Muhammed Ashraf Memon

Hepatitis C: an epidemiological review

The aim of the study was to analyse the current literature regarding the mode of transmission of HCV and its global prevalence in different groups of people. A systematic review of the literature on the epidemiology of hepatitis C from 1991 to 2000 using computerized bibliographic databases which include Medline, Current Content and Embase. The prevalence of hepatitis C virus (HCV) varies tremendously in different parts of the world, with the highest incidence in the Eastern parts of the globe compared with the Western parts. Furthermore, certain groups of individuals such as intravenous drug users are at increased risk of acquiring this disease irrespective of the geographical location. Although the main route of transmission is via contaminated blood, curiously enough in up to 50% of the cases no recognizable transmission factor/route could be identified. Therefore, a number of other routes of transmission such as sexual or household exposure to infected contacts have been investigated with conflicting results. Hepatitis C infection is an important public health issue globally. Better understanding of routes of transmission will help to combat the spread of disease. In order to prevent a world wide epidemic of this disease, urgent measures are required to (i) develop a strategy to inform and educate the public regarding this disease and (ii) expedite the efforts to develop a vaccine.

Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair

The aim was to conduct a meta‐analysis of the randomized evidence to determine the relative merits of laparoscopic (LIHR) and open (OIHR) inguinal hernia repair.

Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: A meta-analysis

BACKGROUND A meta-analysis evaluating surgical outcomes following nutritional provision provided proximal to the anastomosis within 24 hours of gastrointestinal surgery compared with traditional postoperative management was conducted. METHODS Databases were searched to identify randomized controlled trials comparing the outcomes of early and traditional postoperative feeding. Trials involving gastrointestinal tract resection followed by patients receiving nutritionally significant oral or enteral intake within 24 hours after surgery were included for analysis. RESULTS Fifteen studies involving a total of 1240 patients were analyzed. A statistically significant reduction (45%) in relative odds of total postoperative complications was seen in patients receiving early postoperative feeding (odds ratio [OR] 0.55; confidence interval [CI], 0.35 -0.87, P = .01). No effect of early feeding was seen with relation to anastomotic dehiscence (OR 0.75; CI, 0.39-1.4, P = .39), mortality (OR 0.71; CI, 0.32-1.56, P = .39), days to passage of flatus (weighted mean difference [WMD] -0.42; CI, -1.12 to 0.28, P = .23), first bowel motion (WMD -0.28; CI, -1.20 to 0.64, P = .55), or reduced length of stay (WMD -1.28; CI, -2.94 to 0.38, P = .13); however, the direction of clinical outcomes favored early feeding. Nasogastric tube reinsertion was less common in traditional feeding interventions (OR 1.48; CI, 0.93-2.35, P = .10). CONCLUSIONS Early postoperative nutrition is associated with significant reductions in total complications compared with traditional postoperative feeding practices and does not negatively affect outcomes such as mortality, anastomotic dehiscence, resumption of bowel function, or hospital length of stay.

Meta-Analysis of Randomized Clinical Trials Comparing Open and Laparoscopic Anti-Reflux Surgery

