Single port laparoscopic ileocaecal resection for Crohn's disease: a multicentre comparison with multi‐port laparoscopy

Aim

Single port (SP) ileocaecal resection (ICR) is an established technique but there are no large studies comparing SP and multi‐port (MP) laparoscopic surgery in Crohn's disease (CD). The aim of this study was to compare postoperative pain scores and analgesia requirements after SP and MP laparoscopic ICR for CD.

Method

This was a retrospective study of patients undergoing SP or MP ICR for CD in three tertiary referral centres from February 1999 to October 2014. Baseline characteristics (age, sex, body mass index and indication for surgery) were compared. Primary end‐points were postoperative pain scores, analgesia requirements and short‐term postoperative outcomes.

Results

SP ICR (n = 101) and MP ICR (n = 156) patients were included in the study. Visual analogue scale scores were significantly lower after SP ICR on postoperative day 1 (P = 0.016) and day 2 (P = 0.04). Analgesia requirements were significantly reduced on postoperative day 2 in the SP group compared with the MP group (P = 0.007). Duration of surgery, conversion to open surgery and stoma rates were comparable between the two groups. Surgery was more complex in terms of additional procedures when MP was adopted (P = 0.001). There were no differences in postoperative complication rates, postoperative food intake, length of stay and readmissions.

Conclusion

These data suggest that in comparison to standard laparoscopic surgery SP ICR might be less painful and patients might require less opioid analgesia.     

Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomized controlled trial

Aim

Colorectal cancer (CRC) is prevalent in the older population, and surgery is the mainstay of curative treatment. A preoperative geriatric assessment (GA) can identify frail older patients at risk for developing postoperative complications. In this randomized controlled trial we wanted to investigate whether tailored interventions based on a preoperative GA could reduce the frequency of postoperative complications in frail patients operated on for CRC.

Method

Patients > 65 years scheduled for elective CRC surgery and fulfilling predefined criteria for frailty were randomized to either a preoperative GA followed by a tailored intervention or care as usual. The primary end‐point was Clavien–Dindo Grade II–V postoperative complications. Secondary end‐points included complications of any grade, reoperation, length of stay, readmission and survival.

Results

One hundred and twenty‐two patients with a mean age of 78.6 years were randomized. We found no statistically significant differences between the intervention group and the control group for Grade II–V complications (68% vs 75%, P = 0.43), reoperation (19% vs 11%, P = 0.24), length of stay (8 days in both groups), readmission (16% vs 6%, P = 0.12) or 30‐day survival (4% vs 5%, P = 0.79). Grade I–V complications occurred in 76% of patients in the intervention group compared with 87% in the control group (P = 0.10). In secondary analyses adjusting for prespecified prognostic factors, there was a statistically significant difference in favour of the intervention for reducing the total number of Grade I–V complications (P = 0.05).

Conclusion

A preoperative GA and tailored interventions did not reduce the rate of Grade II–V complications, reoperations, readmission or mortality in frail older patients electively operated on for CRC.     

Acute diverticulitis in immunosuppressed patients: a 12-year management experience

Background

Diverticular disease of the colon occurs commonly in developed countries. Immunosuppressed patients are thought to be more at risk of developing acute diverticulitis, worse disease, and higher complications secondary to therapy. This study aimed to assess outcomes for immunosuppressed patients with acute diverticulitis.

Method

A retrospective single-centre review was conducted of all patients presenting with acute diverticulitis at a major tertiary Australian hospital from 2006 to 2018.

Result

A total of 751 patients, comprising of 46 immunosuppressed patients, were included. Immunosuppressed patients were found to be older (62.25 versus 55.96, p = 0.016), have more comorbidities (median Charlson Index 3 versus 1, P < 0.001), and undergo more operative management (13.3% versus 5.1%, P = 0.020). Immunosuppressed patients with paracolic/pelvic abscesses (Modified Hinchey 1b/2) were more likely to undergo surgery (56% versus 24%, P = 0.046), while in patients with uncomplicated diverticulitis, there was no difference in immunosuppressed patients undergoing surgery (6.1% versus 5.1% P = 0.815). Immunosuppressed patients were more likely to have Grade III-IV Clavien-Dindo complication (P < 0.001).

