Sanket Srinivasa

Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery.

Several recent studies have investigated the role of C‐reactive protein (CRP) as an early marker of anastomotic leakage following colorectal surgery. The aim of this systematic review and meta‐analysis was to evaluate the predictive value of CRP in this setting.

Randomized clinical trial of goal‐directed fluid therapy within an enhanced recovery protocol for elective colectomy

Goal‐directed fluid therapy (GDFT) has been compared with liberal fluid administration in non‐optimized perioperative settings. It is not known whether GDFT is of value within an enhanced recovery protocol incorporating fluid restriction. This study evaluated GDFT under these circumstances in patients undergoing elective colectomy.

Laparoscopic Colorectal Surgery Is Associated With a Higher Intraoperative Complication Rate Than Open Surgery

Objectives:Laparoscopic colorectal resection is equivalent to open resection in a number of important areas. However, recent data have raised concern that intraoperative complications may be increased. We conducted a meta-analysis comparing intraoperative complication rates of laparoscopic and equivalent open colorectal resection. Data Sources:Cochrane Central Register of Controlled Trials, MEDLINE, and Embase databases were searched, as were relevant scientific meeting abstracts and reference lists of included articles. Review Methods:Randomized controlled trials (RCTs) evaluating laparoscopic versus open surgery for any colorectal indication were included. Exclusion criteria were: trials assessing hand-assisted resection, and trials that excluded conversions to open surgery. There were no restrictions on language. Data were entered on an intention-to-treat basis in prospectively designed tables with complications categorized per event as: total complications, haemorrhage, bowel injury, and solid organ injury. Corresponding authors were contacted if information was missing. The Cochrane Collaboration tool was used for assessing risk of bias, the PETO odds ratio method was used for meta-analysis. Results:Complete intraoperative complication data were obtained for 10 out of 30 included RCTs. Four thousand and fifty-five patients were analyzed; 2159 in the Laparoscopic Group and 1896 in the Open Group. There was a higher total intraoperative complication rate (OR 1.37, P = 0.010) and a higher rate of bowel injury in the Laparoscopic Group (OR 1.88, P = 0.020). There was no difference in the rate of intraoperative haemorrhage or solid organ injury. Conclusion:Laparoscopic colorectal resection is associated with a significantly higher intraoperative complication rate than equivalent open surgery.

Preoperative Glucocorticoid Use in Major Abdominal Surgery Systematic Review and Meta-Analysis of Randomized Trials

Objective: To determine the clinical safety and efficacy of preoperative glucocorticoid (GC) administration in major abdominal surgery with regards to short term outcomes. Background: Previous randomized controlled trials (RCTs) in major abdominal surgery have displayed conflicting results regarding the short-term benefits of preoperative GC administration. Importantly, the safety of this intervention has not been conclusively determined. Methods: A systematic review and quantitative meta-analysis was conducted of all RCTs exploring preoperative GC administration in major abdominal surgery for the endpoints of complications, hospital length of stay (LOS) and serum IL-6 on postoperative day one. Subset analyses by procedure were planned “a priori.” Results: Eleven RCTs of moderate quality, comprising 439 patients in total, were included in the final analysis. Preoperative GC use decreased complications (OR = 0.37; 95% CI, 0.21–0.64; P < 0.01), LOS (mean = 1.97 days; 95% CI, −3.33 to −0.61; P = 0.01), and serum IL-6 (mean: −55 pg/mL; 95% CI, −82.30 to −27.91; P < 0.01). Preoperative GCs decreased complications in hepatic resection (OR = 0.28; 95% CI, 0.14–0.55; P < 0.01) and mean LOS (mean LOS: −2.66; 95% CI, −5.01 to −0.32; P = 0.03). GCs reduced mean LOS in patients undergoing colorectal surgery (mean LOS: −0.98; 95% CI, −1.67 to −0.27; P = 0.01). There was no difference in complication rates (OR: 0.45; 95% CI, 0.16–1.32; P = 0.15) or anastomotic leaks specifically. Conclusions: Preoperative administration of GCs decreases complications and LOS after major abdominal surgery as a likely consequence of attenuating the postsurgical inflammatory response. There is no evidence of increased complications in colorectal surgery.

Systematic review and meta-analysis of intraperitoneal local anaesthetic for pain reduction after laparoscopic gastric procedures.

With the advent of minimally invasive gastric surgery, visceral nociception has become an important area of investigation as a potential cause of postoperative pain. A systematic review and meta‐analysis was carried out to investigate the clinical effects of intraperitoneal local anaesthetic (IPLA) in laparoscopic gastric procedures.

Triclosan-impregnated sutures to decrease surgical site infections: systematic review and meta-analysis of randomized trials.

