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.

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.

Short-stay compared to long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis.

PURPOSE: Short-stay admissions, with lengths of stay less than 24 h, are used for various surgeries without increasing adverse events. However, it is unclear if short-stay admissions would be safe for loop ileostomy reversals. This review aimed to compare outcomes between short (≤24 hours) and long (>24 hours) admissions for adults undergoing loop ileostomy reversals. METHODS: Medline, Embase, CINAHL, Web of Science, and the Cochrane Library were systematically searched for studies comparing short- to long-stay admissions in adults undergoing loop ileostomy reversals. Meta-analyses were conducted for mortality, reoperation, readmission, and non-reoperative complications. Quality of evidence was assessed with grading of recommendations, assessment, development, and evaluations (GRADE) guidelines. RESULTS: Four observational studies enrolling 24,628 patients were included. Moderate certainty evidence suggests there is no difference in readmissions between short- and long-stay admissions (relative risk (RR) 0.98, 95% CI 0.75 to 1.28, p 0.86). Low certainty evidence demonstrates that short stays may reduce non-reoperative complications (RR 0.44, 95% CI 0.31 to 0.62, p < 0.01). Very low certainty evidence demonstrates that there is no difference in reoperations between short and long stays (RR 1.14, 95% CI 0.26 to 5.04, p 0.87). CONCLUSIONS: Moderate certainty evidence demonstrates that there is no difference in readmission rates between short- and long-stay admissions for loop ileostomy reversals. Less robust evidence suggests equivalence in reoperations and a decrease in non-reoperative complications. Future prospective trials are required to evaluate the feasibility and efficacy of short-stay admissions. TRIAL REGISTRATION: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307381 Prospero (CRD42022307381), January 30, 2022.

Intravenous acetaminophen for postoperative pain control after open abdominal and thoracic surgery in pediatric patients: a systematic review and meta-analysis.

Pediatric opioid exposure increases short- and long-term adverse events (AE). The addition of intravenous acetaminophen (IVA) to pediatric pain regimes to may reduce opioids but is not well studied postoperatively. Our objective was to quantify the impact of IVA on postoperative pain, opioid use, and AEs in pediatric patients after major abdominal and thoracic surgery. Medline, Embase, CINAHL, Web of Science, and Cochrane Library were searched systematically for randomized controlled trials (RCTs) comparing IVA to other modalities. Five RCTs enrolling 443 patients with an average age of 2.12 years (± 2.81) were included. Trials comparing IVA with opioids to opioids alone were meta-analyzed. Low to very low-quality evidence demonstrated equivalent pain scores between the groups (-0.23, 95% CI -0.88 to 0.40, p 0.47) and a reduction in opioid consumption (-1.95 morphine equivalents/kg/48 h, 95% CI -3.95 to 0.05, p 0.06) and minor AEs (relative risk 0.39, 95% CI 0.11 to 1.43, p 0.15). We conclude that the addition of IVA to opioid-based regimes in pediatric patients may reduce opioid use and minor AEs without increasing postoperative pain. Given the certainty of evidence, further research featuring patient-important outcomes and prolonged follow-up is necessary to confirm these findings.

Same-day discharge is safe and feasible following POEM surgery for esophageal motility disorders.

INTRODUCTION: Per-oral endoscopic myotomy (POEM) is an effective treatment for achalasia and other esophageal dysmotility disorders. Current practices surrounding post-operative care involve admission and routine esophagogram prior to discharge. This study aims to establish the safety and feasibility of same-day discharge following POEM. METHODS: Retrospective analysis of prospectively collected data for patients who underwent POEM between November 2013 and June 2019 at a single institution in Ontario, Canada. Patients were discharged home on the same day with controlled pain, when tolerating clear fluids. Patients were admitted if clinically indicated. Esophagography was initially a systematic practice prior to discharge, but later only performed when clinically indicated. Emergency department visits and hospital admissions within 90 days were assessed. RESULTS: In total, 90 patients underwent a successful POEM procedure. A total of 72 patients (79.1%) were discharged on the same day, 14 patients (15.4%) were discharged home the following day, and 5 patients (5.5%) experienced longer admissions to hospital. One POEM was unsuccessful. 22 (24.2%) patients had adverse events, leading to 8 (8.8%) unplanned admissions, with one patient requiring prolonged admission for esophageal leak, identified clinically. Fifty-three patients underwent routine esophagography while part of our protocol, with no identified leak, which prompted our change in practice to only perform esophagography when clinically indicated. In the 90-day post-procedure, ten patients visited the emergency department, of which seven were re-admitted, five for POEM-related issues. Our mean Eckhardt score at 2 weeks was 2.1 from 7.2 preoperatively. CONCLUSION: This study establishes that same-day discharge is both safe and feasible following POEM and suggests that esophagography should be performed only when clinically indicated. This represents a shift from the routine practice of admission and imaging for patients undergoing POEM, encouraging the transition to outpatient POEM procedures.