Validation of the size morphology site access score in endoscopic mucosal resection of large polyps in a district general hospital.

BACKGROUND: Polyp assessment is multimodal and is vital prior to endoscopic mucosal resection. The size, morphology, site and access (SMSA) score has been validated in specialist endoscopic institutions. this study investigated the ability of this score to predict incomplete endoscopic resection of large colorectal polyps in a district general hospital. METHODS: Consecutive patients undergoing endoscopic mucosal resection of large (≥ 20 mm) colorectal polyps at Worthing Hospital. Clinical, endoscopic and histological data were taken from prospective databases. The primary outcome of the study was to investigate the correlation of the SMSA score with incomplete endoscopic resection. RESULTS: Between February 2015 and August 2018, 114 patients underwent colorectal endoscopic mucosal resection. Of these, 67 (59%) were male. The median (interquartile range) age of the study population was 72 years (65-78 years). Some 17 lesions (15%) were pedunculated, 76 (67%) were sessile and 21 were (18%) flat; 84 polyps (77%) were located in the left colon/rectum, with the remainder in the right colon; 51 lesions (45%) were 20-30 mm, 27 (24%) were 30-40 mm and 36 (31%) were greater than 40 mm in diameter. When reclassified into the SMSA score, 9 of the polyps (8%) were level 2, 64 (56%) were level 3 and 41 (36%) were level 4. Incomplete resection was clinically diagnosed in 9/114 (8%). The SMSA score was positively correlated with incomplete endoscopic resection, but not with additional procedure usage, complications or advanced histology. CONCLUSIONS: Many patients with large polyps can be managed outside of specialist units. This study has validated that the SMSA score was associated with incomplete endoscopic mucosal resection for large polyps in a district general hospital setting.

Prolene hernia system versus Lichtenstein repair for inguinal hernia: a meta-analysis.

BACKGROUND: Lichtenstein repair is standard practice for inguinal herniorrhaphy, but there is increasing public concern in the use of mesh and postoperative chronic pain. New mesh technology, such as the prolene hernia system, has a preperitoneal component to reinforce the myopectineal orifice aim to reduce the risk of recurrence and chronic pain. This meta-analysis compares outcomes using prolene hernia system versus lichenstein repair for inguinal hernias. METHODS: Randomized-controlled trials comparing prolene hernia system and Lichtenstein repair were identified using Embase, Medline, and published conference abstracts. Primary outcomes were recurrence and chronic pain. Secondary outcomes were mean operating time, composite complications, surgical reintervention, and time to normal activities. Odds ration and standardized mean differences were calculated. RESULTS: 1377 hernia repairs were identified from a total of 7 trials. Mean follow-up was 12-91 months. There was no difference between the techniques for recurrence [pooled analysis odds ratio: 0.86 (95% CI 0.32-2.28); p = 0.76] and chronic pain [pooled analysis odds ratio: 1.00 (95% CIs 0.65-1.55); p = 1]. Prolene hernia system demonstrated a shorter time to return to normal activities [pooled weighted mean difference - 0.54 (95% CI - 1.07 to - 0.01); p = 0.04]. Other outcomes were similar in mean operating time, composite complications, and surgical reintervention. CONCLUSION: Both prolene hernia system and Lichenstein repair appear comparable acceptable techniques for inguinal herniorrhaphy. Further longer-term studies of new mesh technologies will improve information available to surgeons and their patients.

Early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resections: an integrated systematic review and meta-analysis of published randomized controlled trials.

