Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ

BACKGROUND: There is no clear consensus on the better therapeutic approach (endoscopic versus surgical) to choledocholithiasis. This study is a meta-analysis of the available evidence. METHODS: A search of the Medline and ISI databases identified 12 studies that met the inclusion criteria for data extraction. The analysis was performed using a random-effects model. The outcome was calculated as an odds ratio (OR) or relative risk (RR) with 95 per cent confidence intervals (c.i.). RESULTS: Outcomes of 1357 patients were studied. There was no significant difference in successful duct clearance (OR 0.85 (95 per cent c.i. 0.64 to 1.12); P = 0.250), mortality (RR 1.79 (95 per cent c.i. 0.66 to 4.83); P = 0.250), total morbidity (RR 0.89 (95 per cent 0.71 c.i. to 1.13); P = 0.350), major morbidity (RR 1.34 (95 per cent c.i. 0.92 to 1.97); P = 0.130) or need for additional procedures (OR 1.37 (95 per cent c.i. 0.82 to 2.29); P = 0.230) between the endoscopic and surgical groups. There was also no significant difference between the endoscopic and laparoscopic surgery groups. CONCLUSION: Both approaches have similar outcomes, and treatment should be determined by local resources and expertise.     

Serum adiponectin levels in cholesterol and pigment cholelithiasis

BACKGROUND: Altered adiponectin levels are associated with metabolic abnormalities. The aim of this study was to explore the role of adiponectin in cholelithiasis. METHODS: A radioimmunoassay was used to determine serum adiponectin levels in 58 patients with cholesterol gallstones and 47 with pigment gallstones, and 101 healthy controls. The chemical composition of extracted gallstones was determined by Fourier transform infrared spectroscopy. RESULTS: The mean(s.d.) adiponectin level was decreased in patients with cholesterol gallstones (7.6(4.1) microg/ml; P < 0.001) but raised in patients with pigment gallstones (17.9(9.0) microg/ml; P < 0.001) in comparison with healthy controls (11.7(6.5) microg/ml). Decreased adiponectin levels (odds ratio (OR) 0.85 (95 per cent confidence interval (c.i.) 0.76 to 0.96); P = 0.008) and female sex (OR 6.06 (95 per cent c.i. 2.10 to 17.46); P = 0.001) were associated with cholesterol gallstone formation. Increased adiponectin levels (OR 1.11 (95 per cent c.i. 1.01 to 1.22); P = 0.025) and increased age (OR 1.06 (95 per cent c.i. 1.01 to 1.12); P = 0.029) were associated with pigment gallstone formation. Raised serum aspartate aminotransferase concentration was a risk factor for both cholesterol (OR 1.16 (95 per cent c.i. 1.03 to 1.30); P = 0.013) and pigment (OR 1.23 (95 per cent c.i. 1.10 to 1.38); P < 0.001) gallstones. CONCLUSION: Gallstone formation is associated with altered serum adiponectin levels. Serum adiponectin might serve as a novel marker for cholesterol and pigment cholelithiasis.     

Impact of surgeon volume and specialization on short-term outcomes in colorectal cancer surgery

BACKGROUND: Several studies have shown a relationship between surgeon volume and outcomes in colorectal cancer surgery. The aim of this study was to determine the impact of surgeon volume and specialization on primary tumour resection rate, restoration of bowel continuity following rectal cancer resection, anastomotic leakage and perioperative mortality. METHODS: The Northern Region Colorectal Cancer Audit Group conducts a population-based audit of patients with colorectal cancer managed by surgeons. This study examined 8219 patients treated between 1998 and 2002. Outcomes were modelled using multivariate logistic regression analysis. RESULTS: Tumour resection was performed in 6949 (93.8 per cent) of 7411 patients. High-volume surgeons with an annual caseload of at least 18.5 (odds ratio (OR) 1.53 (95 per cent confidence interval (c.i.) 1.10 to 2.12); P = 0.012) and colorectal specialists (OR 1.42 (95 per cent c.i. 1.06 to 1.90); P = 0.018) were more likely to perform elective sphincter-saving rectal surgery. In elective surgery, the risk of perioperative death was lower for high-volume surgeons (OR 0.58 (95 per cent c.i. 0.44 to 0.76); P < 0.001), but this was not the case in emergency surgery. CONCLUSION: High-volume surgeons had lower perioperative mortality rates for elective surgery, and were more likely to use restorative rectal procedures.     

