Is the 1-cm Rule of Distal Bowel Resection Margin in Rectal Cancer Based on Clinical Evidence? A Systematic Review

Background  

Distal intramural spread is present within 1 cm from visible tumor in a substantial proportion of patients. Therefore, ≥1 cm of distal bowel clearance is recommended as minimally acceptable. However, clinical results are contradictory in answering the question of whether this rule is valid. The aim of this review was to evaluate whether in patients undergoing anterior resection, a distal bowel gross margin of <1 cm jeopardizes oncologic safety.     

Do Intra-Articular Steroid Injections Increase Infection Rates in Subsequent Arthroplasty? A Systematic Review and Meta-Analysis of Comparative Studies

Intra-articular steroid injections are widely used in joint arthritis. The safety of such injections has been questioned as they may increase infection rates in subsequent arthroplasty. We carried out a meta-analysis of studies examining the relation between intra-articular steroid injections and infection rates in subsequent joint arthroplasty. A literature search was undertaken. Eight studies looking at hip and knee arthroplasties were analyzed. Meta-analysis showed that steroid injection had no significant effect on either deep (risk ratio = 1.87; 95% CI 0.80–4.35; P = 0.15) or superficial infection rates (risk ratio = 1.75; 95% CI 0.76–4.04; P = 0.19) of subsequent arthroplasty. Further large cohort studies would be of value in further examining whether steroid injections close to the time of arthroplasty are safe.     

ASO Visual Abstract: The Association of Frailty with Outcomes After Cancer Surgery—A Systematic Review and Meta-Analysis

Annals of Surgical Oncology -     

Total Knee Arthroplasty in Hemophilia: Survivorship and Outcomes—A Systematic Review and Meta-Analysis

BackgroundPatients with hemophilia (PWHs) may experience spontaneous or traumatic bleeding episodes. Recurrent bleeding can lead to end-stage hemophilic arthropathy and total knee replacement (TKR) provides an effective treatment. The aim of this study is to investigate outcomes in PWHs who undergo TKR.MethodsA systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study outcomes included patient-reported functional outcomes, implant survivorship, and complications. Subgroup analysis was performed assessing the effect of recombinant prophylaxis medication by comparing studies that included only TKRs performed after the year 2000 (period A), to those that included TKRs before 2000 (period B).ResultsTwenty-eight studies were included, with a total of 1210 TKRs performed in 917 PWHs. The mean age of patients was 38.5 years (standard deviation 5.1) with a mean length of follow-up of 7.1 years (standard deviation 2.9). The total complication rate was 28.7%, with 19.3% requiring a further procedure. Hospital for Special Surgery Knee Score improved by 44.6 points (confidence interval 38.9-50.4) and Knee Society Score function improved by 35.9 points (confidence interval 30.1-41.8). Total range of motion improved by 22.3°. The most common complication was post-operative hemarthrosis (7.6%, 92 TKRs). Deep infection (6.2% vs 3.9%) and aseptic loosening (3.8% vs 2.1%) rates fell between period B and period A.ConclusionTKR in PWHs is a successful procedure improving function, reducing pain, and improving range of motion. PWHs undergo TKR at a younger age and have a higher risk of complications, though contemporary treatment has reduced these risks. PWHs can expect similar survivorship to the general population.     

What Differences in Morphologic Features of the Knee Exist Among Patients of Various Races? A Systematic Review

Background

Most TKA prostheses are designed based on the anatomy of white patients. Individual studies have identified key anthropometric differences between the knees of the white population and other major ethnic groups, yet there is limited understanding of what these findings may indicate if analyzed collectively.

Question/purpose

What are the differences in morphologic features of the distal femur and proximal tibia among and within various ethnicities?