AIMS: The objective of this study was to evaluate the surgical outcomes and feasibility of early loop defunctioning ileostomy closure, within 2 weeks of index surgery, in patients undergoing distal colorectal resection. METHODS: A systematic review of the literature on published randomized controlled trials reporting the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection using the principles of meta-analysis on RevMan 5.4 statistical software was undertaken. RESULTS: Four randomized, controlled trials on 446 patients evaluating the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing low colorectal resection were analysed. There were 176 patients in the early closure group and 270 patients in the delayed closure group. The risk of anastomotic leak [risk ratio 0.37 (CI: 0.10-1.42), P = 0.15], anastomotic stenosis [risk ratio 4.79 (CI: 0.23-98.47), P = 0.31] and postoperative complications [risk ratio 0.75 (CI: 0.48-1.16), P = 0.19] was similar in both groups. In addition, there was no significant difference between the groups with regard to the duration of operation [standardized mean difference -0.49 (CI: -01.09, -0.12), P = 0.12] and length of hospitalization [standardized mean difference -0.04 (CI: -0.25, -0.18), P = 0.75]. CONCLUSIONS: Early closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection is feasible with comparable outcomes to delayed closure.

A systematic review comparing single-incision versus multi-incision laparoscopic surgery for inguinal hernia repair with mesh.

OBJECTIVE: The objective of this article is to evaluate whether the surgical outcomes differ between single incision laparoscopic surgery (SILS) versus multi-incision laparoscopic surgery (MILS) for the repair of inguinal hernia. METHODS: A systematic review of the literature on published studies reporting the surgical outcomes following SILS versus MILS for inguinal hernia repair was undertaken using the principles of meta-analysis. RESULTS: Fifteen comparative studies on 1651 patients evaluating the surgical outcomes in patients undergoing SILS versus MILS for inguinal hernia repair were systematically analysed. The post-operative recovery time was significantly quicker [odds ratio, -0.35 (CI, -0.57 - 0.14), p = 0.001] following SILS compared to MILS procedure. However, the statistical equivalence was seen in outcomes of length of hospital stay, operative time both for unilateral and bilateral hernias, post-operative pain score, one-week pain score, hernia recurrence [odds ratio, 1.24 (CI, 0.47-3.23), p = 0.66], conversion [odds ratio, 1.07 (CI, 0.37-3.12), p = 0.90], and post-operative complications [odds ratio, 0.95 (CI, 0.66-1.36, p = 0.78] between two approaches. The sub-group analysis of four included randomized, controlled trials showed similarities between outcomes following SILS and MILS except slightly higher postoperative pain score in MILS group. CONCLUSIONS: Both SILS and MILS approaches of inguinal hernia repair are feasible, safe and can be offered to patients depending upon the availability of expertise and resources.

Local anaesthetic infiltration for the rubber band ligation of early symptomatic haemorrhoids: a systematic review and meta-analysis.

The objective of this article is to systematically analyse the randomized, controlled trials evaluating the effectiveness of local anaesthetic infiltration prior to the rubber band ligation of early symptomatic haemorrhoids. Published randomized, controlled trials comparing the use of local anaesthetic (LA) versus no-local anaesthetic (NLA) for the rubber band ligation of early symptomatic haemorrhoids were analysed using RevMan®, and the combined outcomes were expressed as odds ratios (OR) and standardized mean difference (SMD). Four randomized, controlled trials evaluating 387 patients were retrieved from the standard electronic databases. The risk of treatment failure (OR 0.44; 95% CI 0.07, 2.79; z = 0.87; p = 0.39) and post-procedure complications (OR 0.48; 95% CI 0.08, 2.76; z = 0.83; p = 0.41) was similar between two techniques. However, the post-procedure pain score (SMD -5.19; 95% CI -9.08, -1.30; z = 2.62; p < 0.009) was significantly lower in the group of patients undergoing rubber band ligation of haemorrhoids under local anaesthetic injection. The use of LA appears to have clinically measurable advantages over NLA in the rubber band ligation of early symptomatic haemorrhoids to lessen post-procedure pain.

Carbon dioxide insufflation vs conventional air insufflation for colonoscopy: a systematic review and meta-analysis of published randomized controlled trials.

