s Paraskeva

Diagnostic Precision of Fecal Calprotectin for Inflammatory Bowel Disease and Colorectal Malignancy

OBJECTIVES:Fecal calprotectin (FC) is a relatively new marker of intraluminal intestinal inflammation. Using meta-analytical techniques, the study aimed to evaluate the diagnostic precision of FC for inflammatory bowel disease (IBD) and colorectal cancer (CRC) in adults and children.METHODS:Quantitative meta-analysis was performed on prospective studies, comparing FC levels against the histological diagnosis. Sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated for each study. Summary receiver-operating characteristic (sROC) curves and subgroup analysis were undertaken. Study quality and heterogeneity were evaluated.RESULTS:Thirty studies of 5,983 patients were included. FC levels in patients with IBD were higher by 219.2 micrograms per gram (μg/g) compared with normal patients (P < 0.001). sROC curve analysis showed a sensitivity of 0.95 (95% CI 0.93–0.97), specificity of 0.91 (95% CI 0.86–0.91), and an area under the curve (AUC) of 0.95 for the diagnosis of IBD. Patients with colorectal neoplasia had nonsignificantly higher FC levels by 132.2 μg/g compared with noncancer controls (P = 0.18). Sensitivity and specificity of FC for the diagnosis of CRC were 0.36 and 0.71, respectively, with an AUC of 0.66. The diagnostic precision of FC for IBD was higher in children than adults with better accuracy at a cutoff level of 100 μg/g versus 50 μg/g. Sensitivity analysis and metaregression analysis did not significantly alter the results.CONCLUSIONS:FC cannot be recommended as a screening test for CRC in the general population. FC appeared to offer a good diagnostic precision in distinguishing IBD from non-IBD diagnoses, with higher precision at a cutoff of 100 μg/g.

Laparoscopic versus open appendectomy in children: a meta-analysis

Objective:This study aims to use meta-analysis to compare laparoscopic and open appendectomy in a pediatric population. Summary Background Data:Meta-analysis is a statistical tool that can be used to evaluate the literature in both qualitative and quantitative ways, accounting for variations in characteristics that can influence overall estimate of outcomes of interest. Meta-analysis of laparoscopic versus open appendectomy in a pediatric population has not previously been performed. Methods:Comparative studies published between 1992 and 2004 of laparoscopic versus open appendectomy in children were included. Endpoints were postoperative pyrexia, ileus, wound infection, intra-abdominal abscess formation, operative time, and postoperative hospital stay. Results:Twenty-three studies including 6477 children (43% laparoscopic, 57% open) were included. Wound infection was significantly reduced with laparoscopic versus open appendectomy (1.5% versus 5%; odds ratio [OR] = 0.45, 95% confidence interval [CI], 0.27–0.75), as was ileus (1.3% versus 2.8%; OR = 0.5, 95% CI, 0.29–0.86). Intra-abdominal abscess formation was more common following laparoscopic surgery, although this was not statistically significant. Subgroup analysis of randomized trials did not reveal significant difference between the 2 techniques in any of the 4 complications. Operative time was not significantly longer in the laparoscopic group, and postoperative stay was significantly shorter (weighted mean difference, −0.48; 95% CI, −0.65 to −0.31). Sensitivity analysis identified lowest heterogeneity when only randomized studies were considered, followed by prospective, recent, and finally large studies. Conclusions:The results of this meta-analysis suggest that laparoscopic appendectomy in children reduces complications. However, we also see the need for further high-quality randomized trials comparing the 2 techniques, matched not only for age and sex but also for obesity and severity of appendicitis.

An innovative model for teaching and learning clinical procedures

Context  Performing a clinical procedure requires the integration of technical clinical skills with effective communication skills. However, these skills are often taught separately.

