Fragility of Statistically Significant Outcomes in Colonic Diverticular Disease Randomized Trials: A Systematic Review.

BACKGROUND: The p value has been criticized as an oversimplified determination of whether a treatment effect exists. One alternative is the fragility index. It is a representation of the minimum number of nonevents that would need to be converted to events to increase the p value above 0.05. OBJECTIVE: To determine the fragility index of randomized controlled trials assessing the efficacy of interventions for patients with diverticular disease since 2010 to assess the robustness of current evidence. DESIGN: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to August 2022. SETTINGS: Articles were eligible for inclusion if they were randomized trials conducted between 2010 and 2022 with parallel, superiority designs evaluating interventions in patients with diverticular disease. Only randomized trials with dichotomous primary outcomes with an associated p value of <0.05 were considered for inclusion. PARTICIPANTS: Any surgical or medical intervention for patients with diverticular disease. MAIN OUTCOME MEASURES: The fragility index was determined by adding events and subtracting nonevents from the groups with the smaller number of events. Events were added until the p value exceeded 0.05. The smallest number of events required was considered the fragility index. RESULTS: After screening 1271 citations, 15 randomized trials met the inclusion criteria. Nine of the studies evaluated surgical interventions and 6 evaluated medical interventions. The mean number of patients randomly assigned and lost to follow-up per randomized controlled trial was 92 (SD 35.3) and 9 (SD 11.4), respectively. The median fragility index was 1 (range, 0-5). The fragility indices for the included studies did not correlate significantly with any study characteristics. LIMITATIONS: Small sample, heterogeneity, and lack of inclusion of studies with continuous outcomes. CONCLUSIONS: The randomized trials evaluating surgical and medical interventions for diverticular disease are not robust. Changing a single-outcome event in most studies was sufficient to make a statistically significant study finding not significant. See Video Abstract . FRAGILIDAD DE LOS RESULTADOS ESTADSTICAMENTE SIGNIFICATIVOS EN ENSAYOS ALEATORIOS DE ENFERMEDAD DIVERTICULAR DEL COLON UNA REVISIN SISTEMTICA: ANTECEDENTES:El valor p ha sido criticado por una determinación demasiado simplificada de si existe un efecto del tratamiento. Una alternativa es el Índice de Fragilidad. Es una representación del número mínimo de no eventos que deberían convertirse en eventos para aumentar el valor p por encima de 0,05.OBJETIVO:Determinar el IF de ensayos controlados aleatorios que evalúan la eficacia de las intervenciones para pacientes con enfermedad diverticular desde 2010 para evaluar la solidez de la evidencia actual.FUENTES DE DATOS:Se realizaron búsquedas en MEDLINE, Embase y CENTRAL desde el inicio hasta agosto de 2022.SELECCIÓN DE ESTUDIOS:Los artículos eran elegibles para su inclusión si eran ensayos aleatorizados realizados entre 2010 y 2022 con diseños paralelos de superioridad que evaluaran intervenciones en pacientes con enfermedad diverticular. Sólo se consideraron para su inclusión los ensayos aleatorizados con resultados primarios dicotómicos con un valor de p asociado menor que 0,05.INTERVENCIÓNES:Cualquier intervención quirúrgica o médica para pacientes con enfermedad diverticular.PRINCIPALES MEDIDAS DE VALORACIÓN:El índice de fragilidad se determinó sumando eventos y restando no eventos de los grupos con el menor número de eventos. Se agregaron eventos hasta que el valor p superó 0,05. El menor número de eventos requeridos se consideró índice de fragilidad.RESULTADOS:Después de examinar 1271 citas, 15 ensayos aleatorios cumplieron los criterios de inclusión. Nueve de los estudios evaluaron intervenciones quirúrgicas y seis evaluaron intervenciones médicas. El número medio de pacientes aleatorizados y perdidos durante el seguimiento por ECA fue 92 (DE 35,3) y 9 (DE 11,4), respectivamente. La mediana del índice de fragilidad fue 1 (rango: 0-5). Los índices de fragilidad de los estudios incluidos no se correlacionaron significativamente con ninguna característica del estudio.LIMITACIONES:Muestra pequeña, heterogeneidad y falta de inclusión de estudios con resultados continuos.CONCLUSIONES:Los ensayos aleatorios que evalúan las intervenciones quirúrgicas y médicas para la enfermedad diverticular no son sólidos. Cambiar un solo evento de resultado en la mayoría de los estudios fue suficiente para que un hallazgo estadísticamente significativo del estudio no fuera significativo. (Traducción- Dr. Ingrid Melo ).

Assessing the Modified Frailty Index and Post-Operative Outcomes in Adhesive Small Bowel Obstruction: A Retrospective Cohort Study.