AIM: Conventional air insufflation (AI) may cause prolonged abdominal bloating, excessive abdominal pain and discomfort during colonoscopy. Carbon dioxide may be an acceptable alternative to avoid these complications. The object of this study was to evaluate systematically the effectiveness of carbon dioxide insufflation (CI) for colonoscopy compared with AI. METHOD: Randomized controlled trials (RCTs) comparing the effectiveness of CI with that of AI during colonoscopy were retrieved from medical electronic databases and combined analysis was performed using the RevMan statistical package. The combined outcome of dichotomous and continuous variables was expressed as an odds ratio (OR) and standardized mean difference (SMD). RESULTS: Twenty-one RCTs comprising 3607 patients were included in the study. There was statistically significant heterogeneity among included studies. CI showed a significant trend towards reduced procedural pain [SMD -1.34; 95% confidence interval (95% CI) -2.23 to -0.45; z = 2.96; P < 0.003] and also postprocedural pain at 1 h (SMD -1.11; 95% CI -1.83 to -0.38; z = 2.97; P < 0.003), 6 and 24 h (OR 0.44; 95% CI 0.23-0.85; z = 2.44; P < 0.01). CI was associated with faster caecal intubation (SMD -0.20; 95% CI -0.37 to -0.02; z = 2.23; P < 0.03) but the caecal intubation rate was similar (P = 0.59) in both colonic insufflation techniques . CONCLUSION: CI seems to have clinical advantages over AI for colonoscopy with regard to pain during and after the procedure.

Use of transanal minimally invasive surgery for endoscopic resection of rectal tumour: a technical note.

BACKGROUND: The aim of this article is to report and discuss a case of lower rectal cancer undergoing endoscopic transanal resection of tumour (ETART) using a transanal minimally invasive surgery (TAMIS) approach. METHODS: A technical note on a case report. An innovative approach for ETART using TAMIS. RESULTS: This is the first-ever case report of lower rectal cancer treated by ETART using a TAMIS approach. The procedure was completed successfully without any operative or peri-operative complication. Peri-operative flexible sigmoidoscopy confirmed a wide and patent rectal lumen. CONCLUSION: Use of a TAMIS approach for ETART to remove lower rectal cancer for palliation can be technically very effective compared with conventional ETART, due to the potential advantages of avoiding contaminant fluid spillage, easy access, better visualization compared with conventional ETART, and being user-friendly. The results from larger cohorts of patients undergoing TAMIS ETART are required before recommending the routine use of this technique. However, until then, this approach may be considered as an alternative to conventional ETART.

Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer.

AIM: A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery (TEMS) with radical resection (RR) for T1 and T2 rectal cancer. METHOD: An electronic search was carried out of trials reporting the effectiveness of TEMS and RR in the treatment of T1 and T2 rectal cancers. RESULTS: Ten trials including 942 patients were retrieved. There was a trend toward a higher risk of local recurrence (odds ratio 2.78; 95% confidence interval 1.42, 5.44; z = 2.97; P < 0.003) and overall recurrence (P < 0.01) following TEMS compared with RR. The risk of distant recurrence, overall survival (odds ratio 0.90; 95% confidence interval 0.49, 1.66; z = 0.33; P = 0.74) and mortality was similar. TEMS was associated with a shorter operation time and hospital stay and a reduced risk of postoperative complications (P < 0.0001). The included studies, however, were significantly diverse in stage and grade of rectal cancer and the use of neoadjuvant chemoradiotherapy. CONCLUSION: Transanal endoscopic microsurgery appears to have clinically measurable advantages in patients with early rectal cancer. The studies included in this review do not allow firm conclusions as to whether TEMS is superior to RR in the management of early rectal cancer. Larger, better designed and executed prospective studies are needed to answer this question.

Retraction techniques in laparoscopic colorectal surgery: a literature-based review.

AIM: To systematically review the published literature and describe the various techniques of bowel and mesentery retraction available for use in laparoscopic colorectal resection. METHOD: A comprehensive search of the literature was undertaken using MESH terms 'retraction', 'laparoscopic' and 'colorectal'. All articles describing methods of retraction in laparoscopic colorectal surgery were included. RESULTS: Twelve methods of retraction in laparoscopic colorectal surgery were described. Five case-based series and three case studies were reported on 108 patients. Techniques were classified into those offering retraction of the small or large bowel or according to the mode of retraction. CONCLUSION: Many retraction methods are available to the surgeon varying in cost, invasiveness and complexity. Adequate retraction remains a challenge for optimal exposure and dissection during laparoscopic colorectal surgery.