Conclusion

Immunosuppressed patients with uncomplicated diverticulitis can be treated safely with non-operative management. Immunosuppressed patients were more likely to have operative management for Hinchey 1b/II and more likely to have grade III/IV complications.     

Botulinum toxin injection vs topical nitrates for chronic anal fissure: an updated systematic review and meta‐analysis of randomized controlled trials

Aim

Chronic anal fissures (CAFs) are frequently encountered in coloproctology clinics. Chemical sphincterotomy with pharmacological agents is recommended as first‐line therapy. Topical nitrates (TN) heal CAF effectively but recurrences are common. An alternative treatment modality is injection of botulinum toxin (BT) into the anal sphincter. We aimed to perform an updated systematic review and meta‐analysis to compare the effectiveness of BT and TN in the management of CAF.

Method

PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until March 2017. All randomized controlled trials (RCTs) that reported direct comparisons of BT and TN were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates.

Results

Six RCTs describing 393 patients (194 BT, 199 TN) were included. There was significant heterogeneity among the trials. On random effects analysis there were no significant differences in incomplete fissure healing (OR = 0.47, 95% CI 0.13–1.68, P = 0.24) or recurrence (OR = 0.70, 95% CI 0.39–1.25, P = 0.22) between BT and TN, respectively. BT was associated with a higher rate of transient anal incontinence (OR = 2.53, 95% CI 0.98–6.57, P = 0.06) but significantly fewer total side effects (OR = 0.12, 95% CI 0.02–0.63, P = 0.01) and headache (OR = 0.10, 95% CI 0.02–0.60, P = 0.01) compared with TN.

Conclusion

BT is associated with fewer side effects than TN but there is no difference in fissure healing or recurrence. Patients need to be warned regarding the risk of transient anal incontinence associated with BT.     

Improving pancreas graft utilization through importation

Background

We analyze our outcomes utilizing imported allografts as a strategy to shorten wait list time for pancreas transplantation.

Methods

This is an observational retrospective cohort of 26 recipients who received either a locally procured (n = 16) or an imported pancreas graft (n = 10) at our center between January 2014 and May 2017. Wait list times of this cohort were compared to UNOS Region 9 (New York State and Western Vermont). Hospital financial data were also reviewed to analyze the cost‐effectiveness of this strategy.

Results

Imported pancreas grafts had significantly increased cold ischemia times (CIT) and peak lipase (PL) levels compared to locally procured grafts (CIT 827 vs 497 minutes; P = .001, PL 563 vs 157 u/L; P = .023, respectively). There were no differences in graft or patient survival. The median wait time was significantly lower for simultaneous kidney‐pancreas transplants at our center (518 days, n = 21) compared to Region 9 (1001 days, n = 65) P = .038. Despite financial concerns, the cost of transport for imported grafts was offset by lower standard acquisition costs.

Conclusions

Imported pancreas grafts may be a cost‐effective strategy to increase organ utilization and shorten wait times in regions with longer waiting times.     

Weekly nab-paclitaxel is safe and effective in ≥65 years old patients with metastatic breast cancer: a post-hoc analysis

Purpose

This post-hoc analysis of 2 studies investigated the safety and efficacy of weekly and every-3-week (q3w) nanoparticle albumin-bound paclitaxel (nab-paclitaxel) in older patients with metastatic breast cancer (MBC) compared with q3w solvent-based paclitaxel and docetaxel.