Hospital volume does not influence long-term survival of patients undergoing surgery for oesophageal or gastric cancer

BACKGROUND: Guidelines suggest that surgery for oesophageal and gastric cancer should be conducted in large cancer centres. This national study examined the relationship between hospital volume and outcome in Scotland. METHODS: This was a prospective, population-based study of 3293 consecutive patients with oesophageal or gastric cancer diagnosed between 1997 and 1999. Some 1302 patients underwent surgery and were followed for 5 years after operation. RESULTS: The 5-year adjusted overall survival rate for the 3293 patients was 18.7 (95 per cent confidence interval (c.i.) 17.2 to 20.2) per cent and that after surgical resection was 39.6 (95 per cent c.i. 36.3 to 43.0) per cent. Death within 1 year after surgical resection was associated with a postoperative complication (odds ratio (OR) 2.5 (95 per cent c.i. 1.6 to 3.8); P < 0.001) or resection margin involvement by tumour (OR 7.2 (95 per cent c.i. 1.1 to 47.5); P = 0.042) after adjustment for age, sex and tumour location. There was no relationship between hospital volume and postoperative morbidity or mortality, nor between survival and volume of patients either for hospital of diagnosis or hospital of surgery. CONCLUSION: This population-based study of oesophageal and gastric cancer suggests that the link between hospital volume and long-term survival for patients undergoing surgery requires re-evaluation.     

Equivalence of DOACS and LMWH for thromboprophylaxis after hip fracture surgery: Systematic review and meta-analysis

BackgroundPatients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or more effective compared to low molecular weight heparin (LMWH), but DOACs are not yet approved for thromboprophylaxis in trauma patients with HF. The aim of this study was to systematically review the literature comparing the effectiveness of DOACs and LMWH for thromboprophylaxis in trauma patients with surgically treated HF.Materials and MethodsWe searched PubMed, the Cochrane Library, Web of Science, and Embase. The primary outcome was the incidence of VTE (symptomatic and asymptomatic combined). Secondary outcomes were symptomatic VTE; a symptomatic VTE, symptomatic deep venous thrombosis (DVT); symptomatic pulmonary embolism (PE); major, clinically relevant non-major (CRNM), and minor bleeding. Meta-analysis was performed to compare the odds of VTE and secondary outcomes between DOACs and LMWH.ResultsThe search resulted in 738 titles. Five studies matched inclusion criteria. In total, 4748 hip fracture patients were analyzed (DOACs: 2276 patients, LMWH: 2472 patients). The pooled odds ratio for the risk of VTE for DOAC use was 0.52 (95% confidence interval 0.25–1.11, p = 0.09) compared to LMWH. No statistically significant differences between DOAC and LMWH were found for asymptomatic VTE, symptomatic DVT, PE, major or CRNM bleeding, and minor bleeding.ConclusionsMeta-analysis of the literature suggests that DOACs are associated with equivalent effectiveness and safety compared to LMWH.     

Recurrence and survival after mesorectal excision for rectal cancer

BACKGROUND: Mesorectal excision for rectal cancer has resulted in local recurrence rates of 3-11 per cent compared with up to 38 per cent after conventional methods. The results of a prospective Danish study with a historical control group are presented. METHODS: Three hundred and eleven patients with a mobile rectal cancer had mesorectal excision with curative intent performed by certified surgeons and were followed for 3 years. Demographic, perioperative and follow-up data were recorded prospectively. A series of patients who had conventional operations for rectal cancer served as a control group. RESULTS: The cumulative 3-year local recurrence rate was 11 per cent after mesorectal excision compared with 30 per cent after conventional surgery (hazard ratio (HR) 0.33 (95 per cent confidence interval (c.i.) 0.21 to 0.52); P < 0.001). Multivariate regression analysis showed that only advanced age (HR 0.97 (95 per cent c.i. 0.94 to 1.00); P = 0.048) and tumour in the lower third of the rectum (HR 0.21 (95 per cent c.i. 0.04 to 1.97); P = 0.075) were marginal independent predictors of local recurrence after mesorectal excision. The cumulative crude 3-year survival rate was 77 per cent after mesorectal excision and 62 per cent after conventional surgery (HR 0.58 (95 per cent c.i. 0.43 to 0.77); P < 0.001). Age was the only independent predictor of death after mesorectal excision (HR 1.04 (95 per cent c.i. 1.02 to 1.07); P = 0.001). CONCLUSION: Mesorectal excision is associated with a considerably lower risk of local recurrence and a better survival rate than conventional surgery, and is the optimum method for rectal cancer resection.     

