The effect of preoperative stoma site marking on risk of stoma-related complications in patients with intestinal ostomy—protocol of a systematic review and meta-analysis

Background!#!An intestinal ostomy is an artificial bowel opening created on the skin. Procedure-related mortality is extremely rare. However, the presence of an ostomy may be associated with significant morbidity. Complications negatively affect the quality of life of ostomates. Preoperative stoma site marking can reduce stoma-related complications and is recommended by several guidelines. However, there is no consensus on the procedure and recommendations are based on low-quality evidence. The objective of the systematic review will be to investigate if preoperative stoma site marking compared to no preoperative marking in patients undergoing intestinal stoma surgery reduces or prevents the rate of stoma-related complications.!##!Methods!#!We will include (cluster-) randomised controlled trials and cohort studies that involve patients with intestinal ostomies comparing preoperative stoma site marking to no preoperative marking and report at least one patient-relevant outcome. For study identification, we will systematically search MEDLINE/PubMed, EMBASE, CENTRAL and CINHAL as well as Google Scholar, trial registries, conference proceedings and reference lists. Additionally, we will contact experts in the field. Two reviewers will independently perform study selection and data extraction. Outcomes will be prioritised based on findings from telephone interviews with five ostomates and five ostomy and wound nurses prior to conducting the review. Outcomes may include but are not limited to stoma-related complications (infection, parastomal abscess, hernia, mucocutaneous separation, dermatological complications, stoma necrosis, stenosis, retraction and prolapse) or other patient-relevant postoperative endpoints (quality of life, revision rate, dependence on professional care, mortality, length of stay and readmission). We will use the ROBINS-I or the Cochrane risk of bias tool to assess the risk of bias of the included studies. We will perform a meta-analysis and assess the certainty of evidence using the GRADE approach.!##!Discussion!#!With the results of the systematic review, we aim to provide information for future clinical guidelines and influence clinical routine with regard to preoperative stoma site marking in patients undergoing ostomy surgery. When the evidence of our systematic review is low, it would still be a useful basis for future clinical trials by identifying data gaps.!##!Systematic review registration!#!PROSPERO registration number: CRD42021226647

The effect of preoperative stoma site marking on risk of stoma-related complications in patients with intestinal ostomy - A systematic review and meta-analysis

Aim This systematic review and meta-analysis aimed to investigate the effect of preoperative stoma site marking on stoma-related complications in patients with intestinal ostomy. Methods MEDLINE, Embase, CENTRAL, CINHAL, and Google Scholar were searched up to August 2021 for randomised controlled trials (RCTs) and nonrandomised studies of interventions (NRSI) that involved patients with intestinal ostomies comparing preoperative stoma site marking to no marking and which reported at least one patient-relevant outcome. Outcomes were prioritised by stakeholder involvement. Random-effects meta-analyses produced odds ratios (ORs) or standardised mean differences (SMD) and 95% confidence intervals (CIs). The ROBINS-I tool and the GRADE approach were used to assess the risk of bias and certainty of evidence, respectively. Results This review included two RCTs and 25 NRSI. The risk of bias was high in RCTs and serious to critical in NRSI. Although preoperative site marking reduced stoma-related complications (OR: 0.45, 95% CI: [0.31-0.65]), dependence on professional or unprofessional care (narrative synthesis), and increased health-related quality of life (SMD: 1.13 [0.38-1.88]), the evidence is very uncertain. Preoperative site marking may probably reduce leakage (OR: 0.14 [0.06-0.37]) and may decrease dermatological complications (OR: 0.38 [0.29-0.50]) and surgical revision (OR: 0.09 [0.02-0.49]). The confidence in the cumulative evidence was moderate to very low. Conclusion Despite low quality evidence, preoperative stoma site marking can prevent stoma-related complications and should be performed in patients undergoing gastrointestinal surgery given that this intervention poses no harm to patients

Chamber-specific alterations of noradrenaline uptake (uptake(1)) in right ventricles of monocrotaline-treated rats

1. In rats a single injection of the alkaloid monocrotaline (60 mg MCT kg(−1) body weight, i.p.) caused right ventricular hypertrophy and heart failure. The aim of this study was to find out whether, in these MCT-treated rats, the cardiac neuronal noradrenaline uptake (uptake(1)) might undergo chamber-specific alterations. 2. For this purpose we assessed in right and left ventricular slices, uptake(1) activity (by [(3)H]-noradrenaline accumulation), and in right and left ventricular membranes, uptake(1) carrier protein density (by [(3)H]-nisoxetine binding). 3. Uptake(1)-inhibitors blocked [(3)H]-noradrenaline accumulation in ventricular slices and [(3)H]-nisoxetine binding in ventricular membranes with the order of potency: desipramine>nisoxetine>>cocaine⩾GBR 12909, indicating that with both approaches noradrenaline uptake(1) was determined. 4. In right ventricular slices of MCT-treated rats uptake(1) activity was significantly lower than in control rats (84.7±8.2 vs 145.1±6.2 pmol noradrenaline mg(−1) tissue 15 min(−1); P<0.05). This was accompanied by a significant decrease in the density of [(3)H]-nisoxetine binding sites (73.7±14.4 vs 125.9±9.1 fmol mg(−1) protein; P<0.05). 5. In left ventricular slices of MCT-treated rats uptake(1) activity was not significantly altered (131.2±10.5 vs 116.1±5.2 pmol noradrenaline mg(−1) tissue 15 min(−1)); similarly, also the density of [(3)H]-nisoxetine binding sites was unchanged (108±9.7 vs 123±7.7 fmol mg(−1) protein). 6. We conclude that in MCT-treated rats with right ventricular hypertrophy and heart failure uptake(1) activity is chamber-specifically reduced possibly due to a decrease in carrier protein density

S3 guideline anal carcinoma Diagnostics, therapy and follow-up of anal canal and anal margin carcinomas

Anal cancer is a relatively rare tumor but has shown a continuous increase of new diseases with a doubling of the incidence in the last 20 years. Nearly all anal cancers are induced by a persisting infection with human papillomavirus (HPV). In the guidelines program for oncology for the first time German language S3 guidelines for optimization of the diagnostics, treatment and aftercare of anal cancer have been compiled under the patronage of the German Society of Coloproctology. Suggestions for recommendations were compiled in interdisciplinary working groups based on the formulated key questions, which were modified and graded within a nominal consensus procedure. After the systematic literature search the endpoint-related assessment and classification of the evidence was carried out within the framework of the GRADE procedure. A total of 93 recommendations and statements were formulated with respect to the topics prevention and screening, diagnostics and staging, supportive measures before and after targeted tumor treatment, treatment of anal cancer in stages I-III, response evaluation following primary chemoradiotherapy, aftercare, treatment of residual and recurrent anal cancer, treatment of metastatic anal cancer (stage IV), palliative care and rehabilitation. The new guidelines provide a foundation for the optimization of interdisciplinary and cross-sectoral care of anal cancer patients. Based on quality indicators future health services research should investigate whether the guideline recommendations are taken into consideration and whether these contribute to an improvement in care