Methods

A systematic review of the PubMed database and a hand-search of article bibliographies identified 235 potentially eligible English-language studies. Studies were excluded if they did not include morphology results or had insufficient data for analysis, were unrelated to the distal femur or proximal tibia, were conducted in pediatric patients or those undergoing unicondylar knee arthroplasty, or bone surface measurements were obtained for trauma products. This left 30 eligible studies (9050 knees). Study quality was assessed and reported as good, fair, or poor according to the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Morphometric data for the distal femur and proximal tibia were available for four ethnic groups: East Asian (23 studies; 5543 knees), white (11 studies; 3111 knees), Indian (three studies; 283 knees), and black (three studies; 113 knees). Although relatively underrepresented, the knees from the Indian and black studies were maintained for hypothesis-generating purposes and to highlight crucial gaps in the data. The two key dimensions for selecting a suitable implant based on a patient’s unique anatomy—AP length and mediolateral (ML) width—were assessed for the femur and tibia, in addition to aspect ratio, calculated by dividing the ML width by the AP length. Study measurement techniques were compared visually when possible to ensure that each pooled study conducted a similar measurement process. Any significant measurement outliers were reviewed for eligibility to determine if the measurement techniques and landmarks used were comparable to the other studies included.

Results

White patients had larger femoral AP measurements than East Asians (62 mm, [95% CI, 57–66 mm] vs 59 mm, [95% CI, 54–63 mm]; mean difference, 3 mm; p < 0.001), a smaller femoral aspect ratio than East Asians (1.20, [95% CI, 1.11–1.29] vs 1.25, [95% CI, 1.16–1.34]; mean difference, 0.05; p = 0.001), and a larger tibial aspect ratio than black patients (1.55, [95% CI, 1.40–1.71] vs 1.49, [95% CI, 1.33–1.64]; mean difference, 0.06; p = 0.005).

Conclusions

This analysis uncovered differences of size (AP height and ML width of the femur and tibia) and shape (tibial and femoral aspect ratios) among knees from white, East Asian, and black populations. Future research is needed to understand the clinical implications of these discrepancies and to provide additional data with underrepresented groups.

     

The Effectiveness of Bariatric Surgery for Chinese Obesity in 2 Years: A Meta-Analysis and Systematic Review

Aim: Bariatric surgery is becoming an acceptable option for treatment of obesity worldwide, but there is no systemic review and meta-analysis focusing on obese patients in China. This study is to quantify the overall effects of bariatric surgery for Chinese obesity using up-to-date, comprehensive data. Methods: We systematically searched MEDLINE, EMBASE, Cochrane Library, ISI Web of Science, and CNKI databases in English and Chinese. The weighted mean difference (MD) and 95% confidence interval (CI) were calculated from the original literature. Obese Chinese adults (body mass index [BMI] ≥ 30 kg/m²) with a minimum six-month follow-up were included. Results: The meta-analysis included 23 literature reviews with 1,316 morbidly Chinese obese adults. Bariatric surgery could significantly decrease the levels of BMI (MD = 10.75 kg/m², 95% CI: 8.65–12.85, p <.01) and hemoglobin A1c (MD = 2.15%, 95% CI: 1.55–2.75, p <.00001), and improve lipid profile dramatically. In the subgroup analysis by BMI values, subjects lost more weight in BMI ≥ 40 kg/m² group (MD = 14.01 kg/m², 95% CI: 11.20–16.82) than BMI < 40 kg/m² group (MD = 8.09 kg/m², 95% CI: 6.49–9.68, p <.00001) after surgery. When we stratified analysis by surgical procedures, fasting blood glucose decreased more in gastric bypass group (MD = 3.08 mmol/L, 95% CI: 2.18–3.98) than restrictive procedures (MD = 1.27 mmol/L, 95% CI: 0.45–2.09, p =.008) and postprandial blood glucose levels (gastric bypass procedures: 8.44 mmol/L, 95% CI: 6.83–10.04; restrictive procedures: MD = 2.80 mmol/L, 95% CI: 1.86–3.74, p <.00001). Conclusions: Bariatric surgery provides substantial metabolic effects for Chinese morbid obese adults at least in a relative short term. Further high-quality randomized controlled trials with long follow-up periods are needed to provide more reliable evidence.     

