Katie E. Rollins

Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials

Objectives:To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols. Methods:Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality. Results:A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66–0.89, P = 0.0007), hospital length of stay (LOS; mean difference −1.55 days, 95% CI −2.73 to −0.36, P = 0.01), intensive care LOS (mean difference −0.63 days, 95% CI −1.18 to −0.09, P = 0.02), and time to passage of feces (mean difference −0.90 days, 95% CI −1.48 to −0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference −0.63 days, 95% CI −0.94 to −0.32, P < 0.0001) and time to passage of feces (mean difference −1.09 days, 95% CI −2.03 to −0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to −0.84, P = 0.0002) and total hospital LOS (mean difference −2.14, 95% CI −4.15 to −0.13, P = 0.04). Conclusions:GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting.

Systematic review of the impact of HbA1c on outcomes following surgery in patients with diabetes mellitus

BACKGROUND & AIMS Diabetes is a significant risk factor for surgical complications and also increases the prevalence of comorbidities, thereby increasing surgical risk. The aim of this systematic review was to establish the relationship between long-term preoperative glycemic control as measured by HbA1c and postoperative complications. METHODS A systematic search was conducted to source articles published between 1980 and 2014 pertinent to the review. Full-text articles were included if they met the pre-determined criteria as determined by two reviewers. Studies reporting the impact of preoperative HbA1c levels on postoperative outcomes in all disciplines of surgery were included. RESULTS Twenty studies, including a total of 19,514 patients with diabetes mellitus from a range of surgical specialties, were suitable for inclusion. Preoperative glycemic control did not have a bearing on 30-day mortality. There were no significant differences in the incidence of stroke, venous thromboembolic disease, hospital readmission and ITU length of stay based on glycemic control. The majority of studies suggested no link between preoperative HbA1c levels and acute kidney injury or need for postoperative dialysis, dysrhythmia, infection not related to the surgical site and total hospital length of stay. The literature was highly variable with regards to myocardial events, surgical site infection and reoperation rates. CONCLUSIONS Elevated preoperative HbA1c was not definitively associated with increased postoperative morbidity or mortality in patients with diabetes mellitus. The studies included in this review were relatively heterogeneous, predominantly retrospective, and often contained small patient numbers, suggesting that good quality evidence is necessary.

Impact of mechanical bowel preparation in elective colorectal surgery: A meta-analysis

AIM To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery. METHODS Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. RESULTS A total of 36 studies (23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates (OR = 0.90, 95%CI: 0.74 to 1.10, P = 0.32), surgical site infection (OR = 0.99, 95%CI: 0.80 to 1.24, P = 0.96), intra-abdominal collection (OR = 0.86, 95%CI: 0.63 to 1.17, P = 0.34), mortality (OR = 0.85, 95%CI: 0.57 to 1.27, P = 0.43), reoperation (OR = 0.91, 95%CI: 0.75 to 1.12, P = 0.38) or hospital length of stay (overall mean difference 0.11 d, 95%CI: -0.51 to 0.73, P = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlled trials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. CONCLUSION In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery.

Mixed Periampullary Adenocarcinoma and Somatostatinoma with Small Bowel Gastrointestinal Stromal Tumour in Neurofibromatosis Type 1

CONTEXT Gastrointestinal (GI) involvement is present in about one quarter of cases of neurofibromatosis type 1 (NF1). Adenocarcinomas have been reported in several organs. Gastrointestinal stromal tumors are the most common GI lesion seen in NFI. GISTs in combination with ampullary neuroendocrine tumors in NF-1 have been reported rarely. CASE REPORT We present the case of a 44-year-old man who presented with a history of obstructive jaundice and weight loss. Investigations revealed a pancreatic tumor associated with a common bile duct (CBD) stricture. At operation, an ampullary adenocarcinoma that infiltrated into the head of pancreas with an adjacent somatostatinoma was found. In addition, a small bowel GIST was present. CONCLUSIONS Mixed periampullary adenocarcinoma and somatostatinoma in a patient with NF1 has only been previously reported once. The current case highlights the spectrum of associated tumor types which can be seen in association with NF1. Patients with NF1 who present with jaundice and weight loss should be investigated in the usual manner with increased suspicion for duodenal and ampullary tumors.

