Outcomes After Colonic Self-Expanding Metal Stent Insertion Without Fluoroscopy: A Surgeon-Led 10-Year Experience.

INTRODUCTION: Colonic self-expanding metal stents (SEMS) can be used to relieve malignant and benign large bowel obstruction (LBO) as a bridge to surgery (BTS) and for palliation. Guidelines suggest the use of fluoroscopic guidance for deployment. This may be difficult to obtain after hours and in certain centers. We aimed to determine the outcomes of stenting under endoscopic guidance alone. METHODS: All patients who underwent SEMS insertion in our tertiary referral center between August 2010 and June 2021 were identified from a prospectively maintained database. Patient demographics (age/gender), disease characteristics (benign versus malignant/location/stage), stenting intent (BTS versus palliative), and outcomes (technical success/stoma/time from stenting to resection/death/study end) were analyzed. RESULTS: Fifty-three (n = 39, 73.6% male) patients underwent SEMS insertion. Indications included colorectal carcinoma (n = 48, 90.6%), diverticular stricture (n = 3), and gynecological malignancy (n = 2). In five (9.4%) patients (four BTS and one palliative), SEMSs deployment was not completed because of the inability to pass the guidewire. All underwent emergency surgery. In the BTS cohort (n = 29, median 70.4 [range 40.3-91.8] years), 10 patients underwent neoadjuvant chemoradiotherapy. The permanent stoma rate was 20.7% (n = 6). There was no 30- or 90-d mortality. In the palliative cohort (n = 24, median age 77.1 [range 54.4-91.9]), 16 (66.7%) were deceased at the study end. The median time from stenting to death was 5.2 (2.3-7.9) months. CONCLUSIONS: SEMS placed under endoscopic visualization alone, palliatively and as a BTS, had acceptable stoma, morbidity, and mortality rates. These results show that SEMS insertion can be safely performed without fluoroscopy.

Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis.

BACKGROUND: Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention. METHODS: PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS: Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20). CONCLUSION: PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.

Twenty years of restorative proctocolectomy with ileal pouch anal anastomosis in Beaumont Hospital.

INTRODUCTION: An ileal pouch anal anastomosis (IPAA) is the treatment of choice in selected patients to restore intestinal continuity following proctocolectomy. Data on IPAA in the Republic of Ireland is lacking, and surgery for IPAA has evolved over time. The aim of this retrospective study was to report our institutional outcomes from IPAA over a 20-year period. METHODS: Data were retrospectively collated from consecutive primary IPAA cases between 1998 and 2017 at Beaumont Hospital. Patient demographics and operative approach were examined, and pouch failure was estimated using the Kaplan-Meier method. RESULTS: Ninety-five patients underwent IPAA over the study period with a mean follow-up of 9.4 ± 5.6 years. The mean age at IPAA was 35.9 ± 10.0 years, and 58.9% were male. The majority were performed in 3 stages (78.9%), were performed to treat ulcerative colitis (66.3%), were of a J-pouch configuration (96.8%), and had a stapled anastomosis (70.5%). On follow-up, 28.4% reported experiencing at least 1 episode of pouchitis and the 10-year pouch failure rate was 14%. In the last decile of the study period, the mean number of IPAA performed per year increased to 10.5 ± 2.1 (P = 0.013), the age of IPAA formation reduced (P = 0.049), and the proportion completed in a minimally invasive manner increased (P < 0.001). CONCLUSIONS: Acceptable long-term outcomes were observed by our institution. A recent increase in institutional volume, reduction in patient age, and increase in the proportion of cases performed laparoscopically have been identified.

A meta-analysis of carbon dioxide versus room air insufflation on patient comfort and key performance indicators at colonoscopy.

