The necessity of pharmacological prophylaxis against venous thromboembolism in major joint arthroplasty

Purpose

Venous thromboembolism (VTE) is a recognised post-operative complication of major lower limb joint arthroplasty. Current National Institute for Health and Clinical Excellence (NICE) guidelines suggest the use of both mechanical and pharmacological prophylaxis following hip and knee replacement. Since the introduction of enhanced recovery programmes following hip and knee arthroplasty the requirement for routine pharmacological VTE prophylaxis has been questioned. The purpose of this study was to assess the efficacy of pharmacological prophylaxis against symptomatic VTE in patients undergoing hip and knee arthroplasty under an enhanced recovery programme.

Methods

Symptomatic VTE incidence was audited in 1,100 patients undergoing primary or revision total hip or knee arthroplasty at the same hospital with only mechanical prophylaxis from 2007 to 2009. Following addition of chemical prophylaxis (enoxaparin) symptomatic VTE incidence in 522 patients undergoing primary or revision total hip or knee arthroplasty from 2011 to 2012 was re-audited.

Results

In the mechanical prophylaxis group incidence of DVT was 0.73 % [95 % confidence interval (CI) 0.37–1.43 %] and incidence of pulmonary embolism (PE) 0.91 % (95 % CI 0.49–1.67 %). Following addition of pharmacological prophylaxis incidence of DVT was 0.57 % (95 % CI 0.20–1.68 %) and incidence of PE 1.15 % (95 % CI 0.53–2.48 %).

Conclusions

We found no statistically significant difference in symptomatic VTE incidence following the addition of enoxaparin. We question whether routine pharmacological prophylaxis still has a role following total hip and knee arthroplasty. Peri-operative optimisation, including post-operative analgesia and mobility, with current enhanced recovery programmes may be sufficient. As anticoagulants carry increased risk of post-operative bleeding and wound ooze, in addition to significant cost implications, their role remains controversial.     

Meta-analysis of the Efficacies of Extended and Standard Pancreatoduodenectomy for Ductal Adenocarcinoma of the Head of the Pancreas

Background

The purpose of the present study was to evaluate the efficacy of extended pancreatoduodenectomy (EPD) and standard pancreatoduodenectomy (SPD) for ductal adenocarcinoma of the head of the pancreas via meta-analysis.

Methods

Relevant articles (published between 1995 and 2012) were compiled from online data sources. A total of nine studies satisfied the selection criteria, including a total of 973 patients (478 in the SPD group and 495 in the EPD group). Evaluation parameters included 1-, 3-, and 5-year survival, as well as mortality, morbidity, and specific morbidity outcomes.

Results

Meta-analysis revealed (1) differences in morbidity (Odds ratio [OR] = 1.740; 95 % confidence interval [CI], 0.840–3.600; P = 0.140), mortality (OR = 0.890; 95 % CI, 0.560–1.400; P = 0.620), 1-year overall survival (OS) rate (OR = 1.20; 95 % CI, 0.490–2.930; P = 0.69), 3-year OS rate (OR = 0.770; 95 % CI, 0.460–1.280; P = 0.190), and 5-year OS rate (OR = 1.12; 95 % CI, 0.690–1.810; P = 0.560) were not significant between EPD and SPD. (2) For bile leak (OR = 2.640; 95 % CI, 1.040–6.700; P = 0.040), pancreatic leak (OR = 1.740; 95 % CI, 1.040–2.91; P = 0.030), delayed gastric emptying (OR = 2.090; 95 % CI, 1.240–3.520; P = 0.006), and lymphatic fistula (OR = 6.120; 95 % CI, 1.06–35.320; P = 0.040) differences between EPD and SPD were significant, whereas other specific morbidities were not significantly different.

Conclusions

Extended pancreatoduodenectomy does not improve 1-, 3-, 5-year OS rates compared to SPD and there is a trend toward increased bile leak, pancreatic leak, delayed gastric emptying, and lymphatic fistula after EPD.     

Risk factors for deep infection after total knee arthroplasty: a meta-analysis

Objective

Estimated the risk factors for postoperative infection after total knee arthroplasty (TKA) to prevent its occurrence.

Design

The meta-analysis collected twelve cohorts or case–control studies which included 548 infected persons in 57,223 general cases. Review Manager 5.0 was operated to assess the heterogeneity and to give an overall estimate of the association of factors with postoperative infection after TKA.

Results

The main factors distinctly associated with infection after TKA were BMI (BMI >30: OR = 2.53, 95 % CI 1.25, 5.13; BMI >40: OR = 4.00, 95 % CI 1.23, 12.98), diabetes mellitus (OR = 3.72, 95 % CI 2.30, 6.01), hypertension (OR = 2.53, 95 % CI 1.07, 5.99), steroid therapy (OR = 2.04, 95 % CI 1.11, 3.74), and rheumatoid arthritis (OR = 1.83; 95 % CI 1.42, 2.36). It had no sufficient evidences to reveal that gender could lead to infection after TKA. Osteoarthritis appeared to have a moderately protective effect. Statistical analysis revealed no correlation between urinary tract infection, fixation method, ASA, bilateral operation, age, transfusion, antibiotics, bone graft, and infection.

Conclusion

There were positive evidences for some certain factors which could be targeted for prevention of the onset of infection, but more studies are needed to define the association of some other controversial factors in infection, like osteoarthritis, gender and so on. The quality of studies also needs to be improved.     

Nationwide prospective study on readmission after umbilical or epigastric hernia repair

Purpose

The primary aim of the present study was to investigate risk factors for readmission after elective umbilical and epigastric hernia repair and secondarily to evaluate causes for readmission.

Methods

All patients with elective umbilical or epigastric hernias registered in The Danish Hernia Database during January 2007–January 2011 were included. A 100 % 30-day follow-up was obtained by merging with administrative data from The Danish National Patient Register.

Results

A total of 6,783 umbilical and epigastric hernia repairs were included (open = 5,634; laparoscopic = 1,149). Readmissions caused by surgical and medical complications related to the hernia repair were observed in 3.6 and 1.5 % of patients, respectively. Surgical complications were mainly due to pain and wound complications, whereas medical complications were mainly cardiovascular, pulmonary, and renal complications. There were no significant differences in surgical or medical complication rates and in risk factors for readmission between open and laparoscopic repair, P ≥ 0.229. After open repair, independent risk factors for readmission were umbilical hernia repair (vs epigastric repair) (OR = 1.5, 95 % CI 1.1–2.1), hernia defects >2 cm (OR = 1.7, 95 % CI 1.2–2.5), mesh reinforcement (OR = 1.3, 95 % CI 1.0–1.7), and tacked mesh fixation (OR = 2.6, 95 % CI 1.1–6.0). After laparoscopic repair, female gender was the only independent risk factor for readmission (OR = 1.7, 95 % CI 1.1–2.7).

Conclusion

The risk for 30-day readmission after umbilical or epigastric hernia repairs was mainly because of surgical complications. Open mesh repair reduced the risk for readmission in open repairs; no specific approach was found to reduce readmission after laparoscopic repair.     

Correlates of low hemoglobin A1c in maintenance hemodialysis patients

Purpose

The optimal target for glycemic control has not been established for diabetic maintenance hemodialysis (MHD) patients.

Methods

A 6-year cohort (October 2001– December 2006) of 347 diabetic MHD patients with HbA1c data was examined for associations between HbA1c and mortality. Death hazard ratios (HR) were estimated using Cox regressions and cubic splines.

Results

In these 347 patients (age, 59 ± 11 years; 49 % women; 28 % African Americans; and 55 % Hispanics), each 0.5 % decline in HbA1c below 6 % was associated with a 4.7 times higher death risk (HR = 4.7; 95 % CI 1.7–12.7) in the fully adjusted model. Factors associated with lower HbA1c levels (<6 % compared to 6–7 %) were: Hispanic ethnicity (OR = 2.9; 95 % CI 1.1–7.9), higher mid-arm muscle circumstance (OR = 1.1; 95 % CI 1.0–1.3), higher total iron-binding capacity (OR = 1.03; 95 % CI 1.01–1.05), and higher iron saturation ratio (OR = 1.14; 95 % CI 1.03–1.26). HbA1c levels >7 % showed a consistent trend toward elevated mortality risk (HR = 1.18; 95 % CI 0.99–1.41) after multivariate adjustment.

Conclusions

In diabetic MHD patients with burnt-out diabetes, characterized by HbA1c <6 %, even lower HbA1c levels are associated with significantly higher death risk. Additional studies are needed to determine the optimal target for HbA1c levels in different subgroups of diabetic MHD patients.     

Laparoscopy-assisted gastrectomy versus open gastrectomy for resectable gastric cancer: an update meta-analysis based on randomized controlled trials

Background

We carry out a meta-analysis to evaluate the effectiveness and safety of laparoscopy-assisted gastrectomy (LAG) versus open gastrectomy for resectable gastric cancer.