Systematic review and meta-analysis of published, randomized, controlled trials comparing suture anastomosis to stapled anastomosis for ileostomy closure.

The objective of this article is to systematically analyze the randomized, controlled trials comparing the effectiveness of suture anastomosis (SUA) versus stapled anastomosis (STA) in patients undergoing ileostomy closure. Randomized, controlled trials comparing the effectiveness of SUA versus STA in patients undergoing ileostomy closure were analyzed using RevMan(®), and combined outcomes were expressed as odds risk ratio (OR) and standardized mean difference (SMD). Four randomized, controlled trials that recruited 645 patients were retrieved from electronic databases. There were 327 patients in the STA group and 318 patients in the SUA group. There was significant heterogeneity among included trials. Operative time (SMD -1.02; 95 % CI -1.89, -0.15; z = 2.29; p < 0.02) was shorter following STA compared to SUA. In addition, risk of small bowel obstruction (OR 0.54; 95 % confidence interval (CI), 0.30, 0.95; z = 2.13; p < 0.03) was lower in the STA group. Risk of anastomotic leak (OR 0.87; 95 % CI 0.12, 6.33; z = 0.14; p = 0.89), surgical site infection, reoperation and readmission were similar following STA and SUA in patients undergoing ileostomy closure. Length of hospital stay was also similar between STA and SUA groups. In ileostomy closure, STA was associated with shorter operative time and lower risk of postoperative small bowel obstruction. However, STA and SUA were similar in terms of anastomotic leak, surgical site infection, readmission, reoperations and length of hospital stay.

Use of antibacterial sutures for skin closure in controlling surgical site infections: a systematic review of published randomized, controlled trials.

OBJECTIVE: The objective of this article is to systematically analyse the randomized, controlled trials that compare the use of antibacterial sutures (ABS) for skin closure in controlling surgical site infections. METHODS: Randomized, controlled trials on surgical patients comparing the use of ABS for skin closure in controlling the surgical site infections were analysed systematically using RevMan® and combined outcomes were expressed as odds ratios (OR) and standardized mean differences (SMD). RESULTS: Seven randomized, controlled trials evaluating 1631 patients were retrieved from electronic databases. There were 760 patients in the ABS group and 871 patients in the simple suture group. There was moderate heterogeneity among trials (Tau(2) = 0.12; chi(2) = 8.40, df = 6 [P < 0.01]; I(2) = 29%). Therefore in the random-effects model, the use of ABS for skin closure in surgical patients was associated with a reduced risk of developing surgical site infections (OR, 0.16; 95% CI, 0.37, 0.99; z = 2.02; P < 0.04) and postoperative complications (OR, 0.56; 95% CI, 0.32, 0.98 z = 2.04; P = 0.04). The durations of operation and lengths of hospital stay were similar following the use of ABS and SS for skin closure in patients undergoing various surgical procedures. CONCLUSION: Use of ABS for skin closure in surgical patients is effective in reducing the risk of surgical site infection and postoperative complications. ABS is comparable with SS in terms of length of hospital stay and duration of operation.

Open transinguinal preperitoneal mesh repair of inguinal hernia: a targeted systematic review and meta-analysis of published randomized controlled trials.

OBJECTIVE: The objective of this article is to systematically analyse the randomized, controlled trials comparing transinguinal preperitoneal (TIPP) and Lichtenstein repair (LR) for inguinal hernia. METHODS: Randomized, controlled trials comparing TIPP vs LR were analysed systematically using RevMan® and combined outcomes were expressed as risk ratio (RR) and standardized mean difference. RESULTS: Twelve randomized trials evaluating 1437 patients were retrieved from the electronic databases. There were 714 patients in the TIPP repair group and 723 patients in the LR group. There was significant heterogeneity among trials (P < 0.0001). Therefore, in the random effects model, TIPP repair was associated with a reduced risk of developing chronic groin pain (RR, 0.48; 95% CI, 0.26, 0.89; z = 2.33; P < 0.02) without influencing the incidence of inguinal hernia recurrence (RR, 0.18; 95% CI, 0.36, 1.83; z = 0.51; P = 0.61). Risk of developing postoperative complications and moderate-to-severe postoperative pain was similar following TIPP repair and LR. In addition, duration of operation was statistically similar in both groups. CONCLUSION: TIPP repair for inguinal hernia is associated with lower risk of developing chronic groin pain. It is comparable with LR in terms of risk of hernia recurrence, postoperative complications, duration of operation and intensity of postoperative pain.