INTRODUCTION: Studies identifying predictors of postoperative outcomes in adhesive small bowel obstruction are limited. This study investigates the efficacy of the modified frailty index (mFI)to predict postoperative morbidity and mortality among patients undergoing surgery for adhesive small bowel obstruction. METHODS: A multicentre retrospective cohort study including patients undergoing surgery for adhesive small bowel obstruction after failed trial of nonoperative management between January 2015 and December 2020 was performed. Impact of frailty status using the mFI, stratified as frail (≥0.27) and robust (<0.27), on postoperative morbidity, mortality, length of stay, and discharge destination was evaluated using multiple logistic regression. RESULTS: Ninety-two robust patients (mean age 62.4 y, 68% female) and 41 frail patients (mean age 81.7 y, 63% female) were included. On simple stratification, frail patients had significantly increased 30-d morbidity (overall morbidity 80% versus 49%) and need for higher level of care on discharge (41% versus 9%). However, on multiple regression, functional dependence but not the mFI, was independently associated with worse 30-d overall morbidity (odds ratio [OR] 3.97, confidence interval [CI] 1.29-12.19) and lower likelihood of returning to preoperative disposition (OR 0.21, CI 0.05-0.91). The delay in operation beyond 5 d was independently associated with worse 30-d outcomes including overall morbidity and mortality (OR 7.54, CI 2.13-26.73) and decreased return to preoperative disposition (OR 0.14, CI 0.04-0.56). CONCLUSIONS: The mFI, although promising, was not independently predictive of outcomes following surgery for adhesive small bowel obstruction. Further adequately powered studies are required.

Short-term postoperative outcomes for obese versus non-obese inflammatory bowel disease patients undergoing bowel resection: a propensity score matched analysis.

PURPOSE: Up to 40% of patients with inflammatory bowel disease (IBD) are obese. Obesity is a well-known risk factor for increased perioperative morbidity, but this risk has never been quantified in IBD patients undergoing abdominal surgery using the United States National Inpatient Sample (NIS) database. This study aims to compare postoperative morbidity between obese and non-obese patients undergoing bowel resection for IBD using recent NIS data. METHODS: Adult patients who underwent bowel resection for IBD from 2015 to 2019 were identified in the NIS using ICD-10-CM coding. Patients were stratified into obese (BMI > 30 kg/m2) and non-obese groups, then propensity score matched (PSM) for demographic, operative, and hospital characteristics. The primary outcome was postoperative in-hospital morbidity. Secondary outcomes included postoperative in-hospital mortality, system-specific postoperative complications, total admission healthcare costs, and length of stay (LOS). Univariable and multivariable regressions were utilized. RESULTS: Overall, 6601 non-obese patients and 671 obese patients were identified. The PSM cohort included 659 patients per group. Obese patients had significantly increased odds of experiencing postoperative in-hospital morbidity (aOR 1.50, 95% CI 1.10-2.03, p = 0.010) compared to non-obese patients. Specifically, obese patients experienced increased gastrointestinal complications (aOR 1.49, 95% CI 1.00-2.24, p = 0.050), and genitourinary complications (aOR 1.71, 95% CI 1.12-2.61, p = 0.013). There were no differences in total admission healthcare costs (MD - $2256.32, 95% CI - 19,144.54-14,631.9, p = 0.79) or LOS (MD 0.16 days, 95% CI - 0.93-1.27, p = 0.77). CONCLUSIONS: Obese IBD patients are at greater risk of postoperative in-hospital morbidity than non-obese IBD patients. This supports targeted preoperative weight loss protocols for IBD patients to optimize surgical outcomes.

The role of warmed-humidified carbon dioxide insufflation in colorectal surgery: A systematic review and meta-analysis.

BACKGROUND: Maintenance of normothermia is a crucial part of enhanced recovery after colorectal surgery. Dry-cold carbon dioxide (CO2 ) traditionally used for insufflation in laparoscopic surgery and negative pressure operating theatres has been associated with intraoperative hypothermia. Studies suggest that use of warmed-humidified CO2 may promote normothermia. However, due to a scarcity of high-quality studies demonstrating a proven benefit on intraoperative core body temperature, its use in colorectal surgery remains limited. Therefore, the aim of this review was to evaluate the effects of warmed-humidified CO2 compared to traditional dry-cold CO2 , or ambient air in operating theatres, during colorectal surgery. METHODS: A search of Medline, EMBASE, and CENTRAL was performed. Randomised controlled trials (RCTs) that compared patients receiving warmed-humidified CO2 with either dry-cold CO2 insufflation in laparoscopic procedures or no insufflation during open surgery were included. The primary outcome was change in intraoperative core body temperature. Secondary outcomes included length of stay, operating time, return of gastrointestinal function, wound infection, and postoperative pain. A pairwise meta-analysis was performed using inverse variance random effects. RESULTS: Among the six RCTs included, 208 patients received warmed-humidified CO2 (42.3% female, mean age: 65.8 years) and 210 patients received either dry-cold CO2 in laparoscopic procedures or no gas insufflation during open procedures (46.2% female, mean age: 66.1 years). No significant difference was found for change in intraoperative core body temperature (MD = 0.01, 95% CI: -0.1, 0.11, p = 0.90, very low certainty). Patients in the warmed-humidified CO2 group had significantly higher pain scores on postoperative day 1 (MD = 1.61, 95% CI: 0.91, 2.31, p < 0.05, very low certainty). No significant differences were found in any of the other secondary outcomes studied. CONCLUSION: Patients undergoing colorectal surgery receiving warmed-humidified CO2 do not experience any clinically meaningful difference in core body temperature change compared to their counterparts receiving dry-cold CO2 insufflation or no insufflation. However, patients may report greater pain scores on postoperative day 1 with warmed-humidified CO2 . There is likely no clinically important difference between warmed-humidified CO2 and dry-cold CO2 for patients undergoing colorectal surgery. Patient, clinician, and institution factors should be considered when deciding between these two insufflation modalities.

