Emile Tan

Fast-track vs standard care in colorectal surgery: a meta-analysis update

BackgroundFast-track (FT) protocols accelerate patients recovery and shorten hospital stay as a result of the optimization of the perioperative care they offer. The aim of this review is to examine the latest evidence for fast-track protocols when compared with standard care in elective colorectal surgery involving segmental colonic and/or rectal resection.Materials and methodsAll randomized controlled trials and controlled clinical trials on FT colorectal surgery were reviewed systematically. The main end points were short-term morbidity, length of primary postoperative hospital stay, length of total postoperative stay, readmission rate, and mortality. Quality assessment and data extraction were performed independently by two observers.ResultsEleven studies were eligible for analysis (four randomized controlled trials (RCTs) and seven controlled clinical trials (CCT)), including 1,021 patients. Primary hospital stay (weighted mean difference −2.35xa0days, 95% confidence interval (CI) −3.24 to −1.46xa0days, Pu2009<u20090.00001) and total hospital stay (weighted mean difference −2.46xa0days, 95% CI −3.43 to −1.48xa0days, Pu2009<u20090.00001) were significantly lower for FT programs. Morbidity was also lower in the FT group. Readmission rates were not significantly different. No increase in mortality was found.ConclusionsFT protocols show high-level evidence on reducing primary and total hospital stay without compromising patients safety offering lower morbidity and the same readmission rates. Enhanced recovery programs should become a mainstay of elective colorectal surgery.

The Risk of Oral Contraceptives in the Etiology of Inflammatory Bowel Disease: A Meta-Analysis

OBJECTIVES:Several environmental and genetic factors have been implicated to date in the development of Crohns disease (CD) and ulcerative colitis (UC). The aim of this study was to provide a quantification of the risk of oral contraceptive pill (OCP) use in the etiology of inflammatory bowel disease.METHODS:A literature search was performed to identify comparative studies reporting on the association of oral contraceptive use in the etiology of UC and CD between 1983 and 2007. A random-effect meta-analysis was used to compare the incidence of UC or CD between the patients exposed to the OCP and nonexposed patients. The results were adjusted for smoking.RESULTS:A total of 75,815 patients were reported on by 14 studies, with 36,797 exposed to OCP and 39,018 nonexposed women. The pooled relative risk (RR) for CD for women currently taking the OCP was 1.51 (95% confidence interval [CI] 1.17–1.96, P = 0.002), and 1.46 (95% CI 1.26–1.70, P < 0.001), adjusted for smoking. The RR for UC in women currently taking the OCP was 1.53 (95% CI 1.21–1.94, P = 0.001), and 1.28 (95% CI 1.06–1.54, P = 0.011), adjusted for smoking. The RR for CD increased with the length of exposure to OCP. Moreover, although the RR did not reduce once the OCP was stopped, it was no longer significant once the OCP was stopped (CI contains 1), both for CD and for UC.CONCLUSIONS:This study provides evidence of an association between the use of oral contraceptive agents and development of IBD, in particular CD. The study also suggests that the risk for patients who stop using the OCP reverts to that of the nonexposed population.

The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review.

PurposeThis study was designed to evaluate the effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy, and delivery in patients with ulcerative colitis.MethodsA systematic literature search was performed of articles published between 1980 and 2005 on patients undergoing restorative proctocolectomy for ulcerative colitis reporting data on the outcomes of interest. A random-effect, meta-analytical model was used for pooled estimates and 95 percent confidence intervals.ResultsA total of 22 studies, with 1,852 females, were included. Infertility rate was 12 percent before restorative proctocolectomy and 26 percent after, among 945 patients in seven studies. The incidence of sexual dysfunction was 8 percent preoperatively and 25 percent postoperatively (7 studies, nu2009=u2009419). Two studies (nu2009=u200962) reported no urinary dysfunction in patients undergoing restorative proctocolectomy. There was an increased incidence of cesarean section after restorative proctocolectomy. During the third trimester of pregnancy, there was an increase in stool frequency by 1.15 stools per day compared with before pregnancy frequency (nu2009=u200949 95 percent confidence interval, 0.28–2.03 Pu2009=u20090.01 chi-squared statistic, 0.04 Pu2009=u20090.84). No significant differences were seen in pouch function after vaginal delivery (nu2009=u2009456; weighted mean difference, 0.23; 95 percent confidence interval, 0.43–0.88; Pu2009=u20090.49; chi-squared statistic, 1.29; Pu2009=u20090.26).ConclusionsThe incidence of dyspareunia increases after restorative proctocolectomy. There was a decrease in fertility after restorative proctocolectomy. Pregnancy after restorative proctocolectomy was not associated with an increase in complications. There was an increase in stool frequency and pad usage during the third trimester. Vaginal delivery is safe after restorative proctocolectomy. Pouch function after delivery returns to pregestational function within six months.