Glasgow Aneurysm Score as a predictor of immediate outcome after surgery for ruptured abdominal aortic aneurysm

BACKGROUND: The aim of the study was to assess the value of the Glasgow Aneurysm Score in predicting postoperative death after repair of a ruptured abdominal aortic aneurysm (AAA). METHODS: Between 1991 and 1999, 836 patients underwent surgery for ruptured AAA. Their operative risk at presentation was evaluated retrospectively using the Glasgow Aneurysm Score, based on data from the nationwide Finnvasc registry. RESULTS: The operative mortality rate was 47.2 per cent (395 of 836); 164 patients (19.6 per cent) had cardiac complications and 164 (19.6 per cent) required intensive care treatment for more than 5 days. Predictors of postoperative death in univariate analysis were: coronary artery disease (P = 0.005), preoperative shock (P < 0.001), age (P < 0.001), and the Glasgow Aneurysm Score (P < 0.001). In multivariate analysis the predictors were: preoperative shock (odds ratio (OR) 2.13 (95 per cent confidence interval (c.i.) 1.45 to 3.11); P < 0.001) and the Glasgow Aneurysm Score (for an increase of ten units: OR 1.81 (95 per cent c.i. 1.54 to 2.12); P < 0.001). Receiver-operator characteristic (ROC) curves showed that the best cut-off value of the Glasgow Aneurysm Score in predicting postoperative death was 84 (area under the curve 0.75 (95 per cent c.i. 0.72 to 0.78), standard error 0.17; P < 0.001). The operative mortality rate was 28.2 per cent (114 of 404) in patients with a Glasgow Aneurysm Score of 84 or less, compared with 65.0 per cent (281 of 432) in those with a score greater than 84 (P < 0.001). CONCLUSION: The Glasgow Aneurysm Score predicted postoperative death after repair of ruptured AAA in this series.     

Predictors of operative death after oesophagectomy for carcinoma

BACKGROUND: Oesophagectomy for carcinoma provides a chance of cure but carries significant risk. This study defined risk factors for death after oesophageal resection for malignant disease. METHODS: Between 1990 and 2003, 773 oesophagectomies for oesophageal cancer were performed. Continuous variables were categorized into quartiles for analysis. Predictors of operative mortality were identified by univariate and multiple logistic regression analysis. RESULTS: The operative mortality rate was 4.8 per cent (37 of 773). In univariate analysis, advanced age, reduced forced expiratory volume in 1 s (FEV1), reduced forced vital capacity, presence of diabetes and tumour located in the upper third of the oesophagus were associated with a higher mortality rate. Multivariate analysis identified age (highest relative to lowest quartile, odds ratio (OR) 4.87 (95 per cent confidence interval (c.i.) 1.35 to 17.55); P = 0.009), tumour position (upper third relative to other locations, OR 4.23 (95 per cent c.i. 1.06 to 16.86); P = 0.041) and FEV1 (lowest relative to highest quartile, OR 4.72 (95 per cent c.i. 1.01 to 21.99); P = 0.018) as independent predictors of death. CONCLUSION: Advanced age, impaired preoperative respiratory function and a tumour high in the oesophagus are associated with a significantly increased risk of death after oesophagectomy for carcinoma.     

Quantification of mortality risk after abdominal aortic aneurysm repair

BACKGROUND: The study was designed to evaluate the Acute Physiology And Chronic Health Evaluation (APACHE) II risk scoring system in abdominal aortic aneurysm (AAA) surgery. The aim was to create an APACHE-based risk stratification model for postoperative death. METHODS: Prospective postoperative APACHE II data were collected from patients undergoing AAA repair over a 9-year interval from 24 intensive care units (ICUs) in the Thames region. A multilevel logistic regression model (APACHE-AAA) for in-hospital mortality was developed to adjust for both case mix and the variation in outcome between ICUs. RESULTS: A total of 1896 patients were studied. The in-hospital mortality rate among the 1289 patients who had elective AAA repair was 9.6 (95 per cent confidence interval (c.i.) 8.0 to 11.2) per cent and that among the 605 patients who had an emergency repair was 46.9 (95 per cent c.i. 43.0 to 50.9) per cent. Four independent predictors of death were identified: age (odds ratio (OR) 1.05 (95 per cent c.i. 1.03 to 1.07) per year increase), Acute Physiology Score (OR 1.14 (95 per cent c.i. 1.12 to 1.17) per unit increase), emergency operation (OR 4.86 (95 per cent c.i. 3.64 to 6.52)) and chronic health dysfunction (OR 1.43 (95 per cent c.i. 1.04 to 1.97)). The APACHE-AAA model was internally valid, as shown by calibration (Hosmer-Lemeshow C statistic: chi(2) = 6.14, 8 d.f., P = 0.632), discrimination properties (area under receiver-operator characteristic curve 0.845) and subgroup analysis. There was no significant variation in outcome between hospitals. CONCLUSION: APACHE-AAA was shown to be an accurate risk-stratification model that could be used to quantify the risk of death after AAA surgery. It might also be used to determine the relative impact of ICU over high-dependency unit care.     