Frailty in inflammatory bowel disease: analysis of the National Inpatient Sample 2015-2019.

AIM: Preoperative frailty has been associated with adverse postoperative outcomes in various populations, but of its use in patients with inflammatory bowel disease (IBD) remains sparse. The present study aimed to characterize the impact of frailty, as measured by the modified frailty index (mFI), on postoperative clinical and resource utilization outcomes in patients with IBD. METHODS: This retrospective population-based cohort study assessed patients from the National Inpatient Sample database from 1 September 2015 to 31 December 2019. Corresponding International Classification of Diseases 10th Revision Clinical Modification codes were used to identify adult patients (>18 years of age) with IBD, undergoing either small bowel resection, colectomy or proctectomy. Patient demographics and institutional data were collected for each patient to calculate the 11-point mFI. Patients were categorized as either frail or robust using a cut-off of 0.27. Primary outcomes were postoperative in-hospital morbidity and mortality, whilst secondary outcomes included system-specific morbidity, length of stay, in-hospital healthcare costs and discharge disposition. Logistic and linear regression models were used for primary and secondary outcomes. RESULTS: Overall, 7144 patients with IBD undergoing small bowel resection, colectomy or proctectomy were identified, 337 of whom were classified as frail (i.e., mFI < 0.27). Frail patients were more likely to be women, older, have lower income and a greater number of comorbidities. After adjusting for relevant covariates, frail patients were at greater odds of in-hospital mortality (adjusted odds ratio [aOR] 5.42, 95% CI 2.31-12.77, P < 0.001), overall morbidity (aOR 1.72, 95% CI 1.30-2.28, P < 0.001), increased length of stay (adjusted mean difference 1.3 days, 95% CI 0.09-2.50, P = 0.035) and less likely to be discharged to home (aOR 0.59, 95% CI 0.45-0.77, P < 0.001) compared to their robust counterparts. CONCLUSIONS: Frail IBD patients are at greater risk of postoperative mortality and morbidity, and reduced likelihood of discharge to home, following surgery. This has implications for clinicians designing care pathways for IBD patients following surgery.

The impact of operative approach for obese colorectal cancer patients: analysis of the National Inpatient Sample 2015-2019.

AIM: Obesity is a well-established risk factor for the development of colorectal cancer. As such, patients undergoing surgery for colorectal cancer have increasingly higher body mass indices (BMIs). The advances in minimally invasive surgical techniques in recent years have helped surgeons circumvent some of the challenges associated with operating in the setting of obesity. While previous studies suggest that laparoscopy improves outcomes compared with open surgery in obese patients, this has never been established at the population level. Therefore, we designed a retrospective database study using the National Inpatient Sample (NIS) with the aim of comparing laparoscopic with open approaches for obese patients undergoing surgery for colorectal cancer. METHOD: A retrospective analysis of the NIS from 2015 to 2019 was conducted including patients with a BMI of greater than 30 kg/m2 undergoing surgery for colorectal cancer. The primary outcomes were postoperative in-hospital morbidity and mortality. Secondary outcomes included postoperative system-specific complications, total admission healthcare cost and length of stay (LOS). Multivariable logistic and linear regressions were utilized to compare the two operative approaches. RESULTS: A total of 4742 patients underwent open surgery and 3231 underwent laparoscopic surgery. We observed a significant decrease in overall postoperative morbidity [17.5% vs. 31.4%, adjusted odds ratio (aOR) 0.56, 95% confidence interval (CI) 0.50-0.64; p < 0.001], gastrointestinal morbidity (8.1% vs. 14.5%, aOR 0.59, 95% CI 0.50-0.69; p < 0.001) and genitourinary morbidity (10.1% vs. 18.6%, aOR 0.61, 95% CI 0.52-0.70; p < 0.001) with the use of laparoscopy. Postoperative LOS was 1.7 days shorter (95% CI 1.5-2.0, p < 0.001) and cost of admission was decreased by $9106 (95% CI $4638-$13 573, p < 0.001) with laparoscopy. CONCLUSION: Laparoscopic surgery for obese patients with colorectal cancer is associated with significantly decreased postoperative morbidity and improved healthcare resource utilization compared with open surgery. Laparoscopic approaches should be relied upon whenever feasible for these patients.