BACKGROUND: Carbon dioxide (CO2) has been used as an alternative to air insufflation at endoscopy with good results; however, uptake of the technique has been poor, possibly due to perceived lack of outcome equivalency. This meta-analysis evaluates the effectiveness of CO2 versus air in reducing pain post-colonoscopy and furthermore examines other key performance indicators (KPIs) such as sedative use, procedure times and polyp detection rates. METHODS: This meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pubmed, Pubmed Central, Embase and Cochrane Library were searched for randomized studies from 2004 to 2019, reporting outcomes for patients undergoing colonoscopy with air or CO2 insufflation, who reported pain on a numerical or visual analogue scale (VAS). Results were reported as mean differences (MD) or pooled odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS: Of 3586 citations, 23 studies comprising 3217 patients were analysed. Patients undergoing colonoscopy with air insufflation had 30% higher intraprocedural pain scores than those receiving CO2 (VAS 3.4 versus 2.6, MD -0.7, 95% CI - 1.4-0.0, p = 0.05), with a sustained beneficial effect amongst those in the CO2 group at 30 min, 1-2-h and 6-h post procedure (MD - 0.8, - 0.6 and - 0.2, respectively, p < 0.001 for all), as well as less distension, bloating and flatulence (p < 0.01 for all). There were no differences between the two groups in KPIs such as the sedation required, procedure time, caecal intubation or polyp detection rates. CONCLUSIONS: CO2 insufflation improves patient comfort without compromising colonoscopic performance.

Systemic Molecular Mediators of Inflammation Differentiate Between Crohn's Disease and Ulcerative Colitis, Implicating Threshold Levels of IL-10 and Relative Ratios of Pro-inflammatory Cytokines in Therapy.

BACKGROUND AND AIMS: Faecal diversion is associated with improvements in Crohn's disease but not ulcerative colitis, indicating that differing mechanisms mediate the diseases. This study aimed to investigate levels of systemic mediators of inflammation, including fibrocytes and cytokines, [1] in patients with Crohn's disease and ulcerative colitis preoperatively compared with healthy controls and [2] in patients with Crohn's disease and ulcerative colitis prior to and following faecal diversion. METHODS: Blood samples were obtained from healthy individuals and patients with Crohn's disease or ulcerative colitis. Levels of circulating fibrocytes were quantified using flow cytometric analysis and their potential relationship to risk factors of inflammatory bowel disease were determined. Levels of circulating cytokines involved in inflammation and fibrocyte recruitment and differentiation were investigated. RESULTS: Circulating fibrocytes were elevated in Crohn's disease and ulcerative colitis patients when compared with healthy controls. Smoking, or a history of smoking, was associated with increases in circulating fibrocytes in Crohn's disease, but not ulcerative colitis. Cytokines involved in fibrocyte recruitment were increased in Crohn's disease patients, whereas patients with ulcerative colitis displayed increased levels of pro-inflammatory cytokines. Faecal diversion in Crohn's disease patients resulted in decreased circulating fibrocytes, pro-inflammatory cytokines, and TGF-ß1, and increased IL-10, whereas the inverse was observed in ulcerative colitis patients. CONCLUSIONS: The clinical effect of faecal diversion in Crohn's disease and ulcerative colitis may be explained by differing circulating fibrocyte and cytokine responses. Such differences aid in understanding the disease mechanisms and suggest a new therapeutic strategy for inflammatory bowel disease.

Classical Limberg versus classical Karydakis flaps for pilonidal disease- an updated systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Pilonidal disease (PD) is associated with significant disability culminating in time off work/school. Recurrence rates remain high following conventional surgical interventions. Flap-based techniques are postulated to decrease recurrence. We performed a systematic review and meta-analysis to compare the effectiveness of the classical Limberg (LF) and Karydakis (KF) flaps in the treatment of PD. METHODS: The online databases of Medline, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials as well as Google Scholar were searched for relevant articles from inception until May 2017. All randomized studies that reported direct comparisons of classical LF and KF were included. Two independent reviewers performed data extraction. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was also carried out. RESULTS: Five randomized controlled trials describing 727 patients (367 in LF, 360 in KF) were examined. There was significant heterogeneity among studies. On overall random effects analysis, there was a lower rate of seroma formation associated with LF, and this approached statistical significance (OR = 0.47, 95% CI = 0.22 to 1.03, p = 0.06). However, there were no significant differences in recurrence (OR = 1.03, 95% CI = 0.48 to 2.21, p = 0.939), wound dehiscence (OR = 0.53, 95% CI = 0.09 to 2.85, p = 0.459), wound infection (OR = 0.59, 95% CI = 0.23 to 1.52, p = 0.278) or haematoma formation (OR = 2.08, 95% CI = 0.82 to 5.30, p = 0.124) between LF and KF. On sensitivity analysis, focusing only on primary and excluding recurrent PD, the results remained similar. CONCLUSIONS: LF and KF appear comparable in efficacy for primary PD, although LF is associated with less seroma formation.