Results

Patients ≥65 years (median: 69) were analyzed. In phase 2 (n = 52), overall response rates (ORR) for weekly nab-paclitaxel were 60–64% vs 22% for q3w nab-paclitaxel and 32% for docetaxel. In phase 3 (n = 62), ORRs were 27% for q3w nab-paclitaxel and 19% for solvent-based paclitaxel. In phase 2, median progression-free survival (PFS) was 18.9 months for 150 mg/m² weekly nab-paclitaxel vs 8.5–13.8 months for all other regimens. In phase 3, median PFS for q3w nab-paclitaxel and solvent-based paclitaxel were 5.6 months and 3.5 months, respectively. Weekly nab-paclitaxel resulted in less serious adverse events compared with all other regimens.

Conclusions

Weekly nab-paclitaxel was safe and more efficacious compared with the q3w schedule and with solvent-based taxanes in older patients with MBC.     

What to do with the rectal stump during sphincter preserving rectal cancer resection with end colostomy: a collaborative snapshot study

Aim

Low Hartmann's resection (LHR) and intersphincteric abdominoperineal excision (iAPR) are both feasible options in the treatment of rectal cancer when restoration of bowel continuity is not desired. The aim of this study was to compare the incidence of pelvic abscess and associated need for re‐intervention and readmission after LHR and iAPR.

Method

From a snapshot research project in which all rectal cancer resections from 71 Dutch hospitals in 2011 were evaluated, patients who underwent LHR or iAPR were selected.

Results

A total of 185 patients were included: 139 LHR and 46 iAPR. No differences in baseline characteristics were found except for more multivisceral resections in the iAPR group (22% vs 10%; P = 0.041). Pelvic abscesses were diagnosed in 17% of the LHR group after a median of 21 days (interquartile range 10–151 days), compared to 11% in the iAPR group (P = 0.352) after a median of 90 days (interquartile range 44–269 days; P = 0.102). All 28 patients with a pelvic abscess underwent at least one re‐intervention. Four patients (9%) in the iAPR group and nine (7%) after LHR were readmitted because of a pelvic abscess over a median 39 months of follow‐up.

Conclusion

This cross‐sectional multicentre study suggests that cross‐stapling and intersphincteric resection of the rectal stump, during non‐restorative rectal cancer resection, are associated with an equal risk of pelvic abscess formation and have a similar need for re‐intervention and readmission.     

Total Hip Arthroplasty or Arthroscopy for Pigmented Villonodular Synovitis of the Hip: A Retrospective Study with 3-Year Follow-Up at Minimum

Objective

Pigment Villonodular synovitis of the hip, a rare pain proliferation of the synovium, was treated successfully with total hip arthroplasty and arthroscopy. Most recent results come from small case series with no study comparing arthroscopy and arthroplasty. In this study, we aimed to show and compare the clinical outcomes of arthroscopy and total hip arthroplasty (THA) in pigment Villonodular synovitis of the hip.

Methods

This was a retrospective clinical trial with data from patients with pigment Villonodular synovitis of the hip between 2010 and 2019. The study included 17 patients in the THA group, and 20 patients in the arthroscopy group. The clinical outcomes were evaluated at 3, 6, and 12 months, at 1 and 2 years, and every 5 years afterward. The clinical efficacy was measured using the Harris hip scores (HHSs) and visual analogue scale (VAS) score.

Results

The mean HHS improved from 45.24 ± 10.36 to 78.94 ± 19.11 in the THA group (t = −6.394, P = 0.000) and 45.30 ± 11.08 to 71.60 ± 19.78 (t = −5.187, P = 0.000) in the arthroscopy group from pre-operation to the final follow-up. There is no significant difference between the two groups (t = 1.051, P = 0.301). The mean VAS improved from 3.65 ± 0.79 to 0.35 ± 0.70 (t = 12.890, P = 0.000) in the THA group and 4.05 ± 0.94 to 1.35 ± 1.79 (t = 5.979, P = 0.001) in the arthroscopy group postoperatively. There is no significant difference between the two groups (t = 1.329, P = 0.193). Recurrence of PVNS was diagnosed in four patients (20%) of the arthroscopy group and they underwent THA after arthroscopy, and the mean interval was 44.25 ± 6.98 months. All patients reached level 5 muscle strength by the final follow-up. All the patients' buckling ranges were over 105 degrees. Their internal and external hip rotation was over 15 degrees. Their hip adduction was over 20 degrees, and abduction over 30 degrees.