Using preoperative C-reactive protein levels to predict anastomotic leaks and other complications after elective colorectal surgery: A systematic review and meta-analysis.

AIM: While postoperative C-reactive protein (CRP) is used routinely as an early indicator of anastomotic leak (AL), preoperative CRP remains to be established as a potential predictor of AL for elective colorectal surgery. The aim of this systematic review and meta-analysis is to examine the association between preoperative CRP and postoperative complications including AL. METHOD: MEDLINE, EMBASE, Web of Science, PubMed, Cochrane Library and CINAHL databases were searched. Studies with reported preoperative CRP values and short-term surgical outcomes after elective colorectal surgery were included. An inverse variance random effects meta-analysis was performed for all meta-analysed outcomes to determine if patients with or without complications and AL differed in their preoperative CRP levels. Risk of bias was assessed with MINORS and certainty of evidence with GRADE. RESULTS: From 1945 citations, 23 studies evaluating 7147 patients were included. Patients experiencing postoperative infective complications had significantly greater preoperative CRP values [eight studies, n = 2421 patients, mean difference (MD) 8.0, 95% CI 3.77-12.23, p < 0.01]. A significant interaction was observed with subgroup analysis based on whether patients were undergoing surgery for inflammatory bowel disease (X2 = 8.99, p < 0.01). Preoperative CRP values were not significantly different between patients experiencing and not experiencing AL (seven studies, n = 3317, MD 2.15, 95% CI -2.35 to 6.66, p = 0.35), nor were they different between patients experiencing and not experiencing overall postoperative morbidity (nine studies, n = 2958, MD 4.54, 95% CI -2.55 to 11.62, p = 0.31) after elective colorectal surgery. CONCLUSION: Higher preoperative CRP levels are associated with increased rates of overall infective complications, but not with AL alone or with overall morbidity in patients undergoing elective colorectal surgery.

Financial toxicity among patients undergoing resectional surgery for inflammatory bowel disease in the United States.

AIM: Financial toxicity describes the financial burden and distress that patients experience due to medical treatment. Financial toxicity has yet to be characterized among patients with inflammatory bowel disease (IBD) undergoing surgical management of their disease. This study investigated the risk of financial toxicity associated with undergoing surgery for IBD. METHODS: This study used a retrospective analysis using the National Inpatient Sample from 2015 to 2019. Adult patients who underwent IBD-related surgery were identified using the International Classification of Diseases (10th Revision) diagnostic and procedure codes and stratified into privately insured and uninsured groups. The primary outcome was risk of financial toxicity, defined as hospital admission charges that constituted 40% or more of patient's post-subsistence income. Secondary outcomes included total hospital admission cost and predictors of financial toxicity. RESULTS: The analytical cohort consisted of 6412 privately insured and 3694 uninsured patients. Overall median hospital charges were $21 628 (interquartile range $14 758-$35 386). Risk of financial toxicity was 86.5% among uninsured patients and 0% among insured patients. Predictors of financial toxicity included emergency admission, being in the lowest residential income quartile and having ulcerative colitis (compared to Crohn's disease). Additional predictors were being of Black race or male sex. CONCLUSION: Financial toxicity is a serious consequence of IBD-related surgery among uninsured patients. Given the pervasive nature of this consequence, future steps to support uninsured patients receiving surgery, in particular emergency surgery, related to their IBD are needed to protect this group from financial risk.

Evaluating frailty using the modified frailty index for colonic diverticular disease surgery: analysis of the national inpatient sample 2015-2019.

BACKGROUND: Frailty has been associated with increased postoperative mortality and morbidity; however, the use of the modified frailty index (mFI-11) to assess patients undergoing surgery for diverticular disease has not been widely assessed. This paper aims to examine frailty, evaluated by mFI-11, to assess postoperative morbidity and mortality among patients undergoing operative intervention for colonic diverticular disease. METHODS: We used data from the Healthcare Cost and Utilization Project National Inpatient Sample (October 1, 2015-December 31, 2019). ICD-10-CM codes were utilized to identify a cohort of adult patients with a primary admission diagnosis of diverticulitis. mFI-11 items were adapted to correspond with ICD-10-CM codes. Patients were stratified into robust (mFI < 0.27) and frail (mFI ≥ 0.27) groups. Primary outcomes were in-hospital postoperative morbidity and mortality. Secondary outcomes included system-specific postoperative complications, length of stay (LOS), total admission cost, and discharge disposition. Multivariable regression models were fit. RESULTS: Of the 26,826 patients, there were 24,194 patients with mFI-11 < 0.27 (i.e., robust) and 2,632 patients with mFI-11 ≥ 0.27 (i.e., frail). Adjusted analysis showed significant increases in postoperative mortality (aOR 2.16, 95% CI 1.38-3.38, p = 0.001) and overall postoperative morbidity (aOR 1.84, 95% CI 1.65-2.06, p < 0.001). LOS was higher in the frail group (MD 1.78 days, 95% CI 1.46-2.11, p < 0.001) as well as total cost (MD $25,495.19, 95% CI $19,851.63-$31,138.75, p < 0.001). CONCLUSION: In the elective setting, a high mFI-11 (i.e., presence of the variables comprising the index) could alert clinicians to the possibility of implementing preoperative optimization strategies. In the emergent setting, a high mFI-11 may help guide prognostication for these vulnerable patients.

