Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis

AIM: To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery. METHODS: Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. RESULTS: A total of 36 studies (23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates (OR = 0.90, 95%CI: 0.74 to 1.10, p = 0.32), surgical site infection (OR = 0.99, 95%CI: 0.80 to 1.24, p = 0.96), intraabdominal collection (OR = 0.86, 95%CI: 0.63 to 1.17, p = 0.34), mortality (OR = 0.85, 95%CI: 0.57 to 1.27, p = 0.43), reoperation (OR = 0.91, 95%CI: 0.75 to 1.12, p = 0.38) or hospital length of stay (overall mean difference 0.11 d, 95%CI: -0.51 to 0.73, p = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlled trials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. CONCLUSION: In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery

A comparison of two different software packages for the analysis of body composition using computed tomography images

Objectives: Body composition analysis from computed tomography (CT) imaging has become widespread. However, the methodology used is far from established. Two main software packages are in common usage for body composition analysis, with results used interchangeably. However, the equivalence of these has not been well established. The aim of this study was to compare the results of body composition analysis performed using the two software packages to assess their equivalence. Methods: Tri-phasic abdominal CT scans from 50 patients were analysed for a range of body composition measures at the third vertebral level using OsiriX (v7.5.1, Pixmeo, Switzerland) and SliceOmatic (v5.0, TomoVision, Montreal, Canada) software packages. Measures analysed were skeletal muscle index (SMI), fat mass (FM), fat free mass (FFM) and mean skeletal muscle Hounsfield Units (SMHU). Results: The overall mean SMI calculated using the two software packages was significantly different (SliceOmatic 51.33 vs. OsiriX 53.77, p<0.0001), and this difference remained significant for non-contrast and arterial scans. When FM and FFM were considered, again the results were significantly different (SliceOmatic 33.7kg vs. OsiriX 33.1kg, p<0.0001; SliceOmatic 52.1kg vs. OsiriX 54.2kg, p<0.0001, respectively), and this difference remained for all phases of CT. Finally, when mean SMHU was analysed, this was also significantly different (SliceOmatic 32.7 HU vs. OsiriX 33.1 HU, p=0.046). Conclusions: All four body composition measures were statistically significantly different by the software package used for analysis, however the clinical significance of these differences is doubtful. Nevertheless, the same software package should be utilised if serial measurements are being performed

Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials

Objectives: To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols.Methods: Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality.Results: A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66–0.89, P = 0.0007), hospital length of stay (LOS; mean difference −1.55 days, 95% CI −2.73 to −0.36, P = 0.01), intensive care LOS (mean difference −0.63 days, 95% CI −1.18 to −0.09, P = 0.02), and time to passage of feces (mean difference −0.90 days, 95% CI −1.48 to −0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference −0.63 days, 95% CI −0.94 to −0.32, P < 0.0001) and time to passage of feces (mean difference −1.09 days, 95% CI −2.03 to −0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to −0.84, P = 0.0002) and total hospital LOS (mean difference −2.14, 95% CI −4.15 to −0.13, P = 0.04).Conclusions: GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting

Gastric IgG4-Related Autoimmune Fibrosclerosing Pseudotumour: A Novel Location

We describe the first reported case of an IgG4-related autoimmune fibrosclerosing pseudotumour located in the stomach of a 75-year old woman presenting with weight loss and vomiting. A lesion was detected in the gastric body at endoscopy. Subsequent characterisation by CT was suggestive of a gastrointestinal stromal tumour. Following laparoscopic resection, the patient recovered uneventfully. Histological examination of the resected specimen revealed an IgG4-related fibrosclerosing pseudotumour, a novel location for this histopathological entity

Computer Tomography-Based Psoas Skeletal Muscle Area and Radiodensity are Poor Sentinels for Whole L3 Skeletal Muscle Values