Methods

We searched EMBASE, the Cochrane Library, PubMed, Science Citation Index (SCI), Chinese biomedicine literature database to identify randomized controlled trials (RCTs) from their inception to April 2012. Meta-analyses were performed using RevMan 5.0 software. It was in line with the preferred reporting items for systematic reviews and meta-analyses statement. The quality of evidence was assessed by GRADEpro 3.6.

Results

Eight RCTs totaling 784 patients were analyzed. Compared with open gastrectomy group, no significant differences were found in postoperative mortality (OR = 1.49; 95 % CI 0.29–7.79), anastomotic leakage (OR = 1.02; 95 % CI 0.24–4.27) , overall mean number of harvested lymph nodes [weighed mean difference (MD) = ?3.17; 95 % CI ?6.39 to 0.05]; the overall postoperative complication morbidity (OR = 0.54; 95 % CI 0.36–0.82), estimated blood loss (MD = ?107.23; 95 % CI ?148.56 to ?65.89,) frequency of analgesic administration (MD = ?1.69; 95 % CI ?2.18 to ?1.21, P < 0.00001), incidence of pulmonary complications (OR = 0.43, 95 % CI 0.20–0.93, P = 0.03) were significantly less in LAG group; LAG had shorter time to start first flatus (MD = ?0.23; 95 % CI ?0.41 to ?0.05) and decreased hospital stay (MD = ?1.72; 95 % CI ?3.40 to 0.04), but, LAG still had longer operation time (MD = 76.70; 95 % CI 51.54–101.87).

Conclusions

On the basis of this meta-analysis we conclude that although LAG was still a time-consuming and technically dependent procedure, it has the advantage of better short-term outcome. Long term survival data from other studies are urgently needed to estimate the survival benefit of this technique.     

The Impact of Surgical Complications as a Main Risk Factor for Venous Thromboembolism: A Multicenter Study

Background

Studies suggest that postoperative complications are a risk factor for venous thromboembolism (VTE) after bariatric surgery. Knowledge of factors associated with a higher risk of VTE after bariatric surgery may be essential to select patients who may benefit from either prolonged or intensified thrombosis prophylaxis. The aim of this study is to determine the relationship between postoperative complications and VTE after bariatric surgery and other classical risk factors.

Methods

A retrospective multicenter case-control study was performed in patients who had bariatric surgery between January 2008 and September 2011. VTE until 6 months after surgery was registered, and patients were contacted to ascertain the results. For every case of VTE after surgery, 6 control patients were selected who were matched for gender, age, participating center and type of surgery. Risk factors for VTE before and after surgery and postoperative complications were registered.

Results

A total of 2,064 surgeries were included. In 12 patients, VTE occurred within 6 months after bariatric surgery (incidence 0.58 %, 95 % confidence interval (CI)?=?0.25–0.93). There was a strong association of complications after surgery (cases 91.7 %, controls 15.3 %, odds ratio (OR) 61.0; 95 % CI?=?7.1–521.3) or intensive care admission (cases 50.0 %, controls 11.1 %, OR?=?8.0; 95 % CI?=?2.1–30.8) with VTE. The majority of postoperative complications were anastomotic leak, abdominal abscess, and infection. We could not detect an association between classical thrombosis risk factors and postoperative VTE.

Conclusions

The incidence of VTE is low after bariatric surgery using thrombosis prophylaxis. However, there is a strong association between postoperative complications and VTE. These patients may benefit from more intensive thrombosis prophylaxis.     

Factors associated with lumbar fusion surgery: a case–control study

Purpose

The objective of this study is to identify the demographic and payer factors that are associated with lumbar fusion surgery.

Methods

A case–control study was conducted utilizing a population of 38,092 patients from the 2010 Florida Agency for Health Care Administration (AHCA), USA hospital discharge data. The case population included 16,236 records with any of five ICD-9-CM principal procedure codes for initial lumbar fusion. The control group was comprised of 21,856 patients who were admitted for the same principal diagnoses as the cases, but who did not have initial fusion surgery. Logistic regression was used to analyze the association of age, gender, race and principal payer type with initial lumbar fusions. The interaction between age and payer was also examined, as payer type may moderate the association between age and lumbar fusion surgery.

Results

Gender, race, principal payer and age were all found to be significantly associated with lumbar fusion surgery. The interaction of payer and age was also found to be significant. Being female was significantly associated with having a fusion (OR = 1.11, 95 % CI 1.07–1.16). The association between age and receiving surgery was greatest for the less than 20 age group (OR = 10.43, 95 % CI 8.74–12.45). Employees and dependents of Federal government agencies (Tricare, etc.) and patients with commercial insurance were significantly associated with surgery (OR = 1.48, 95 % CI 1.29–1.70 and OR = 1.12, 95 % CI 1.04–1.20, respectively). Patients insured through Medicaid (a social health care program for those with low incomes and limited resources), and the uninsured were negatively associated with surgery (OR = 0.53, 95 % CI 0.47–0.60 and OR = 0.52, 95 % CI 0.46–0.58, respectively).