Primary anastomosis with diverting loop ileostomy versus Hartmann's procedure for acute complicated diverticulitis: analysis of the National Inpatient Sample 2015-2019.

BACKGROUND: Up to 50% of patients with acute complicated diverticulitis require operative management on their index admission. There is ongoing debate as to whether primary anastomosis with diverting ileostomy versus a Hartmann's procedure is the optimal surgical approach for these patients. This study aims to compare postoperative complications in patients undergoing either Hartmann's procedure or primary anastomosis and diverting ileostomy for perforated diverticulitis using recent National Inpatient Sample data. METHODS: Patients who underwent either primary anastomosis with diverting ileostomy or Hartmann's procedure for acute complicated diverticulitis from the 2015 to 2019 NIS database sample were included. Primary outcomes were postoperative in-hospital mortality and morbidity. Secondary outcomes were postoperative cause-specific complications, total admission cost, and length of stay (LOS). Univariate and multivariate regression were utilized to compare the two operative approaches. RESULTS: Overall, 642 patients underwent primary anastomosis with diverting ileostomy and 4,482 patients underwent Hartmann's procedure. There was no difference in in-hospital mortality (OR 0.93, 95%CI 0.45-1.92, p = 0.84) or in-hospital morbidity (OR 1.10, 95%CI 0.90-1.35, p = 0.33). Adjusted analysis suggested shorter postoperative LOS for patients undergoing Hartmann's procedure (MD 0.79 days, 95%CI 0.15-1.43 days, p = 0.013) and decreased total admission cost (MD $4,893.99, 95%CI $1,425.04-$8,362.94, p = 0.006). CONCLUSIONS: The present study supports that primary anastomosis with diverting ileostomy is safe for properly selected patients presenting with complicated diverticulitis. Primary anastomosis with diverting ileostomy is associated with greater total hospitalization costs and LOS.

HEmoRhoidal disease management with Band ligation versus polidocanol Sclerotherapy: a systematic review and meta-analysis (the HerBS Review).

PURPOSE: Symptomatic internal hemorrhoids affect up to 40% of people in Western society. Patients with grade I-III hemorrhoids, who fail lifestyle and medical management, may benefit from office-based procedures. As per the American Society of Colon and Rectum Surgeons (ASCRS), rubber band ligation (RBL) is the first-line office-based treatment. Polidocanol sclerotherapy is a relatively new approach for these patients. The aim of this systematic review is to compare the efficacy of RBL and polidocanol sclerotherapy with the treatment of symptomatic grade I-III internal hemorrhoids. METHODS: The systematic review was completed by searching MEDLINE, Embase, and CENTRAL databases from inception to August 2022 for prospective studies comparing RBL and polidocanol sclerotherapy or evaluating the efficacy of polidocanol sclerotherapy alone for adult (> 18 years) patients with grade I-III internal hemorrhoids. Treatments were evaluated for therapeutic success and post-procedure morbidity. RESULTS: Of 155 citations obtained, 10 studies (3 comparative and 7 single-arm studies) and 4 abstracts (2 comparative and 2 single arm) were included in the study. The patients undergoing sclerotherapy had a 93% (151/163) therapeutic success rate compared to 75% (68/91) in the RBL group (OR 3.39, 95% CI 1.48-7.74, p < 0.01). The post-procedure morbidity was 8% (17/200) in the sclerotherapy group and 18% (23/128) in the RBL group (OR 0.53, 95% CI 0.15-1.82, p = 0.31). CONCLUSION: This study highlights that polidocanol sclerotherapy may be associated with higher therapeutic success in patients with symptomatic grade I-III internal hemorrhoids. Further evaluations in the form of randomized trials are required to evaluate patient populations, which may benefit more from sclerotherapy.

Perioperative intravenous dexamethasone for patients undergoing colorectal surgery: a systematic review and meta-analysis.