Inclusion of the Mesentery in Ileocolic Resection for Crohn's Disease is Associated With Reduced Surgical Recurrence.

BACKGROUND AND AIMS: Inclusion of the mesentery during resection for colorectal cancer is associated with improved outcomes but has yet to be evaluated in Crohn's disease. This study aimed to determine the rate of surgical recurrence after inclusion of mesentery during ileocolic resection for Crohn's disease. METHODS: Surgical recurrence rates were compared between two cohorts. Cohort A [n = 30] underwent conventional ileocolic resection where the mesentery was divided flush with the intestine. Cohort B [n = 34] underwent resection which included excision of the mesentery. The relationship between mesenteric disease severity and surgical recurrence was determined in a separate cohort [n = 94]. A mesenteric disease activity index was developed to quantify disease severity. This was correlated with the Crohn's disease activity index and the fibrocyte percentage in circulating white cells. RESULTS: Cumulative reoperation rates were 40% and 2.9% in cohorts A and B [P = 0.003], respectively. Surgical technique was an independent determinant of outcome [P = 0.007]. Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher [12.25 ± 13 versus 2.4 ± 2.9, P = 0.002]. Advanced mesenteric disease predicted increased surgical recurrence [Hazard Ratio 4.7, 95% Confidence Interval: 1.71-13.01, P = 0.003]. The mesenteric disease activity index correlated with the mucosal disease activity index [r = 0.76, p < 0.0001] and the Crohn's disease activity index [r = 0.70, p < 0.0001]. The mesenteric disease activity index was significantly worse in smokers and correlated with increases in circulating fibrocytes. CONCLUSIONS: Inclusion of mesentery in ileocolic resection for Crohn's disease is associated with reduced recurrence requiring reoperation.

Oral versus topical calcium channel blockers for chronic anal fissure-a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Chemical sphincterotomy with pharmacological agents is recommended as first line therapy for chronic anal fissures (CAF). Calcium channel blockers (CCB) are associated with similar efficacy but fewer side effects compared to nitrates. However, the optimal formulation (oral versus topical) is unknown. We aimed to perform a systematic review and meta-analysis to compare the effectiveness of oral and topical CCB in the treatment of CAF. METHODS: PubMed and Embase online databases were searched for relevant articles. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was also carried out. RESULTS: Four randomized controlled trials describing 279 patients (138 in oral, 141 in topical group) were examined. There was significant heterogeneity among studies. On random effects analysis, topical CCB were associated with a significantly lower rate of unhealed fissure (21.3% vs. 38.4%; OR = 2.65, 95% CI = 1.50 to 4.69, p = 0.0008) when compared to oral therapy. However, there were no significant differences in fissure recurrence (5.4% vs. 5.5%; OR = 1.01, 95% CI = 0.31 to 3.33, p = 0.98) or side effects (15.6% vs. 39.1%; OR = 4.54, 95% CI = 0.46 to 44.3, p = 0.19) between topical and oral CCB. On sensitivity analysis, having excluded the most heavily biased trial, topical CCB were associated with significantly fewer side effects compared to oral therapy (4.3% vs. 38.0%; OR = 13.16, 95% CI = 5.05 to 34.3, p < 0.00001). CONCLUSIONS: Topical CCB are associated with better healing and fewer side effects when compared to oral therapy but there is no difference in recurrence rates.

Aspirin in the primary prophylaxis of venous thromboembolism in surgical patients.