Conclusion

Both THA and arthroscopy in the setting of PVNS can improve patients' function and lead to a low rate of local recurrence. By selecting patients well for each approach, one can expect a reasonable result.     

Pain assessment by pupil dilation reflex in response to noxious stimulation in anaesthetized adults

Background

In response to noxious stimulation, pupillary dilation reflex (PDR) occurs even in anaesthetized patients. The aim of the study was to evaluate the ability of pupillometry with an automated increasing stimulus intensity to monitor intraoperative opioid administration.

Methods

Thirty‐four patients undergoing elective surgery were enrolled. Induction by propofol anaesthesia was increased progressively until the sedation depth criteria (SeD) were attained. Subsequently, a first dynamic pupil measurement was performed by applying standardized nociceptive stimulation (SNS). A second PDR evaluation was performed when remifentanil reached a target effect‐site concentration. Automated infrared pupillometry was used to determine PDR during nociceptive stimulations generating a unique pupillary pain index (PPI). Vital signs were measured.

Results

After opioid administration, anaesthetized patients required a higher stimulation intensity (57.43 mA vs 32.29 mA, P < .0005). Pupil variation in response to the nociceptive stimulations was significantly reduced after opioid administration (8 mm vs 28 mm, P < .0005). The PPI score decreased after analgesic treatment (8 vs 2, P < .0005), corresponding to a 30% decrease. The elicitation of PDR by nociceptive stimulation was performed without changes in vital signs before (HR 76 vs 74/min, P = .09; SBP 123 vs 113 mm Hg, P = .001) and after opioid administration (HR 63 vs 62/min, P = .4; SBP 98.66 vs 93.77 mm Hg, P = .032).

Conclusions

During propofol anaesthesia, pupillometry with the possibility of low‐intensity standardized noxious stimulation via PPI protocol can be used for PDR assessment in response to remifentanil administration.     

Sustainable functional urethral reconstruction improves early urinary continence after robot-assisted radical prostatectomy: a randomised controlled trial

Objective

To evaluate the impact of sustainable functional urethral reconstruction (SFUR) on early recovery of urinary continence (UC) after robot-assisted radical prostatectomy.

Patients and Methods

Overall, 96 patients with primary prostate cancer were randomised into the SFUR or standard group (n = 48 each). The primary outcome was the 1-month UC recovery. Secondary outcomes included short-term (≤3 months) UC recovery, urinary function, micturition-related bother, perioperative complications, and oncological outcomes. Kaplan–Meier curves and Cox proportional hazard models were used to assess the 3-month UC recovery. Generalised estimating equations were used to compare postoperative urinary function and micturition-related bother.

Results

The 1-month UC recovery rates, median 24-h pad weights, and median operative time in the SFUR and standard groups were 73% and 49% (P = 0.017), 0 and 47 g (P = 0.001), and 125 and 103 min (P = 0.025), respectively. The UC recovery rates in the SFUR vs standard groups were 53% vs 23% at 1 week (P = 0.003), 53% vs 32% at 2 weeks (P = 0.038), and 93% vs 77% at 3 months (P = 0.025). The median time to UC recovery in the SFUR and standard groups was 5 and 34 days, respectively (log-rank P = 0.006); multivariable Cox regression supported this result (hazard ratio 1.73, 95% confidence interval 1.08–2.79, P = 0.024). Similar results were observed when UC was defined as 0 pads/day. Urinary function (P = 0.2) and micturition-related bother (P = 0.8) were similar at all follow-up intervals. The perioperative complication rates, positive surgical margin rates, and 1-year biochemical recurrence-free survival were comparable between both groups (all P > 0.05).