The Pylorus: Take It or Leave It? Systematic Review and Meta-Analysis of Pylorus-Preserving versus Standard Whipple Pancreaticoduodenectomy for Pancreatic or Periampullary Cancer

Background Our objective was to determine the relative effects of pylorus-preserving pancreaticoduodenectomy (PPPD) and standard Whipple pancreaticoduodenectomy (SWPD) in patients with pancreatic or periampullary cancer. Methods We searched seven bibliographic databases, conference proceedings, and reference lists of articles and textbooks, and we contacted experts in the field of hepatobiliary surgery. We included published and unpublished randomized controlled trials. We evaluated the methodological quality of trials and, in duplicate, extracted data regarding operative, perioperative, and long-term outcomes. We contacted all authors and asked them to provide additional information regarding the trials. We pooled results from the studies by using a random-effects model, evaluated the degree of heterogeneity, and explored potential explanations for heterogeneity. Results Six trials that included a total of 574 patients met eligibility criteria. In the pooled analysis, PPPD was 72 minutes faster (P < .001, 95% confidence interval [95% CI], 53–92), with 284 mL less blood loss (P < .001, 95% CI, 176–391) and .66 fewer units of blood transfused (P = .002, 95% CI, .25–1.16). Other perioperative and long-term outcomes did not statistically differ, although the confidence intervals include important differences. Conclusions Moderate-quality evidence suggests PPPD is a faster procedure with less blood loss compared with SWPD. Large absolute differences in other key outcomes are unlikely; excluding relatively small differences will, however, require larger, methodologically stronger trials.     

How is Adrenocortical Cancer being Managed in the UK?

INTRODUCTION

Adrenocortical carcinomas are rare. This case series is reported to give an overview of how adrenocortical carcinoma is currently managed in the UK.

PATIENTS AND METHODS

A retrospective review was made of case notes from patients with adrenocortical carcinomas presenting to the authors (TWJL, RDB, BJH, and DS-C) over the past 10 years in Newcastle, Sheffield and Cardiff.

RESULTS

Newcastle treated twelve, Sheffield eleven and Cardiff seven cases. The median follow-up was 25.5 months (range, 1–102 months). All tumours were greater than 5 cm in diameter. The majority presented with symptoms of hormone excess. Adrenalectomy was performed in 83% – this was radical in 30% and followed by excision of recurrence in 13%. Adjuvant mitotane was given in 64% of patients, in combination with cytotoxic chemotherapy in 20%. One-third of patients did not receive any adjuvant therapy. There was no significant difference in survival between the three centres. The majority of patients (57%) died during the period of follow-up of this study. The median survival was 37 months (range, 2–102 months).

CONCLUSIONS

The size of tumour, stage and mode of presentation, age and overall survival of patients in this study are comparable to published series of adrenocortical carcinomas from major endocrine surgical centres world-wide. Despite controversies about benefits, adjuvant mitotane was used in the majority of cases, whereas cytotoxic chemotherapy was only used in the minority. The exact role of adjuvant therapy in the management of adrenocortical carcinoma is not as well established as for other more common malignancies. Establishing a database for adrenocortical carcinomas in the UK would contribute to our understanding of the management of this disease.     

Tourniquet Use During Open Reduction and Internal Fixation of Ankle Fractures – A Systematic Review and Meta-Analysis

The intra-operative use of tourniquet in open reduction and internal fixation (ORIF) of ankle fractures remains a topic of debate. The purpose of this study was to perform a systematic review and meta-analysis of randomized control trials (RCTs) comparing clinical outcomes of patients undergoing ankle ORIF with tourniquet use versus a control group where no tourniquet was used. A systematic review was performed with reference to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of the Pubmed, Scopus, Embase, and Cochrane Library databases. Studies were included if they were an RCT comparing tourniquet and no-tourniquet in ankle ORIF. Meta-analysis was performed using RevMan, and p-value <.05 was considered to be statistically significant. On completion of the literature search, a total of 4 RCTs including 350 ankles (52.6% males), with a mean age of 47.1 ± 5.7 years were included. There were 173 patients in the tourniquet group (T), versus 177 patients in the no tourniquet control group (NT), with nonsignificant differences between the groups for age, gender and body mass index demographics (all p > .05). There were significantly shorter duration of surgery, with significantly higher patient-reported rates of pain levels at day 2 postoperatively (both p < .001) in the T group. Additionally, there were significantly greater ranges of ankle motion at 6 weeks postoperatively (p = .03), with nonsignificant differences reported incidence of wound infections and deep vein thrombosis (p = .056 and p = .130 respectively) between the groups. In conclusion, current evidence suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively.     