Conclusions

Lumbar fusion surgery is not recommended in clinical practice guidelines for the top four principal diagnoses in this study. Yet, patients covered by certain types of insurance were found to be significantly associated with fusion surgery.

     

Risk factors for heterotopic ossification and spur formation after total knee arthroplasty

Introduction

The present study investigated the incidence and risk factors of heterotopic ossification (HO) after implantation of knee prosthesis.

Materials and methods

We undertook a retrospective cohort study in 434 cases (363 patients) treated with a total knee replant using a Press-Fit-Condylar (P.F.C.^®Sigma^®) prosthesis. The occurrence of HO in radiograph after a follow-up period of 11.2 ± 2.4 months was correlated in a regression model with a variety of influencing factors.

Results

21 patients (4.8 %) developed heterotopic ossifications, all located in the area of the distal femur. The only risk factor found concerning the development of HO was osteoarthritis when compared to rheumatoid arthritis (OR = 4.07, 95 % CI 1.18–14.05; p = 0.0201) and postoperative wound healing problems (OR = 11.32, 95 % CI 3.26–39.33; p = 0.0001). Notching (OR = 2.22, 95 % CI 0.92–5.36; p = 0.0765) and osteophyte forming (hypertrophic) arthrosis (OR = 2.40, 95 % CI 0.97–5.95; p = 0.0596), however, were associated with the development of a bony spur in the contact area of the femoral component of the prosthesis.

Conclusions

Our study has revealed that patients with rheumatoid arthritis are at lower risk of HO than patients with osteoarthritis. An impairment of wound healing would appear to promote the development of a HO. Notching and hypertrophic arthrosis are highly likely to be associated with the development of a bony spur in the ventral contact area of the prosthesis.     

Venous thromboembolism after laparoscopic cholecystectomy: clinical burden and prevention

Background

The clinical benefit of prophylaxis for venous thromboembolism (VTE) in laparoscopic cholecystectomy is unclear. This study aimed to assess the clinical burden of VTE and the efficacy and safety of antithrombotic prophylaxis during laparoscopic cholecystectomy.

Methods

Data sources and study selection studies were searched in MEDLINE and Embase using the terms “cholecystectomy and venous thrombosis” and “cholecystectomy and venous thromboembolism.” Studies were considered for a systematic review and a metaanalysis if they reported on the methods of antithrombotic prophylaxis and on the incidence of objectively confirmed VTE in patients who had undergone laparoscopic cholecystectomy. Overall, 15 studies of patients who had undergone laparoscopic cholecystectomy were included in the systematic review.

Results

The incidence of VTE was lower after laparoscopic cholecystectomy than after open cholecystectomy [odds ratio (OR), 0.47; 95 % confidence interval (CI), 0.40–0.56]. No statistically significant reduction in VTE was observed in patients receiving heparin prophylaxis after laparoscopic cholecystectomy (OR, 0.86; 95 % CI, 0.12–5.82).

Conclusions

The rate of VTE after laparoscopic cholecystectomy seems to be relatively low. The clinical benefit of heparin prophylaxis for patients undergoing laparoscopic cholecystectomy remains unclear.     

Genetic polymorphisms on 8q24.1 and 4p16.3 are not linked with urothelial carcinoma of the bladder in contrast to their association with aggressive upper urinary tract tumours

Purpose

Bladder urothelial carcinoma (bladder-UC) displays distinct genotypic differences compared to upper tract UC (UTUC). We recently reported specific 8q24 SNP variants confer susceptibility to UTUC and aggressive disease features. Herein, we evaluate a bladder-UC cohort to see whether similar polymorphisms are linked similarly same way with disease risk and aggressiveness.

Methods

231 bladder-UC patients and 261 benign controls were matched for gender, age, ethnicity and smoking habits. We retrospectively retrieved information on tumour stage, grade, size, multiplicity, carcinoma in situ and tumour number. DNA was extracted from paraffin-embedded primary bladder-UC samples and blood of benign controls. Genotyping of rs9642880[T] (8q24.1) and rs798766[T] (4p16.3) was performed using commercially available Taqman^® assays and the ABI? 7000 Sequence Detector.