Conclusion

SFUR resulted in earlier UC recovery without compromising postoperative urinary function. Long-term validation and multicentre studies are required to confirm the results of this novel technique.     

Full‐thickness neorectal prolapse after transanal transabdominal proctosigmoidectomy for low rectal cancer: a cohort study

Aim

Transanal transabdominal proctosigmoidectomy (TATA) with a coloanal anastomosis is an alternative to abdominoperineal excision of the rectum (APR) for low rectal cancer. Neorectal prolapse is an unusual complication following TATA. This study aimed to determine the incidence of neorectal prolapse after TATA for low rectal cancer.

Method

This cohort study was conducted in a tertiary referral colorectal centre. From a prospectively maintained database including 1093 patients treated for rectal cancer between 1984 and 2016 we identified those who underwent sphincter‐preserving surgery. Data regarding the incidence, management and outcomes of neorectal prolapse were analysed.

Results

A total of 409 patients were identified, of whom 185 underwent open surgery and 224 a minimally invasive surgical procedure (MIS). All received neoadjuvant chemoradiation. Neorectal prolapse occurred in 4.6% (n = 19) with an incidence of 2.2% in the open and 6.7% in the MIS group (P = 0.023), with no difference between MIS techniques. There was one recurrence of neorectal prolapse (5.9%). The incidence of neorectal prolapse was higher in women (9.5%) than men (2.5%) (P = 0.011). There were no differences in local recurrence rates between the neorectal prolapse group (5.3%) and our population without prolapse (3.4%) (P = 0.79).

Conclusion

Neorectal prolapse is a rare occurrence following minimally invasive sphincter‐saving surgical procedures performed for rectal cancer. It appears to be more frequent in patients who undergo MIS procedures and in women.     

High neutrophil‐to‐lymphocyte ratio predicts worse overall survival in patients with advanced/metastatic urothelial bladder cancer

Objectives

To study the role of the neutrophil‐to‐lymphocyte ratio in predicting survival outcomes for patients with advanced bladder cancer.

Methods

We retrospectively reviewed 150 patients diagnosed with advanced or metastatic bladder cancer between January 2004 and June 2014. The neutrophil‐to‐lymphocyte ratio was computed on diagnosis and after the first cycle of chemotherapy. A neutrophil‐to‐lymphocyte ratio cut‐off of 3.0 was determined, with a concordance index of 0.89. Kaplan–Meier curves, log–rank tests, Cox proportional hazards and logistic regression models were used to predict the association of the neutrophil‐to‐lymphocyte ratio with survival outcomes.

Results

Just five patients were alive at the end of the study; the rest died from metastatic bladder cancer. On multivariate analysis, higher Eastern Cooperative Oncology Group status, lymphadenopathy, visceral metastases and neutrophil‐to‐lymphocyte ratio ≥3.0 were associated with poorer overall survival (hazard ratio 1.67, P = 0.03; hazard ratio 1.97, P = <0.01; hazard ratio 2.02, P = <0.01; hazard ratio 5.06, P = <0.01), whereas chemotherapy conferred better overall survival (hazard ratio 0.546, P = 0.01). Furthermore, the role of chemotherapy prolonged survival longer in patients with a neutrophil‐to‐lymphocyte ratio <3.0 (median overall survival 13.0 vs 22.0 months, hazard ratio 0.273, P = 0.008) compared with a neutrophil‐to‐lymphocyte ratio ≥3.0 (median overall survival 4.0 vs 7.0 months, hazard ratio 0.452, P = 0.020). More importantly, when dichotomized to the four different pre‐ and post‐chemotherapy groups, patients with a pre‐ and post‐chemotherapy neutrophil‐to‐lymphocyte ratio <3.0 had the best additional median overall survival of 19.0 months compared with patients with a pre‐ and post‐chemotherapy neutrophil‐to‐lymphocyte ratio ≥3.0 (3.0 months).