Lymphoepithelial Cyst of the Pancreas and Elevated Cyst Fluid Carcinoembryonic Antigen: A Diagnostic Challenge

CONTEXT Pancreatic lymphoepithelial cysts are rare, benign cysts which can present diagnostic difficulties. Non-invasive imaging alone is unreliable in distinguishing between benign and malignant cysts. Endoscopic ultrasound (EUS) and fine needle aspiration (FNA) with analysis of cyst fluid is more reliable, but invasive. In addition, tumor markers such as carcinoembryonic antigen (CEA) can be grossly elevated in cyst fluid of benign cysts. CASE REPORT We present the case of a 67 year old man with an incidental finding of a pancreatic cyst. EUS and FNA-guided aspiration of cyst fluid was performed. Fluid CEA was grossly elevated and resectional surgery was performed. On histological examination the diagnosis was confirmed as lymphoepithelial cyst of the pancreas. CONCLUSION Tumor markers such as CEA can be elevated in the cyst fluid of benign pancreatic conditions such as lymphoepithelial cyst. Although the diagnosis is challenging preoperatively, if a systematic algorithm is followed, these conditions can be managed safely and efficiently.

Ascorbic acid ameliorates renal injury in a murine model of contrast-induced nephropathy

BackgroundContrast induced nephropathy (CIN) is the commonest cause of iatrogenic renal injury and its incidence has increased with the advent of complex endovascular procedures. Evidence suggests that ascorbic acid (AA) has a nephroprotective effect in percutaneous coronary interventions when contrast media are used. A variety of biomarkers (NGAL, NGAL:creatinine, mononuclear cell infiltration, apoptosis and RBP-4) in both the urine and kidney were assayed using a mouse model of CIN in order to determine whether AA can reduce the incidence and/or severity of renal injury.MethodsTwenty-four BALB/c mice were divided into 4 groups. Three groups were exposed to high doses of contrast media (omnipaque) in a well-established model of CIN, and then treated with low or high dose AA or placebo (saline). CIN severity was determined by measurement of urinary neutrophil gelatinase-associated lipocalin (NGAL):creatinine at specific time intervals. Histological analysis was performed to determine the level of mononuclear inflammatory infiltration as well as immunohistochemistry to determine apoptosis in the glomeruli by staining for activated caspase-3 and DNA nicking (TUNEL assays). Reverse transcriptase PCR (rtPCR) of mRNA transcripts prepared from mRNA extracted from mouse kidneys was also performed for both lipocalin-2 (Lcn2) encoding NGAL and retinol binding protein-6 (RBP4) genes. NGAL protein expression was also confirmed by ELISA analysis of kidney lysates.ResultsUrinary NGAL:creatinine ratio was significantly lower at 48 h with a 44% and 62% (204.3μg/mmol versus 533.6μg/mmol, p = 0.049) reduction in the low and high dose AA groups, respectively. The reduced urinary NGAL:creatinine ratio remained low throughout the time period assessed (up to 96 h) in the high dose AA group. In support of the urinary analysis ELISA analysis of NGAL in kidney lysates also showed a 57% reduction (12,576 ng/ml versus 29,393 ng/ml) reduction in the low dose AA group. Immunohistochemistry for apoptosis demonstrated decreased TUNEL and caspase-3 expression in both low and high dose AA groups.ConclusionsAscorbic acid reduced the frequency and severity of renal injury in this murine model of CIN. Further work is required to establish whether AA can reduce the incidence of CIN in humans undergoing endovascular procedures.

Non-operative management of uncomplicated acute appendicitis in children: where is the evidence?

Appendicitis is the most common emergency condition in children, with a lifetime incidence of 7% to 8%. Appendicectomy has been the mainstay of treatment of acute appendicitis in both adults and children for over 100 years, with the laparoscopic approach being favoured in recent times. However, in addition to the need for general anaesthetia, there are potential risks and complications associated with the procedure. Moreover, in children, surgical procedures are associated frequently with both physiological and psychological stress for the patient and their parents, as well as having an economic impact. The management of uncomplicated acute appendicitis, in both adults and children, is currently in a state of significant flux. Evidence from a number of randomised controlled trials and case-controlled series have been combined in systematic reviews and meta-analyses, and in the adult literature the role of primary antibiotic therapy for the management of uncomplicated acute appendicitis is becoming supported increasingly.1 Surgery is generally regarded as a more effective initial treatment option than antibiotic therapy due to the largely unknown long-term risk of recurrent appendicitis following non-operative management. However, in adults, surgery is associated with greater complication rates and increased incidence of readmission than primary antibiotic therapy.1 Nevertheless, antibiotic therapy is not recommended currently as the first-line treatment strategy.2 Within the field of paediatrics, the evidence base for non-operative treatment is limited, with just one randomised controlled trial3 investigating its role in acute non-perforated appendicitis. However, this was a pilot study, …

A comparison of two different software packages for the analysis of body composition using computed tomography images.

Highlights • We clarify the equivalence of body composition analysis from computed tomography images using two different software packages.• Analysis was performed using SliceOmatic and OsiriX packages on 50 patients who had undergone triphasic scans.• Body composition measures were significantly different between the two software packages, but the clinical significance of these is doubtful.• We recommend that for serial body composition analysis and for comparative purposes, the software package employed should be consistent.