Results

Using a case–control analysis, bladder-UC risk was increased in individuals carrying the T/T genotype of rs9642880 [OR = 1.72 (95 % CI 1.1–2.8); p = 0.028] and rs798766 [OR = 1.84 (95 % CI 0.9–2.3); p = 0.01]. When analysing parameters of bladder-UC aggressiveness, the T/T genotypes for rs9642880 and rs798766 were not found to be associated with either grade [OR = 0.89 (95 % CI 0.52–1.32; p = 0.68) and OR = 0.95 (95 % CI 0.58–1.48; p = 0.61), respectively] or pathological stage [OR = 0.79 (95 % CI 0.42–1.48; p = 0.46) and OR = 0.90 (95 % CI 0.49–1.61; p = 0.72), respectively]. SNP variability of rs9642880[T] and rs798766[T] is associated with an increased risk of bladder-UC but we did not find an association with disease aggressiveness as we did previously for UTUC.

Conclusions

This is further evidence of the distinct genetic differences that exist between bladder-UC and UTUC, and it is not possible to extrapolate results of genetic studies between these two urothelial disease entities.     

The Influence of Surgical Factors on Persisting Symptoms 3 Years after Esophageal Cancer Surgery: A Population-Based Study in Sweden

Background

Little is known about the long-term effects of surgical approach and type of anastomosis in the surgical treatment of esophageal cancer on patient-reported outcomes.

Methods

A Swedish nationwide, population-based cohort study included patients undergoing esophagectomy for esophageal cancer in 2001–2005. The predefined exposures included surgical approach (transhiatal or transthoracic) and anastomotic technique (hand-sewn or mechanical). The outcomes were esophageal-specific symptoms 3 years after the surgery. Symptoms were measured using the cancer-specific quality of life questionnaire, the QLQ-C30, supplemented by an esophageal cancer-specific module (QLQ-OES18), both developed by the European Organisation for Research and Treatment of Cancer. Logistic regression models were used to estimate relative risk, expressed as odds ratios (OR) with 95 % confidence intervals (CI), of experiencing symptoms as assessed by the questionnaires.

Results

Among the 178 included patients, there was an 84 % participation rate. No statistically significant differences were found regarding surgical approach. However, point estimates indicate that patients operated on with a transhiatal approach had a lower risk for symptoms of nausea and vomiting (OR = 0.5, 95 % CI 0.1–1.9), diarrhea (OR = 0.5, 95 % CI 0.2–1.8), and trouble swallowing (OR = 0.4, 95 % CI 0–3), and a slightly higher risk for loss of appetite (OR = 2, 95 % CI 0.7–5.6) compared with patients operated on with a transthoracic approach. Anastomotic technique did not seem to influence the risk for any of the selected symptoms.

Conclusions

Surgical approach and type of anastomosis do not seem to influence the risk of general and esophageal-specific cancer symptoms 3 years after surgery for esophageal cancer.     

The estrogen receptor α gene (XbaI,PvuII) polymorphisms and susceptibility to idiopathic scoliosis: a meta-analysis

Study design

A genetic association meta-analysis of estrogen receptor α gene (ERα) polymorphisms with idiopathic scoliosis.

Objective

To determine whether the ERα gene polymorphisms correlate with idiopathic scoliosis.

Summary of background data

Idiopathic scoliosis represents a complex genetic trait under the influence of multiple predisposition genes. Several studies showed that single nucleotide polymorphism (SNP) in ERα was associated with idiopathic scoliosis, but the results from some studies were conflicting.

Methods

We searched PubMed, EMBASE, and Cochrane CENTRAL databases from January 1994 to January 2014. All the case–control studies included should mainly study the relationship between XbaI A/G, PvuII T/C polymorphisms and the susceptibility of idiopathic scoliosis.

Results

A total of 299 articles were found, six of which fulfilled the inclusion criteria after being assessed by two reviewers. A pooled odds ratio (OR) with 95 % confidence interval (95 % CI) was calculated to assess the associations. Subgroup meta-analyses were performed according to ethnicity. Overall, ERα Xbal A/G polymorphism was not associated with risk of idiopathic scoliosis (G versus A, OR 1.07, 95 % CI 0.88–1.30, P = 0.51; AG versus AA, OR 1.03, 95 % CI 0.89–1.21, P = 0.67; GG versus AA, OR 1.12, 95 % CI 0.72–1.73, P = 0.61; AG/GG versus AA, OR 1.05, 95 % CI 0.91–1.22, P = 0.49; GG versus AG/AA, OR 1.10, 95 % CI 0.75–1.63, P = 0.62). ERα PvuII T/C polymorphism was also not associated with risk of idiopathic scoliosis under five models (C versus T, OR 0.93, 95 % CI 0.75–1.14, P = 0.48; TC versus TT, OR 0.99, 95 % CI 0.80–1.23, P = 0.93; CC versus TT, OR 1.05, 95 % CI 0.80–1.39, P = 0.72; TC/CC versus TT, OR 1.01, 95 % CI 0.83–1.23, P = 0.93; CC versus TC/TT, OR 1.05, 95 % CI 0.82–1.33, P = 0.72).

Conclusion

ERα Xbal and ERα PvuII polymorphisms are not obviously associated with risk of idiopathic scoliosis.     

Urinary tract infections and post-operative fever in percutaneous nephrolithotomy

Purpose

To review the incidence of UTIs, post-operative fever, and risk factors for post-operative fever in PCNL patients.

Materials and methods

Between 2007 and 2009, consecutive PCNL patients were enrolled from 96 centers participating in the PCNL Global Study. Only data from patients with pre-operative urine samples and who received antibiotic prophylaxis were included. Pre-operative bladder urine culture and post-operative fever (>38.5°C) were assessed. Relationship between various patient and operative factors and occurrence of post-operative fever was assessed using logistic regression analyses.

Results

Eight hundred and sixty-five (16.2%) patients had a positive urine culture; Escherichia coli was the most common micro-organism found in urine of the 350 patients (6.5%). Of the patients with negative pre-operative urine cultures, 8.8% developed a fever post-PCNL, in contrast to 18.2% of patients with positive urine cultures. Fever developed more often among the patients whose urine cultures consisted of Gram-negative micro-organisms (19.4–23.8%) versus those with Gram-positive micro-organisms (9.7–14.5%). Multivariate analysis indicated that a positive urine culture (odds ratio [OR] = 2.12, CI [1.69–2.65]), staghorn calculus (OR = 1.59, CI [1.28–1.96]), pre-operative nephrostomy (OR = 1.61, CI [1.19–2.17]), lower patient age (OR for each year of 0.99, CI [0.99–1.00]), and diabetes (OR = 1.38, CI [1.05–1.81]) all increased the risk of post-operative fever. Limitations include the use of fever as a predictor of systemic infection.

Conclusions

Approximately 10% of PCNL-treated patients developed fever in the post-operative period despite receiving antibiotic prophylaxis. Risk of post-operative fever increased in the presence of a positive urine bacterial culture, diabetes, staghorn calculi, and a pre-operative nephrostomy.     

Role of Survivin Gene Promoter Polymorphism (−31G>C) in Susceptibility and Survival of Esophageal Cancer in Northern India

Background and Aim

Survivin is an upregulated inhibitor of apoptosis protein in esophageal cancer (EC), and a promoter region polymorphism (?31G>C) in the survivin gene has been reported as a modulator of gene expression. We aim to explore the role of survivin ?31G>C polymorphism in susceptibility and survival of EC patients in northern Indian population.

Materials and Methods

A case–control study was performed in 500 subjects (250 EC patients and 250 controls), and genotyping was done by polymerase chain reaction (PCR) restriction fragment length polymorphism (RFLP) method.

Results

Survivin CC genotype was found to be significantly associated with EC susceptibility [odds ratio (OR) = 2.29; 95% confidence interval (CI) = 1.27–4.14; P = 0.006], particularly in males (OR = 4.91; 95% CI = 2.19–11.02; P = 0.0001) having squamous cell carcinoma (SCC) histopathology (OR = 2.4; 95% CI = 1.36–4.21; P = 0.002) at middle third esophagus location (OR = 2.60; 95% CI = 1.40–4.82; P = 0.002). Patients carrying CC genotype were found to have higher susceptibility to lymph node metastasis (OR = 2.82; 95% CI = 1.46–5.48; P = 0.002). However, on survival analysis, no prognostic role of survivin ?31G>C polymorphism was detected. In case-only analysis, no gene–environment interaction was observed.

Conclusion

Survivin promoter region polymorphism (?31G>C) is associated with susceptibility and clinical characteristics but not prognosis of esophageal cancer in northern Indian population.     

Association between IGF1 gene single nucleotide polymorphism (rs5742612) and adolescent idiopathic scoliosis: a meta-analysis

Purpose

Insulin-like growth factor 1 (IGF1) gene single nucleotide polymorphism (rs5742612) has been associated with adolescent idiopathic scoliosis (AIS) in several studies with limited sample size and inconsistent outcomes. So we perform this meta-analysis to assess the precise association between IGF1 gene single nucleotide polymorphism (rs5742612) and AIS.

Methods

We systematically searched Pubmed, Embase, Web of Science and Cochrane Library up to January 19, 2016 to obtain relevant studies using our research strategy. Four articles all belonging to case–control studies were included in our meta-analysis.

Results

A total of four studies containing 763 cases and 559 controls satisfied the inclusion criteria after judgment by two reviewers. No significant associations were detected between IGF1 gene single nucleotide polymorphism (rs5742612) and AIS (T vs. C, OR = 1.10, 95 % CI 0.91–1.34, p = 0.32; TT vs. CC: OR = 1.28, 95 % CI 0.82–2.02, p = 0.28; TC vs. CC: OR = 1.29, 95 % CI 0.82–2.06, p = 0.27; TT/TC vs. CC: OR = 1.28, 95 % CI 0.83–1.98, p = 0.27; TT vs. TC/CC: OR = 1.06, 95 % CI 0.82–1.36, p = 0.66).

Conclusions

IGF1 gene single nucleotide polymorphism (rs5742612) is not significant associated with susceptibility to AIS in either Asian or Caucasian populations. However, IGF1 gene rs5742612 may be associated with severity of AIS. Further studies with larger sample size and different population groups involving the relationship are required to confirm the potential association.

     

A Systematic Review and Meta-analysis Comparing the Efficacy and Surgical Outcomes of Total Thyroidectomy Between Harmonic Scalpel Versus Ligasure

Background

Both ultrasonic coagulation (Harmonic Scalpel) (HS) and bipolar coagulation (Ligasure) (LS) are new energy devices commonly used in open thyroidectomy. This systematic review aimed at comparing the efficacy and surgical outcomes of total thyroidectomy (TT) between HS and. LS.

Methods

A systematic review of the literature was performed to identify studies comparing HS and LS. Intraoperative outcomes, surgically related complications, overall morbidity, and hospital stay were evaluated. Meta-analysis was performed using a fixed-effects model.

Results

There were 8 studies that matched the selection criteria. Of the 963 patients who underwent TT, 433 (45.0 %) used HS (HS group) while 530 (55.0 %) used LS (LS group). Compared with LS, the HS group had significantly less volume of blood loss by 2.22 ml (95 % CI = 0.26–4.23 ml) (standardized mean difference [SMD] = ?0.2, 95 % CI = ?0.38 to ?0.02) and reduced total operating time by 3.32 minutes (95 % CI = 1.62–5.03 minutes) (SMD = ?0.28, 95 % CI = ?0.42 to ?0.15). There was no significant difference in temporary postoperative hypocalcemia (OR = 1.29, 95 % CI = 0.88–1.90), permanent postoperative hypocalcemia (OR = 1.45, 95 % CI = 0.23–9.26), temporary recurrent laryngeal nerve (RLN) injury (OR = 1.34; 95 % CI = 0.66–2.71), permanent RLN injury (OR = 1.00; 95 % CI = 0.25–4.03), hematoma (OR = 1.00; 95 % CI = 0.3–3.31), overall morbidity (OR = 1.21, 95 % CI = 0.87–1.69), and hospital stay (SMD = ?0.03; 95 % CI = ?0.07 to 0.01).

Conclusions

Compared with LS, using HS in TT significantly reduced the volume of blood loss and operating time. However, the clinical significance of these findings remained questionable because the overall mean difference appeared small. There was no significant difference in the rate of complications, overall morbidity, and hospital stay between the two devices.     

Safety of fondaparinux to prevent venous thromboembolism in Japanese patients undergoing colorectal cancer surgery: a multicenter study

Purpose

To investigate the safety and efficacy of fondaparinux (FPX) for venous thromboembolism (VTE) prophylaxis in Japanese patients undergoing colorectal cancer surgery.

Methods

The subjects of this multicenter, open-label, prospective observational study were patients undergoing resection of the colon/rectum for colorectal cancer. All patients were given FPX 2.5 or 1.5 mg by subcutaneous injection, once daily for 4–8 days, starting 24 h after surgery. The primary endpoint was any major bleeding event and the secondary endpoint was any symptomatic VTE event.

Results

Between February 2009 and December 2010, 619 patients from 23 institutions were enrolled in this study. The median duration of FPX prophylaxis was 4 days. The incidence of major bleeding was 0.81 % [5/619, 95 % confidence interval (CI) 0.3–1.9] and the incidence of minor bleeding was 9.5 % (59/619, 95 % CI 7.3–12.1). There was no fatal bleeding or symptomatic VTE. Multivariable analysis revealed the following to be risk factors for bleeding events: preoperative platelet count <15 × 10⁴/µl [odds ratio (OR) 4.521], male sex (OR 2.078), and blood loss during surgery <50 ml (OR 2.019).