Background and aimsComputed tomography (CT)-based measurement of skeletal muscle cross-sectional area (CSA) and Hounsfield unit (HU) radiodensity are used to assess the presence of sarcopenia and myosteatosis, respectively. The validated CT-based technique involves analysis of skeletal muscle at the third lumbar vertebral (L3) level. Recently there has been increasing interest in the use of psoas muscle alone as a sentinel. However, this technique has not been extensively investigated or compared with the previous validated standard approach.MethodsPortovenous phase CT images at the L3 level were identified retrospectively from a single institution in 150 patients who had non-emergency scans and were analysed by a single assessor using SliceOmatic software v5.0 (TomoVision, Canada). Manual segmentation based upon validated HU thresholds for skeletal muscle density was performed for all skeletal muscle, as well as the individual muscle groups. The muscle CSA and mean radiodensity of each group were compared against the whole L3 slice values.ResultsWhen compared with whole L3 slice CSA, anterior abdominal wall CSA had the strongest correlation (r = 0.9315, p < 0.0001) followed by paravertebral (r = 0.8948, p < 0.0001), then psoas muscle (r = 0.7041, p < 0.0001). The mean ± SD density of the psoas muscle (42 ± 8.4 HU) was significantly higher than the whole slice radiodensity (32.3 ± 9.5 HU, p < 0.0001), with paravertebral radiodensity being a more accurate estimation (34.5 ± 10.8 HU). There was a significant difference in the prevalence of myosteatosis when the density measured from the psoas was compared with that of the whole L3 skeletal muscle (27.7% vs. 66.0%, p < 0.0001).ConclusionWhole L3 slice CSA correlated positively with psoas muscle CSA but was subject to wide variability in results. Psoas muscle radiodensity was significantly greater than whole L3 slice density and resulted in underestimation of the prevalence of myosteatosis. Given the lack of equivalence from individual muscle groups, we recommend that further work be undertaken to investigate which muscle group, or indeed whether the gold standard of whole L3 skeletal muscle, provides the best correlation with clinical outcomes

Enhanced recovery after surgery: current status and future progress

Enhanced Recovery After Surgery (ERAS) pathways were first introduced almost a quarter of a century ago and represent a paradigm shift in perioperative care that reduced postoperative complications and hospital length of stay, improved postoperative quality of life and reduced overall healthcare costs. Gradual recognition of the generalizability of the interventions and transferable improvements in postoperative outcomes, led them to becoming standard of care for several surgical procedures. In this article we critically review the current status of ERAS pathways, address related controversies, and propose measures for future progress

The role of oral antibiotic preparation in elective colorectal surgery: a meta-analysis

© 2018 The Author(s). Published by Wolters Kluwer Health, Inc. Objectives:To compare the impact of the use of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcome in elective colorectal surgery.Summary Background Data:Meta-analyses have demonstrated that MBP does not impact upon postoperative morbidity or mortality, and as such it should not be prescribed routinely. However, recent evidence from large retrospective cohort and database studies has suggested that there may be a role for combined OAB and MBP, or OAB alone in the prevention of surgical site infection (SSI).Methods:A meta-analysis of randomized controlled trials and cohort studies including adult patients undergoing elective colorectal surgery, receiving OAB with or without MBP was performed. The outcome measures examined were SSI, anastomotic leak, 30-day mortality, overall morbidity, development of ileus, reoperation and Clostridium difficile infection.Results:A total of 40 studies with 69,517 patients (28 randomized controlled trials, n = 6437 and 12 cohort studies, n = 63,080) were included. The combination of MBP+OAB versus MBP alone was associated with a significant reduction in SSI [risk ratio (RR) 0.51, 95% confidence interval (CI) 0.46-0.56, P < 0.00001, I2 = 13%], anastomotic leak (RR 0.62, 95% CI 0.55-0.70, P < 0.00001, I2 = 0%), 30-day mortality (RR 0.58, 95% CI 0.44-0.76, P < 0.0001, I2 = 0%), overall morbidity (RR 0.67, 95% CI 0.63-0.71, P < 0.00001, I2 = 0%), and development of ileus (RR 0.72, 95% CI 0.52-0.98, P = 0.04, I2 = 36%), with no difference in Clostridium difficile infection rates. When a combination of MBP+OAB was compared with OAB alone, no significant difference was seen in SSI or anastomotic leak rates, but there was a significant reduction in 30-day mortality, and incidence of postoperative ileus with the combination. There is minimal literature available on the comparison between combined MBP+OAB versus no preparation, OAB alone versus no preparation, and OAB versus MBP.Conclusions:Current evidence suggests a potentially significant role for OAB preparation, either in combination with MBP or alone, in the prevention of postoperative complications in elective colorectal surgery. Further high-quality evidence is required to differentiate between the benefits of combined MBP+OAB or OAB alone

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

Perioperative Nutrition: Recommendations from the ESPEN Expert Group

Background and aims: Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. Methods: This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. Results: Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. Conclusions: Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient