under the presence of factor XIII and calcium chloride, and produces a 'fibrin clot' as would occur through the natural clotting cascade. FG is thought to close over any small vessels including lymphatics that are too small for conventional surgical closure, thereby reducing seroma formation, seroma incidence and related comorbidities. OBJECTIVES: To assess the evidence on the effectiveness of FG in people undergoing breast and axillary surgery and to establish whether FG is an efficient modality to prevent postoperative seroma and seroma-related outcomes. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register (9 December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2012), MEDLINE (9 December 2011), EMBASE (9 December 2011), LILACS (22 October 2012), SCI-E (22 October 2012), the World Health Organization's International Clinical Trial Registry (9 December 2011) and ClinicalTrials.gov (22 October 2012). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing the effectiveness of FG in terms of reducing the postoperative seroma incidence and related comorbidities in people undergoing breast and axillary surgery. DATA COLLECTION AND ANALYSIS: At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. The pooled analysis of the extracted data was achieved by the statistical analysis on Review Manager software. The quality of studies was assessed using The Cochrane Collaboration's 'Risk of bias' tool. MAIN RESULTS: The search of four standard electronic databases yielded 119 potentially relevant studies but only 18 RCTs involving 1252 people were found suitable for statistical analysis. There was significant heterogeneity among trials and the majority of trials were of poor quality. The use of FG under skin flaps following breast and axillary surgery failed to reduce the incidence of postoperative seroma (risk ratio (RR) 1.02; 95% Confidence Interval (CI) 0.90 to 1.16, P value = 0.73), mean volume of seroma (standardised mean difference (SMD) -0.25; 95% CI -0.92 to 0.42, P value = 0.46), wound infection (RR 1.05; 95% CI 0.63 to 1.77, P value = 0.84), postoperative complications (RR 1.13; 95% CI 0.63 to 2.04, P value = 0.68) and length of hospital stay (SMD -0.2; 95% CI -0.78 to 0.39, P value = 0.51). FG reduced the total volume of drained seroma (SMD -0.75, 95% CI -1.24 to -0.26, P value = 0.003) and duration of persistent seromas requiring frequent aspirations (SMD -0.59; CI 95% -0.95 to -0.23, P value = 0.001). AUTHORS' CONCLUSIONS: FG did not influence the incidence of postoperative seroma, the mean volume of seroma, wound infections, complications and the length of hospital stays in people undergoing breast cancer surgery. Due to significant methodological and clinical diversity among the included studies this conclusion may be considered weak and biased. Therefore, a major multicentre and high-quality RCT is required to validate these findings.

Appendiceal Foreign Bodies in Adults: A Systematic Review of Case Reports.

Adults can accidentally swallow foreign bodies (FBs) with food. In rare occasions, these can lodge in the appendix lumen causing inflammation. This is known as foreign body appendicitis. We conducted this study to review different types and management of appendiceal FBs. A comprehensive search on PubMed, MEDLINE, Embase, Cochrane Library and Google Scholar was performed to detect appropriate case reports for this review. Case reports eligible for this review included patients above 18 years of age with all types of FB ingestion causing appendicitis. A total of 64 case reports were deemed to be eligible for inclusion in this systematic review. The patient mean age was 44.3 ± 16.7 years (range, 18-77). Twenty-four foreign bodies were identified in the adult appendix. They were mainly lead shot pellet, fishbone, dental crown or filling, toothpick, and others. Forty-two percent of the included patients presented with classic appendicitis pain, while 17% were asymptomatic. Moreover, the appendix was perforated in 11 patients. Regarding modalities used for diagnosis, computed tomography (CT) scans confirmed the presence of FBs in 59% of cases while X-ray only managed to detect 30%. Almost all of the cases (91%) were treated surgically with appendicectomy and only six were managed conservatively. Overall, lead shot pellets were the most common foreign body found. Fishbone and toothpick accounted for most of the perforated appendix cases. This study concludes that prophylactic appendicectomy is recommended for the management of foreign bodies detected in the appendix, even if the patient is asymptomatic.

Systematic review with meta-analysis of transverse vs. vertical midline extraction incisional hernia risk following laparoscopic colorectal resections.