Conclusions

Elevated neutrophil‐to‐lymphocyte ratio is independently associated with poorer chemotherapeutic response and overall survival in patients with advanced or metastatic bladder cancer. The neutrophil‐to‐lymphocyte ratio can be an inexpensive novel factor in prognosticating disease progression and providing better patient counseling.     

Assessing the utility of ultrasound-guided vascular access placement with longer catheters in critically ill pediatric patients

Background

Critically ill pediatric patients can have difficulty with establishing and maintaining stable vascular access. A long-dwelling peripheral intravenous catheter placement decreases the need for additional vascular interventions.

Aim

The study sought to compare longevity, catheter-associated complications, and the need for additional vascular interventions when using ultrasound-guided longer peripheral intravenous catheters comparing to a traditional approach using standard-sized peripheral intravenous catheters in pediatric critically ill patients with difficult vascular access.

Methods

This single-center retrospective cohort study included children 0–18 years of age with difficult vascular access admitted to the pediatric intensive care unit between 01/01/2018–06/01/2021.

Results

One hundred and eighty seven placements were included in the study, with 99 ultrasound-guided long intravenous catheters placed and 88 traditionally placed standard-sized intravenous catheters. In the univariate analysis, patients in the traditional approach were at a higher risk of intravenous failure compared to those in the ultrasound-guided approach (HR = 2.20, 95% CI [1.45–3.34], p = .001), with median intravenous survival times of 108 and 219 h, respectively. Adjusting for age, patients in the traditional approach remained at higher risk of intravenous failure (HR = 1.99, 95% CI: [1.28–3.08], p = .002). Adjusting for hospital length of stay, patients in the ultrasound-guided approach were less likely to have additional peripheral intravenous access placed during hospitalization (OR = 0.39, 95% CI [0.18–0.85] p = .017).

Conclusion

In critically ill pediatric patients with difficult vascular access, ultrasound-guided long peripheral intravenous catheters provide an alternative to traditional approach standard-sized intravenous catheters with improved longevity, lower failure rates, and reduced need for additional vascular interventions.     

Management of patients with incurable colorectal cancer: a retrospective audit

Aim

Counselling patients and their relatives about non‐curative management options in colorectal cancer is difficult because of a paucity of published data. This study aims to determine outcomes in patients unsuitable for curative surgery and the rates of subsequent surgical intervention.

Method

This was an analysis of all colorectal cancers managed without curative surgery in a district general hospital from a prospectively maintained cancer registry between 2009 and 2016, as decided by a multidisciplinary team. Primary outcomes were overall survival and secondary outcomes were subsequent intervention rates and impact of tumour stage.

Results

In all, 183 patients out of 976 patients (18.8%) were identified. The median age at diagnosis was 81 years [interquartile range (IQR) 71–87 years]. Overall median survival from diagnosis was 205 days (IQR 60–532 days). One‐year mortality was 62.3%. Patients were classified into two groups depending on the reason for a non‐curable approach: patient‐related (PR) or disease‐related (DR). The difference in survival between PR (median 277 days, IQR 70–593) and DR (median 179 days, IQR 51–450) was 98 days (P = 0.023). Twenty‐four patients were alive at the end of the study period; 19 out of 91 cases in PR (20.8%) and five out of 92 cases in DR (5.4%). Overall intervention rates were 11.9%, with higher rates in the DR group (P = 0.005). Disease stage was not associated with subsequent surgical intervention between the two groups (P = 0.392).

Conclusion

Life expectancy for non‐curatively managed patients within our unit was 6.8 months with one in nine patients requiring subsequent surgical admission for palliation. This information may be useful when counselling patients with incurable colorectal malignancy.     

The Comparison between Cemented and Uncemented Hemiarthroplasty in Patients with Femoral Neck Fractures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Hemiarthroplasty is the standard treatment for patients with femoral neck fractures (FNFs). Controversy exists over the use of bone cement in hip fractures treated with hemiarthroplasty.

Objective

We performed an updated systematic review and meta-analysis to compare cemented and uncemented hemiarthroplasty in patients with femoral neck fractures.