Objective:To determine the efficacy and safety of triclosan-impregnated sutures. Background:Surgical-site infections (SSIs) produce considerable morbidity and increase health care costs. A potential strategy to decrease the rates of SSIs may be the use of triclosan-impregnated sutures. These have been endorsed and/or funded by professional and governmental bodies in numerous countries. Laboratory studies and nonsystematic reviews have suggested that these sutures may reduce SSIs but there has been no summative assessment of this intervention with regard to clinical efficacy and safety. Hence, a systematic review and meta-analysis of all randomized controlled trials (RCTs) investigating triclosan-impregnated sutures were conducted. Methods:The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Pubmed databases, and trial registries were searched for published and unpublished RCTs. The endpoints of interest were the incidence of SSIs and wound breakdown. A random effects model was used and pooled estimates were reported as odds ratios (ORs) with the corresponding 95% confidence interval (CI). Results:Seven RCTs encompassing a total of 836 patients were included in the final analysis. The studies were of moderate quality. Triclosan-impregnated sutures did not statistically significantly reduce the rates of SSIs (OR = 0.77; 95% CI: 0.40–1.51; P = 0.45; I2 = 24%). There was no difference in the rates of wound breakdown between the 2 groups (OR = 1.07; 95% CI: 0.21–5.43; P = 0.93; I2 = 44%) Conclusions:Triclosan-impregnated sutures do not decrease the rate of SSIs or decrease the rate of wound breakdown. Further high-quality independent studies within the right context are required before routine clinical use can be considered.

High quantity and variable quality of guidelines for acute pancreatitis: a systematic review.

OBJECTIVES:Several clinical guidelines exist for acute pancreatitis, with varying recommendations. The aim of this study was to determine the quality of guidelines for acute pancreatitis.METHODS:A literature search identified relevant guidelines, which were then reviewed to determine their document format and scope and the presence of endorsement by a professional body. The quality of guidelines was determined using the validated Grilli, Shaneyfelt, and AGREE instruments.RESULTS:Twenty-one of the 30 guidelines analyzed were endorsed by professional bodies. Median quality scores were as follows: Grilli, 2; Shaneyfelt, 13; and AGREE, 50. Guideline quality did not improve over time. Guidelines endorsed by a professional body had higher scores than those without official endorsement. Guidelines with tables, a recommendations summary, evidence grading, and audit goals had significantly higher scores than guidelines lacking those features.CONCLUSIONS:The many clinical guidelines for acute pancreatitis range widely in quality. Guidelines developed by professional bodies, and those with tables, a recommendations summary, evidence grading, and audit goals, are of higher quality. Further research is required to determine whether guideline quality alters clinical outcomes.

Systematic review and meta‐analysis of oesophageal Doppler‐guided fluid management in colorectal surgery

Oesophageal Doppler monitor (ODM)‐guided fluid therapy has been recommended for routine use in patients undergoing colorectal surgery. However, recent trials have suggested either equivalent or inferior results for patients randomized to ODM‐guided fluid management, especially when compared with fluid restriction or within the context of optimized perioperative care. Hence, an updated systematic review and meta‐analysis was conducted.

Optimizing Perioperative Care in Bariatric Surgery Patients

Enhanced recovery after surgery (ERAS) programs have been shown to minimise morbidity in other types of surgery, but comparatively less data exist investigating ERAS in bariatric surgery. This article reviews the existing literature to identify interventions which may be included in an ERAS program for bariatric surgery. A narrative literature review was conducted. Search terms included ‘bariatric surgery’, ‘weight loss surgery’, ‘gastric bypass’, ‘ERAS’, ‘enhanced recovery’, ‘enhanced recovery after surgery’, ‘fast-track surgery’, ‘perioperative care’, ‘postoperative care’, ‘intraoperative care’ and ‘preoperative care’. Interventions recovered by the database search, as well as interventions garnered from clinical experience in ERAS, were used as individual search terms. A large volume of evidence exists detailing the role of multiple interventions in perioperative care. However, efficacy and safety for a proportion of these interventions for ERAS in bariatric surgery remain unclear. This review concludes that there is potential to implement ERAS programs in bariatric surgery.

Oesophageal Doppler-guided fluid administration in colorectal surgery: critical appraisal of published clinical trials.

The evidence underpinning oesophageal Doppler monitoring (ODM)‐guided fluid administration in colorectal surgery has not been critically appraised despite quantitative meta‐analyses. A qualitative systematic review of the methodology and findings of all published randomised‐controlled trials (RCTs) exploring ODM‐guided fluid administration in major abdominal surgery was conducted. Four, well‐designed single‐centre trials inclusive of 393 patients in total have primarily demonstrated that ODM‐guided intraoperative fluid administration decreases hospital length of stay (LOS) and complications by optimising intraoperative cardiac parameters. One subsequently published RCT shows that ODM‐guided fluid administration predisposes to a greater LOS and significantly increased complications. However, all the trials have been hampered by imprecise definitions with heterogeneity in patient selection, intraoperative fluid administration strategies and methods of outcome assessment. ODM‐guided fluid administration has only been investigated in the setting of laparoscopic colonic surgery and within an optimised perioperative care protocol in one trial, where it was not shown to be beneficial. Nevertheless, it was recommended for use in this context before the trial was even published. ODM‐guided fluid administration has not been compared with intraoperative fluid restriction. Current evidence regarding the use of Doppler‐guided fluid administration is limited by heterogeneity in the trial design, and the initial clinical benefits observed may be largely offset by recent advances in surgical techniques and perioperative care.