PURPOSE: Dexamethasone is a glucocorticoid that is often administered intraoperatively as prophylaxis for postoperative nausea and vomiting (PONV). Several randomized controlled trials (RCTs) have examined its use in colorectal surgery. This systematic review aims to assess the postoperative impacts of dexamethasone use in colorectal surgery. METHODS: MEDLINE, Embase, and CENTRAL were searched from database inception to January 2023. Articles were included if they compared perioperative intravenous dexamethasone to a control group in patients undergoing elective colorectal surgery in terms of postoperative morbidity. The primary outcomes were prolonged postoperative ileus (PPOI) and PONV. Secondary outcomes included postoperative infectious morbidity and return of bowel function. A pair-wise meta-analysis and GRADE assessment of the quality of evidence were performed. RESULTS: After reviewing 3476 relevant citations, seven articles (five RCTs, two retrospective cohorts) met the inclusion criteria. Overall, 1568 patients received perioperative dexamethasone and 1459 patients received a control. Patients receiving perioperative dexamethasone experienced significantly less PPOI based on moderate-quality evidence (three studies, OR 0.46, 95%CI 0.28-0.74, p < 0.01). Time to first flatus was significantly reduced with intravenous dexamethasone. There was no difference between groups in terms of PONV (four studies, OR 0.90, 95%CI 0.64-1.27, p = 0.55), postoperative morbidity (OR 0.93, 95%CI 0.63-1.39, p = 0.74), or rate of postoperative infectious complications (seven studies, OR 0.74, 95%CI 0.55-1.01, p = 0.06). CONCLUSION: This review presents moderate-quality evidence that perioperative intravenous dexamethasone may reduce PPOI and enhance the return of bowel function following elective colorectal surgery. There was no significant observed effect on PONV or postoperative infectious complications.

Laparoscopic ovarian transposition prior to pelvic radiation in young women with anorectal malignancies: a systematic review and meta-analysis of prevalence.

AIM: Young women undergoing radiotherapy (RT) for pelvic malignancies are at risk of developing premature ovarian insufficiency. Ovarian transposition (OT) aims to preserve ovarian function in these patients. However, its role in anorectal malignancy has yet to be firmly established. The aim of this review was to determine the effectiveness of laparoscopic OT in preserving ovarian function in premenopausal women undergoing neoadjuvant pelvic RT for anorectal malignancies. METHODS: MEDLINE, Embase and CENTRAL were systematically searched from inception through to May 2022. Articles were included if they evaluated ovarian function after OT in women with anorectal malignancies undergoing pelvic RT. The primary outcome was ovarian function preservation. The secondary outcome was 30-day postoperative morbidity following OT. RESULTS: From 207 citations, 10 studies with 133 patients with rectal or anal cancer who underwent OT prior to RT were included. Meta-analysis of pooled proportions of preserved ovarian function demonstrated an incidence of 66.9% (95% CI 55.0-79.0%, I2 = 43%). The 30-day postoperative morbidity rate was 1.2% (n = 1). There was heterogeneity in interventions and outcome reporting. CONCLUSIONS: Laparoscopic OT in premenopausal patients undergoing pelvic radiation for anorectal malignancies might be an effective technique at reducing ovarian exposure to RT. The meta-analyses must be interpreted within the context of clinical heterogeneity of the included studies. Further studies are required to fully investigate the outcomes of OT in patients undergoing pelvic radiation for anorectal malignancies.

Management of left-sided malignant colorectal obstructions with curative intent: a network meta-analysis.

BACKGROUND: Several management options exist for colonic decompression in the setting of malignant large bowel obstruction, including oncologic resection, surgical diversion, and SEMS as a bridge-to-surgery. Consensus has yet to be reached on optimal treatment pathways. The aim of the present study was to perform a network meta-analysis comparing short-term postoperative morbidity and long-term oncologic outcomes between oncologic resection, surgical diversion, and self-expanding metal stents (SEMS) in left-sided malignant colorectal obstruction with curative intent. METHODS: Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared two or more of the following in patients presenting with curative left-sided malignant colorectal obstruction: (1) emergent oncologic resection; (2) surgical diversion; and/or (3) SEMS. The primary outcome was overall 90-day postoperative morbidity. Pairwise meta-analyses were performed with inverse variance random effects. Random-effect Bayesian network meta-analysis was performed. RESULTS: From 1277 citations, 53 studies with 9493 patients undergoing urgent oncologic resection, 1273 patients undergoing surgical diversion, and 2548 patients undergoing SEMS were included. Network meta-analysis demonstrated a significant improvement in 90-day postoperative morbidity in patients undergoing SEMS compared to urgent oncologic resection (OR0.34, 95%CrI0.01-0.98). Insufficient RCT data pertaining to overall survival (OS) precluded network meta-analysis. Pairwise meta-analysis demonstrated decreased five-year OS for patients undergoing urgent oncologic resection compared to surgical diversion (OR0.44, 95%CI0.28-0.71, p < 0.01). CONCLUSIONS: Bridge-to-surgery interventions may offer short- and long-term benefits compared to urgent oncologic resection for malignant colorectal obstruction and should be increasingly considered in this patient population. Further prospective study comparing surgical diversion and SEMS is needed.

Video-based coaching for surgical residents: a systematic review and meta-analysis.

BACKGROUND: Video-based coaching (VBC) is used to supplement current teaching methods in surgical education and may be useful in competency-based frameworks. Whether VBC can effectively improve surgical skill in surgical residents has yet to be fully elucidated. The objective of this study is to compare surgical residents receiving and not receiving VBC in terms of technical surgical skill. METHODS: The following databases were searched from database inception to October 2021: Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed. Articles were included if they were randomized controlled trials (RCTs) comparing surgical residents receiving and not receiving VBC. The primary outcome, as defined prior to data collection, was change in objective measures of technical surgical skill following implementation of either VBC or control. A pairwise meta-analyses using inverse variance random effects was performed. Standardized mean differences (SMD) were used as the primary outcome measure to account for differences in objective surgical skill evaluation tools. RESULTS: From 2734 citations, 11 RCTs with 157 residents receiving VBC and 141 residents receiving standard surgical teaching without VBC were included. There was no significant difference in post-coaching scores on objective surgical skill evaluation tools between groups (SMD 0.53, 95% CI 0.00 to 1.01, p = 0.05, I2 = 74%). The improvement in scores pre- and post-intervention was significantly greater in residents receiving VBC compared to those not receiving VBC (SMD 1.62, 95% CI 0.62 to 2.63, p = 0.002, I2 = 85%). These results were unchanged with leave-one-out sensitivity analysis and subgroup analysis according to operative setting. CONCLUSION: VBC can improve objective surgical skills in surgical residents of various levels. The benefit may be most substantial for trainees with lower baseline levels of objective skill. Further studies are required to determine the impact of VBC on competency-based frameworks.

Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis.

BACKGROUND: Though gastrojejunostomy (GJ) has been a standard palliative procedure for gastric outlet obstruction (GOO), endoscopic stenting (ES) has shown to provide benefits due to its non-invasive approach. The aim of this review is to perform a comprehensive evaluation of ES versus GJ for the palliation of malignant GOO. METHODS: MEDLINE, Embase, and CENTRAL databases were searched and comparative studies of adult GOO patients undergoing ES or GJ were eligible for inclusion. The primary outcomes were survival time and mortality. Secondary outcomes included technical success, clinical success, reinterventions, days until oral food tolerance, postoperative adjuvant palliative chemotherapy, postoperative morbidities, length of stay (LOS), and costs. Pairwise meta-analyses using inverse-variance random effects were performed. RESULTS: After identifying 2222 citations, 39 full-text articles fit the inclusion criteria. In total, 3128 ES patients (41.4% female, age: 68.0 years) and 2116 GJ patients (40.4% female, age: 66.8 years) were included. ES patients experienced a shorter survival time (mean difference -24.77 days, 95% Cl - 45.11 to - 4.43, p = 0.02) and were less likely to undergo adjuvant palliative chemotherapy (risk ratio 0.81, 95% Cl 0.70 to 0.93, p = 0.004). The ES group had a shorter LOS, shorter time to oral intake of liquids and solids, and less surgical site infections (risk ratio 0.30, 95% Cl 0.12 to 0.75, p = 0.01). The patients in the ES group were at greater risk of requiring reintervention (risk ratio 2.60, 95% Cl 1.87 to 3.63, p < 0.001). CONCLUSION: ES results in less postoperative morbidity and shorter LOS when compared to GJ, however, this may be at the cost of decreased initiation of adjuvant palliative chemotherapy and overall survival, as well as increased risk of reintervention. Both techniques are likely appropriate in select clinical scenarios.

Ghost Ileostomy Versus Loop Ileostomy Following Oncologic Resection for Rectal Cancer: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this study was to compare ghost ileostomy (GI) and loop ileostomy (LI) in patients undergoing oncologic resection for rectal cancer in terms of postoperative morbidity. SUMMARY BACKGROUND DATA: LIs are often fashioned to protect downstream anastomoses following oncologic resection for low rectal cancer at medium-to-high risk of anastomotic leak. More recently, GIs have been utilized in patients with low-to-medium risk anastomoses to reduce the rate of unnecessary stomas. METHODS: Medline, Embase, and CENTRAL were systematically searched. Studies investigating the use of GI in patients undergoing oncologic resection for rectal cancer were included. The primary outcomes were anastomotic leak and postoperative morbidity. Secondary outcomes included stoma-related complications and length of stay (LOS). Pairwise meta-analyses were performed with inverse variance random effects. RESULTS: From 242 citations, 14 studies with 946 patients were included. In comparative studies, 359 patients were undergoing GI and 266 patients were undergoing LI. Pairwise meta-analysis revealed no differences in the prevalence of anastomotic leak (OR 1.40, 95%CI .73-2.68, P = .31), morbidity (OR .76, 95%CI .44-1.30, P = .32), or LOS (SMD -.05, 95%CI -.33-.23, P = .72). International Study Group of Rectal Cancer anastomotic leak grades were as follows: Grade A (GI 0% vs LI 13.3%), Grade B (GI 80.9% vs LI 86.7%), Grade C (GI 19.1% vs LI 0%). CONCLUSIONS: GI appears to be a safe alternative to LI following oncologic resection for rectal cancer. Larger, prospective comparative studies are warranted to evaluate the use of GI in patients deemed to be at low-to-medium risk of anastomotic leak.