Methods

A literature review was conducted using Cochrane Library, ScienceDirect, PubMed, Embase, Medline, Web of Science, CNKI, VIP, Wang Fang, and Sino Med databases. Studies comparing cemented with uncemented hemiarthroplasty for FNFs in elderly patients up to June 2022 were included. Data were extracted, meta-analyzed, and pooled as risk ratios (RRs) and weighted mean differences (WMDs) with a 95% confidence interval (95% CI).

Results

Twenty-four RCTs involving 3471 patients (1749 cement; 1722 uncemented) were analyzed. Patients with cemented intervention had better outcomes regarding hip function, pain, and complications. Significant differences were found in terms of HHS at 6 weeks (WMD 12.5; 95% CI 6.0–17.0; P < 0.001), 3 months (WMD 3.3; 95% CI 1.6–5.0; P < 0.001), 4 months (WMD 7.3; 95% CI 3.4–11.2; P < 0.001), and 6 months (WMD 4.6; 95% CI 3.3–5.8; P < 0.001) postoperatively. Patients with cemented hemiarthroplasty had lower rates of pain (RR 0.59; 95% CI 0.39–0.9; P = 0.013), prosthetic fracture (RR 0.24; 95% CI 0.16–0.38; P < 0.001), subsidence/loosening (RR 0.29; 95% CI 0.11–0.78; P = 0.014), revisions (RR 0.59; 95% CI 0.40–0.89; P = 0.012), and pressure ulcers (RR 0.43; 95% CI 0.23–0.82; P = 0.01) at the expense of longer surgery time (WMD 7.87; 95% CI 5.71–10.02; P < 0.001).

Conclusion

This meta-analysis demonstrated that patients with cemented hemiarthroplasty had better results in hip function and pain relief and lower complication rates at the expense of prolonged surgery time. Cemented hemiarthroplasty is recommended based on our findings.     

Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta‐analysis

Aim

It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta‐analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates.

Method

The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end‐point. A subgroup meta‐analysis of randomized controlled trials was performed in addition to a meta‐analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively.

Results

Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)].

Conclusion

This meta‐analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.     

Are health outcomes in the older colorectal cancer patients treated by curative intent surgery any different to the younger patients?

Background

Colorectal cancer poses a major burden. Its incidence increases with age and older patients with comorbidities have a higher likelihood of major complications. This study investigated the impact of age on health outcomes in colorectal cancer patients treated by surgery.

Methods

A prospective database of all patients undergoing colorectal cancer surgery with curative intent between 2012 and 2017 was used to identify patients. A retrospective review of existing medical records investigating health-related outcomes in colorectal cancer patients undergoing surgery was performed. Primary outcomes measured were overall survival (OS) and disease-free survival (DFS). Difference in restricted mean survival times (RMST) up to a pre-specified time point of 24 months was used to compare four age groups.

Results

Six-hundred and fifty-one patients were divided into four age group categories: ≤65-years (n = 244), 66 to 75-years (n = 213), 76 to 85-years (n = 162) and >85-years (n = 32). Older patients were found to have a higher rate of post-operative medical complications (including confusion) (P = 0.001) and a longer length of stay (LOS) (P = 0.01). There was no difference between the 76 to 85-year age group and >85-year age group in OS and DFS. However, there was a reduced OS in older patients (>65) compared to their younger cohorts (<65) (P = 0.04).

Conclusion

Older patients who undergo curative surgery have reduced OS, increased LOS and higher complication rates. Complex older patients may benefit from geriatric assessment and management in the peri-operative period.     

Chronic loose stools following right-sided hemicolectomy for colon cancer and the association with bile acid malabsorption and small intestinal bacterial overgrowth

Aim

Patients treated with right-sided hemicolectomy for colon cancer may suffer from long-term bowel dysfunction, including loose stools, urgency and faecal incontinence. The underlying causes are poorly understood. The aim of this case–control study was to investigate the aetiology of chronic loose stools among patients with right-sided hemicolectomy curatively operated for cancer.

