Bowel necrosis associated with early jejunal tube feeding: A omplication of postoperative enteral nutrition

Hypothesis: Postoperative enteral nutrition may sometimes be responsible for severe complications such as mesenteri ischemia. Data Sources Studies in the English literature were identified by a computer-assisted search of the MEDLINE database using the key words "enteral feeding OR jejunostomy" AND "complications OR mesenteric ischemia." Cited references of each retrieved paper were checked for relevance. Study Selection All reports of mesenteric ischemia in the setting of postoperative enteral feeding were included. In cases of multiple articles from the same institution with overlapping patients, the most exhaustive article was included. Data Extraction All reports were abstracted for number of patients, presence of preoperative comorbidities, development of perioperative hypotension or mesenteric occlusion, and outcome. Data Synthesis Nine studies were retrieved in which enteral feedings were responsible for bowel ischemia; we report an additional case. The common clinical picture is that of a patient without significant risk factors for mesenteric ischemia, which during the early postoperative course develops nonspecific abdominal symptoms and then rapidly progresses to septic shock and eventually to multisystem organ failure and death. Mesenteric ischemia may present in up to 3.5% of enterally fed surgical patients; the associated mortality approaches 100%. The lack of specific symptoms requires a high index of suspicion for diagnosis; prompt abdominal exploration and bowel resection are the only chance for survival. Conclusions :The benefits of enteral nutrition outweigh the likelihood of severe complications; when mesenteric ischemia develops, early diagnosis is challenging and the prognosis is poor

Complete pathologic response after combined modality treatment for rectal cancer and long-term survival: A meta-analysis

Background: Complete pathologic response (CPR) after neoadjuvant chemoradiotherapy (combined modality treatment, CMT) for rectal cancer seems associated with improved survival compared to partial or no response (NPR). However, previous reports have been limited by small sample size and single-institution design. Methods: A systematic literature review was conducted to detect studies comparing long-term results of patients with CPR and NPR after CMT for rectal cancer. Variables were pooled only if evaluated by 3 or more studies. Study end points included rates of CPR, local recurrence (LR), distant recurrence (DR), 5-year overall survival (OS), and diseasefree survival (DFS). Results: Twelve studies (1,913 patients) with rectal cancer treated with CMT were included. CPR was observed in 300 patients (15.6%). CPR and NPR patient groups were similar with respect to age, sex, tumor size, distance of tumor from the anus, and stage of disease before treatment. Median follow-up ranged from 23 to 46 months. CPR patients had lower rates of LR [0.7% vs. 2.6%; odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22-0.90, P = 0.03], DR (5.3% vs. 24.1%; OR 0.15, 95% CI 0.07-0.31, P = 0.0001), and simultaneous LR + DR (0.7% vs. 4.8%; OR 0.32, 95% CI 0.13-0.79, P = 0.01). OS was 92.9% for CPR versus 73.4% for NPR (OR 3.6, 95% CI 1.84-7.22, P = 0.002), and DFS was 86.9% versus 63.9% (OR 3.53, 95% CI 1.62-7.72, P = 0.002). Conclusions: CPR after CMT for rectal cancer is associated with improved local and distal control as well as better OS and DFS. © Society of Surgical Oncology 2012

Usefulness of infra-hepatic inferior vena cava clamping during liver resection: a meta-analysis of randomized controlled trials

Infra-hepatic vena cava clamping (IIVCC) may reduce blood losses during liver resection. However, available literature is limited to reports from single institutions with a small sample size. To overcome those limitations, we performed a meta-analysis to examine the association between IIVCC and surgical outcomes

Meta-analysis of trials comparing minimally-invasive and open distal pancreatectomy