The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases

Background and aimsLoop ileostomies are used currently in surgical practice to reduce the consequences of distal anastomotic failure following colorectal resection. It is often assumed that reversal of a loop ileostomy is a simple and safe procedure. However, many studies have demonstrated high morbidity rates following loop ileostomy closure. The aims of this systematic review were to examine all the existing evidence in the literature on morbidity and mortality following closure of loop ileostomy.MethodA literature search of Ovid, Embase, the Cochrane database, Google Scholar™ and Medline using Pubmed as the search engine was used to identify studies reporting on the morbidity of loop ileostomy closure (latest at June 15th 2008), was performed. Outcomes of interest included demographics, the details regarding the original indication for operation, operative and hospital-related outcomes, post-operative bowel-related complications, and other surgical and medical complications.ResultsForty-eight studies from 18 countries satisfied the inclusion criteria. Outcomes of a total of 6,107 patients were analysed. Overall morbidity following closure of loop ileostomy was found to be 17.3% with a mortality rate of 0.4%. 3.7% of patients required a laparotomy at the time of ileostomy closure. The most common post-operative complications included small bowel obstruction (7.2%) and wound sepsis (5.0%).ConclusionThe consequences of anastomotic leakage following colorectal resection are severe. However, the consequences of stoma reversal are often underestimated. Surgeons should adopt a selective strategy regarding the use of defunctioning ileostomy, and counsel patients further prior to the original surgery. In this way, patients at low risk may be spared the morbidity of stoma reversal.

Appendicectomy and Cholecystectomy Using Single-Incision Laparoscopic Surgery (SILS): The First UK Experience

Introduction. Single-incision laparoscopic surgery (SILS) has the potential advantages of reduced postoperative pain and reduced port-site complications. Careful attention to closure can lead to virtually “scarless” surgery. In this article, we present our first experiences with SILS appendicectomy and cholecystectomy. Method . SILS appendicectomy and cholecystectomy was performed in 12 and 14 patients, respectively. Data were collected prospectively and analyzed retrospectively from case notes and the theater database. Results. The average operating times were 61.3 and 142.9 minutes for SILS appendicectomy and SILS cholecystectomy, respectively. There was a good correlation between increasing experience and a reduction in operative time with Pearson’s coefficient being −1 for appendicectomy and −0.56 for cholecystectomy. There were no postoperative complications in the SILS appendicectomy group. One patient in the SILS cholecystectomy group suffered a postoperative biliary leak from an accessory duct of Lushka. Conclusions. In our series, we have demonstrated SILS to be a safe and efficacious method for appendicectomy and cholecystectomy. Further studies are required to investigate any potential advantages of this method over standard laparoscopic techniques.

Single-incision laparoscopic surgery for cholecystectomy: an evolving technique

BackgroundLaparoscopic techniques have allowed surgeons to perform complicated intraabdominal surgery with minimal trauma. Recent innovators have pioneered the use of single-incision laparoscopic surgery (SILS), which has the potential of further reducing the trauma of surgical access. This may lead to reduced postoperative pain and improved patient cosmesis.MethodsThis article reports the authors’ method of performing SILS cholecystectomy, with carefully placed sutures used to puppeteer the gallbladder and thus aid retraction.ResultsThe authors have performed SILS cholecystectomy for 23 patients with good results.ConclusionsSingle-incision laparoscopic surgery is a feasible way to perform cholecystectomy. Further work in the form of randomized controlled trials is needed to investigate the advantages of this new technique.

Single-incision Laparoscopic Surgery (SILS) in general surgery: a review of current practice.

Single-incision laparoscopic surgery (SILS) aims to eliminate multiple port incisions. Although general operative principles of SILS are similar to conventional laparoscopic surgery, operative techniques are not standardized. This review aims to evaluate the current use of SILS published in the literature by examining the types of operations performed, techniques employed, and relevant complications and morbidity. This review considered a total of 94 studies reporting 1889 patients evaluating 17 different general surgical operations. There were 8 different access techniques reported using conventional laparoscopic instruments and specifically designed SILS ports. There is extensive heterogeneity associated with operating methods and in particular ways of overcoming problems with retraction and instrumentation. Published complications, morbidity, and hospital length of stay are comparable to conventional laparoscopy. Although SILS provides excellent cosmetic results and morbidity seems similar to conventional laparoscopy, larger randomized controlled trials are needed to assess the safety and efficacy of this novel technique.