Method

Cases with chronic loose stools (Bristol stool type 6–7) after right-sided hemicolectomy were compared with a control group of patients with right-sided hemicolectomy without loose stools. All patients underwent a selenium-75 homocholic acid taurine (SeHCAT) scan to diagnose bile acid malabsorption (BAM) and a glucose breath test to diagnose small intestinal bacterial overgrowth (SIBO). Gastrointestinal transit time (GITT) was assessed with radiopaque markers. In a subgroup of patients, fibroblast growth factor 19 (FGF19) was measured in fasting blood. SIBO was treated with antibiotics and BAM was treated with bile acid sequestrants.

Results

We included 45 cases and 19 controls. In the case group, 82% (n = 36) had BAM compared with 37% (n = 7) in the control group, p < 0.001. SIBO was diagnosed in 73% (n = 33) of cases with chronic loose stools and in 74% (n = 14) of controls, p = 0.977. No association between BAM and SIBO was observed. GITT was similar in cases and controls. No difference in median FGF19 was observed between cases and controls (p = 0.894), and no correlation was seen between FGF19 and SeHCAT retention (r_s 0.20, p = 0.294). Bowel symptoms among cases were reduced after treatment.

Conclusion

BAM and SIBO are common in patients having undergone right-sided hemicolectomy for cancer. Chronic loose stools were associated with BAM but not with SIBO.     

Maternal priorities for preventive therapy among HIV‐positive pregnant women before and after delivery in South Africa: a best–worst scaling survey

Introduction

Pregnant women newly diagnosed with HIV during pregnancy are often lost to follow up and their adherence rates drop after delivery. We quantified changes in priorities related to isoniazid preventive therapy (IPT) and antiretroviral therapy (ART) among pregnant women living with HIV.

Methods

We enrolled pregnant women recently diagnosed with HIV from 14 primary health clinics during pregnancy and followed them after delivery in Matlosana, South Africa. Best–worst scaling (BWS) was used to determine the women's priorities out of 11 attributes related to preventive therapy in the ante‐ versus postpartum periods. Aggregate BWS scores were calculated based on the frequency with which participants selected each attribute as the best or worst among five options (across multiple choice sets). Individual BWS scores were also calculated and rescaled from 0 (always selected as worst) to 10 (always selected as best), and changes in BWS scores in the ante‐ versus postpartum periods were compared, using a paired t‐test. Factors associated with the changes in BWS scores were examined in multiple linear regressions. Spearman's rho was used to compare the ranking of attributes.

Results

Out of a total of 204 participants, 154 (75.5%) completed the survey in the postpartum at the median 15 (IQR: 11 to 27) weeks after delivery. Trust in healthcare providers was most highly prioritized both in the ante‐ (individual BWS Score = 7.34, SE = 0.13) and postpartum periods (BWS = 7.21 ± 0.11), followed by living a long life (BWS = 6.77 ± 0.09 in the ante‐ vs. BWS = 6.86 ± 0.10 in the postpartum). Prevention for infants’ health was more prioritized in the post‐ (BWS = 6.54 ± 0.09) versus antepartum periods (BWS = 6.11 ± 0.10) (p = 0.05). This change was associated with IPT initiation at enrolment (regression coefficient = 0.78 ± 0.33, p = 0.001). Difficulty in daily pill‐uptake was significantly more prioritized in the postpartum (BWS = 5.03 ± 0.11) than in the antepartum (BWS = 4.43 ± 0.10) (p < 0.01). Transportation cost and worry about side effects of pills were least prioritized. Overall ranking of attributes was similar in both time periods (spearman's rho = 0.90).

Conclusions

Comprehensive interventions to build trust in healthcare providers and support adherence may increase uptake of preventive therapy. Counselling needs to emphasize medication benefits for both maternal and infant health among HIV‐positive pregnant women.