How Valid is the Quantity and Quality Relationship in CABG Surgery? A Review of the Literature

Numerous analyses have identified an inverse relationship between case volume in coronary artery bypass graft (CABG) surgery and mortality, and have led some to call for the consideration of minimum-volume standards for open-heart surgery programs. These findings, however, have been questioned by studies that demonstrate a weak or absent association, and by the availability of risk-adjusted mortality data. There is also growing evidence that clinical care processes have greater impact on mortality than sheer numbers alone. Policy decisions that may address this issue in the future need to consider the impact of mandating referrals away from low-volume programs, including the negative financial and programmatic effect on hospitals and both the clinical and social ramifications for patients and families, particularly in rural regions of the country.     

Efficacy and Safety of High-dose Vitamin C on Complex Regional Pain Syndrome in Extremity Trauma and Surgery—Systematic Review and Meta-Analysis

Complex regional pain syndrome (CRPS) is a devastating condition often seen after foot and ankle injury and surgery. Prevention of this pathology is attractive not only to patients but also to surgeons, because the treatment of this condition can be difficult. We evaluated the effectiveness of vitamin C in preventing occurrence of CRPS in extremity trauma and surgery by systematically reviewing relevant studies. The databases used for this review included: Ovid EMBASE, Ovid MEDLINE, CINAHL, and the Cochrane Database. We searched for comparative studies that evaluated the efficacy of more than 500 mg of daily vitamin C. After screening for inclusion and exclusion criteria, we identified 4 studies that were relevant to our study question. Only 1 of these 4 studies was on foot and ankle surgery; the rest concerned the upper extremities. All 4 studies were in favor of this intervention with minimal heterogeneity (Tau² = 0.00). Our quantitative synthesis showed a relative risk of 0.22 (95% confidence interval = 0.12, 0.39) when daily vitamin C of at least 500 mg was initiated immediately after the extremity surgery or injury and continued for 45 to 50 days. A routine, daily administration of vitamin C may be beneficial in foot and ankle surgery or injury to avoid CRPS. Further foot and ankle specific and dose-response studies are warranted.     

What is the Significance of the Circumferential Margin in Locally Advanced Rectal Cancer After Neoadjuvant Chemoradiotherapy?

Background

The circumferential resection margin (CRM) is highly prognostic for local recurrence in rectal cancer surgery without neoadjuvant treatment. However, its significance in the setting of long-course neoadjuvant chemoradiotherapy (nCRT) is not well defined.

Methods

Review of a single institution’s prospectively maintained database from 1998 to 2007 identified 563 patients with locally advanced rectal cancer (T3/T4 and/or N1) receiving nCRT, followed after 6 weeks by total mesorectal excision (TME). Kaplan-Meier, Cox regression, and competing risk analysis were performed.

Results

The authors noted that 75 % of all patients had stage III disease as determined by endorectal ultrasound (ERUS) and/or magnetic resonance imaging (MRI). With median follow-up of 39 months after resection, local and distant relapse were noted in 12 (2.1 %) and 98 (17.4 %) patients, respectively. On competing risk analysis, the optimal cutoff point of CRM was 1 mm for local recurrence and 2 mm for distant metastasis. Factors independently associated with local recurrence included CRM ≤1 mm, and high-grade tumor (p = 0.012 and 0.007, respectively). CRM ≤2 mm, as well as pathological, nodal, and overall tumor stage are also significant independent risk factors for distant metastasis (p = 0.025, 0.010, and <0.001, respectively).

Conclusion

In this dataset of locally advanced rectal cancer treated with nCRT followed by TME, CRM ≤1 mm is an independent risk factor for local recurrence and is considered a positive margin. CRM ≤2 mm was associated with distant recurrence, independent of pathological tumor and nodal stage.