利伐沙班与低相对分子质量肝素预防人工髋膝关节置换术后静脉血栓栓塞症的前瞻性随机对照研究

目的 通过比较利伐沙班与低相对分子质量肝素(LMWH)对静脉血栓栓塞症(VTE)的预防作用,评价两者预防人工全髋关节置换术(THA)和全膝关节置换术(TKA)后VTE的有效性与安全性.方法 2009年8月至2010年7月共收治84例行THA和TKA的患者,随机分为利伐沙班组和LMWH组,利伐沙班组48例,男13例,女35例;平均年龄63.9岁;THA 25例,其中1例行双侧置换术;TKA23例,其中10例行双侧置换术.LMWH组36例,男10例,女26例;平均年龄57.2岁;THA 16例,其中5例行双侧置换术;TKA 20例,其中6例行双侧置换术.THA患者术后第1～35天、TKA患者术后第1～14天,利伐沙班组给予利伐沙班10 mg,1次/d,口服;LMWH组给予LMWH 0.4 mL,1次/d,皮下注射. 结果两组患者围手术期失血量差异均无统计学意义(P＞0.05).所有患者术后获3个月随访.利伐沙班组深静脉血栓形成(DVT)发生率为20.8%(10/48),LMWH组DVT发生率为25.0%(9/36),两组比较差异无统计学意义(χ2=0.204,P=0.651).两组患者均未发生症状性肺栓塞. 结论利伐沙班能有效预防THA、TKA后下肢DVT的发生,同时具有良好的安全性,其疗效与LMWH相当,且不会增加出血等并发症.     

Predictors of operative morbidity and mortality in gastric cancer surgery

BACKGROUND: The aim of this study was to identify factors that predict morbidity and mortality in gastric cancer surgery. METHODS: Data on 719 consecutive patients who underwent operations for gastric cancer at Seoul National University Hospital between January and December 2002 were reviewed. RESULTS: Overall morbidity and mortality rates were 17.4 per cent (125 patients) and 0.6 per cent (four patients) respectively, and the rates of surgical and non-surgical complications were 14.7 per cent (106 patients) and 3.3 per cent (24 patients). Morbidity rates were higher in patients aged over 50 years (odds ratio (OR) 1.04 (95 per cent confidence interval (c.i.) 1.02 to 1.06)), when the gastric tumour was resected with another organ (36 per cent for combined resection versus 15.4 per cent for gastrectomy only; OR 3.25 (95 per cent c.i. 1.76 to 6.03)) and when gastrojejunostomy was used for reconstruction after subtotal gastrectomy (17.0 per cent for Billroth II versus 9.5 per cent for Billroth I; OR 2.00 (95 per cent c.i. 1.05 to 3.79)). Only three patients (2.8 per cent) with a surgical complication underwent reoperation, two for adhesive obstruction and one for intra-abdominal bleeding. CONCLUSION: Age, combined resection and Billroth II reconstruction after radical subtotal gastrectomy were independently associated with the development of complications after gastric cancer surgery.     

