How to do laparoscopic right hemicolectomy with transvaginal natural orifice specimen extraction.

The key steps of performing a laparoscopic right hemicolectomy with transvaginal natural orifice specimen extraction surgery.

Surgical prevalence and outcomes in ischemic colitis: A systematic review and meta-analysis.

BACKGROUND/AIM: This study reviews the literature to examine the proportion of patients requiring surgical management in ischemic colitis (IC) and identify surgical outcomes. METHOD: A systematic review of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials was conducted in accordance with the latest Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. English language studies and adult patients were included. Studies with fewer than 10 patients, and IC post aortic or cardiac surgery was excluded. We present our systematic review and meta-analysis with pooled proportions of right sided IC distribution and prevalence of surgical treatment. RESULTS: 23 studies with a total of 12,844 patients were included in the systematic review, with 19 studies and 12,420 patients included in the meta-analysis. Four studies were excluded from the meta-analysis due to only including specific cohorts of patients-two with cocaine induced colitis, one with phlebosclerotic colitis, and one with IC associated with acute myocardial infarction. The pooled proportion of right sided IC distribution was 15% (CI 14%-17%, p < 0.001), whilst the pooled proportion of surgical management of IC was 15% (CI 13%-16% p < 0.001). CONCLUSION: Prevalence of surgical management of IC is rare. Right sided IC is associated with higher mortality and higher rates of surgical management. Reporting of surgical outcomes is scant.

Surgical resection of adrenal metastasis from colorectal cancers: a systematic review.

BACKGROUND: The decision for resection of adrenal metastasis from colorectal cancers remain controversial and there is no proposed standard treatment. The aim of the article is to review the available literature on outcomes and complications rates following adrenalectomy for adrenal metastasis from colorectal cancer. METHODS: Relevant papers were identified through electronic databases. Data was extracted independently by two authors on a Microsoft Excel spreadsheet up to June 2023. RESULTS: A total of 55 studies were included in the final analysis (145 cases). A large proportion of patients had an uneventful postoperative recovery following surgical adrenalectomy. The mean length of follow up ranged from 2 months to 9.5 years. A total of 33 (22.8%) patients were alive and well with no evidence of local or systemic recurrence; 2 (1.4%) patients had recurrence in the bed of adrenalectomy; 2 (1.4%) patients were alive with recurrence in the contralateral adrenal gland; 4 (2.8%) patients were alive with extra-adrenal metastasis, and 7 (4.8%) patients were alive and well with no comments regarding local and systemic recurrence. Post-operative mortality following adrenalectomy was uncommon: 1 patient died due to systemic sepsis following anastomotic leak. 17.2% of patients died due to disease progression. CONCLUSION: If complete resection can be achieved, surgical adrenalectomy in the surgically fit patient should be strongly considered, especially in patients with solitary adrenal metastasis which may translate into survival benefits and potential surgical cure.

Proposed clinical operative synoptic report for ileocolic resection for Crohn's disease.

BACKGROUND: Crohn's disease patients may require multiple surgeries during their lifetime. Because operative reports are not standardized, information relevant to future management may not be documented. Synoptic reports used in other fields such as histopathology have proven to be effective and allow consistent documentation of results. The aim of this study was to retrospectively review the completeness of the operative reports for ileocolic Crohn's resections (ICR) and to propose a synoptic report. METHODS: A draft synoptic operative report for ICR for Crohn's disease was presented in the IBD multidisciplinary meeting and a Delphi process used to gain consensus for inclusion in the synoptic report. Retrospective analysis of consecutive ICR from January 2010 to April 2023 was undertaken to determine the presence of the standardized criteria. RESULTS: A total of 66 ICR were performed in 63 patients during the study period. No operation reports were excluded. The examination of bowel for macroscopic disease was partially documented in 88% cases. The extent of mesenteric resection and any difficulty encountered during dissection were poorly documented. The remaining length of small and large intestines was not documented in most operative reports. The clinical sections that were compulsory entrance in the electronic operative report achieved 100% compliance. CONCLUSION: This study has demonstrated that key information was often deficient in the operative report. This may have a significant impact on the future management of Crohn's patients and affects the interpretation of research outcomes. A proposed clinical synoptic operative report is easy to use and ensures compliance.

Pre- and post-treatment FDG PET-CT as a predictor of patient outcomes in anal squamous cell carcinoma: A systematic review and meta-analysis.

