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Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: a systematic review and meta-analysis

BACKGROUND The effect of sleeve gastrectomy (SG) on the prevalence of gastroesophageal reflux disease (GERD) remains unclear. We aimed to outline the currently available literature. DATA SOURCES All relevant databases were searched for publications examining the effect of laparoscopic SG on GERD. Primary outcome measure was change in prevalence of GERD symptoms, antireflux medication use, and esophageal function tests. Secondary outcomes were prevalence of new-onset GERD and esophagitis. Thirty-three articles were included. Eleven studies used questionnaires to assess changes in the prevalence of GERD symptoms, with a risk difference in prevalence of 4.3%. Eight studies used esophageal function tests, with paradoxical results. Pooled incidence of new-onset GERD symptoms was 20%, with a strong suggestion of heterogeneity. New-onset esophagitis ranged from 6.3% to 63.3%. CONCLUSIONS Because of high heterogeneity among available studies and paradoxical outcomes of objective esophageal function tests, the exact effect of laparoscopic SG on the prevalence of GERD remains unanswered. Surgeons should carefully evaluate preoperative GERD symptoms when choosing the proper bariatric technique.

Use of antibiotics in uncomplicated diverticulitis

The value of antibiotics in the treatment of acute uncomplicated left‐sided diverticulitis is not well established. The aim of this review was to assess whether or not antibiotics contribute to the (uneventful) recovery from acute uncomplicated left‐sided diverticulitis, and which types of antibiotic and route of administration are most effective.

Long-term prevalence of post-traumatic stress disorder symptoms in patients after secondary peritonitis

IntroductionThe aim of this study was to determine the long-term prevalence of post-traumatic stress disorder (PTSD) symptomology in patients following secondary peritonitis and to determine whether the prevalence of PTSD-related symptoms differed between patients admitted to the intensive care unit (ICU) and patients admitted only to the surgical ward.MethodA retrospective cohort of consecutive patients treated for secondary peritonitis was sent a postal survey containing a self-report questionnaire, namely the Post-traumatic Stress Syndrome 10-question inventory (PTSS-10). From a database of 278 patients undergoing surgery for secondary peritonitis between 1994 and 2000, 131 patients were long-term survivors (follow-up period at least four years) and were eligible for inclusion in our study, conducted at a tertiary referral hospital in Amsterdam, The Netherlands.ResultsThe response rate was 86%, yielding a cohort of 100 patients; 61% of these patients had been admitted to the ICU. PTSD-related symptoms were found in 24% (95% confidence interval 17% to 33%) of patients when a PTSS-10 score of 35 was chosen as the cutoff, whereas the prevalence of PTSD symptomology when borderline patients scoring 27 points or more were included was 38% (95% confidence interval 29% to 48%). In a multivariate analyses controlling for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of relaparotomies and length of hospital stay, the likelihood of ICU-admitted patients having PTSD symptomology was 4.3 times higher (95% confidence interval 1.11 to 16.5) than patients not admitted to the ICU, using a PTSS-10 score cutoff of 35 or greater. Older patients and males were less likely to report PTSD symptoms.ConclusionNearly a quarter of patients receiving surgical treatment for secondary peritonitis developed PTSD symptoms. Patients admitted to the ICU were at significantly greater risk for having PTSD symptoms after adjusting for baseline differences, in particular age.

Incidence and risk factors of delirium in the elderly general surgical patient

BACKGROUND This study evaluates the incidence of delirium and risk factors associated with delirium in elderly patients admitted to a general surgical ward. METHODS Patients aged over 60 years who were admitted with an acute or elective general surgical diagnosis were eligible for this prospective cohort study. Risk factors associated with delirium were analyzed using univariate and multivariate analysis to identify those independently associated with delirium. RESULTS A total of 209 patients were included in the study. The incidence of delirium was 16.9% (23.2% for acute admission, P < .001). Variables associated with delirium were dementia, presence of an urinary catheter, cognitive decline at admission measured with the mini-mental state examination, white blood cell count >10.0 × 10(9)/L, and urea >7.5 mmol/L. Median length of hospital stay was 13 days (range 3-85) for patients with delirium versus 7 (range 1-54) for patients without (P = .002). CONCLUSIONS The incidence of delirium is high in elderly patients, especially after an acute admission, leading to an increase in length of hospital stay. To minimize delirium, associated risk factors must be identified and, if possible, treated.