INTRODUCTION: Venous thromboembolism (VTE) is a common complication in surgical patients, especially those undergoing lower limb orthopaedic procedures as well as oncological resectional surgery. Numerous studies have evaluated the role of acetylsalicylic acid (ASA, aspirin) in primary VTE prevention, with contradictory results reflected in divergent guidelines. We reviewed current evidence for ASA as primary VTE prophylaxis. METHODS: English language studies meeting our inclusion criteria were retrieved from PubMed, EMBASE and Cochrane databases. Six studies (3 meta-analyses and 3 randomized trials) comparing ASA with placebo and 7 studies (1 meta-analysis, 5 randomized trials, and 1 prospective) comparing ASA with other anticoagulants were included in the final analysis. Retrospective studies and case reports were excluded. RESULTS: ASA is more effective than placebo in primary VTE prevention. Although there is clinical equipoise when ASA is compared with other anticoagulants, studies specific to orthopaedic surgery suggest that ASA appears as effective as low molecular weight heparin (LMWH) and may reduce bleeding risk. Extended prophylaxis up to 4 weeks post surgery reduces VTE episodes. CONCLUSIONS: ASA may be considered as a potential strategy in primary VTE prophylaxis in orthopaedic patients at high-risk of bleeding complications. Further studies comparing ASA with LMWH/oral anticoagulants in primary thromboprophylaxis following non-orthopaedic surgery are warranted.

Grading operative findings at laparoscopic cholecystectomy- a new scoring system.

INTRODUCTION: Variation in outcomes from surgery is a major challenge and defining surgical findings may help set benchmarks, which currently do not exist in laparoscopic cholecystectomy. This study outlines a new surgical scoring system incorporating key operative findings. METHODS: English language studies (from January 1965 to July 2014) pertaining to severity scoring and predictors of difficult laparoscopic cholecystectomy were searched for in PubMed, Embase and Cochrane databases using the search terms 'Laparoscopic cholecystectomy or Lap chole' and/or 'Scoring Index or Grading system or Prediction of difficulty or Conversion to open' in various combinations. Cross-referencing from papers retrieved in the original search identified additional articles. RESULTS: Sixteen published papers report a gallbladder (GB) scoring system, but all relate to pre-operative clinical and imaging findings, rather than operative findings. The current scoring system, using operative findings incorporates the appearance of the GB, presence of GB distension, ease of access, potential biliary complications and time taken to identify cystic duct and artery. A score of <2 would imply mild difficulty, 2-4 moderate, 5-7 severe and 8-10 extreme. CONCLUSION: This paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy. It has the potential to allow benchmarks for international collaboration of operative and patient outcomes in patients undergoing laparoscopic cholecystectomy.

Short-term outcomes following the use of self-expanding metallic stents in acute malignant colonic obstruction--a single centre experience.

BACKGROUND: Colonic self-expanding metallic stents (SEMS) may provide prompt relief of acute malignant colorectal obstruction (AMCO) and are increasingly used either palliatively or as a bridge to surgery (BTS) in patients in whom a definitive surgical approach is unsuitable. We evaluated short-term outcomes of malignant colorectal obstructive patients who underwent SEMS insertion in our institution over a 3-year period. METHODS: A prospectively maintained database was reviewed to identify all patients who presented to our institution with AMCO between August 2010 and 2013 and who were treated with a SEMS either temporarily or permanently. Additional data was retrieved from chart reviews and operation notes. RESULTS: Sixteen patients (12 males, 4 females) each had a single stent inserted during the study period, either palliatively (n = 11) or as a BTS (n = 5). The technical and clinical success rates were both 87.5% (14/16). The two unsuccessful stenting cases both had disseminated disease and required emergency surgery while five patients with curable disease proceeded to elective resections. There was no procedure-related mortality or stent-related perforations. The mean (standard deviation) length of stay post acute surgery was longer than elective surgery [45 ± 21.2 vs. 15.8 ± 4.0, days]. All patients in the BTS group were stoma-free post-operatively, while both patients who had emergency surgery ended up with permanent stomas. Finally, the stent complication rate was 6.2% (1/16), secondary to migration. CONCLUSIONS: Although limited by a small sample size, the study shows that SEMS have favourable short-term outcomes. Further adequately powered trials are needed to confirm those findings.

Should patients taking aspirin for secondary prevention continue or discontinue the medication prior to elective, abdominal surgery? Best evidence topic (BET).

This best evidence topic was investigated according to a described protocol. The question asked was: should patients on acetylsalicylic acid (ASA) for secondary prevention stop or continue the medication prior to elective, abdominal surgery. Using the reported search 826 papers were found of which five represented the best evidence to answer the clinical question. The strongest evidence was from a randomized controlled trial (RCT) specifically looking at elective abdominal surgery, which showed no statistically significant difference between ASA continuation and discontinuation in terms of haemorrhagic or thrombotic events. Two other RCT's examined elective non-cardiac surgery but only a minor proportion (20.6% and 23.6%) of patients underwent abdominal surgery and data were unavailable regarding adverse events in these patients. However, one of these trials did show a 7.2% absolute risk reduction in postoperative cardiac adverse events when ASA was continued. One prospective cohort study found no difference between ASA maintenance and cessation except for longer duration of surgery in the ASA continuation group. Finally one recent retrospective cohort study revealed similar bleeding rates between ASA-treated and non-ASA-treated patients but increased cardiac complication rates in the ASA group. Only two studies compared continuation versus discontinuation of ASA, while the remaining three looked at patients on ASA versus those not on ASA. This heterogeneity in methodology makes it difficult to draw justifiable conclusions from the data. However, it appears that continuing ASA isn't associated with excessive bleeding. Further adequately powered trials with well-defined end points are needed to answer this important clinical question.

Metastatic breast cancer presenting as a gallstone ileus.

Metastatic breast cancer to the small bowel (SB) presenting as gallstone ileus and resulting in SB obstruction has not been described previously. A 76-year-old woman with previous metastatic breast cancer to the axial spine and hips presented with abdominal pain and bilious vomiting. CT scanning revealed SB obstruction consistent with gallstone ileus. The patient underwent two segmental SB resections for distal ileal strictures mimicking what appeared to be macroscopic Crohn's disease. The entero-biliary fistula was undisturbed. Pathological analysis revealed the dual pathologies of gallstone ileus and metastatic carcinoma from a breast primary causing luminal SB obstruction. Improvements in staging and treatment modalities have contributed to the increased overall long-term survival for breast cancer, compelling clinicians to consider metastatic breast cancer as a differential diagnosis in women presenting with new onset of gastrointestinal symptoms in order that appropriate treatment be administered in a timely fashion.

The effect of gastric band slippage on patient body mass index and quality of life.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a popular surgical procedure for the management of morbid obesity. Gastric band slippage (GBS) is the most common long-term complication. In this study, the effect of GBS on body mass index (BMI) and quality of life (QOL) were assessed. METHODS: This was a retrospective, case-controlled study. Patient demographics and BMI were prospectively recorded, and QOL was assessed via telephone questionnaire using the medical outcomes study short-form-36 (SF-36). The QOL of the GBS group were compared with an age, sex, and duration of follow-up matched control group who underwent uncomplicated LAGB (n = 10). RESULTS: Seventeen patients with GBS who underwent surgery were identified. Ten patients underwent band removal, and seven underwent revision surgery (six band repositioning and one Roux-en-Y gastric bypass); all were managed laparoscopically. Mean follow-up since re-operation was 17.2 ± 2.9 months. A significant increase in BMI occurred following GBS surgery (29.0 ± 1.5 vs. 33.8 ± 1.0, P = 0.035), which did not differ between the removal or revision groups. Overall, there was no difference in QOL between the GBS and control groups. On subgroup analysis, those who underwent revision surgery had a worse score in limitations in social activities because of physical or emotional problems than those who underwent band removal (92.0 ± 3.9 vs. 70.8 ± 10.0, P = 0.046). CONCLUSIONS: Following surgery for GBS, patients experience a rise in BMI. Overall, this does not affect patient QOL but may limit social activities because of physical or emotional problems in those who have band revision surgery.

Synchronous presentation of acute acalculous cholecystitis and appendicitis: a case report.

INTRODUCTION: Acute acalculous cholecystitis is traditionally associated with elderly or critically ill patients. CASE PRESENTATION: We present the case of an otherwise healthy 23-year-old Caucasian man who presented with acute right-sided abdominal pain. An ultrasound examination revealed evidence of acute acalculous cholecystitis. A laparoscopy was undertaken and the dual pathologies of acute acalculous cholecystitis and acute appendicitis were discovered and a laparoscopic cholecystectomy and appendectomy were performed. CONCLUSION: Acute acalculous cholecystitis is a rare clinical entity in young, healthy patients and this report describes the unusual association of acute acalculous cholecystitis and appendicitis. A single stage combined laparoscopic appendectomy and cholecystectomy is an effective treatment modality.