Anal squamous cell carcinoma (ASCC) has a generally acceptable outlook in terms of survival. 18-fluorodeoxyglucose-positron emission tomography/computer tomography (FDG PET-CT) is not recommended for routine monitoring post-ASCC treatment. We examine herein if FDG PET-CT has a use in the prognostic evaluation of patients with ASCC, what FDG PET-CT metrics are of value and if a pre- or post-chemo/radiotherapy scan is more prognostic of outcomes. PubMed, EMBASE and Cochrane Central Registry of Controlled Trials were comprehensively searched until 3 May, 2023. A modified Newcastle Ottawa scale was used to assess for study bias. We present our systematic review alongside pooled hazard ratios (HR) for maximum standardised uptake values (SUV) as a predictor of overall survival (OS) and progression-free survival (PFS). Seven studies including 523 patients were included in our systematic review. Current evidence suggests that SUV maximum and median, metabolic tumour volume, total lesion glycolysis and complete and partial metabolic response may be prognostic when considering overall or progression-free survival (OS)/(PFS) along with local recurrence (LR). Pooled HR from two included studies indicate SUV max is prognostic of OS, HR 1.179, CI (1.039-1.338), P = 0.011 and PFS 1.176, CI (1.076-1.285), P < 0.01. FDG PET-CT may have a role to play in the prognostic evaluation of ASCC patients. Current evidence suggests post-treatment scanning may hold superior prognostic value at this time.

Predictors for success of non-operative management of adhesive small bowel obstruction.

BACKGROUND: Majority of adhesive small bowel obstruction (SBO) cases can be managed non-operatively. However, a proportion of patients failed non-operative management. AIM: To evaluate the predictors of successful non-operative management in adhesive SBO. METHODS: A retrospective study was performed for all consecutive cases of adhesive SBO from November 2015 to May 2018. Data collated included basic demographics, clinical presentation, biochemistry and imaging results and management outcomes. The imaging studies were independently analyzed by a radiologist who was blinded to the clinical outcomes. The patients were divided into group A operative (including those that failed initial non-operative management) and group B non-operative for analysis. RESULTS: Of 252 patients were included in the final analysis; group A (n = 90) (35.7%) and group B (n = 162) (64.3%). There were no differences in the clinical features between both groups. Laboratory tests of inflammatory markers and lactate levels were similar in both groups. From the imaging findings, the presence of a definitive transition point [odds ratio (OR) = 2.67, 95% confidence interval (CI): 0.98-7.32, P = 0.048], presence of free fluid (OR = 2.11, 95%CI: 1.15-3.89, P = 0.015) and absence of small bowel faecal signs (OR = 1.70, 95%CI: 1.01-2.88, P = 0.047) were predictive of the need of surgical intervention. In patients that received water soluble contrast medium, the evidence of contrast in colon was 3.83 times predictive of successful non-operative management (95%CI: 1.79-8.21, P = 0.001). CONCLUSION: The computed tomography findings can assist clinicians in deciding early surgical intervention in adhesive SBO cases that are unlikely to be successful with non-operative management to prevent associated morbidity and mortality.

Enhanced recovery after surgery protocols and emergency surgery: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: This systematic review and meta-analysis seeks to assess the modified protocols used and patient outcomes when enhanced recovery after surgery (ERAS) protocols are utilized in an emergency setting. METHODS: PubMed, MEDLINE, EMBASE and Cochrane Central Registry of Controlled Trials were comprehensively searched until 13 March 2023. The Cochrane Risk of Bias Assessment Tool was used to assess for bias, along with funnel plot asymmetry. We present log risk ratios for dichotomous variables and raw mean differences for continuous variables. RESULTS: Seven randomized trials were included, comprising 573 patients. Results of the primary outcomes when comparing ERAS to standard care are as follows; withdrawal of nasogastric tube (raw mean difference -1.87 CI: -2.386 to -1.359), time to first liquid diet (raw mean difference -2.56 CI: -3.435 to -1.669), time to first solid diet (raw mean difference -2.35 CI: -2.933 to -1.76), time to first flatus (raw mean difference -2.73 CI: -5.726 to 0.257), time to first stool passed (raw mean difference -1.83 CI: -2.307 to -1.349), time to removal of drains (raw mean difference -3.23 CI: -3.609 to -2.852), time to removal of urinary catheter (raw mean difference -1.57 CI: -3.472 to 0.334), mean pain score (raw mean difference -1.79 CI: -2.222 to -1.351) and length of hospital stay (raw mean difference -3.16 CI: -3.688 to -2.63). CONCLUSIONS: The adoption of ERAS protocols in an emergency surgery setting was observed to enhance patient recovery, while not indicating any statistically significant increase in adverse outcomes.