Systematic review of the use of topical diltiazem compared with glyceryltrinitrate for the nonoperative management of chronic anal fissure.

AIM: The study analyzed clinical trials investigating the effectiveness of diltiazem (DTZ) and glyceryltrinitrate (GTN) for the nonsurgical management of chronic anal fissure (CAF). METHOD: Randomized trials on the effectiveness of DTZ and GTN were analyzed systematically using RevMan(®) where combined outcome was expressed as risk ratio (RR). RESULTS: Seven randomized controlled trials that included 481 patients were analyzed. Two-hundred and thirty-eight patients were treated with DTZ and 243 patients were treated with GTN. There was significant heterogeneity [Tau(2) = 0.24, χ2 = 13.16, d.f. = 6 (P < 0.05); I(2) = 54%] among the included trials. In the random-effects model, DTZ was associated with a lower incidence of side effects (RR = 0.48; 95% CI = 0.27, 0.86; z = 2.46; P < 0.01), headache (RR = 0.39; 95% CI = 0.24, 0.66; z = 3.54; P < 0.004) and recurrence (RR = 0.68; 95% CI = 0.52, 0.89; z = 2.77; P < 0.006) of CAF. Both GTN and DTZ were equally effective (RR = 1.10; 95% CI = 0.90, 1.34; z = 0.92; P = 0.36) in the nonsurgical management of CAF. CONCLUSION: This systematic review of seven trials validates and strengthens the finding of a previously published meta-analysis of two randomized trials. Both DTZ and GTN are equally effective in the management of CAF. However, DTZ is associated with a lower incidence of headache and recurrent fissure. Therefore DTZ should be the preferred first line of treatment for CAF.

Suture mesh fixation versus glue mesh fixation in open inguinal hernia repair: a systematic review and meta-analysis.

OBJECTIVE: To systematically analyse the trials comparing suture mesh fixation (SMF) versus glue mesh fixation (GMF) in open inguinal hernia repair (OIHR). METHODS: Trials comparing the SMF versus GMF in OIHR were analysed systematically using RevMan(®), and combined outcomes were expressed as risk ratio (RR) and standardised mean difference (SMD). RESULTS: Seven randomised controlled trials encompassing 1259 patients were retrieved from the electronic databases. There were 628 patients in the SMF group and 653 patients in the GMF group. In the meta-analysis, postoperative complications (RR, 1.07; 95% CI, 0.72, 1.58; z = 0.34; p = 0.74), postoperative pain (SMD, 0.31; 95% CI, -0.03, 0.64; z = 1.81; p = 0.07), chronic groin pain (RR, 1.60; 95% CI, 0.78, 3.28; z = 1.28; p = 0.20) and length of hospital stay (SMD, 0.06; 95% CI, -0.08, 0.20; z = 0.82; p = 0.41) were statistically comparable between two techniques of mesh fixation in OIHR. However, GMF was associated with a reduced operating time (SMD, 0.15; 95% CI, 0.03, 0.26; z = 2.38; p = 0.02). CONCLUSION: GMF is comparable to SMF in terms of postoperative complications, postoperative pain, chronic groin pain and length of hospital stay. GMF is associated with a reduced operative time compared with SMF. Based on the results of this review the GMF approach may be considered as an alternative for mesh fixation in OIHR. Results should be interpreted cautiously due to relatively short follow up time in studies. A major, multicentre randomised, controlled trial is required to validate these findings.