Background: The aim of this article is to explore the risk of incisional hernia (IH) occurrence at the site of specimen extraction following laparoscopic colorectal resection (LCR), highlighting the comparison between transverse incision versus midline vertical abdominal incision. Methods: Analysis was conducted according to PRISMA guidelines. Systematic search of medical databases, EMBASE, MEDLINE, PubMed and Cochrane Library were performed to find all types of comparative studies reporting the incidence of IH at the specimen extraction site of transverse or vertical midline incision following LCR. The analysis of the pooled data was done using the RevMan statistical software. Results: Twenty-five comparative studies (including 2 randomised controlled trials) on 10,362 patients fulfilled the inclusion criteria. There were 4,944 patients in the transverse incision group and 5,418 patients in the vertical midline incision group. In the random effects model analysis, the use of transverse incision for specimen extraction following LCR reduced the risk of IH development (odds ratio =0.30, 95% CI: 0.19-0.49, Z=4.88, P=0.00001). However, there was significant heterogeneity (Tau2=0.97; Chi2=109.98, df=24, P=0.00004; I2=78%) among included studies. The limitation of the study is due to lack of RCTs, this study includes both prospective and retrospective studies along with 2 RCTs which makes the meta-analysis potentially biased in source of evidence. Conclusions: Transverse incision used for specimen extraction following LCR seems to reduce the risk of postoperative IH incidence compared to vertical midline abdominal incisions.

Preoperative antibiotic prophylaxis in acute cholecystectomy: a systematic review and meta-analysis of randomised controlled trials.

Background: Laparoscopic cholecystectomy (LC) in patients admitted with acute cholecystitis is considered the preferred, feasible and safe mode of managing gallstone disease. The objective of this study is to evaluate the role of single-dose pre-operative prophylactic antibiotics in patients undergoing emergency LC for mild to moderate acute cholecystitis. Methods: All randomized control trials (RCTs) reporting the use of single-dose pre-operative prophylactic antibiotics in patients undergoing acute cholecystectomy were retrieved from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5. Results: Standard medical databases search produced only 3 RCTs on 781 patients undergoing acute cholecystectomy. There were 384 patients in single dose pre-operative antibiotics group whereas 397 patients were recruited in the no-antibiotics group. In the random effects model analysis, the use of single-dose preoperative prophylactic antibiotics in patients undergoing acute cholecystectomy for mild to moderate cholecystitis failed to demonstrate any extra advantage of reducing the risk of [risk ratio (RR) =0.69; 95% confidence interval (CI): 0.46-1.03; Z=1.80; P=0.07] infective complications. There was no heterogeneity [Tau2 =0; Chi2 =1.74, df =2 (P=0.42; I2=0%)] among included studies. Conclusions: A preoperative single dose of prophylactic antibiotics in patients undergoing acute LC for mild to moderate acute cholecystitis does not offer extra benefits to reduce infective complications.

Comparing Thoracic Epidural Anaesthesia to Rectus Sheath Catheter Analgesia for Postoperative Pain After Major Abdominal Surgeries: A Systematic Review.

Controlling postoperative pain is essential for the greatest recovery following major abdominal surgery. Thoracic epidural analgesia (TEA) has traditionally been considered the preferred method of providing pain relief after major abdominal surgeries. Thoracic epidural analgesia has a wide range of complications, including residual motor blockade, hypotension, urine retention with the need for urinary catheterisation, tethering to infusion pumps, and occasional failure rates. In recent years, rectus sheath catheter (RSC) analgesia has been gaining popularity. The purpose of this review is to compare the effectiveness of TEA and RSC in reducing pain following major abdominal surgeries. Four randomised controlled trials (RCTs) reporting outcomes of the visual analogue scale (VAS) pain score were included according to the set criteria. A total of 351 patients undergoing major abdominal surgery were included in this meta-analysis. There were 176 patients in the TEA group and 175 patients in the RSC group. In the random effect model analysis, there was no significant difference in VAS pain score in 24 hours at rest (standardised mean difference (SMD) -0.46; 95% CI -1.21 to 0.29; z=1.20, P=0.23) and movement (SMD -0.64; 95% CI -1.69 to -0.14; z=1.19, P=0.23) between TEA and RSC. Similarly, there was no significant difference in pain score after 48 hours at rest (SMD -0.14; 95% CI -0.36 to 0.08; z=1.29, P=0.20) or movement (SMD -0.69; 95% CI -2.03 to 0.64; z=1.02, P=0.31). In conclusion, our findings show that there was no significant difference in pain score between TEA and RSC following major abdominal surgery, and we suggest that both approaches can be used effectively according to the choice and expertise available.

