Minimal Ιnvasive Surgery in Benign Anorectal Diseases, a systematic review

ΕΙΣΑΓΩΓΗ: Η καλύτερη κατανόηση της ανατομίας του πρωκτικού σωλήνα και του κατώτερου τριτημορίου του ορθού τις τελευταίες δεκαετίες και η τεχνολογική εξέλιξη οδήγησε στην ανάπτυξη ελάχιστα επεμβατικών τεχνικών για την αντιμετώπιση καλοήθων παθήσεων του ορθοπρωκτικού σωλήνα. ΣΚΟΠΟΣ: Να μελετηθούν στην υπάρχουσα βιβλιογραφία οι τεχνικές αυτές και να εκτιμηθεί η δυναμική τους να αντικαταστήσουν καθιερωμένες επεμβατικές τεχνικές στο μέλλον ΥΛΙΚΑ ΚΑΙ ΜΕΘΟΔΟΣ: Έγινε συστηματική ανασκόπηση της υπάρχουσας βιβλιογραφίας σε τρεις βάσεις δεδομένων, χρησιμοποιώντας στα παράθυρα αναζήτησης, τους καθιερωμένους ιατρικούς όρους αιμορροΐδες, περιεδρικό συρίγγιο, και ακράτεια κοπράνων. Μελέτες που συμπεριλήφθηκαν στην έρευνα ήταν αυτές που μελετούσαν τις ελάχιστα επεμβατικές τεχνικές που εφαρμόζονται στην θεραπεία των παθήσεων του ορθοπρωκτικού σωλήνα και αυτές που συγκρίνουν τις τεχνικές αυτές με τις καθιερωμένες επεμβάσεις. ΑΠΟΤΕΛΕΣΜΑΤΑ: Ογδόντα έξι μελέτες συμπεριλήφθηκαν στην συστηματική ανασκόπηση. Η ερμηνεία των αποτελεσμάτων ήταν δύσκολη καθώς πολλές από αυτές ήταν αναδρομικές και είχαν μεγάλη ετερογένεια στον τρόπο επιλογής των ασθενών και στον τρόπο που εφαρμοζόταν η κάθε τεχνική. Αντικρουόμενα συμπεράσματα προέκυψαν ακόμα και για τις ίδιες τεχνικές όταν αυτές συγκρίνονταν μεταξύ τους ως προς τα πρώιμα και όψιμα αποτελέσματα τους. Παγκοσμίως, η χρήση των μεθόδων αυτών αυξάνεται λόγω του ελάχιστα επεμβατικού τους χαρακτήρα αλλά η υπεροχή τους έναντι των παραδοσιακών τεχνικών δεν προκύπτει από την βιβλιογραφία. Οι αναφορές που γίνονται στην χρήση τους ως επικουρικές επεμβάσεις στην υπάρχουσα χειρουργική θεραπεία χρήζουν μεγαλύτερης έρευνας καθώς υπάρχει μεγάλη ετερογένεια στις μικτές αυτές τεχνικές από κέντρο σε κέντρο και δεν υπάρχουν μελέτες που να συγκρίνουν τα αποτελέσματα με αυτά των επιμέρους τεχνικών όταν αυτές εφαρμοστούν ως μονοθεραπεία. ΣΥΜΠΕΡΑΣΜΑΤΑ: Σε επιλεγμένα περιστατικά η εφαρμογή των ελάχιστα επεμβατικών τεχνικών μπορεί να έχει παρόμοια αποτελέσματα με την κλασσική χειρουργική. Οι παλαιότερες τεχνικές δεν φαίνεται να απειλούνται ακόμα από τις νέες. Ωστόσο η συνεχιζόμενη τεχνολογική εξέλιξη μπορεί να οδηγήσει και σε περαιτέρω βελτίωση των τεχνικών αυτών στο μέλλον.INTRODUCTION: Over the last two decades understanding of the anatomy of the anal sphincter and the lower third of the rectum, combined with the development of new equipment has lead to new minimally invasive techniques as a part of the treatment armamentarium of benign anorectal diseases. OBJECTIVE: The aim of this review was to examine the current literature about minimally invasive techniques in the treatment of benign anorectal diseases, specifically in regard to their potential to replace traditional operations. MATERIALS AND METHODS: A systematic search through the electronic databases Medline, Pubmed and Cohrane Library was conducted by using the MeSH terms hemorrhoids, fistula in ano and faecal incontinence. Studies were included if they examined the role of minimally invasive techniques in the treatment of the above medical conditions. Studies were also included if they compared these techniques with the conventional and established surgical treatment. RESULTS: Eighty six studies were included after excluding the duplicate records. The comparison between series was difficult because many were retrospective with a variety of application of the new surgical approaches and with different patient selection criteria. The heterogeneity of the published trials has lead even in conflicting results at the highest level of evidence regarding the efficacy of some of the techniques in short and long term follow up studies. The use of these techniques due to their minimal invasive nature is increasing worldwide but their superiority compared to the conventional treatment has not been proven yet. Their use as a complimentary treatment to the traditional treatment is also reported in some case series but the combined technique is not standardized and there are not randomised controlled trials to compare the reported improved results to the results of these techniques separately. CONCLUSION: Performing a minimal invasive operation in selected cases may improve the overall results but the replacement of the conventional techniques has not been proven yet. Further research is required to assess their role as complimentary treatment to the established more invasive techniques

Umbilical Sebaceous Cyst Mimicking Infected Urachal Sinus

In addition to the most likely diagnoses for umbilical signs in adults (umbilical hernia, metastatic tumour, endometriosis, congenital abnormalities such as umbilical-urachal sinus and gallstones retained or spilled at the umbilicus), the differential diagnosis should also include epidermoid cyst arising from the skin of the umbilicus.We describe the case of a young man who presented with a persistent umbilical discharge which was initially thought to be umbilical-urachal sinus, but later found to be a sebaceous cyst

Does the Choice of Extraction Site During Minimally Invasive Colorectal Surgery Change the Incidence of Incisional Hernia? Protocol for a Systematic Review and Network Meta-Analysis.