Colorectal Surgery in Patients with Liver Cirrhosis: A Systematic Review.

BACKGROUND: Colorectal surgery in patients with liver cirrhosis poses a significant challenge due to the associated peri-operative morbidity and mortality risks. The aim of this systematic review was to evaluate the outcomes in this cohort of patients following colorectal surgery. METHODS: The PubMed, Embase and Cochrane databases and references were searched up to October 2022 using the PRISMA guidelines. The data collated included: patient demographics, pathology or type of colorectal operation performed, severity of liver cirrhosis, post-operative complication rates, mortality rates and prognostic factors. A quality assessment of included studies was performed with the Newcastle-Ottawa scale. RESULTS: Sixteen studies reporting the outcomes of colorectal surgery in patients with liver cirrhosis were identified, including the results of 8646 patients. The indications, pathologies and/or type of operations varied. The overall complication rate ranged from 29 to 75%, minor complication ranged 14.5-37% and major complication ranged 6.7-59.3%. The mortality rates ranged from 0 to 37%. CONCLUSION: Colorectal surgery in patients with liver cirrhosis still carries considerable morbidity and mortality rates. This group of patients needs to be managed in a multidisciplinary setting to achieve excellent outcomes. Future research should focus on uniform definitions to enable interpretable outcomes.

Relationship of computed tomography quantified visceral adiposity with the severity and complications of acute pancreatitis: a systematic review.

Whilst obesity and visceral adipose tissue (VAT) have been reported to be associated with an increased risk of severe AP, the established predictive scoring systems have not yet encompassed the impact of obesity or visceral adiposity. In the acute setting, computed tomography (CT) is often performed to assess AP severity and associated complications. With the added benefit of quantifying body fat distribution, it can be opportunistically used to quantify visceral adiposity and assess its relationship with the course of AP. This systematic review identified fifteen studies evaluating the relationship between visceral adiposity measured on CT and the severity of presentations of acute pancreatitis from January 2000 to November 2022. The primary outcome was to assess the relationship between CT quantified VAT and AP severity. The secondary outcomes were to assess the impact of VAT on patients developing local and systemic complications associated with AP. Whilst ten studies showed there was a significant correlation between an increased VAT and AP severity, five studies found otherwise. The majority of current literature demonstrate a positive correlation between increased VAT and AP severity. CT quantification VAT is a promising prognostic indicator with the potential to guide initial management, prompt more aggressive treatment measures or earlier re-evaluation and to aid disease prognostication in patients with acute pancreatitis.

Utility of CT colonography and/or PET-CT preoperatively in obstructing left-sided colorectal cancers - a systematic review.

PURPOSE: 15-20% of patients present with near obstructing left-sided colorectal cancer. CT colonography (CTC) or PET-CT has been used to detect synchronous lesions, which may alter preoperative planning of colonic resection. We aim to synthesize the usefulness of CT colonography and/or PET-CT in detecting synchronous proximal colon carcinomas in patients who have undergone an incomplete colonoscopy due to a stenosing or obstructing distal colorectal cancer. METHODOLOGY: A systematic review was performed by searching the databases up to December 2021. Data collected included demographics of the study population, rate of detection of synchronous carcinomas and impact on management of detection of synchronous carcinomas. RESULTS: A total of 22 studies were included: 17 studies focused on CTC, 3 on PET-CT, and 2 integrated PET-CT with CTC; 2855 patients were included; 53% of patients were male, and 47% were female. All studies reported detection of synchronous proximal colorectal carcinomas using CTC, PET-CT or CTC, and PET-CT combined. CTC detected synchronous carcinomas in 0.2-12.2% of patients. PET-CT was useful in detecting synchronous carcinomas in 4.05-23% of patients. Integrated PET-CT and CTC detected synchronous carcinomas in 2-15% of patients. The surgical plan was changed in 2.4-14.3% of patients after the use of CTC. One PET-CT study reported a change in management in 13.5%. No complication was reported by the use of CTC. CONCLUSION: CTC is an effective and useful adjunct to colonoscopy in assessing the proximal colon when colonoscopy fails to do so. However, more evidence is needed with the use of PET-CT for this patient population.

Poorer outcomes associated with sarcopenia following emergency laparotomy: a systematic review and meta-analysis.