Systematic review of medical therapy to prevent recurrent diverticulitis

Aim and backgroundOne of today’s controversies remains the prevention of recurrent diverticulitis. Current guidelines advise a conservative approach, based on studies showing low recurrence rates and a high operative morbidity and mortality. Conservative measures in prevention recurrence are dietary advises and medical therapies, including probiotics and 5-aminosalicylic acid.ObjectivesThe aim of this systematic review is to assess whether medical or dietary therapies can prevent recurrent diverticulitis after a primary episode of acute diverticulitis.Method and search strategyWe searched different databases for papers published between January 1966 and January 2011.Study selectionClinical studies were eligible for inclusion if they assessed the prevention of recurrent diverticulitis with a medical or dietary therapy. Exclusion criteria were studies without a control group.ResultsThree randomized controlled trials (RCT), all with a Jadad quality score of 2 out of 5, were included in this systematic review. Mesalazine results in significantly less disease recurrence and fewer symptoms after an acute episode. The use of probiotics decreases symptoms but does not reduce recurrence. No difference in effect is seen when Balsalazide is added to probiotics compared to probiotics only. No relevant studies on dietary therapy/advices or antibiotics for prevention of recurrent diverticulitis were found.ConclusionThe evidence that supports medical therapy to prevent recurrent diverticulitis is of poor quality. Treatment with 5-aminosalicylic acid seems promising. Based on current data, no recommendation of any non-operative relapse prevention therapy for diverticular disease can be made.

Treatment Modalities for Small Saphenous Vein Insufficiency: Systematic Review and Meta-analysis

Purpose: To investigate and compare the anatomical success rates and complications of the treatment modalities for small saphenous vein (SSV) incompetence. Methods: A systematic literature search was performed in PubMed, EMBASE, and the Cochrane Library on the following therapies for incompetence of SSVs: surgery, endovenous laser ablation (EVLA), radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (UGFS), steam ablation, and mechanochemical endovenous ablation (MOCA). The search found 49 articles (5 randomized controlled trials, 44 cohort studies) reporting on the different treatment modalities: surgery (n=9), EVLA (n=28), RFA (n=9), UGFS (n=6), and MOCA (n=1). A random-effects model was used to estimate the primary outcome of anatomical success, which was defined as closure of the treated vein on follow-up duplex ultrasound imaging. The estimate is reported with the 95% confidence interval (CI). Secondary outcomes were technical success and major complications [paresthesia and deep vein thrombosis (DVT)], given as the weighted means. Results: The pooled anatomical success rate was 58.0% (95% CI 40.9% to 75.0%) for surgery in 798 SSVs, 98.5% (95% CI 97.7% to 99.2%) for EVLA in 2950 SSVs, 97.1% (95% CI 94.3% to 99.9%) for RFA in 386 SSVs, and 63.6% (95% CI 47.1% to 80.1%) for UGFS in 494 SSVs. One study reported results of MOCA, with an anatomical success rate of 94%. Neurologic complications were most frequently reported after surgery (mean 19.6%) and thermal ablation (EVLA: mean 4.8%; RFA: mean 9.7%). Deep venous thrombosis was a rare complication (0% to 1.2%). Conclusion: Endovenous thermal ablation (EVLA/RFA) should be preferred to surgery and foam sclerotherapy in the treatment of SSV incompetence. Although data on nonthermal techniques in SSV are still sparse, the potential benefits, especially the reduced risk of nerve injury, might be of considerable clinical importance.

Routine colonoscopy after left-sided acute uncomplicated diverticulitis: a systematic review

The use of routine colonoscopy after an episode of acute diverticulitis (AD) remains a point of debate. Most international and clinical practice guidelines advise endoscopy after conservatively treated diverticulitis. The rationale has always been to exclude an underlying malignancy or advanced colonic neoplasia (ACN). However, this is based merely on expert opinion. A recent article indicated that presently this may be different with increased use of abdominal CT imaging of diverticulitis. Furthermore, the yield of colonoscopy in patients after an episode of AD also casts doubt on current international practice. Routine colonoscopy after an uncomplicated episode of diverticulitis dates from a time where the diagnosis was primarily based on clinical examination and laboratory results with frequent use of barium enema. However, in today’s clinical practice, CT is widely used for the diagnosis of diverticulitis, with the possibility to assess potential adverse events such as abscess, fistula, obstruction, or perforation as well. Because of high sensitivity of 94%, a specificity of 99%, and a low interobserver variability, this modality is currently preferred for the diagnosis of diverticulitis, although US also has a good sensitivity. Nevertheless, it remains uncertain if the prevalence of colorectal carcinoma (CRC) and advanced adenoma (AA) in patients with imaging-proven diverticulitis is higher than in an average-risk population. Apart from diagnosing CRC, the detection of AA is of great importance because it bears the potential to progress to carcinoma. Colonoscopy is accompanied by such disadvantages as invasiveness and discomfort, potential adverse events such as perforation, and additional costs. It is important

Outpatient treatment for acute uncomplicated diverticulitis.

