Yasir Bashir

The potential role of gut microbiota in pancreatic disease: A systematic review

BACKGROUND Several studies have suggested a link between microbiota imbalance and some gastrointestinal, inflammatory and neoplastic diseases. However, the role in pancreatic diseases remain unclear. To evaluate the available evidence for pancreatic diseases, we undertook a systematic review. METHODS OVID Medline (1946-2017), EMBASE (1980-2017) and the Cochrane Central Register of Controlled Trials (CENTRAL Issue 3, 2017) were searched for studies on microbiota in pancreatic disease. We also searched the reference lists of retrieved papers, and conference proceedings. We excluded animal studies, reviews, and case reports. RESULTS A total of 2833 articles were retrieved. After screening and applying the exclusion criteria, 10 studies were included. Three studies showed lower levels of Bifidobacterium or Lactobacillus and higher levels of Enterobacteriaceae in chronic pancreatitis. Two of these studies were uncontrolled, and the third (controlled) study which compared patients with endocrine and exocrine insufficiency, reported that Bacteroidetes levels were lower in those patients without diabetes, while Bifidobacteria levels were higher in those without exocrine insufficiency. Only one study investigated acute pancreatitis, showing higher levels of Enterococcus and lower levels of Bifidobacterium versus healthy participants. There was an overall association between pancreatic cancer and lower levels of Neisseria elongate, Streptococcus mitis and higher levels of Porphyromonas gingivalis and Granulicatella adiacens. CONCLUSIONS Current evidence suggests a possible link between microbiota imbalance and pancreatic cancer. Regarding acute and chronic pancreatitis, data are scarce, dysbiosis appears to be present in both conditions. However, further investigation is required to confirm these findings and to explore therapeutic possibilities.

Short-term outcomes of transanal haemorrhoidal dearterialization versus tissue-selecting technique

A recent randomized controlled trial (RCT) published in your journal by Leung et al. evaluating the short-term outcomes of transanal haemorrhoidal dearterialization versus tissue-selecting technique (TST) [1] attracted our attention as the results were different from those reported in the literature: Outcomes after THD were significantly worse than after tissue-selecting technique. We also read the correspondence by Ratto et al. [2] who highlighted some serious weaknesses in the trial, especially that the CONSORT protocol was not followed by the authors, the trial was not registered, leading to inability to check the predetermined endpoints, and the sample size was calculated using a pain score as a standard and endpoint instead of intention to treat. We would like to draw your attention to a very important question regarding this trial, which needs urgent attention. In 2014, an article was published in your journal by the same group of surgeons [3]. It compared THD with stapled haemorrhoidectomy, and looking back at the results we see that a 10.26% (3) recurrence rate was reported after THD performed on 40 patients. In the study on THD versus TST, the recurrence rate after THD was 42.5% [1]. Moreover, 42.5% recurrence after THD does not agree with any previously reported recurrence rates for THD. A systematic review done by Sajid et al. [4] showed recurrence rates ranging from 10% [5] to 21% [6] in multiple RCTs, while in our own experience with 324 patients the recurrence rate after THD was 16% [7]. In our opinion, all these questions need to be answered by the authors to clarify these discrepancies and ensure the integrity of their data. Compliance with ethical standards

Step by step guide to do a systematic review and meta-analysis for medical professionals

IntroductionSystematic review and meta-analysis are statistical tools used to review researches performed on a same topic. They extract the collective effect of the studies performed on the topic of interest after statistically analysing the data of all the studies included.Aims and objectivesSystematic reviews and meta-analysis are getting more and more popular in the medical field. Statistics is never the strong aspect of medical professionals, and facing a large number of statistical tests and values could be quite confusing for them. The aim of this article is to simplify these two very important research modalities for medical professionals.ConclusionThis article will provide a step-to-step guide for the medical colleagues to perform a meta-analysis if they are interested.

First Irish and tenth case of small bowel obstruction secondary to suprapubic catheterisation in the world. Case report and case review of a rare complication of suprapubic catheterisation

Highlights • We are reporting a very rare complication of suprapubic catheterisation that is small bowel obstruction.• Our case is first Irish and 10th global case of small bowel obstruction secondary to SPC.• We also searched the literature to find similar reported cases to extract useful information from these cases, use this information to draw conclusions and make recommendations to avoid injuries in future.• We found that significantly distended bladder, use of ultrasound and extra precaution in elderly patients can reduce the risk of damage to bowel.