Introduction: Current literature suggests that minimally-invasive distal pancreatectomy (MIDP) is associated with faster post-operative recovery and decreased morbidity compared to open surgery. However most studies have been limited by a small sample size and single-institution design. To overcome these limitations, we performed a meta-analysis of studies comparing MIDP and open distal pancreatectomy (ODP). Methods: A systematic literature review was conducted to detect studies comparing MIDP and ODP. Study endpoints included post-operative overall morbidity and mortality, rates of pancreatic fistula, blood loss, time to oral intake and length of hospital stay. Meta-analyses were performed using a random-effects model. Variables were pooled only if evaluated by 3 or more studies. Both qualitative and quantitative data were pooled using a random-effects model. Results: Ten studies comparing MIDP and ODP were considered suitable for the meta-analysis; the reports were primarily retrospective studies of comparable patients. A total of 349 patients underwent MIDP and 380 had ODP. Patients in the two groups were similar with respect to age, BMI, ASA classification, and indication for surgery (mostly for non-malignant disease). The MIDP group had a higher proportion of females than the ODP group (odds ratio 0.44, 95% CI 0.22 - 0.85). Operative times were longer for MIDP but the difference was neither clinically relevant, nor statistically significant (19 minutes, 95% CI -8.2 - 46.4, p = 0.17). The conversion rates from laparoscopic to hand-assisted- and open- procedures were 0.11 (95% CI 0.07 - 0.15) and 0.37 (95% CI 0.10 - 0.64), respectively. Patients undergoing MIDP had less blood loss (difference 309 mL, 95% CI 171 - 447), shorter time to oral intake (difference 2.6 days, 95% CI 1.0 - 4.2), and a shorter post-operative hospital stay (difference 12 days, 95% CI 7.5 - 17.1). Mortality and re-operative rates did not differ between MIDP and ODP. MIDP had fewer overall complications (odds ratio 0.49, 95% CI 0.27 - 0.90), major complications (odds ratio 0.57, 95% CI 0.34 - 0.96), surgical site infections (odds ratio 0.32, 95% CI 0.19 - 0.54), and pancreatic fistulas (odds ratio 0.68, 95% CI 0.47 - 0.98). Conclusions: Our meta-analysis indicates that MIDP is feasible, safe and associated with reduced blood losses, time to oral intake, post-operative hospital stay and overall complications. Furthermore, a minimally-invasive approach seems to reduce rates of pancreatic leaks and surgical site infections following distal pancreatectomy

Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoneal adrenalectomy

Background. Laparoscopic adrenalectomies are being performed increasingly, either with transperitoneal or retroperitoneal approaches. Studies comparing the 2 approaches have not shown the superiority of either technique, but these studies are limited by small sample sizes and single-institution designs. To overcome these limitations, we performed a meta-analysis of studies comparing lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy. Methods. A systematic review of studies comparing lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy was conducted. Study endpoints included perioperative outcomes and measures of postoperative recovery. Meta-analysis was performed using a random effects model, pooling variables evaluated by more than 3 studies. Results. Twenty-one studies comparing a total of 1,205 lateral transperitoneal adrenalectomies and 688 retroperitoneal adrenalectomies were suitable for meta-analysis. Patients in the 2 groups were similar in term of age, sex, body mass index, lesion size and location, and rates of malignancy. There were no statistically significant differences between lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy in terms of operative time, blood loss, hospital stay, time to oral intake, overall and major morbidity, and mortality. Conclusion. Both lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy are associated with very low rates of perioperative complications. According to our meta-analysis, clinical outcomes after either technique are similar. For most adrenal lesions requiring operation, minimally invasive adrenalectomy can be performed safely and effectively with either transperitoneal or the retroperitoneal approach. Additional studies may be needed to analyze if any difference in long-term results exist.</br

Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies

Background The current literature suggests that minimally invasive distal pancreatectomy (MIDP) is associated with faster recovery and less morbidity than open surgery. However, most studies have been limited by a small sample size and a single-institution design. To overcome this problem, the first metaanalysis of studies comparing MIDP and open distal pancreatectomy (ODP) has been performed. Methods A systematic literature review was conducted to identify studies comparing MIDP and ODP. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model. Results For the metaanalysis, 10 studies including 349 patients undergoing MIDP and 380 patients undergoing ODP were considered suitable. The patients in the two groups were similar with respect to age, body mass index (BMI), American Society of Anesthesiology (ASA) classification, and indication for surgery. The rate of conversion from full laparoscopy to hand-assisted procedure was 37%, and that from minimally invasive to open procedure was 11%. Patients undergoing MIDP had less blood loss, a shorter time to oral intake, and a shorter postoperative hospital stay. The mortality and reoperative rates did not differ between MIDP and ODP. The MIDP approach had fewer overall complications [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27–0.89], major complications (OR, 0.57; 95% CI, 0.34–0.96), surgical-site infections (OR, 0.32; 95% CI, 0.19–0.53), and pancreatic fistulas (OR, 0.68; 95% CI, 0.47–0.98). Conclusions The MIDP procedure is feasible, safe, and associated with less blood loss and overall complications, shorter time to oral intake, and shorter postoperative hospital stay. Furthermore, the minimally invasive approach reduces the rate of pancreatic leaks and surgical-site infections after ODP

A Meta-analysis of prospective randomized trials comparing minimally invasive and open distal gastrectomy for cancer

Current literature suggests that minimally invasive distal gastrectomy (MIDG) may enhance post-operative recovery and decrease morbidity compared to open surgery (ODG) in patients with gastric cancer. A meta-analysis of six Prospective Randomized Trials comparing MIDG (343 patients) and ODG (323 patients) for gastric cancer was conducted. MIDG was associated with increased operative time, reduced blood loss and overall morbidity. There was not sufficient data to draw solid conclusions about the oncologic quality of MIDG