Sanjay Purkayastha

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.

Comparison of colonic stenting and open surgery for malignant large bowel obstruction

BackgroundColonic stents potentially offer effective palliation for those with bowel obstruction attributable to incurable malignancy, and a “bridge to surgery” for those in whom emergency surgery would necessitate a stoma. The current study compared the outcomes of stents and open surgery in the management of malignant large bowel obstruction.MethodsA literature search of the Medline, Ovid, Embase and Cochrane databases was performed to identify comparative studies reporting outcomes on colonic stenting and surgery for large bowel obstruction. Random effects meta-analytical techniques were applied to identify differences in outcomes between the two groups. Sensitivity analysis of high quality studies, those reporting on more than 35 patients, those solely concerning colorectal cancer and studies performing intention to treat analysis was undertaken to evaluate the study heterogeneity.ResultsA total of 10 studies satisfied the criteria for inclusion, with outcomes reported for 451 patients. Stent insertion was attempted for 244 patients (54.1%), and proved successful for 226 (92.6%). The length of hospital stay was shorter by 7.72 days in the stent group (p < 0.001), which also had lower mortality (p = 0.03) and fewer medical complications (p < 0.001). Stoma formation at any point during management was significantly lower than in the stent group (odds ratio, 0.02; p < 0.001), and “bridging to surgery” did not adversely influence survival.ConclusionsColonic stenting offers effective palliation for malignant bowel obstruction, with short lengths of hospital stay and a low rate for stoma formation, but data on quality of life and economic evaluation are limited. There is no evidence of differences in long-term survival between those who have stents followed by subsequent resection and those undergoing emergency bowel resection.

Diagnostic precision of nanoparticle-enhanced MRI for lymph-node metastases: a meta-analysis

BACKGROUND At present, there is no accepted, ideal imaging modality or technique for diagnosis of lymph-node metastases. We aimed to assess the diagnostic precision of MRI with ferumoxtran-10-an ultrasmall superparamagnetic iron-oxide nanoparticle used as a contrast agent for diagnosis of lymph-node metastases, compared with that of unenhanced MRI and final histological diagnosis. METHODS We did a meta-analysis of prospective studies that compared MRI, with and without ferumoxtran-10, with histological diagnosis after surgery or biopsy. Sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated for every study; summary receiver operating characteristic (ROC) and subgroup analyses were done; and study quality and heterogeneity were assessed. Metaregression analysis was used to analyse the effect of ferumoxtran-10 in diagnostic precision of MRI. FINDINGS Summary ROC curve analysis for per-lymph-node data showed an overall sensitivity of 0.88 (95% CI 0.85-0.91) and overall specificity of 0.96 (0.95-0.97) for ferumoxtran-10-enhanced MRI. Overall weighted area under the curve for ferumoxtran-10-enhanced MRI was 0.96 (SE 0.01), DOR 123.05 (95% CI 5.93-256.93). Unenhanced MRI had less overall sensitivity (0.63 [0.57-0.69]) and specificity (0.93 [0.91-0.94]), with an overall weighted area under the ROC curve of 0.84 (SE 0.11) and DOR of 26.75 (95% CI 8.48-84.42). Significant heterogeneity was noted for studies reporting enhanced MRI and unenhanced MRI. Metaregression analysis confirmed the significant effect of ferumoxtran-10 in the diagnostic precision of MRI (p=0.001). INTERPRETATION Ferumoxtran-10-enhanced MRI is sensitive and specific in detection of lymph-node metastases for various tumours. It offers higher diagnostic precision than does unenhanced MRI for detection of lymph-node metastases, and allows functional and anatomical definition when used as an imaging modality.

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.

primary Resection With Anastomosis vs . Hartmann's Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review

PurposeThis study compares primary resection with anastomosis and Hartmanns procedure in an adult population with acute colonic diverticulitis.MethodsComparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmanns procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed.ResultsFifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmanns procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome.ConclusionsPatients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmanns procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.

Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare

The demand for the highest‐quality patient care coupled with pressure on funding has led to the increasing use of quality improvement (QI) methodologies from the manufacturing industry. The aim of this systematic review was to identify and evaluate the application and effectiveness of these QI methodologies to the field of surgery.

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.

A meta-analysis comparing conventional end-to-end anastomosis vs. other anastomotic configurations after resection in Crohn's disease

PurposeThis study compared outcomes between end-to-end anastomosis and other anastomotic configurations after intestinal resection for patients with Crohn’s disease by using meta-analytical techniques.MethodsComparative studies published between 1992 and 2005 of end-to-end anastomosis vs. other anastomotic configurations were included. Using a random effects model, end points evaluated were short-term complications and perianastomotic recurrence of Crohn’s disease. Heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection.ResultsEight studies (2 prospective, randomized, controlled trials; 1 nonrandomized, prospective; 5 nonrandomized, retrospective studies) reported on 661 patients who underwent 712 anastomoses, of which 383 (53.8 percent) were sutured end-to-end anastomosis and 329 (46.2 percent) were other anastomotic configurations (259 stapled side-to-side, 59 end-to-side or side-to-end, 11 stapled circular end-to-end). Anastomotic leak rate was significantly reduced in the other anastomotic configurations group (odds ratio (OR), 4.37; P = 0.02) and remained significantly lower in studies comparing only side-to-side anastomosis vs. end-to-end anastomosis (OR, 4.37; P = 0.02) and studies including only ileocolonic anastomosis (OR, 3.8; P = 0.05). Overall postoperative complications (OR, 2.64; P < 0.001), complications other than anastomotic leak (OR, 1.89; P = 0.04), and postoperative hospital stay (weighted mean difference, 2.81; P = 0.007) were significantly reduced in the side-to-side anastomosis group when considering studies comparing only side-to-side anastomosis vs. end-to-end anastomosis. There was no significant difference between the groups in perianastomotic recurrence and reoperation needed because of perianastomotic recurrence.ConclusionsEnd-to-end anastomosis after resection for Crohn’s disease may be associated with increased anastomotic leak rates. Side-to-side anastomosis may lead to fewer anastomotic leaks and overall postoperative complications, a shorter hospital stay, and a perianastomotic recurrence rate comparable to end-to-end anastomosis. Further randomized, controlled trials should be performed for confirmation.

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.