The role of fibrin glue instillation under skin flaps in the prevention of seroma formation and related morbidities following breast and axillary surgery for breast cancer: a meta-analysis.

A systematic review of randomised, controlled trials investigating the effectiveness of fibrin glue (FG) in reducing the postoperative seroma and seroma related morbidities following breast and axillary surgery was conducted. FG failed to influence the incidence of postoperative seroma, average volume of seroma, wound infection, complications and length of hospital stay in patients undergoing breast cancer surgery. However, a major multicentre and high quality randomised, controlled trial is required to validate these findings.

Comparison of radioguided occult lesion localization (ROLL) and wire localization for non-palpable breast cancers: a meta-analysis.

Four randomized trials encompassing 449 patients of non-palpable breast cancer undergoing with radio-guided occult lesion localization (ROLL) or wire guided localization (WGL). In the fixed effects model, accurate localization, peri-procedural complications, and reoperation rate were comparable between two techniques. Risk of having positive resection margins following WGL was higher. Duration of localization and surgical excision was shorter for ROLL. Volume and weight of the excised occult breast lesion was similar in WGL and ROLL groups.

Laparoscopic Nissen fundoplication with or without short gastric vessel division: a meta-analysis.

OBJECTIVE: The aim of this work is to systematically analyse the prospective randomised controlled trials on laparoscopic Nissen fundoplication (LNF) with and without short gastric vessel division (SGVD) for management of gastro-oesophageal reflux disease (GORD). METHODS: After an extensive literature search, all previous trials on laparoscopic Nissen fundoplication with and without SGVD for management of GORD were assessed. Those meeting study quality criteria were analysed to generate summative data expressed by standardised mean difference (SMD) and risk ratio (RR). RESULTS: Five randomised controlled trials on 388 patients qualified for the meta-analysis. There were 194 patients in the no-SGVD group and 194 patients in the SGVD group. No-SGVD was associated with shorter operative time and length of stay. In both fixed- and random-effects models, there were no statistically significant differences in laparoscopic to open conversion rate or complications between the two groups. Three trials presented data on 1-year follow-up, with 118 patients in the no-SGVD group and 112 patients in the SGVD group. There was no statistically significant difference in heartburn, dysphagia, regurgitation or gas bloat syndrome between these two groups. Two trials presented data on 10-year follow-up, with 84 patients in the no-SGVD group and 86 patients in the SGVD group. There was no significant difference in heartburn, dysphagia, regurgitation or gas bloat syndrome between these two groups either. There was no heterogeneity between trials. CONCLUSIONS: Based on this review, SGVD in LNF is associated with longer operative time and hospital stay. However, there is no difference in terms of functional outcomes for 1- and 10-year follow-up. Routine use of SGVD may therefore not be necessary in LNF.

Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: meta-analysis and systematic review of randomized controlled trials.

BACKGROUND: The objective of this study was to analyze systematically the randomized, controlled trials that compared single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC). METHODS: The meta-analysis was conducted according to the Quality of Reporting of Meta-analysis (QUORUM) standards. The included studies were analyzed systematically using the statistical software package RevMan. The summated outcomes were expressed as the risk ratios (RR) for dichotomous variables and standardized mean differences (SMD) for continuous variables. RESULTS: Eleven randomized trials encompassing 858 patients were retrieved from the electronic databases. In the random effects model, postoperative pain, postoperative complications, length of hospital stay, cosmesis score, conversion rate, and time to return to normal activities were statistically comparable between the two cholecystectomy techniques. SILC was associated with a longer operating time [SMD 0.71; 95 % confidence interval (CI) 0.38, 1.05; z = 4.18; p < 0.0001) and an increased requirement for additional port insertion (RR 6.54; 95 % CI 2.19, 19.57; z = 3.36; p < 0008). However, there was significant heterogeneity among the trials. CONCLUSIONS: SILC does not offer any advantage over CLC for treating benign gallbladder disorders. CLC may be used assiduously for this purpose.

Single layer versus double layer suture anastomosis of the gastrointestinal tract.

BACKGROUND: Gastrointestinal anastomosis (GIA) is an essential step to maintain the continuity of gastrointestinal tract following intestinal resection. GIA is still a source of significant controversy among surgeons due to the use of variety of approaches. Adequate apposition by single layer or double layer anastomosis may affect outcome after GIA OBJECTIVES: The objective of this review is to compare the effectiveness of single layer GIA (SGIA) versus double layer GIA (DGIA) being used in general surgery. The particular question we would attempt to answer will be; is single layer hand made GIA in surgical patients is as effective as double layer? SEARCH METHODS: The CCCG (Colorectal Cancer Cochrane Group) Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 1, 2011), MEDLINE (until April 2011) , EMBASE ( The Intelligent Gateway to Biomedical & Pharmacological Information until April 2011), LILACS (The Latin American and Caribbean Health Sciences Library until April 2011 ) and Science Citation Index Expanded (SCI-E until April 2011) using the medical subject headings (MeSH) terms were searched without date, language or age restrictions. SELECTION CRITERIA: Randomised, controlled trials comparing the effectiveness of SGIA versus DGIA DATA COLLECTION AND ANALYSIS: At least two review authors independently scrutinised search results, selected eligible studies and extracted data. MAIN RESULTS: Seven randomised, controlled trials encompassing 842 patients undergoing SGIA versus DGIA were retrieved from the electronic databases. There were 408 patients in the SGIA group and 432 patients in the DGIA group. All included studies were small, with sample sizes ranging from 60 to 172. There was no heterogeneity among the included trials. Therefore, in the fixed effects model, incidence of anastomotic dehiscence, peri-operative complications and mortality was statistically equivalent between two techniques of GIA. Average hospital stay following SGIA and DGIA was also comparable. However, SGIA was superior in terms of shorter operative time. Sensitivity analysis of relatively good quality and poor quality trials supported same conclusion. AUTHORS' CONCLUSIONS: SGIA can be performed quicker as compared to double layer GIA. SGIA is comparable to DGIA in terms of anastomotic leak, peri-operative complications, mortality and hospital stay. SGIA may routinely be used for GIA following bowel resection. However, since this conclusion is derived from smaller number of patients recruited in relatively moderate quality trials, further trials should be aimed to reduce the limitations of this review.

Knee length versus thigh length graduated compression stockings for prevention of deep vein thrombosis in postoperative surgical patients.

BACKGROUND: Graduated compression stockings (GCS) are a valuable means of thromboprophylaxis in hospitalised postoperative surgical patients. But it is still unclear whether knee length graduated compression stockings (KL) or thigh length (TL) stockings are more effective. OBJECTIVES: The aim of this review was to systematically analyse the randomised, controlled trials that have evaluated the effectiveness of KL versus TL GCS as a thromboprophylaxis tool in hospitalised patients undergoing various types of surgery. SEARCH METHODS: The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2012) and CENTRAL (2012, Issue 1). The authors searched MEDLINE and EMBASE (until 27 February 2012) and they also searched the reference lists of relevant articles to identify additional trials. SELECTION CRITERIA: Randomised controlled trials published in any language on KL versus TL GCS used as a thromboprophylaxis tool in hospitalised patients of any age and either gender. DATA COLLECTION AND ANALYSIS: Data extraction was undertaken independently by two review authors using data extraction sheets and confirmed by the third review author. MAIN RESULTS: Three studies, with a combined total of 496 patients, matched the inclusion criteria for this review. All three included studies evaluated the role of KL and TL in thromboprophylaxis among a group of postoperative patients. These studies showed no significant difference in the ability of the two modalities of leg compression to reduce the incidence of deep vein thrombosis in postoperative patients. In both the fixed-effect model (odds ratio (OR) 1.55, 95% confidence interval (CI) 0.78 to 3.07, P = 0.21) and random-effects model (OR 1.32, 95% CI 0.43 to 4.06, P = 0.63) KL graduated compression stockings were as effective as TL stockings in thromboprophylaxis. However, there was significant heterogeneity (Tau(2) = 0.50; Chi(2) = 4.12, df = 2 (P = 0.13); I(2) = 51%) among trials. Results of this review may be considered weak because there was significant heterogeneity among included trials resulting from inadequate randomisation techniques, allocation concealment, power calculations and the absence of intention-to-treat analysis. AUTHORS' CONCLUSIONS: This review found that there is insufficient high quality evidence to determine whether or not KL and TL GCS differ in their effectiveness in terms of reducing the incidence of deep vein thrombosis (DVT) in hospitalised patients.  A major multicentre RCT is required to address this issue. In the meantime, the decision on which type of stocking to use in clinical practice is likely to be influenced by factors such as patient compliance, ease of use and cost implications.

An updated meta-analysis on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures.

To systematically analyze published randomized trials on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures. Trials on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgery were selected and analyzed to generate summated data (expressed as risk ratio [RR]) by using RevMan 5.0. Nine randomized controlled trials encompassing 3720 patients undergoing breast surgery were retrieved from the electronic databases. The antibiotics group comprised a total of 1857 patients and non-antibiotics group, 1863 patients. There was no heterogeneity [χ(2) = 7.61, d.f. = 7, p < 0.37; I(2) = 8%] amongst trials. Therefore, in the fixed-effects model (RR, 0.64; 95% CI, 0.50-0.83; z = 3.48; p < 0.0005), the use of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures was statistically significant in reducing the incidence of surgical site infection (SSI). Furthermore, in the fixed-effects model (RR, 1.30; 95% CI, 0.89-1.90; z = 1.37; p < 0.17), adverse reactions secondary to the use of prophylactic antibiotics was not statistically significant between the two groups. Preoperative prophylactic antibiotics significantly reduce the risk of SSI after breast surgical procedures. The risk of adverse reactions from prophylactic antibiotic administration is not significant in these patients. Therefore, preoperative prophylactic antibiotics in breast surgery patients may be routinely administered. Further research is required, however, on risk stratification for SSI, timing and duration of prophylaxis, and the need for prophylaxis in patients undergoing breast reconstruction versus no reconstruction.

Intraperitoneal local anesthesia for postoperative pain management in patients undergoing laparoscopic colorectal surgery: a systematic review and meta-analysis.

INTRODUCTION: Intraperitoneal instillation of local anesthetic agents has been reported as an effective adjunct to pain management and early functional recovery in colorectal surgery. Laparoscopic colorectal resection (LCR) is considered as the gold standard approach to resect benign and malignant lesions of the colon and rectum due to the advantages of reduced pain score, quicker recovery, and shorter hospitalization. The objective of this study was to systematically analyze the published RCTs evaluating the effectiveness of intraperitoneal local anesthetic (IPLA) instillation versus standard analgesia in patients undergoing LCR. EVIDENCE ACQUISITION: Electronic databases such as Embase, Medline, PubMed, PubMed Central and the Cochrane library pertaining to the use of IPLA infiltration after LCR were systematically reviewed using the principles of meta-analysis. EVIDENCE SYNTHESIS: Five RCTs on 292 patients undergoing LCR were either given IPLA or standard postoperative analgesia. In the random-effects model analysis using the statistical software Review Manager (Cochrane, London, UK), statistically 2-4 hours pain score (Standardized mean difference [SMD]=-1.72; 95% CI: -2.62 to -0.81; z=3.71; P=0.0002) was significantly lower in the IPLA group. The 12 hours postoperative pain score (P=0.23) was also lower in the IPLA group but failed to reach the statistical significance. Opioid analgesia requirement was lower in the IPLA group (SMD=-7.60; 95% CI: -11.21 to -3.90; z=4.12; P=0.0001) but the time to flatus, length of stay and the frequency of nausea/vomiting were statistically similar in both groups. CONCLUSIONS: IPLA instillation is an effective modality to reduce the postoperative pain score and lower the opioid analgesic requirements in patients undergoing LCR without influencing the time to first flatus, length of stay, and postoperative nausea/vomiting.