A meta-analysis examining the use of tacker fixation versus no-fixation of mesh in laparoscopic inguinal hernia repair.

OBJECTIVE: The objective of this article is to systematically analyse the randomised, controlled trials comparing tacker mesh fixation (TMF) versus no-mesh fixation (NMF) in laparoscopic inguinal hernia repair (LIHR). METHODS: Randomised, controlled trials comparing TMF versus NMF in LIHR were analysed systematically using RevMan(®), and combined outcomes were expressed as risk ratio (RR) and standardised mean difference (SMD). RESULTS: Eight randomised, controlled trials encompassing 1386 patients were retrieved from the electronic databases. There were 691 patients in the TMF group and 695 patients in the NMF group. Statistically there was non-significant heterogeneity among trials. In random effects models, operating time (p = 0.15), post-operative pain (p = 0.45), post-operative complications (p = 0.55) and length of hospital stay (p = 0.11) were statistically comparable between two techniques of mesh fixation in LIHR. The risk of developing chronic groin pain (p = 0.67) and risk of hernia recurrence (p = 0.77) was also similar. CONCLUSION: NMF in LIHR does not increase the risk of hernia recurrence. It is comparable with TMF in terms of operation time, post-operative pain, post-operative complications, length of hospital stay and chronic groin pain. Therefore, based upon the results of this review NMF approach may be adopted routinely and safely in LIHR.

Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair.

BACKGROUND: The objective of this study was systematically to analyse published randomized trials comparing lightweight mesh (LWM) with heavyweight mesh (HWM) in open inguinal hernia repair. METHODS: Randomized trials on LWM versus HWM were selected from the standard electronic databases. Reported outcomes were analysed systematically using RevMan. Pooled risk ratios were calculated for categorical outcomes, and mean differences for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis. RESULTS: Nine randomized trials containing 2310 patients were included. There was significant heterogeneity among trials. There was no difference in duration of operation, postoperative pain, recurrence rate, testicular atrophy and time to return to work between LWM and HWM groups. The two mesh types had a similar risk of perioperative complications, but LWM was associated with a reduced risk of developing chronic groin pain (risk ratio (RR) 0·61, 95 per cent confidence interval 0·50 to 0·74) and a reduced risk of developing other groin symptoms, such as stiffness and foreign body sensations (RR 0·64, 0·50 to 0·81). CONCLUSION: The use of LWM for open inguinal hernia repair was not associated with an increased risk of hernia recurrence. LWM reduced the incidence of chronic groin pain as well as the risk of developing other groin symptoms.

A systematic review comparing transanal haemorrhoidal de-arterialisation to stapled haemorrhoidopexy in the management of haemorrhoidal disease.

BACKGROUND: The aim of this study was to systematically analyse the clinical trials on the effectiveness of transanal haemorrhoidal de-arterialisation (THD) and stapled haemorrhoidopexy (SH) in the management of haemorrhoidal disease (HD). METHODS: Clinical trials on the effectiveness of THD and SH in the management of HD were analysed systematically using RevMan(®), and combined outcomes were expressed as risk ratio (RR) and mean difference (MD). RESULTS: Three randomised, controlled trials encompassing 150 patients were analysed systematically. There were 80 THD patients and 70 SH patients. There was no significant heterogeneity (P = 0.40) among included trials. Therefore, in the fixed effects model, THD and SH were statistically equivalent in terms of treatment success rate (P = 0.19), operation time (P = 0.55), postoperative complications (P = 0.11) and recurrence (P = 0.46) of HD. THD was associated with significantly less postoperative pain (MD, -2.00; 95% CI, -2.06, -1.94; z = 63.59; P < 0.00001) compared to SH. CONCLUSIONS: Both THD and SH are equally effective and can be attempted for the management of HD. However, THD is associated with significantly lesser postoperative pain and therefore may be considered a preferred procedure. This conclusion is based only on treating 150 patients by THD or SH in three moderate-quality randomised trials. A major, multicenter, randomised trial is required to validate this conclusion and investigate other variables like hospital stay, cost-effectiveness and health-related quality of life measurement.

