The Impact of Sham Feeding with Chewing Gum on Postoperative Ileus Following Colorectal Surgery: a Meta-Analysis of Randomised Controlled Trials

© 2020, The Author(s). Background: Chewing gum as a form of sham feeding is an inexpensive and well-tolerated means of promoting gastrointestinal motility following major abdominal surgery. Although recognised by the Enhanced Recovery After Surgery (ERAS) Society as one of the multimodal approaches to expedite recovery after surgery, strong evidence to support its use in routine postoperative practice is lacking. Methodology: A comprehensive literature review of all randomised controlled trials (RCTs) was performed in the Medline and Embase databases between 2000 and 2019. Studies were selected to compare the use of chewing gum versus standard care in the management of postoperative ileus (POI) in adults undergoing colorectal surgery. The primary outcome assessed was the incidence of POI. Secondary outcomes included time to passage of flatus, time to defecation, total length of hospital stay and mortality. Results: Sixteen RCTs were included in the systematic review, of which ten (970 patients) were included in the meta-analysis. The incidence of POI was significantly reduced in patients utilising chewing gum compared to those having standard care (RR 0.55, 95% CI 0.39, 0.79, p = 0.0009). These patients also had a significant reduction in time to passage of flatus (WMD − 0.31, 95% CI − 0.36, − 0.26, p < 0.00001) and time to defecation (WMD − 0.47, 95% CI − 0.60, − 0.34, p < 0.00001), without significant differences in the total length of hospital stay or mortality. Conclusion: The use of chewing gum after colorectal surgery is a safe and effective intervention in reducing the incidence of POI and merits routine use alongside other ERAS pathways in the postoperative setting

The Impact of Preoperative Immune Modulating Nutrition on Outcomes in Patients Undergoing Surgery for Gastrointestinal Cancer: A Systematic Review and Meta-analysis

Objective: To define the influence of preoperative immune modulating nutrition (IMN) on postoperative outcomes in patients undergoing surgery for gastrointestinal cancer.Summary background data: Although studies have shown that perioperative IMN may reduce postoperative infectious complications, many of these have included patients with benign and malignant disease, and the optimal timing of such an intervention is not clear.Methods: The Embase, Medline and Cochrane databases were searched from 2000 to 2018, for prospective randomized controlled trials evaluating preoperative oral or enteral IMN in patients undergoing surgery for gastrointestinal cancer. The primary end point was the development of postoperative infectious complications. Secondary end points included postoperative non-infectious complications, length of stay and up to 30-day mortality. The analysis was performed using RevMan v5.3 software. Results: Sixteen studies reporting on 1387 patients (715 IMN group, 672 control group) were included. Six of the included studies reported on a mixed population of patients undergoing all gastrointestinal cancer surgery. Of the remaining, four investigated IMN in colorectal cancer surgery, two in pancreatic surgery and another two in patients undergoing surgery for gastric cancer. There was one study each on liver and esophageal cancer. The formulation of nutrition used in all studies in the treated patients was ImpactR(Novartis/Nestle), which contains ω-3 fatty acids, arginine and nucleotides. Preoperative IMN in patients undergoing surgery for gastrointestinal cancer reduced infectious complications [odds ratio (OR) 0.52, 95% confidence interval (CI) 0.38 to 0.71, p [less than] 0.0001, I2=16%, n=1387] and length of hospital stay [weighted mean difference -1.57 days, 95% CI -2.48 to -0.66, p=0.0007, I2=34%, n=995) when compared with control (isocaloric isonitrogeneous feed or normal diet). It, however, did not affect non-infectious complications (OR 0.98, 95% CI 0.73 to 1.33, p=0.91, I2=0%, n=1303) or mortality (OR 0.55, 95% CI 0.18 to 1.68, p=0.29, I2=0%, n=955).Conclusion: Given the significant impact on infectious complications and a tendency to shorten length of stay preoperative IMN should be encouraged in routine practice in patients undergoing surgery for gastrointestinal cancer

Incidence and treatment of splanchnic vein thrombosis in patients with acute pancreatitis: A systematic review and meta‐analysis

Background and AimThis meta-analysis aimed to estimate the incidence of splanchnic vein thrombosis (SVT) in patients with acute pancreatitis and assess the effects of therapeutic anticoagulation.MethodsSystematic searches of the Medline, Embase, and Cochrane databases were undertaken to identify studies reporting the incidence and outcomes associated with SVT in patients with acute pancreatitis. The pooled incidence, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. PROSPERO database registration no. CRD 42021230912.ResultsOnly 18 of the 238 studies identified met the inclusion criteria. Of the 943 patients who had SVT, 264 (28.0%) received anticoagulation. The pooled incidence of SVT at first presentation of acute pancreatitis was 15% (95% CI 5 to 26%), but was 17% (95% CI 14 to 20%) in all studies. Recanalization was more likely to occur in the anticoagulation-treated than in the untreated group (OR 0.51, 95% CI 0.31 to 0.83, P = 0.007). There were no differences in hemorrhagic complications (OR 2.27, 95% CI 0.81 to 6.37, P = 0.12) or overall mortality (OR 2.37, 95% CI 0.86 to 6.52, P = 0.10) in relation to the use of anticoagulation. The overall incidence of portal hypertension in patients was 60% (95% CI 55 to 65%). However, it was not possible to determine the incidence in each group.ConclusionsThe incidence of SVT in patients with acute pancreatitis is significant. Treatment with anticoagulants improved the odds of recanalization but did not increase the risk of hemorrhagic complications or overall mortality

