Takero Mazaki

Enteral versus Parenteral Nutrition after Gastrointestinal Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials in the English Literature

BackgroundAlthough previous studies recommend the use of enteral nutrition (EN), the benefit of EN after elective gastrointestinal surgery has not been comprehensively demonstrated as through a meta-analysis. Our aim is to determine whether enteral nutrition is more beneficial than parenteral nutrition.MethodsA search was conducted on Medline, Web of Science, the Cochrane Library electronic databases, and bibliographic reviews. The trials were based on randomization, gastrointestinal surgery, and the reporting of at least one of the following end points: any complication, any infectious complication, mortality, wound infection and dehiscence, anastomotic leak, intraabdominal abscess, pneumonia, respiratory failure, urinary tract infection, renal failure, any adverse effect, and duration of hospital stay.ResultsTwenty-nine trials, which included 2,552 patients, met the criteria. EN was beneficial in the reduction of any complication (relative risk (RR), 0.85; 95% confidence interval (CI), 0.74–0.99; P = 0.04), any infectious complication (RR, 0.69; 95% CI, 0.56–0.86; P = 0.001), anastomotic leak (RR, 0.67; 95% CI, 0.47–0.95; P = 0.03), intraabdominal abscess (RR, 0.63; 95% CI, 0.41–0.95; P = 0.03), and duration of hospital stay (weighted mean difference, −0.81; 95% CI, −1.25–0.38; P = 0.02). There were no clear benefits in any of the other complications.ConclusionThe present findings would lead us to recommend the use of EN rather than PN when possible and indicated.

Prophylactic pancreatic stent placement and post-ERCP pancreatitis: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS Pancreatitis is one of the most frequent complications of endoscopic retrograde cholangiopancreatography (ERCP). The placement of a prophylactic pancreatic stent after ERCP can help prevent post-ERCP pancreatitis (PEP). We aimed to provide an up-to-date meta-analysis regarding pancreatic stent placement for prevention of PEP and review the immediate adverse events associated with pancreatic stent placement. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) considering pancreatic stent placement and the subsequent incidence of PEP. The primary outcome measure was the incidence of PEP. We also did a meta-analysis of RCTs and observational studies that reported on immediate adverse events, in order to estimate their incidence. RESULTS Eight studies, involving 680 patients, were included in the meta-analysis; 336 patients had pancreatic stent placement, and 344 patients formed the control group. Pancreatic stent placement was associated with a statistically significant reduction in PEP (relative risk [RR] 0.32, 95 % confidence interval [CI] 0.19 - 0.52; P<0.001). Subgroup analysis with stratification according to PEP severity showed that pancreatic stenting was beneficial in patients with mild to moderate PEP (RR 0.36, 95 %CI 0.22 -0.60; P<0.001) and in patients with severe PEP (RR 0.23, 95 %CI 0.06 - 0.91; P=0.04). Subgroup analysis according to patient selection demonstrated that pancreatic stenting was effective for both high risk and mixed-case groups. Weighted pooled estimates from between one and 17 studies for incidences of immediate adverse events were: overall complications 4.4 %; any infection 3.0 %; bleeding 2.5 %; cholangitis or cholecystitis 3.1 %; necrosis 0.4 %; pancreatic stent migration 4.9 % and occlusion 7.9 %; perforation 0.8 %; pseudocysts 3.0 %; and retroperitoneal perforation 1.2 %. CONCLUSIONS The meta-analysis shows that pancreatic stent placement after ERCP reduces the risk of PEP.

Antibiotic Prophylaxis for the Prevention of Surgical Site Infection after Tension-Free Hernia Repair: A Bayesian and Frequentist Meta-Analysis

BACKGROUND Efficacy of antibiotic prophylaxis for the prevention of surgical site infection (SSI) after open tension-free hernia repair remains controversial. In light of additional data, the aim of this study was to determine whether antibiotic prophylaxis reduces SSI after hernia repair. STUDY DESIGN We conducted a systematic review and meta-analysis to identify randomized controlled trials comparing antibiotic prophylaxis and the subsequent incidence of SSI after inguinal or femoral hernia repair. The primary outcomes measure was the incidence of SSI. Subgroup analysis was evaluated by stratifying the categories of SSI. The meta-analysis was performed using Bayesian and frequentist methods. RESULTS Twelve studies were included in this meta-analysis; 1,902 patients received antibiotic prophylaxis and the other 1,936 patients were allocated to the control group. Incidence of SSI was 47 (pooled rate 3.0%) in the antibiotic group and 91 (6.0%) in the control group. The number needed to treat to prevent 1 episode of SSI is 41. The Bayesian meta-analysis yielded a significant reduction of SSI in the antibiotic group (odds ratio = 0.49; 95% credible interval 0.25-0.81). Subgroup analysis showed that an antibiotic prophylaxis was beneficial for the prevention of superficial SSI (odds ratio = 0.40; 95% credible interval 0.12-0.98), but not beneficial for prevention of deep SSI (odds ratio = 0.59; 95% credible interval 0.11-3.20). Also, the results were similar to those with frequentist methods. CONCLUSIONS This meta-analysis suggests that antibiotic prophylaxis is efficacious for the prevention of SSI after open mesh hernia repair.

Immunoenhancing enteral and parenteral nutrition for gastrointestinal surgery: a multiple-treatments meta-analysis.