Is the structure of anatomy curriculum adequate for safe medical practice

INTRODUCTION Anatomy has been considered a core subject within the medical education curriculum. In the current setting of ever-changing diagnostic and treatment modalities, the opinion of both students and trainers is crucial for the design of an anatomy curriculum which fulfils the criteria required for safe medical practice. METHODS Medical students, trainees and specialist trainee doctors and specialists from the London (England) area were surveyed to investigate the how curriculum changes have affected the relevance of anatomical knowledge to clinical practice and to identify recommendations for optimum teaching methods. The survey employed 5-point Likert scales and multiple-choice questions. Where the effect of training level was statistically significant (p < 0.05), post-hoc analysis was carried out using Mann-Whitney U tests. Significance levels were modified according to the Bonferroni method. RESULTS Two hundred and twenty-eight individuals completed the survey giving a response rate of 53%. Medical students, trainees and specialists all agreed (mean Likert score 4.51, 4.79, 4.69 respectively) that knowledge of anatomy is important for medical practice. Most of the trainees (88.4%) and specialists (81.3%) used dissection to learn anatomy, but only 61.4% of medical students used this approach. Dissection was the most commonly recommended approach for learning anatomy across all the groups (41.7%-69.3%). CONCLUSIONS Knowledge of anatomy is perceived to be important for safe clinical practice. Anatomy should be taught with other relevant system or clinical modules. Newer tools for anatomy teaching need further validation before incorporation into the curriculum.

Single-Incision Laparoscopic Surgery for Cholecystectomy: A Retrospective Comparison With 4-Port Laparoscopic Cholecystectomy

OBJECTIVES To report our experience with single-incision laparoscopic surgery (SILS) for cholecystectomy and to perform a retrospective comparison with conventional 4-port laparoscopic cholecystectomy. DESIGN, SETTING, AND PATIENTS Data were prospectively collected for all patients undergoing SILS for cholecystectomy at St Marys Hospital, Imperial College NHS Trust, London, England (n = 41 patients between June 13, 2008, and June 30, 2009) and compared with data for those who had undergone conventional 4-port laparoscopic cholecystectomy in the preceding year (n = 58 patients between June 26, 2007, and May 30, 2008). This included patient demographic data and intraoperative and postoperative outcomes. INTERVENTIONS Four-port laparoscopic cholecystectomy and SILS for cholecystectomy. MAIN OUTCOME MEASURES Operative time, conversion to open operation, and length of hospital stay. RESULTS Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P < .001). A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient, -0.29). Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports. No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group. Patients stayed an average of 0.76 days following SILS for cholecystectomy and 1.53 days following conventional laparoscopic cholecystectomy. One patient in each group had a postoperative biliary leak. CONCLUSIONS Single-incision laparoscopic surgery for cholecystectomy may be equal to conventional laparoscopic cholecystectomy in terms of safety and efficacy. Further randomized studies are required to investigate any significant advantages of this new and attractive technique.

A clinical review of single-incision laparoscopic surgery

Laparoscopic surgery is one of the most significant surgical advances of the twentieth century. Recently, the focus has been on the development of minimally invasive techniques in the form of single-incision laparoscopic surgery. The single-incision technique provides a less invasive alternative to conventional laparoscopic surgery, requiring only one incision disguised within the umbilical folds in contrast to the three to five incisions in conventional laparoscopic surgery. The availability of a number of specialised ports has aided the development of single-incision laparoscopic surgery, and led to its widespread use. The successful use of single-incision laparoscopic surgery has been reported for a number of surgical procedures, and offers several potential benefits versus conventional laparoscopic surgery, including reduced pain, reduced time to recovery and improved cosmesis. This review of international literature assesses the current status, as well as the experience, of single-incision laparoscopic surgery within general, colorectal, bariatric, metabolic, gynaecological and urological surgery. The challenges faced with single-incision laparoscopic surgery are discussed, as well as the clinical studies that are required in order to establish single-incision surgery as a significant improvement to conventional laparoscopic surgery in terms of reduced pain and improved cosmesis.