23 Small intestinal bacterial overgrowth in chronic pancreatitis patients with pancreatic exocrine insufficiency; a prospective cohort study

Background Pancreatic exocrine insufficiency (PEI) causes malabsorption and is a major complication of chronic pancreatitis (CP). Small intestinal bacterial overgrowth (SIBO) worsens symptoms and nutritional status in CP, its prevalence is unclear Aim We examined SIBO prevalence in CP patients with PEI (defined as faecal elastase-1<200 ug/g) versus matched healthy controls. Method 34 patients and 25 controls (matched for age/gender/smoking status) underwent hydrogen breath-testing using a glucose substrate. Exclusion criteria included gastric/pancreatic/intestinal surgery, or antibiotic treatment <4 weeks prior to study. Persistent rise in breath hydrogen 12 ppm above basal was diagnostic of SIBO. Results Patients and controls were well-matched, with 67% and 64% males respectively (p=0.775), a mean (standard deviation) age of 52.4 (10.4) and 53.3 (10.5) year respectively (p=0.919), and 47.1% and 28% smokers respectively (p=0.143). Among patients, there was no association found between the presence of SIBO and gender (p=0.156), or PPI use (p=0.328). There was a significantly positive association found between the presence of SIBO and diabetes (p=0.033), while the positive association between the presence of SIBO and pancreatic enzyme replacement therapy (PERT) use just reached significance (p=0.052) Conclusions SIBO prevalence was 15% and not associated with gender, age, or PPI use, but was positively associated with PERT use, and concurrent diabetes. Patients with diabetes may be more likely to suffer from SIBO due to small bowel dysmotility, whilst SIBO and PEI may co-exist, with similar symptoms. We recommend that SIBO should be considered in non-surgical CP patients, if they have gastro-intestinal symptoms that are unresponsive to high-dose PERT, particularly if there is co-existent diabetes. Treatment should be aggressive, and there may be a requirement for repeat therapy.

Idiopathic chylous ascites simulating acute appendicitis: A case report and literature review

Highlights • A rare case of idiopathic chylous ascites in a young female is reported. The management and outcome with long term follow up were discussed.• The variable nature of presentation of chylous ascites necessitates high index of suspicion. Diagnosis predominately requires abdominal paracentesis and triglyceride levels in the ascetic fluid obtained.• Management of idiopathic chylous ascites is mostly conservative, once the diagnosis is established. The treatment may include low fat diet and occasional somatostatin use.• Further research is mandatory as there is a significant rise in reported cases with no standardized guidelines for management.

Transanal Hemorrhoid Dearterialization and mucopexy: a minimal invasive approach for prolapsed hemorrhoids. Four cases report.

Hemorrhoidal disease is one of the most frequent causes of anal pathology. Surgical therapy is reserved for patients who do not respond to non-operative management and for advanced third and fourth degree hemorrhoids. Milligan-Morgan and Ferguson hemorrhoidectomies are considered the first-choice therapy, but these procedures are associated with postoperative complications including infection, stenosis, pelvic floor dysfunction, rectal bleeding and postoperative pain. In order to minimize postoperative complications, less invasive procedures have been described and two of them are reported with promising results: Stapled hemorrhoidopexy (PPH) and Transanal Hemorrhoid Dearterialization (THD). THD involves ligation of the hemorrhoidal arteries under Doppler guidance resulting reduced inflow that facilitates reduction in size of hemorrhoids, while suture mucopexy addresses the prolapsed mucosa. THD is proven as a reliable technique for third degree hemorrhoids, but its role in fourth degree hemorrhoids is not generally accepted. Herein we report four cases of prolapsed hemorrhoids which were treated with THD and mucopexy. The procedure was successful in all patients. Photographs taken, before and after the procedure, show an impressive reduction of the prolapsed hemorrhoids. THD and mucopexy appears to be an effective technique with the potential of treating not only third degree, but advanced hemorrhoids as a safe one-day procedure with immediate visible results.