Systematic review of inframalleolar endovascular interventions and rates of limb salvage, wound healing, restenosis, rest pain, reintervention and complications.

OBJECTIVES: Peripheral artery disease is estimated to affect 237 million individuals worldwide. Critical limb ischaemia, also known as chronic limb threatening ischaemia is a consequence of the progression of peripheral artery disease which occurs in ∼21% of patients over a five-year period. The aim of this systematic review is to assess the use of additional below-the-ankle angioplasty in comparison to the use of above-the-ankle angioplasty alone, and the subsequent rates of amputation, wound healing, restenosis, rest pain, reintervention and complications. METHODS: This systematic review was undertaken in accordance with PRISMA guidelines following a registered protocol (CRD42019154893). Online databases were searched using a search strategy of 20 keywords. Included articles reported the outcome for inframalleolar (pedal artery, pedal arch, plantar arteries) angioplasty with additional proximal angioplasty in comparison to proximal angioplasty alone. GRADE assessment was applied to assess the quality of the evidence. RESULTS: After screening 1089 articles, 10 articles met the inclusion criteria. Comparative performance assessment of below-the-ankle with above-the-ankle versus above-the-ankle angioplasty alone was undertaken in 3 articles, with the remaining 7 articles reporting outcomes of below-the-ankle with above-the-ankle angioplasty with no distinct comparator group. Significant decrease in major lower limb amputation at the last follow-up in the below-the-ankle group when compared with the above-the-ankle angioplasty alone group was observed in a single study (3.45% vs. 14.9%, p < 0.05). Improved wound healing rate at follow-up in the below-the-ankle group versus above-the-ankle angioplasty alone group was also reported in a single study (59.3% vs. 38.1%, p < 0.05). Subsequent rate of amputation after below-the-ankle angioplasty has been estimated as 23.5%. CONCLUSION: To date, there is a lack of studies assessing inframalleolar interventions and their use in improving limb salvage, wound healing and symptomatology. Prospective RCTs should be undertaken with adequate participant numbers to be sufficiently powered and report clinically important end-points.

Systematic review on the benefit of graduated compression stockings in the prevention of venous thromboembolism in low-risk surgical patients.

OBJECTIVES: The aim of this systematic review is to assess the performance of graduated compression stockings (GCS) in comparison to no venous thromboembolism (VTE) prophylaxis in the prevention of hospital-acquired thrombosis in low-risk surgical patients undergoing short-stay procedures. METHODS: Aligning with PRISMA guidelines, online databases MEDLINE and EMBASE, Cochrane Library® and trial registries were searched. Eligible articles reported the VTE rate in low-risk surgical patients either receiving GCS or no VTE prophylaxis. RESULTS: Narrative synthesis was performed on a single eligible article. The included study arm consisted of participants undergoing knee arthroscopy with the use of GCS alone reporting a total of 29 VTE events (4.4%), 16 of which were asymptomatic DVTs (2.4%). CONCLUSION: There is a complete lack of evidence to support the use of GCS in the prevention of HAT for low-risk surgical patients. An adequately powered trial is required to provide level-IA evidence to support this practice.

Systematic review on the management of ileoanal pouch-vaginal fistulas after restorative proctocolectomy in the treatment of ulcerative colitis.

AIM: Ileoanal pouch-vaginal fistula (PVF) is a relatively common complication of restorative proctocolectomy with ileal pouch-anal anastomosis. There are several operative approaches in the management of PVF. There is currently no consensus as to which approach is the most effective or which should be attempted first. METHOD: A systematic review was undertaken following a publicly available protocol registered with PROSPERO (CRD42019133750) in accordance with PRISMA guidelines. Online searches of databases MEDLINE and Embase, Cochrane Library, ClinicalTrials.gov, EU Clinical Trials and ISRCTN registry were performed. RESULTS: Twenty-seven articles met the criteria for inclusion in the study: 13 retrospective cohort studies, two prospective cohort studies, eight case series, three case reports and a case-control study. A narrative synthesis was performed due to heterogeneity between included articles. Our study included 577 PVFs, and the incidence rate was 2.1%-17.1%. Both local and abdominal approaches were used in the management of PVF. The overall success of local and abdominal procedures was 44.9% and 60.2% respectively. ROBINS-I assessment revealed a critical risk of bias. GRADE assessment indicated a very low certainty in effect size and evidence quality. CONCLUSION: Local interventions and abdominal approaches have a high failure rate. The results of this review will aid the counselling of patients with this condition. Furthermore, we provide an algorithm for discussion on the management of PVF based on experience at our local centre. The studies available on the management of PVF are low quality; a large prospective registry and Delphi consensus are required to further this area of research.

A systematic review of the management of synthetic mesh erosion of the rectum following urogynaecological surgery.

AIM: Synthetic rectal mesh erosion is a challenging complication following urogynaecological surgery. The aim of this study was to determine the optimal management of rectal mesh erosion following urogynaecological surgery. METHOD: A systematic review was undertaken following a pre-defined protocol registered with PROSPERO (CRD42018112425) in accordance with PRISMA guidelines. Searches of MEDLINE online database, Cochrane Library and clinical trial registries (ClinicalTrials.gov, EU Clinical Trials, ISRCTN registry) were performed. The included articles were heterogeneous - therefore a narrative synthesis was performed. RESULTS: Fourteen studies were included in the review: 11 case reports, one case series, one retrospective cohort and one prospective multicentre trial. Fourteen rectal mesh erosions were identified. Eight (57%) of the rectal erosions underwent major abdominal surgery. In two of these cases, the abdominal approach was used only after failure of the transanal route. Five (36%) of the mesh erosions were managed using a transanal approach. In one case, the mesh passed without intervention. CONCLUSION: Synthetic rectal mesh erosion can be managed successfully via either a transanal or a transabdominal approach with a partial or complete excision of the mesh. An examination under anaesthetic with an attempted transanal removal of mesh should be considered the first step in the management of this condition before consideration of more invasive surgery.