Diagnostic precision of carcinoembryonic antigen in the detection of recurrence of colorectal cancer

INTRODUCTIONnThe aim of the study was to evaluate the diagnostic precision of serum carcinoembryonic antigen (CEA) in the detection of local or distant recurrence following resectional surgery for colon and rectal cancer.nnnMETHODSnQuantitative meta-analysis was performed on 20 studies, comparing serum CEA with radiological imaging and/or pathology in detecting colorectal cancer (CRC) recurrence in 4285 patients. The cut-off for a positive CEA ranged from 3 to 15 ng/ml between the various studies. Sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each study. Summary receiver operating characteristic curves (SROC) and sub-group analysis were undertaken.nnnRESULTSnThe overall sensitivity and specificity of CEA for detecting CRC recurrence was 0.64 (95% CI: 0.61-0.67) and 0.90 (95% CI: 0.89-0.91), respectively. The area under the SROC curve was 0.75 (SE=0.04) and the diagnostic odds ratio was 18.44 (95% CI: 11.94-28.49). A CEA cut-off of 5 ng/ml yielded a higher diagnostic odds ratio than a cut-off of 3 ng/ml (15.5 vs. 11.1). Using meta-regression analysis the optimum CEA cut-off point for the best combination of sensitivity and specificity was 2.2 ng/ml. On sub-group analysis high quality studies, and those involving > or =100 patients yielded a marginal improvement in the sensitivity and specificity with minimal change to the SROC.nnnCONCLUSIONnSerum CEA is a test with high specificity but insufficient sensitivity for detecting CRC recurrence in isolation. A cut-off of 2.2 ng/ml may provide an ideal balance of sensitivity and specificity. It may be useful as a first-line surveillance investigation in patients during surgical follow-up based on serial CEA measurements using temporal trends in conjunction with clinical, radiological and/or histological confirmation.

Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis

BACKGROUNDnLateral pelvic lymph-node metastases occur in 10-25% of patients with rectal cancer, and are associated with higher local recurrence and reduced survival rates. A meta-analysis was undertaken to assess the value of extended lateral pelvic lymphadenectomy in the operative management of rectal cancer.nnnMETHODSnWe searched Medline, Embase, Ovid, Cochrane Library, and Google Scholar for studies published between 1965 and 2009 that compared extended lymphadenectomy (EL) with standard rectal resection. 20 studies, which included 5502 patients from one randomised, three prospective non-randomised, and 14 retrospective case-control studies published between 1984 and 2009, met our search criteria and were assessed. 2577 patients underwent EL and 2925 underwent non-EL for rectal cancer. Random and fixed-effects meta-analytical models were used where indicated, and between-study heterogeneity was assessed. End-points evaluated included peri-operative outcomes, 5-year survival and recurrence rates.nnnFINDINGSnOperating time was significantly longer in the EL group by 76.7 min (95% CI 18.77-134.68; p=0.0096). Intra-operative blood loss was greater in the EL group by 536.5 mL (95% CI 353.7-719.2; p<0.0001). Peri-operative mortality (OR 0.81, 95% CI 0.34-1.93; p=0.63) and morbidity (OR 1.45, 95% CI 0.89-2.35; p=0.13) were similar between the two groups. Data from individual studies showed that male sexual dysfunction and urinary dysfunction (three studies: OR 3.70, 95% CI 1.66-8.23; p=0.0012) were more prevalent in the EL group. There were no significant differences in 5-year survival (hazard ratio [HR] 1.09, 95% CI 0.78-1.50; p=0.62), 5-year disease-free survival (HR 1.23, 95% CI 0.75-2.03, p=0.41), and local (OR 0.83, 95% CI 0.61-1.13; p=0.23) or distant recurrence (OR 0.93, 95% CI 0.72-1.21; p=0.60).nnnINTERPRETATIONnExtended lymphadenectomy does not seem to confer a significant overall cancer-specific advantage, but does seem to be associated with increased urinary and sexual dysfunction.