BACKGROUND: Despite the negative effect of sarcopenia on postoperative outcomes being well recognized in the elective setting, there remains a paucity of studies describing this phenomenon in the emergency laparotomy (EL) setting. This systematic review and meta-analysis aimed to compare short- and long-term postoperative outcomes following EL in patients with and without sarcopenia. METHODS: A systematic review using PRISMA guidelines was used to identify studies comparing perioperative outcomes following EL for patients with and without sarcopenia. A subsequent meta-analysis was conducted. The following data were extracted from the included studies: patient demographics, pathology or type of operation performed for EL, post-operative mortality at inpatient, 30-day, 90-day and 1-year, and functional outcomes. A quality assessment of included studies was undertaken. RESULTS: Twelve studies reporting the outcomes of sarcopenia following EL were identified. Sarcopenia was significantly associated with higher 30-day and 1-year mortality rates following EL (OR 3.50, P < 0.01; OR 3.49, P < 0.01, respectively). Additionally, sarcopenia was significantly associated with unfavourable functional outcomes at discharge following emergency laparotomy (OR 2.44, p < 0.01). CONCLUSION: Opportunistically identified on cross-sectional imaging, sarcopenia is a valuable predictor of short- and long-term morbidity and mortality following EL. Further studies are required to identify the most appropriate diagnostic criteria of sarcopenia and better define this physiological phenomenon.

Hepatic metastasis of anal squamous cell carcinoma.

A 50-year-old woman was diagnosed with anal squamous cell carcinoma following a colonoscopy performed for positive test from the National Bowel Screening Programme. During the staging imaging, it was discovered to have a liver lesion that was atypical for metastasis. She underwent a segmental liver resection, and histopathology showed the liver lesion as a metastatic squamous cell carcinoma. We aim to discuss the incidence, presentation and management strategies for this rare hepatic metastasis of anal squamous cell carcinoma.

Investigation of a method for long-term preservation of the vascular allograft.

BACKGROUND/OBJECTIVE: During multiple organ procurement, blood vessels are routinely retrieved and stored in University of Wisconsin solution and then discarded after two weeks, if not used at organ transplantation owing to lack of a method for long-term preservation. Therefore, the aim of this study is to investigate a method for long-term preservation of vascular allografts in ethanol. METHODS: Aorta and vena cava allografts were retrieved and stored in 75% ethanol solution for 12 months at 4°C. Four pigs were divided into two groups. A segment of aorta was excised and replaced by insertion of preserved aorta graft (Group A) or vena cava graft (Group V). The pigs were observed for six weeks. A laparotomy was performed and the vascular graft was harvested for histopathology followed by euthanasia at the end of study. RESULTS: Three pigs recovered uneventfully, while one pig died from venous graft rupture in the third week after surgery. There was no aneurysmal formation or thrombosis in the grafts. Some calcification was seen over aorta allograft. On histopathology, the elastic pattern was almost normal, although the endothelial cells degenerated after preservation. After implantation, the formation of the endothelium cell-like layer was seen in both aorta and vena cava allografts. CONCLUSION: Vascular allografts were functional after preservation for 12 months. The vena cava grafts had much less wall calcification than the aorta grafts. Further studies are necessary to investigate vascular graft remodelling with a longer observation period after implantation.

One-Year Outcomes Following Emergency Laparotomy: A Systematic Review.

BACKGROUND: Emergency laparotomies (EL) are associated with significant morbidity and mortality. To date, 30-day mortality has been predominately reported, and been the focus of various national emergency laparotomy audits. Only a few studies have reported on the long-term mortality associated with EL. The aim of this study was to review the one-year mortality following EL. METHOD: A systematic review was conducted using PRISMA guidelines to identify studies published in the last 10 years reporting on long-term mortality associated with EL. The data abstracted included: patient demographics, pathology or type of operation performed for EL, post-operative mortality at 7-day, 30-day, 90-day, 1-year, beyond 1-year and inpatient, functional outcomes and risk factors associated with mortality. A quality assessment of included studies was performed. RESULTS: Fifteen studies reporting long-term outcomes associated with EL were identified, including the results of 48,023 patients. The indications and/or pathologies for ELs varied. The 30-day mortality after EL ranged from 5.3% to 21.8%, and the one-year mortality ranged from 15.1 to 47%. The mortality in the six studies focusing on elderly patients ranged from 30 to 47%. CONCLUSION: The long-term mortality rate associated with EL is substantial. Further study is required to understand the 1-year mortality described in the studies and translate these findings for meaningful application into the clinical care of these patients.