Identification and Adjudication of Adverse Events Following Rectal Cancer Surgery: Observational Case Series in a Region of Ontario, Canada.

BACKGROUND: For patients undergoing rectal cancer surgery, we evaluated whether suboptimal preoperative surgeon evaluation of resection margins is a latent condition factor-a factor that is common, unrecognized, and may increase the risk of certain adverse events, including local tumour recurrence, positive surgical margin, nontherapeutic surgery, and in-hospital mortality. METHODS: In this observational case series of patients who underwent rectal cancer surgery during 2016 in Local Health Integrated Network 4 region of Ontario (population 1.4 million), chart review and a trigger tool were used to identify patients who experienced the adverse events. An expert panel adjudicated whether each event was preventable or nonpreventable and identified potential contributing factors to adverse events. RESULTS: Among 173 patients, 25 (14.5%) had an adverse event and 13 cases (7.5%) were adjudicated as preventable. Rate of surgeon awareness of preoperative margin status was low at 50% and similar among cases with and without an adverse event (p = 0.29). Suboptimal surgeon preoperative evaluation of surgical margins was adjudicated a contributing factor in all 11 preventable local recurrence, positive margin, and nontherapeutic surgery cases. Failure to rescue was judged a contributing factor in the two cases with preventable in-hospital mortality. CONCLUSIONS: Suboptimal surgeon preoperative evaluation of surgical margins in rectal cancer is likely a latent condition factor. Optimizing margin evaluation may be an efficient quality improvement target.

Endoscopic Full-Thickness Resection for Colorectal Lesions: A Systematic Review and Meta-Analysis.

INTRODUCTION: Endoscopic full-thickness resection (EFTR) with an over-the-scope full-thickness resection device is a relatively new technique for the resection of colorectal lesions. Multiple centers have published the results of case series and observational cohorts regarding the use of this technique for managing difficult polyps. This study aims to aggregate the results of these studies to determine the effectiveness and safety of this technique in the resection of these technically challenging colonic lesions. METHODS: MEDLINE, EMBASE, and CENTRAL were searched. Articles were included if they reported technical success rate for EFTR of colonic lesions. The primary outcome was technical success rate and secondary outcomes included rate of R0 resection and overall 30-d morbidity. DerSimonian and Laird random-effects meta-analysis of proportions was used to generate effect sizes for pooled outcomes. RESULTS: From 2211 citations, 21 studies with 1539 patients (mean age 67.2 y, 39.5% female) undergoing 1551 procedures were included. Difficult to resect benign lesions were the most commonly excised lesions (hyperplastic: 35.9%; adenomas: 30.2%), followed by T1 adenocarcinomas (25.6%) and neuroendocrine tumors (6.1%). Technical success rate was 89% (95% confidence interval [CI] 87-92), and R0 resection rate was 79% (95% CI 76-82). Mean procedure time was 53.5 min and mean specimen size was 17.5 mm. Overall 30-d morbidity was 11% (95% CI 7-13), and incidences of perforation and postpolypectomy bleeding were 2% (95% CI 1-2) and 5% (95% CI 3-7), respectively. Lesion recurrence at 3-mo follow-up was 8%. CONCLUSIONS: EFTR requires further large sample size, comparative studies with reporting of long-term oncologic data. However, preliminary findings indicate that it is a safe and effective technique with high rates of technical success and acceptable rates of R0 resection when employed by experienced endoscopists for high-risk colonic lesions.

Sugammadex in Colorectal Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Traditionally, reversal of neuromuscular blocking agents following the completion of surgery was achieved with cholinesterase inhibitors. Recently, sugammadex has been increasingly relied upon. Sugammadex is a γ-cyclodextrin molecule that rapidly reverses steroidal neuromuscular blocking drugs. Its use following colorectal surgery has become more common, and while the rapidity of reversal is undoubtedly improved, whether sugammadex impacts clinical postoperative outcomes is unknown. This systematic review and meta-analysis aims to compare postoperative outcomes in patients receiving sugammadex to those receiving a control during colorectal surgery. METHODS: Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared sugammadex with a control (e.g., neostigmine, pyridostigmine, placebo) in patients undergoing colorectal surgery in terms of total hospital length of stay and frequency of postoperative adverse respiratory events. Pairwise meta-analyses using inverse variance random effects was performed. RESULTS: From 269 citations, five studies with 535 patients receiving sugammadex (45.8% female; mean age: 64.4) and 569 patients receiving a control (45.0% female; mean age: 64.3) were included. There was no significant difference in length of stay between the two groups (MD -0.01, 95% CI -0.27 to 0.25, P = 0.95). The risk of adverse respiratory events postoperatively was similar between the two groups (RR 1.33, 95% CI 0.81-2.19, P = 0.25). CONCLUSION: There are no current data to suggest an improvement in postoperative outcomes with the use of sugammadex in patients undergoing colorectal surgery. This study is limited by the number of included studies. Further prospective studies comparing sugammadex and a control in colorectal surgery is required.