Background Traditionally, treatment of acute diverticulitis has mostly been based on inpatient care. The question arises whether these patients can be treated on an outpatient basis as the admissions for diverticular disease have been shown to be increasing every year. We studied whether outpatient treatment of acute uncomplicated diverticulitis is feasible and safe, and which patients could benefit from outpatient care. Materials and methods A retrospective cohort study was carried out in two teaching hospitals using hospital registry codes for diverticulitis. All patients diagnosed with acute uncomplicated diverticulitis between January 2004 and January 2012, confirmed by imaging or colonoscopy, were included. Exclusion criteria were patients with recurrent diverticulitis, complicated diverticulitis (Hinchey stages 2, 3, and 4), and right-sided diverticulitis. Inpatient care was compared with outpatient care. Primary outcome was admission for outpatient care and the complication rate in both groups. Multivariate analysis was carried out to identify potential factors for inpatient care. Results Of 627 patients with diverticulitis, a total of 312 consecutive patients were identified with primary uncomplicated diverticulitis of the sigmoid colon; 194 patients had been treated as inpatients and 118 patients primarily as outpatients. In this last group, 91.5% had been treated successfully without diverticulitis-related complications or the need for hospital admission during a mean follow-up period of 48 months. Conclusion Despite inherent patient selection in a retrospective cohort, ambulatory treatment of patients presenting with uncomplicated acute diverticulitis seems feasible and safe. In mildly ill and younger patients, hospital admission can be avoided.

Systematic review of clinical applications of monitoring muscle tissue oxygenation with near-infrared spectroscopy in vascular disease

BACKGROUND The use of wavelengths of the near-infrared region by near-infrared spectroscopy (NIRS) has been studied for several applications in vascular disease. This systematic review aims to explore the clinical relevance of monitoring muscle tissue oxygenation in vascular disease with NIRS. METHODS A systematic search in PubMed, EMBASE, CINAHL and Cochrane databases was performed to identify clinical NIRS studies, published until April 2015, involving muscle tissue oxygenation in vascular disease. RESULTS After screening 183 manuscripts, 38 studies (n=2010) were included. Studies concerned peripheral arterial disease (PAD) (twelve studies, n=848), compartment syndrome of lower extremities (seven studies, n=205), deep vein thrombosis (DVT) (six studies, n=429), buttock and lower extremity ischaemia in abdominal aortic aneurysm repair (six studies, n=139), free flap failure (five studies, n=354), and spinal cord ischaemia in thoracoabdominal aortic aneurysm repair (two studies, n=35). Nine studies compared NIRS with gold standards and provided cut-off values. Four studies regarding chronic compartment syndrome and DVT determined higher sensitivity (78%-97%) than specificity (56%-76%). Two studies regarding PAD and buttock claudication determined higher specificity (87%-95%) than sensitivity (33%-88%). Three studies regarding free flap failure determined sensitivity and specificity of 100%. CONCLUSION We found sufficient evidence to use NIRS in clinical setting for assessment of chronic compartment syndrome of lower extremities, and as surveillance tool for detection of free flap failure. So far, clinical relevance of routine use of NIRS in other vascular applications is less clear. Cut-off values to discriminate are not yet unanimous and better validation has to be awaited for.

Evaluating routine diagnostic imaging in acute appendicitis

AIM To evaluate the impact of selective imaging on clinical management of patients who present with symptoms suggesting acute appendicitis. MATERIALS AND METHODS During a two-and-half year period, 941 consecutive patients with right lower quadrant pain were analyzed. Patients who underwent selective imaging were compared to those treated without further imaging. RESULTS In 650 (69%) patients with right lower quadrant pain, diagnosis was based on medical history, physical and laboratory examination only. The diagnostic accuracy was 84%. Another 291 patients (31%) underwent selective imaging reaching a diagnostic accuracy of 71%. Ultrasound was conducted in 277 patients (sensitivity: 59%; specificity: 91%). CT scan was conducted in 43 patients (sensitivity: 100%; specificity: 95%). CONCLUSION The present study shows that, in the majority of patients, appendicitis acuta can be diagnosed without the aid of imaging studies. In all these cases, high diagnostic accuracy rates and low morbidity rates were achieved. In all the other cases when clinical diagnosis is uncertain, further evaluation should include imaging. In our series ultrasound is of limited value; CT scan or diagnostic laparoscopy seems superior.