Conclusion

The administration of 2.5/1.5 mg FPX 24 h after colorectal cancer surgery is safe and effective.     

Geographic and Temporal Trends in the Management of Occult Primary Breast Cancer: A Systematic Review and Meta-Analysis

Background

Management of occult primary breast cancer (OPBC), including the role of magnetic resonance imaging (MRI), is controversial. We conducted a pooled analysis of OPBC patients and a meta-analysis of MRI accuracy in OPBC in order to elucidate current practices.

Methods

A literature search yielded 201 studies. Patient-level data for clinically/mammographically OPBC from studies published after 1993 and from our institution were pooled; logistic regression examined associations between patient/study data and outcomes, including treatments and recurrence. We report adjusted odds ratios (OR) and 95 % confidence intervals (95 % CI) significant at 2-tailed p < 0.05. Meta-analysis included data for patients who received MRIs for workup of clinically/mammographically OPBC. We report pooled sensitivity and specificity with 95 % CIs.

Results

The pooled analysis included 92 patients (15 studies [n = 85] plus our institution [n = 7]). Patients from Asia were more likely to receive breast surgery (OR = 5.98, 95 % CI = 2.02–17.65) but not chemotherapy (OR = 0.32, 95 % CI = 0.13–0.82); patients from the United States were more likely to receive chemotherapy (OR = 13.08, 95 % CI = 2.64–64.78). Patients from studies published after 2003 were more likely to receive radiotherapy (OR = 3.86, 95 % CI = 1.41–10.55). Chemotherapy recipients were more likely to have distant recurrence (OR = 9.77, 95 % CI = 1.10–87.21). More patients with positive MRIs received chemotherapy than patients with negative MRIs (10 of 12 [83.3 %] vs 5 of 13 [38.5 %]; p = 0.0414). In the MRI-accuracy meta-analysis (10 studies, n = 262), pooled sensitivity and specificity were 96 % (95 % CI = 91–98 %) and 63 % (95 % CI = 42–81 %), respectively.

Conclusions

OPBC management varied geographically and over time. We recommend establishing an international OPBC patient registry to facilitate longitudinal study and develop global treatment standards.     

Defining Incidence and Risk Factors of Venous Thromboemolism after Hepatectomy

Background

The incidence of venous thromboembolism (VTE) among patients undergoing hepatic surgery is poorly defined, leading to varied use of VTE prophylaxis among surgeons. We sought to define the incidence of VTE after liver surgery and identify risk factors associated with VTE.

Methods

Incidence of VTE and associated risk factors within 90 days of hepatic resection between 2006 and 2012 at a major academic center was analyzed. Risk factors for VTE were identified using univariate and multivariate analyses.

Results

A total of 599 patients were included in the study cohort; 30 (5.0 %) had a prior history of VTE. The indications for surgery were malignant (90.8 %) and benign lesions (9.2 %). The majority of patients underwent a minor hepatectomy (<3 Couinaud segments; n?=?402, 67.1 %) while 195 (32.6 %) patients underwent a major hepatectomy (≥3 Couinaud segments). Three hundred seven (51.3 %) patients were started on VTE chemoprophylaxis preoperatively with 407 (67.8 %) patients receiving VTE chemoprophylaxis within 24 h of surgery. Twenty-eight (4.7 %) patients developed VTE; 20 (3.3 %) had deep venous thrombosis (DVT), 11 (1.8 %) had pulmonary embolism (PE), and three (0.5 %) developed both DVT and PE. Among the VTE patients, 23 (82.1 %) had received VTE chemoprophylaxis. On multivariate analyses, history of VTE (odds ratio [OR] 4.51, 95 % confidence interval [CI] 1.81–17.22, P?=?0.03), prolonged operative time (OR 1.17 per additional hour, 95 % CI 1.04–1.32, P?=?0.009), and increased length of stay (LOS) (OR 1.07, 95 % CI 1.02–1.12, P?=?0.01) were independent risk factors for VTE.

Conclusion

VTE within 90 days of hepatic resection is common, occurring in nearly one in 20 patients. Most VTE events occurred among patients who received current best practice prophylaxis for VTE. More aggressive strategies to identify and reduce the risk of VTE in patients at highest risk of VTE, including those with a history of VTE, extended operative time, and prolonged LOS, are warranted.