Impact of socioeconomic deprivation on outcome after surgery for colorectal cancer

BACKGROUND: Previous studies have demonstrated that socioeconomic deprivation is associated with poorer survival in patients with colorectal cancer. These differences have been attributed to more advanced disease at presentation.METHODS: A total of 2269 patients undergoing resection for colorectal cancer in hospitals in central Scotland between 1991 and 1994 were studied. Socioeconomic status was defined using the Carstairs deprivation index. The impact of deprivation on case mix, treatment and outcome was analysed.RESULTS: There were no significant differences in mode of presentation, extent of disease at presentation, type of resection and postoperative mortality rate among the socioeconomic groups. Following curative resection, the overall survival rate at 5 years was 47.0 per cent in deprived patients, compared with 55.4 per cent in affluent patients (P = 0.05); the cancer-specific survival rate was 62.6 per cent in the deprived and 68.1 per cent in the affluent (P = 0.05). Compared with the affluent, the adjusted hazard ratios for the deprived were 1.36 (95 per cent confidence interval (c.i.) 1.09 to 1.69) for overall mortality and 1.26 (95 per cent c.i. 0.95 to 1.67) for cancer-specific mortality. Following palliative resection, there was no difference in survival between the affluent and deprived for either overall (P = 0.27) or cancer-specific (P = 0.89) mortality.CONCLUSION: These findings confirm that the cancer-specific survival rate following surgery for colorectal cancer is lower in deprived patients. Stage of disease at presentation and type of operation did not account for this difference. The excess mortality was confined to patients undergoing apparently curative resection.     

Co-morbidity leads to altered treatment and worse survival of elderly patients with colorectal cancer

BACKGROUND: The aim of this study was to evaluate the effects of co-morbidity on the treatment and prognosis of elderly patients with colorectal cancer. METHODS: The independent influence of age and co-morbidity on treatment and survival was analysed for 6931 patients with colorectal cancer aged 50 years or more diagnosed between 1995 and 2001 in the southern part of the Netherlands. RESULTS: Co-morbidity had no influence on resection rate. The use of adjuvant chemotherapy in patients with stage III colonic cancer was influenced by co-morbidity, especially a previous malignancy (odds ratio (OR) 0.2 (95 per cent confidence interval (c.i.) 0.1 to 0.6); P = 0.002) or chronic obstructive pulmonary disease (COPD) (OR 0.3 (95 per cent c.i. 0.1 to 0.9); P = 0.043). Co-morbidity also influenced use of adjuvant radiotherapy in patients with rectal cancer, especially the presence of hypertension in combination with diabetes (OR 0.5 (95 per cent c.i. 0.2 to 0.9); P = 0.031). Co-morbidity influenced survival (hazard ratio up to 1.6), when adjusted for age, sex, tumour stage and treatment. The greatest influence on survival of patients with colonic cancer was previous malignancy, cardiovascular disease and COPD, and that of patients with rectal cancer was COPD, hypertension, and hypertension in combination with diabetes. CONCLUSION: Elderly patients with co-morbidity were treated less aggressively and had a worse survival than those with no concomitant disease.     

Predicting the survival of patients with peritoneal carcinomatosis of colorectal origin treated by aggressive cytoreduction and hyperthermic intraperitoneal chemotherapy

BACKGROUND: Peritoneal carcinomatosis in the absence of distant metastasis occurs in approximately 8 per cent of patients with colorectal cancer. Cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is a new treatment option. Patient selection is crucial to outcome. METHODS: Cytoreduction followed by HIPEC was performed in 102 patients with peritoneal carcinomatosis. The following factors were studied for association with survival: perforation and obstruction of the primary lesion, location of the primary lesion, obstruction associated with carcinomatosis, presentation, tumour differentiation and histological type. Extent of disease and completeness of cytoreduction were also studied. Hazard ratios (HRs) were used to study these factors. RESULTS: Location of the primary tumour in rectum (HR 3.14 (95 per cent confidence interval (c.i.) 1.11 to 8.91); P = 0.069), poor differentiation (HR 1.73 (95 per cent c.i. 1.04 to 2.88); P = 0.031) and signet cell histological type (HR 2.24 (95 per cent c.i. 1.21 to 4.16); P = 0.008) were associated with shorter survival. Important factors predicting survival were the number of affected regions (HR 1.38 (95 per cent c.i. 1.20 to 1.59); P < 0.001), the simplified peritoneal cancer score (HR 1.19 (95 per cent c.i. 1.12 to 1.26); P < 0.001) and completeness of cytoreduction (HR 8.54 (95 per cent c.i. 4.01 to 18.18); P < 0.001). No other factor correlated with survival. CONCLUSION: The survival of patients with peritoneal carcinomatosis of colorectal origin is dominated by the extent of disease and the amount of residual tumour after cytoreduction.     