OBJECTIVES:The aim of this study was to conduct a meta-analysis of randomized evidence to determine the relative merits of laparoscopic anti-reflux surgery (LARS) and open anti-reflux surgery (OARS) for proven gastro-esophageal reflux disease (GERD).METHODS:A search of the Medline, Embase, Science Citation Index, Current Contents, and PubMed databases identified all randomized clinical trials that compared LARS and OARS and that were published in the English language between 1990 and 2007. A meta-analysis was carried out in accordance with the QUOROM (Quality of Reporting of Meta-Analyses) statement. The six outcome variables analyzed were operating time, hospital stay, return to normal activity, perioperative complications, treatment failure, and requirement for further surgery. Random-effects meta-analyses were carried out using odds ratios (ORs) and weighted mean differences (WMDs).RESULTS:Twelve trials were considered suitable for the meta-analysis. A total of 503 patients underwent OARS and 533 had LARS. For three of the six outcomes, the summary point estimates favored LARS over OARS. There was a significant reduction of 2.68 days in the duration of hospital stay for the LARS group compared with that for the OARS group (WMD: −2.68, 95% confidence interval (CI): −3.54 to −1.81; P<0.0001), a significant reduction of 7.75 days in return to normal activity for the LARS group compared with that for the OARS group (WMD: −7.75, 95% CI: −14.37 to −1.14; P=0.0216), and finally, there was a statistically significant reduction of 65% in the relative odds of complication rates for the LARS group compared with that for the OARS group (OR: 0.35, 95% CI: 0.16–0.75; P=0.0072). The duration of operating time was significantly longer (39.02 min) in the LARS group (WMD: 39.02, 95% CI: 17.99–60.05; P=0.0003). Treatment failure rates were comparable between the two groups (OR: 1.39, 95% CI: 0.71–2.72; P=0.3423). Despite this, the requirement for further surgery was significantly higher in the LARS group (OR: 1.79, 95% CI: 1.00–3.22; P=0.05).CONCLUSIONS:On the basis of this meta-analysis, the authors conclude that LARS is an effective and safe alternative to OARS for the treatment of proven GERD. LARS enables a faster convalescence and return to productive activity, with a reduced risk of complications and a similar treatment outcome, than an open approach. However, there is a significantly higher rate of re-operation (79%) in the LARS group.

The outcome of unretrieved gallstones in the peritoneal cavity during laparoscopic cholecystectomy. A prospective analysis.

AbstractBackground: Gallbladder perforation during laparoscopic cholecystectomy (LC) with spillage of bile and gallstones occurs in a substantial number of patients (up to 40%). Most surgeons believe that free intraperitoneal stones are not a justification for conversion to laparotomy even if a large number of stones are left in situ. There are, however, a number of reports demonstrating that, on occasion, these unretrieved gallstones may cause infection or abscess, inflammation, fibrosis, adhesions, cutaneous sinuses, small bowel obstruction, or generalized septicemia. The aim of this study was to determine the outcome of unretrieved gallstones in the peritoneal cavity after gallbladder perforation during LC. Methods: In a 7-year period between 1989 and 1996, prospective data were maintained on 856 patients who underwent LCs by a single surgeon (R.J.F.). Of the 856 patients, 165 (16%) had gallbladder perforations resulting in lost gallstones in the peritoneal cavity. A concerted attempt was made to remove the lost stones using a variety of extraction devices. Of these 165 patients, 106 (64%) were available for follow-up through mail (76%) and by telephone (24%). The mean age of these patients was 64.9 years (range, 18 to 98 years), and the mean follow-up was 44.8 months (range 4.9 to 92.3 months). Results: Of the 106 patients with unretrieved gallstones, we identified four patients with short-term complications and one patient with a long-term complication. The first patient with a short-term complication had pyrexia for 10 days postoperatively. Diagnostic evaluation, which included computed tomography (CT) scan, failed to reveal any abnormality. The patient was treated conservatively with a course of oral antibiotics. In the second patient, cellulitis developed at a drain site after its removal, which resolved with oral antibiotics. The third patient acquired an umbilical wound abscess, which drained spontaneously, requiring no treatment. A sterile subphrenic collection developed in the fourth patient 1 month postoperatively, which was treated with percutaneous drainage under CT guidance. The only long-term complication was spontaneous erosion of a gallstone from the back of a patient with a questionable history of inflammatory bowel disease 8 months postoperatively. All of the patients made complete recoveries. Conclusions: In most patients, unretrieved gallstones are of no consequence, but complications occur occasionally. It is therefore advisable to retrieve as many gallstones as possible during LC short of converting to a laparotomy.