A systematic review on the effectiveness of slowly-absorbable versus non-absorbable sutures for abdominal fascial closure following laparotomy.

OBJECTIVE: To systematically analyse the effectiveness of delayed-absorbable (Polydioxanone; PDS) versus non-absorbable (Polypropylene; Prolene, and Nylon) for abdominal fascial closure in patients undergoing laparotomy. METHODS: Randomised trials evaluating PDS versus Prolene/Nylon for abdominal fascial closure were selected and analysed by using the statistical tool RevMan where summative data was expressed as odds ratio (OR). RESULTS: Eight randomised trials encompassing 4261 patients undergoing laparotomy closure with either PDS or Prolene/Nylon were retrieved. There was no statistically significant heterogeneity among trials. In the fixed effect model PDS was comparable to Prolene/Nylon in terms of risk of incisional hernia (OR, 1.10; 95% CI, 0.87, 1.37; z = 0.79; p = 0.43), wound dehiscence (OR, 1.04; 95% CI, 0.67, 1.62; z = 0.19; p = 0.85), peri-operative complications (OR, 0.94; 95% CI, 0.66, 1.33; z = 0.37; p = 0.71), suture sinus formation (OR, 0.58; 95% CI, 0.33, 1.04; z = 1.84; p = 0.07) and surgical site infection (OR, 0.98; 95% CI, 0.68, 1.39; z = 0.14; p = 0.89). Subgroup analysis separately comparing Prolene and Nylon with PDS supported same outcome. CONCLUSION: PDS and Prolene/Nylon are equally effective for the closure of abdominal fascia following laparotomy. Given that there are no significant differences between two suture materials, further studies may be conducted to evaluate their cost-effectiveness and measurement of health-related quality of life instead of analysing their effectiveness in laparotomy closure.

Lithotomy-related neurovascular complications in the lower limbs after colorectal surgery.

AIM: To review the literature on lithotomy-related neurovascular complications (LRNVC) of the lower limbs after colorectal surgery. METHOD: Electronic databases were searched for relevant articles, including Medline, EMBASE, Pubmed, CENTRAL and CINHL. RESULTS: LRNVC after prolonged lithotomy position during colorectal surgery can be classified into vascular, neurological and neurovascular combined. Compartment syndrome (CS) is the most common clinical presentation. Seven case reports and 10 case series on 34 patients (27 men, 6 women) with CS have been reported. Risk factors included the lithotomy position and duration of surgery of more than 4 h. CONCLUSION: In colorectal surgery, lower limb LRNCVs, and CS are rare. A high index of clinical suspicion and early decompression may reduce morbidity.

Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis.

BACKGROUND: We performed a meta-analysis of published literature comparing the complications after open and laparoscopic elective sigmoidectomy for diverticular disease. METHODS: Electronic databases were searched from January 1991 to March 2009. A systematic review was performed to obtain a summative outcome. RESULTS: Nineteen comparative studies involving 2,383 patients were analyzed. There were 1,014 patients in the laparoscopic group and 1,369 patients in the open group. There was no significant heterogeneity among any of the complications analyzed. Patients in the laparoscopic sigmoid resection group had fewer wound infections (fixed effects model: risk ratio [RR], .54; 95% confidence interval [CI], .36-.80; z, -3.05; P < .01; random effects model: RR, .59; 95% CI, .39-.89; z, -2.54; P < .05), blood transfusions (fixed effects model: RR, .25; 95% CI, .10-.60; z, -3.10; P < .01; random effects model: RR, .28; 95% CI, .11-.68; z, -2.81; P < .01), and ileus rates (fixed effects model: RR, .37; 95% CI, .20-.66; z, -3.34; P = .001; random effects model: RR, .37; 95% CI, .20-.68; z, -3.21; P = .001) compared with open sigmoid resections. No difference was seen for medical complications, need for rehospitalization, and reoperation. CONCLUSIONS: Laparoscopic sigmoid resection is safe and has fewer postoperative surgical complications. This approach should be considered for elective cases, however, more randomized controlled trials are required to strengthen the evidence.