Meta-analysis of the value of somatostatin and its analogues in reducing complications associated with pancreatic surgery

BACKGROUND: The role of somatostatin and its analogues in reducing complications after pancreatic resection is controversial. This is a meta-analysis of the evidence of benefit. METHODS: A literature search using Medline and ISI Proceedings with exploration of the references identified 22 studies. Of these, ten met the inclusion criteria for data extraction. Estimates of effectiveness were performed using fixed- and random-effects models. The effect was calculated as an odds ratio (OR) with 95 per cent confidence intervals (c.i.) using the Mantel-Haenszel method. Level of significance was set at P < 0.050. RESULTS: Outcomes for 1918 patients were compared. Somatostatin and its analogues did not reduce the mortality rate after pancreatic surgery (OR 1.17 (0.70 to 1.94); P = 0.545) but did reduce both the total morbidity (OR 0.62 (0.46 to 0.85); P = 0.003) and pancreas-specific complications (OR 0.56 (0.39 to 0.81); P = 0.002). Somatostatin and its analogues reduced the rate of biochemical fistula (OR 0.45 (0.33 to 0.62); P < 0.001) but not the incidence of clinical anastomotic disruption (OR 0.80 (0.44 to 1.45); P = 0.459). CONCLUSION: Somatostatin and its analogues reduce the incidence of complications after surgery.     

Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery.

BACKGROUND: Low molecular weight heparins (LMWHs) have become routine thromboprophylaxis in general surgery. However, their actual clinical effect, its magnitude relative to that of unfractionated heparin (UFH), and the optimal dose are still debated. METHODS: A meta-analysis was performed of all available randomized trials in general surgery comparing LMWH with placebo or no treatment, or with UFH. RESULTS: Comparison versus placebo or no treatment confirmed that the significant reduction in asymptomatic deep vein thrombosis (DVT) obtained with LMWH (n = 513; relative risk (RR) 0.28 (95 per cent confidence interval 0.14-0.54)) was associated with a significant reduction in clinical pulmonary embolism (n = 5456; RR 0.25 (0.08-0.79)) and clinical venous thromboembolism (VTE) (n = 4890; RR 0.29 (0.11-0.73)), and a trend towards a reduction in overall mortality rate. Comparison versus UFH showed a trend in favour of LMWH, with a significant reduction in clinical VTE (P = 0.049), a trend also found for cancer surgery. LMWH at doses below 3400 anti-Xa units seemed to be as effective as, and safer than, UFH, while higher doses yielded slightly superior efficacy but increased haemorrhagic risk, including that of major haemorrhage. CONCLUSION: Asymptomatic DVT may be regarded as a reliable surrogate endpoint for clinical outcome in studies investigating thromboprophylaxis in general surgery. LMWH seems to be as effective and safe as UFH. Determination of the optimal dose regimen of LMWH for this indication requires further investigation.     

Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery

BACKGROUND: Use of intravenous fluids is an important part of perioperative management. The aim of this study was to compare outcome following administration of restricted or standard postoperative intravenous fluids and sodium in patients undergoing elective colorectal surgery. METHODS: Eighty patients were randomized to restricted fluids (less than 2 litres water and 77 mmol sodium for 24 h after surgery) or a standard postoperative fluid regimen (3 litres water and 154 mmol sodium per day for as long as necessary). The primary endpoint was hospital stay. RESULTS: The median (i.q.r.) total intravenous fluid intake in the restricted group was 4.50 (4.00-5.62) litres compared with 8.75 (8.00-9.80) litres in the standard group (P < 0.001). Intravenous sodium intake was also significantly less in the restricted group (229 (131-332) versus 560 (477-667) mmol; P < 0.001). There was no difference in median time to first flatus (2.9 versus 2.9 days; hazard ratio (HR) 0.85 (95 per cent confidence interval (c.i.) 0.54 to 1.32); P = 0.466) or first bowel motion (4.7 versus 4.9 days; HR 1.06 (95 per cent c.i. 0.68 to 1.65); P = 0.802) between the restricted and standard groups, or in median hospital stay (7.2 versus 7.2 days; HR 1.03 (95 per cent c.i. 0.66 to 1.61); P = 0.902). CONCLUSION: Restriction of postoperative intravenous fluid and sodium does not reduce hospital stay following elective colorectal surgery.     