Gastrointestinal carcinoid tumors: Current management strategies

BACKGROUND: Carcinoid or neuroendocrine tumors of the gastrointestinal tract, although characteristically indolent, are also quite heterogeneous both with respect to histologic and endocrine features and with respect to clinical presentation and behavior. PURPOSE: This study was undertaken to review and summarize the current literature on classification controversies, site-specific carcinoid presentation and behavior, and diagnostic and management strategies for primary and advanced carcinoid tumors and the carcinoid syndrome. RESULTS: For carcinoid tumors, oncologic results depend on the location of the primary tumor, extent of locoregional and metastatic disease, functioning status of the tumor, and the feasibility of complete surgical extirpation. Whereas favorable survival rates are typically observed for appendiceal and rectal primaries, less favorable rates are often observed for colonic and ileal tumors. A search for additional tumors is generally advised because multiple carcinoids and second neoplasms are not uncommon. Because of the indolent nature of the tumor and because these therapies have been shown to improve quality and quantity of life, otherwise fit patients with advanced carcinoid disease should be treated with aggressive medical and surgical therapies. Development of a malignant carcinoid syndrome indicates the presence of a functionally active carcinoid tumor and portends a poor prognosis. CONCLUSION: Gastrointestinal carcinoids, although malignant, behave differently from other carcinomas. Results are highly variable and must be individualized according to the site of the primary tumor, extent of spread, and general condition of the patient. A prolongation of quality life can often be accomplished through aggressive medical and surgical therapies.

Long-term consequences of intraoperative spillage of bile and gallstones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy is associated with a higher incidence of iatrogenic perforation of the gallbladder than open cholecystectomy. The long-term consequences of spilled bile and gallstones are unknown. Data were collected prospectively from 1059 consecutive patients undergoing laparoscopic cholecystectomy over a 3-year period. Details of the operative procedures and postoperative course of patients in whom gallbladder perforation occurred were reviewed. Long-term follow-up (range 24 to 59 months) was available for 92% of patients. Intraoperative perforation of the gallbladder occurred in 306 patients (29%); it was more common in men and was associated with increasing age, body weight, and the presence of omental adhesions (each P < 0.001). There was no increased risk in patients with acute cholecystitis (P = 0.13). Postoperatively pyrexia was more common in patients with spillage of gallbladder contents (18% vs. 9%; P < 0.001). Of the patients with long-term follow-up, intra-abdominal abscess developed in 1 (0.6%) of 177 with spillage of only bile, and in 3 (2.9%) of 103 patients with spillage of both bile and gallstones, whereas no intra-abdominal abscesses occurred in the 697 patients in whom the gallbladder was removed intact (P < 0.001). Intraperitoneal spillage of gallbladder contents during laparoscopic cholecystectomy is associated with an increased risk of intra-abdominal abscess. Attempts should be made to irrigate the operative field to evacuate spilled bile and to retrieve all gallstones spilled during the operative procedure.

Laparoscopic common bile duct exploration: the past, the present, and the future

BACKGROUND The advent of laparoscopic cholecystectomy (LC) has created a dilemma for treating patients with known or suspected choledocholithiasis. With rapid technologic growth and experience in laparoscopic skills, many surgeons are now routinely performing laparoscopic common bile duct exploration (LCBDE) and questioning the wisdom of preoperative endoscopic retrograde cholangiography (ERC) with or without endoscopic sphincterotomy. The purpose of this article is to review the current literature on the subject of LCBDE and critically evaluate the clinical results of this emerging technology. METHODS Medline and Science Citation Index databases were used to search English language articles published on LCBDE since 1989. RESULTS Transcystic common bile duct exploration has a better clearance rate, and carries less morbidity and mortality compared with laparoscopic choledochotomy. Compared with two-stage ERCP and LC, one-stage LC and LCBDE seems to be associated with a shorter hospital stay, a quicker recovery, less expense, and less morbidity and mortality. CONCLUSIONS LCBDE is a feasible, safe and effective procedure that carries a low morbidity and mortality and will decrease the need for unnecessary ERC in the future for suspected or proved choledocholithiasis.

Laparoscopic repair of recurrent hernias

AbstractBackground: Recurrence after primary conventional inguinal herniorrhaphy occurs in approximately 10% of patients depending on the type of repair and expertise of the surgeon. The repair of the resulting recurrent hernia is a daunting task because of already weakened tissues and obscured and distorted anatomy. The failure rate of these repairs using an open anterior approach may reach as high as 36%. Because of such a high failure rate, a number of investigators have focused on repairing these difficult recurrent hernias laparoscopically using a tension-free approach. Some of the earlier reports suggested a low recurrence rate of 0.5% to 5% when a laparoscopic approach was used to repair these hernias. The purpose of this study was to evaluate the efficacy of laparoscopic treatment for recurrent hernias in our institutions. Methods: Between February 1991 and February 1995, 96 recurrent hernias were repaired in 85 patients (78 men and 7 women). There were 48 right, 26 left, and 11 bilateral hernias. The mean age of the patients was 59 years (range, 18–86 years); the mean height was 69 in. (range, 54–77 in.); and the mean weight was 176 pounds (range, 109–280 pounds). A total of 68 herniorrhaphies were performed using the transabdominal preperitoneal (TAPP) method: 19 using intraperitoneal on-lay mesh (IPOM) repair and 8 using the total extraperitoneal (TEP) method. The method of repair in one patient was not recorded. The mean operating time was 76 min (range, 47–172 min). Thirteen patients underwent additional procedures. Results: Long-term follow-up was performed by questionnaire, examination, or both in 76 patients (85 hernias). Median follow-up time was 27 months (range, 2–56 months). There were four recurrences (2 in IPOM and 2 in TAPP). Three of these were repaired laparoscopically and one conventionally. There were 20 minor and 14 major complications and no mortality. One conversion occurred in the TAPP group. Mean postoperative stay was 1.4 days (range, 0–4 days). It was felt by 92% of the patients that their symptoms were completely relieved, whereas 4% of the patients continued to exhibit symptoms for which their hernia was repaired, and 3.6% failed to answer. As reported, 86% of the patients preferred their laparoscopic repair; 1% preferred the conventional repair; and 13% failed to reply. Afterward, 77% of the patients returned to normal activity, and 35% returned to vigorous activity within 4 weeks of surgery. Satisfaction with laparoscopic repair was expressed by 92% of the patients, whereas 8% either were dissatisfied or did not answer. In the end, 95% of the patients stated that they would recommend laparoscopic hernia surgery to their family and friends. Conclusions: These preliminary data show that laparoscopic repair of recurrent inguinal hernia is a safe alternative procedure with acceptable rates of recurrence and complications.

Effect of timing of pharmaconutrition (immunonutrition) administration on outcomes of elective surgery for gastrointestinal malignancies: A systematic review and meta-analysis

BACKGROUND Pharmaconutrition has previously been reported in elective surgery to reduce postoperative infective complications and duration of hospital length of stay. OBJECTIVE To update previously published meta-analyses and elucidate potential benefits of providing arginine-dominant pharmaconutrition in surgical patients specifically with regard to the timing of administration of pharmaconutrition. DESIGN Randomized controlled trials comparing the use of pharmaconutrition with standard nutrition in elective adult surgical patients between 1980 and 2011 were identified. The meta-analysis was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA) recommendations. RESULTS Twenty studies yielding 21 sets of data met inclusion criteria. A total of 2005 patients were represented (pharmaconutrition, n = 1010; control, n = 995), in whom pharmaconutrition was provided preoperatively (k = 5), perioperatively (k = 2), or postoperatively (k = 14). No differences were seen in postoperative mortality with the provision of pharmaconutrition irrespective of timing of administration. Statistically significant reductions in infectious complications and length of stay were found with perioperative and postoperative administration. Perioperative administration was also associated with a statistically significant reduction in anastomotic dehiscence, whereas a reduction in noninfective complications was demonstrated with postoperative administration. Preoperative pharmaconutrition demonstrated no notable advantage over standard nutrition provision in any of the clinical outcomes assessed. CONCLUSIONS This meta-analysis highlights the importance of timing as a clinical consideration in the provision of pharmaconutrition in elective gastrointestinal surgical patients and identifies areas where further research is required.