Mortality after extrahepatic gastrointestinal and abdominal wall surgery in patients with alcoholic liver disease: A systematic review and meta-analysis

Aims: This meta-analysis aimed to define the perioperative risk of mortality in patients with alcoholic liver disease (ALD) undergoing extrahepatic gastrointestinal surgery.Methods: Systematic searches of Embase, Medline and CENTRAL were undertaken to identify studies reporting about patients with ALD undergoing extrahepatic gastrointestinal surgery published since database inception to January 2019. Studies were only considered if they reported on mortality as an outcome. Pooled analysis of mortality was stratified as benign and malignant surgery; and specific operative procedures where feasible.Results: Of the 2899 studies identified only five studies met inclusion criteria. The operative procedures undertaken were cholecystectomy(n=1), umbilical hernia repair(n=1) and oesophagectomy(n=3). The total number of patients with ALD studied were 172. Therefore, any study on liver disease patients undergoing extrahepatic surgery that crucially included a subset with alcohol aetiology were included as a secondary analysis even though they failed to stratify mortality by underlying aetiology. The total number of studies that met this expanded inclusion criteria was 62, reporting on 37,703 patients with liver disease of which 1735 (4.5%) had a definite diagnosis of ALD. Meta-analysis of proportions of in-hospital mortality in patients with ALD undergoing upper gastrointestinal cancer surgery (oesophagectomy) was 23% (95% CI 14-35% I2=0%). In-hospital mortality following oesophagectomy in liver disease patients of all aetiologies was lower, 14% (95% CI 9-21% I2=41.1%).Conclusion: Postoperative in-hospital mortality is high in patients with liver disease and ALD in particular. However, the currently available evidence on ALD is limited and precludes definitive conclusions on postoperative mortality risk

Outcomes after emergency appendicectomy in patients with liver cirrhosis: a population-based cohort study from England

IntroductionThe mortality risk after appendicectomy in patients with liver cirrhosis is predicted to be higher than in the general population given the associated risk of perioperative bleeding, infections and liver decompensation. This population-based cohort study aimed to determine the 90-day mortality risk following emergency appendicectomy in patients with cirrhosis.MethodsAdult patients undergoing emergency appendicectomy in England between January 2001 and December 2018 were identified from two linked primary and secondary electronic healthcare databases, the clinical practice research datalink and hospital episode statistics data. Length of stay, re-admission, case fatality and the odds ratio of 90-day mortality were calculated for patients with and without cirrhosis, adjusting for age, sex and co-morbidity using logistic regression.ResultsA total of 40,353 patients underwent appendicectomy and of these 75 (0.19%) had cirrhosis. Patients with cirrhosis were more likely to be older (p < 0.0001) and have comorbidities (p < 0.0001). Proportionally, more patients with cirrhosis underwent an open appendicectomy (76%) compared with 64% of those without cirrhosis (p = 0.03). The 90-day case fatality rate was 6.67% in patients with cirrhosis compared with 0.56% in patients without cirrhosis. Patients with cirrhosis had longer hospital length of stay (4 (IQR 3–9) days versus 3 (IQR 2–4) days and higher readmission rates at 90 days (20% vs 11%, p = 0.019). Most importantly, their odds of death at 90 days were 3 times higher than patients without cirrhosis, adjusted odds ratio 3.75 (95% CI 1.35–10.49).ConclusionPatients with cirrhosis have a threefold increased odds of 90-day mortality after emergency appendicectomy compared to those without cirrhosis

Postoperative arginine-enriched immune modulating nutrition: Long-term survival results from a randomised clinical trial in patients with oesophagogastric and pancreaticobiliary cancer

Background and AimsImmune modulating nutrition (IMN) has been shown to reduce postoperative infectious complications and length of stay in patients with gastrointestinal cancer. Two studies study of IMN in patients undergoing surgery for head and neck cancer also suggested that this treatment might improve long-term survival and progression-free survival. In the present study, we analysed follow-up data from our previous randomised controlled trial of IMN, in patients undergoing surgery for oesophagogastric and pancreaticobiliary cancer, in order to evaluate the long-term impact on survival of postoperative IMN versus an isocaloric, isonitrogenous control feed.MethodsThis study included patients undergoing surgery for cancers of the pancreas, oesophagus and stomach, who had been randomised in a double-blind manner to receive postoperative jejunostomy feeding with IMN (Stresson, Nutricia Ltd.) or an isonitrogenous, isocaloric feed (Nutrison High Protein, Nutricia) for 10-15 days. The primary outcome was long-term overall survival.ResultsThere was complete follow-up for all 108 patients, with 54 patients randomised to each group. There were no statistically significant differences between groups by demographics [(age, p=0.63), sex (p=0.49) or site of cancer (p=0.25)]. 30-day mortality was 11.1% in both groups. Mortality in the intervention group was 13%, 31.5%, 70.4%, 85.2%, 88.9%, and 96.3% at 90 days, and 1, 5, 10, 15 and 20 years respectively. Corresponding mortality in the control group was 14.8%, 35.2%, 68.6%, 79.6%, 85.2% and 98.1% (p>0.05 for all comparisons).ConclusionEarly postoperative feeding with arginine-enriched IMN had no impact on long-term survival in patients undergoing surgery for oesophagogastric and pancreaticobiliary cancer