Prognostic significance of alarm symptoms in patients with gastric cancer

BACKGROUND: The aim of this study was to determine the incidence and spectrum of alarm symptoms in patients with newly diagnosed gastric cancer, and to examine the relationship between symptoms and outcome. METHODS: Three hundred consecutive patients with gastric adenocarcinoma were studied prospectively. The outcomes of 40 patients (13.3 per cent) without alarm symptoms (21 men; median age 69 years) were compared with those of the 260 patients (86.7 per cent) with alarm symptoms (175 men; median age 72 years). RESULTS: It was possible to perform an R0 gastrectomy more often in patients without alarm symptoms (21 patients; 52 per cent) than in those with alarm symptoms (71 patients; 27.3 per cent) (chi(2) = 10.35, 1 d.f., P = 0.001). The cumulative survival rate at 5 years was 38 per cent for patients without alarm symptoms versus 15.0 per cent for those with alarm symptoms (chi(2) = 10.18, 1 d.f., P = 0.001). In a multivariate analysis, distant metastasis (hazard ratio (HR) 2.73 (95 per cent confidence interval (c.i.) 2.04 to 3.66); P < 0.001), overall stage of cancer (HR 1.83 (95 per cent c.i. 1.53 to 2.19); P < 0.001) and persistent vomiting at diagnosis (HR 1.66 (95 per cent c.i. 1.26 to 2.18); P < 0.001) were independently associated with length of survival. CONCLUSION: Alarm symptoms are absent in a significant minority of patients with gastric cancer at diagnosis; these patients stand a better chance of curative surgery and long-term survival than those with alarm symptoms.     

Prevalence of anaemia before major joint arthroplasty and the potential impact of preoperative investigation and correction on perioperative blood transfusions

BACKGROUND: Preoperative investigation and treatment of anaemia is recommended before orthopaedic surgery. We measured the prevalence of anaemia among admissions presenting for elective major joint arthroplasty (MJA), assessed their transfusion requirements, and investigated factors associated with perioperative blood transfusion. METHODS: All admissions to a dedicated elective orthopaedic hospital during 2000-2001 were studied. The patients' database was merged with the haematology and transfusion databases. Population estimates for different types of anaemia and their blood transfusion requirements were generated using local reference ranges (males <130 g litre(-1); females <115 g litre(-1)). RESULTS: One thousand three hundred and twenty-two admissions were included; haematology data were complete for 1142 (544 primary hip, 490 primary knee, 77 revision hip, 31 revision knee). About 19.6% were anaemic [7.1% haemoglobin (Hb) <110 g litre(-1); 1.6% Hb<100 g litre(-1)]. Overall, 21.3% of admissions were transfused (mean 0.58 units per case: 95% CI 0.50-0.61). For anaemic admissions, 42.0% were transfused (mean 1.11 units per case: 95% CI 0.90-1.32). Mean red cell use for admissions with normocytic normochromic anaemia (12.7% of admissions) and hypochromic anaemia (4.6%) was 1.04 (95% CI 0.78-1.31) and 1.14 (95% CI 0.71-1.57) units per admission, respectively. Factors strongly associated independently with transfusion were preoperative haemoglobin 相似文献   

Meta-analysis of prophylactic antibiotic use in acute necrotizing pancreatitis

BACKGROUND: Death from infected necrosis in acute pancreatitis is common and prevention has focused on prophylactic antibiotics. This study assesses whether intravenous prophylactic antibiotic use reduces infected necrosis and death in acute necrotizing pancreatitis. METHODS: A meta-analysis of randomized controlled trials was carried out. Medline, Web of Science, the Cochrane controlled trials register and international conference proceedings were searched, with a citation review of relevant primary and review articles. RESULTS: Six of 328 studies assessed were included in data extraction. Primary outcome measures were infected necrosis and death. Secondary outcome measures were non-pancreatic infections, surgical intervention and length of hospital stay. Prophylactic antibiotic use was not associated with a statistically significant reduction in infected necrosis (relative risk (RR) 0.77 (95 per cent confidence interval (c.i.) 0.54 to 1.12); P = 0.173), mortality (RR 0.78 (95 per cent c.i. 0.44 to 1.39); P = 0.404), non-pancreatic infections (RR 0.71 (95 per cent c.i. 0.32 to 1.58); P = 0.402) and surgical intervention (RR 0.78 (95 per cent c.i. 0.55 to 1.11); P = 0.167). It was, however, associated with a statistically significant reduction in hospital stay (P = 0.040). CONCLUSION: Prophylactic antibiotics do not prevent infected necrosis or death in acute necrotizing pancreatitis.