OBJECTIVE Frequentist meta-analyses have demonstrated that immunoenhancing parenteral nutrition (IMPN) and enteral nutrition (IMEN) reduce the incidence of infection and shorten the length of hospital stays compared with standard parenteral nutrition (SPN) and enteral nutrition (SEN). The aim of this study was to evaluate which kind of nutrition-SPN, SEN, IMPN, and IMEN-is most efficacious for reducing the incidence of complications after gastrointestinal surgery. METHODS An English literature search was carried out for randomized controlled trials published from January 1990 to February 2013 that evaluated the clinical efficacy of 4 kinds of nutrition after gastrointestinal surgery. A Bayesian framework was used to calculate the odds ratio between each treatment and the rank order. RESULTS Seventy-four studies (7572 participants) were included. According to the surface below the cumulative ranking curve (SUCRA) ordering from the best to the worst, IMEN was ranked first for reducing the incidence of 7 complications-any infection (SUCRA = 0.86), overall complication (SUCRA = 0.88), mortality (SUCRA = 0.81), wound infection (SUCRA = 0.79), intra-abdominal abscess (SUCRA = 0.98), anastomotic leak (SUCRA = 0.79), and sepsis (SUCRA = 0.92). Also, IMEN was ranked second for pneumonia and urinary tract infection. IMPN was ranked first for pneumonia (SUCRA = 0.81) and urinary tract infection (SUCRA = 0.86), third for mortality, and fourth for both intra-abdominal abscess and anastomotic leak. SPN showed an inferior efficacy for almost all outcomes. CONCLUSIONS This study suggests that IMEN outperformed other nutrition types for reducing complications and IMEN should be considered the best available option.

A randomized trial of antibiotic prophylaxis for the prevention of surgical site infection after open mesh-plug hernia repair

BACKGROUND The efficacy of antibiotic prophylaxis for the prevention of surgical-site infection (SSI) after open tension-free inguinal hernia repair remains controversial. METHODS A double-blind, randomized, placebo-controlled trial was conducted. Patients who underwent elective open mesh-plug hernia repair were eligible for randomization. In the antibiotic prophylaxis group, 1.0 g cefazolin was intravenously administrated 30 minutes before the incision. In the placebo group, an equal volume of sterile saline was administered. The primary end point was the incidence of SSI. RESULTS A total of 200 patients were enrolled. SSI developed in 2 of 100 patients (2%) in the antibiotic prophylaxis group and 13 of 100 patients (13%) in the placebo group, indicating a significant difference between the 2 groups (relative risk ratio, 0.25; 95% confidence interval, 0.070 to 0.92; P = .003). Other complications occurred in 23 patients: 7 (7%) in the antibiotic prophylaxis group and 16 (16%) in the placebo group (P = .046). CONCLUSIONS This study indicates that antibiotic prophylaxis is effective for the prevention of SSI after open mesh-plug hernia repair.

Polymorphisms and pancreatic cancer risk: a meta-analysis.

Increasing evidence suggests that variants of common and low-penetrance genes are involved in pancreatic cancer (PC) carcinogenesis. We undertook a meta-analysis of published studies to assess evidence regarding the risk associated with these genes. Medline, Web of Science, ProQuest, Google Scholar, and international conference proceedings were searched and citations in relevant primary and review articles were collected. The studies that we considered eligible included all reports that investigated an association between genetic polymorphisms and PC. We identified 23 studies that evaluated the risk effects on PC of common alleles for 13 gene polymorphisms. A significant association was recognized between ALDH 2*1*2 polymorphisms and PC [odds ratio (OR)=1.37, 95% confidence interval (CI)=1.07–1.75, P=0.01] based on only two studies. Although the overall results for MTHFR T677T are negative, sensitivity analysis stratified by ethnic background showed a significant association between Caucasian and MTHFR T677T polymorphisms and PC (OR=1.66, 95% CI=1.10–2.52, P=0.02). The risk for PC was higher in individuals with MTHFR C677T or TT polymorphisms and a smoking habit (OR=2.52, 95% CI=1.05–6.09, P=0.04). These findings lead us to support the hypothesis that MTHFR T677T and ALDH 2*1*2 polymorphisms may play a carcinogenetic role in PC and represent the candidates for low-penetrance susceptibility alleles identified to date. Although their genetic risks are modest, the high frequency in the population shows that they may have a considerable impact on the incidence of PC. Definite conclusions will be contingent on studies with a larger sample size that determine the risk estimates associated with other variants, gene–gene, and gene–environment interactions.

A case of bone metastasis of colon cancer that markedly responded to S-1/CPT-11 combination chemotherapy and became curable by resection

BackgroundAn oral combined fluoropyrimidine anticancer drug, tegafur/gimeracil/oteracil potassium (S-1), has recently been used alone or in combination for colon cancer.Case presentationThe patient was a 42-year-old man with sigmoid colon cancer with direct invasion of the urinary bladder and multiple costal metastases. A diagnosis of T4, M1, stage IV sigmoid colon cancer was made, and curative resection was considered impossible. S-1 at 50 mg/m2 was administered by oral route from day 1 to day 14. Irinotecan (CPT-11) at 40 mg/m2 was administered by intravenous day 1 and 15. This treatment was followed by 2 weeks absent period, and repeated every 4 weeks. Six cycles of administration were performed in total. Following this treatment, the multiple costal metastases resolved. Down-staging to T3, M0, stage IIA was achieved, and curative resection was judged to be possible.ConclusionOccasional cases in which S-1/CPT-11 therapy was effective have been recently reported. The patients tumor became resectable despite the discovery of colon cancer associated with bone metastasis at the initial examination, offering hope for cancer patients.