Meta-analysis: alvimopan vs. placebo in the treatment of post-operative ileus

Alvimopan is a selective, competitive μ‐opioid receptor antagonist with limited oral bioavailability which may be used to reduce length of post‐operative ileus.

Meta-analysis: sacral nerve stimulation versus conservative therapy in the treatment of faecal incontinence

AimSacral nerve stimulation (SNS) has recently been used in the management of faecal incontinence (FI). This study compared SNS to conservative management with regards to functional and quality of life outcomes.MethodsMeta-analysis of studies published between 1995 and 2008 on SNS for FI was performed. Outcomes evaluated were functional, physiological and quality of life. A random-effects model was used and sensitivity analyses performed. Subgroup analyses were performed on age and sphincter status.ResultsThirty-four studies were included, reporting on 944 patients undergoing peripheral nerve evaluation; 665 underwent permanent SNS. Weekly incontinence episodes (weighted mean difference [WMD] −6.83; 95% confidence intervals [CI] −8.05, −5.60; pu2009<u20090.001) and incontinence scores (WMD −10.57; 95% CI −11.89, −9.24; pu2009<u20090.001) were significantly reduced with SNS; ability to defer defecation (WMD 7.99xa0min; 95% CI 5.93, 10.05; pu2009<u20090.001) was increased. Most SF-36 and FIQL domains improved following SNS, and mean anal pressures increased significantly (pu2009<u20090.001). Results remained consistent on sensitivity analysis. The under-56xa0years age group showed smaller functional but greater physiological and quality of life improvements. Results were similar between sphincter intact and impaired subgroups. The complication rate was 15% for permanent SNS, with 3% resulting in permanent explantation.ConclusionSNS results in significant improvements in objective and subjective measures for faecally incontinent patients.

Meta-analysis: narrow band imaging for lesion characterization in the colon, oesophagus, duodenal ampulla and lung

Backgroundu2002 Narrow band imaging is a new endoscopic technology that highlights mucosal surface structures and microcapillaries, which may be indicative of neoplastic change.

Outcomes of Crohn's disease presenting with abdominopelvic abscess.

PURPOSE: The aim of this study was to evaluate clinical outcomes, quality-adjusted life-years, and the cost-effectiveness gained from percutaneous drainage followed by elective surgery vs. initial surgery for abdominopelvic abscesses related to Crohns disease. METHODS: All consecutive patients with spontaneous Crohns disease-related abdominopelvic abscess from 1997 to 2007 were reviewed. The authors excluded postoperative and perirectal abscesses. Decision analysis during one year of patient life was used to calculate quality-adjusted life-years and the cost-effectiveness of each strategy. RESULTS: Of 94 patients, 48 (51 percent) were initially approached with percutaneous drainage. Thirty-one (65 percent) had successful percutaneous drainage and delayed elective surgery. The factors significantly associated with percutaneous drainage failure were steroid use, colonic phenotype, and multiple or multilocular abscesses. The initial treatment was surgery in the remaining 46 (49 percent) patients. The initial approach with percutaneous drainage gave higher quality-adjusted life-years and was more cost-effective than initial surgery. Percutaneous drainage was the optimal strategy in spite of the risk of failure and septic complications within the plausible range. CONCLUSIONS: Percutaneous drainage failure is associated with steroid use, colonic phenotype, and multiple or multilocular abscesses. When feasible, percutaneous drainage is the most effective strategy from the perspective of patients and third-party payers.

Surgical strategies for faecal incontinence--a decision analysis between dynamic graciloplasty, artificial bowel sphincter and end stoma.

Background Artificial bowel sphincter (ABS) and dynamic graciloplasty (DG) are surgical treatments for faecal incontinence (FI). FI may affect quality of life (QOL) so severely that patients are often willing to consider a permanent end stoma (ES). It is unclear which is the more cost‐effective strategy.