BACKGROUND: Various sites are used for specimen extraction in oncological minimally invasive colorectal surgery. The objective is to determine if the choice of extraction site modulates the incidence of incisional hernia (IH). METHODS/DESIGN: A systematic review will be performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. MEDLINE, Embase and CENTRAL will be searched to look for original studies reporting the incidence of IH after minimally invasive colorectal surgery. Studies will be excluded from the analysis if: 1) they do not report original data, 2) the outcome of interest (incidence of incisional hernia) is not clearly reported and does not allow to extrapolate and/or calculate the required data for network meta-analysis, 3) they include pediatric patients, 4) they include a patients' population with a conversion rate to laparotomy >10%, 5) they do not compare at least two different extraction sites for the operative specimen, 6) they report patients who underwent pure (and not hybrid) natural orifice transluminal endoscopic surgery (NOTES). Network meta-analysis will be performed to determine the incidence of IH per extraction site. DISCUSSION: By determining which specimen extraction site leads to reduced rate of IH, this systematic review and network meta-analysis will help colorectal surgeons to choose their extraction site and reduce the morbidity and costs associated with IH. REGISTRATION: The systematic review and meta-analysis protocol is registered in the International Prospective Register of Ongoing Systematic Reviews (PROSPERO) with number CRD42021272226. HIGHLIGHTS: Various sites are used for specimen extraction in oncological minimally invasive colorectal surgery, and the choice of the site may probably modulate the incidence of incisional hernia.The present protocol aims to design a systematic review which will identify original studies comparing two extraction sites during minimally invasive colorectal surgery in terms of incidence of incisional hernia.Network meta-analysis will be performed to determine the incidence of IH per extraction site

Assessing the quality of primary care referrals to surgery of patients with diabetes in the East of England: A multi-centre cross-sectional cohort study

Aim: Peri-operative hyperglycaemia is associated with an increased incidence of adverse outcomes. Communication between primary and secondary care is paramount to minimise these harms. National guidance in the UK recommends that the glycated haemoglobin (HbA1c) should be measured within 3 months prior to surgery and that the concentration should be less that 69 mmol/mol (8.5%). In addition, national guidance outlines the minimum dataset that should be included in any letter at the time of referral to the surgeons. Currently, it is unclear how well this process is being carried out. This study investigated the quality of information being handed over during the referral from primary care to surgical outpatients within the East of England. Methods: Primary care referrals to nine different NHS hospital Trusts were gathered over a 1-week period. All age groups were included from 11 different surgical specialties. Referral letters were analysed using a standardised data collection tool based on the national guidelines. Results: A total of 1919 referrals were received, of whom 169 (8.8%) had previously diagnosed diabetes mellitus (DM). However, of these, 38 made no mention of DM in the referral letter but were on glucose-lowering agents. Only 13 (7.7%) referrals for patients with DM contained a recent HbA1c, and 20 (11.8%) contained no documentation of glucose-lowering medication. Conclusion: This study has shown that the quality of referral letters to surgical specialties for patients with DM in the East of England remain inadequate. There is a clear need for improving the quality of clinical data contained within referral letters from primary care. In addition, we have shown that the rate of referral for surgery for people with diabetes is almost 50% higher than the background population with diabetes

Antioxidant and Cytoprotective Potential of the Essential Oil Pistacia lentiscus var. chia and Its Major Components Myrcene and α-Pinene

The antioxidant, cytoprotective, and wound-healing potential of the essential oil from the resin of Pistacia lentiscus var. chia (mastic oil) was evaluated, along with that of its major components, myrcene and α-pinene. Antioxidant potential was monitored as: (i) direct antioxidant activity as assessed by 2,2-di-phenyl-1-picrylhydrazyl (DPPH), 2,2-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid), and ABTS assays; (ii) DNA damage protection activity; and (iii) cytoprotective activity as assessed via induction of transcription of genes related to the antioxidant response in human keratinocyte cells (HaCaT). The cytoprotective potential of the test substances was further evaluated against ultraviolet radiation B (UVB)- or H2O2-induced oxidative damage, whereas their regenerative capability was accessed by monitoring the wound closure rate in HaCaT. Μastic oil and major components did not show significant direct antioxidant activity, however they increased the mRNA levels of antioxidant response genes, suggesting indirect antioxidant activity. Treatment of HaCaT with the test substances before and after UVB irradiation resulted in increased cell viability in the cases of pre-treatment with mastic oil or post-treatment with myrcene. Increased cytoprotection was also observed in the case of cell treatment with mastic oil or its major components prior to H2O2 exposure. Finally, mastic oil and myrcene demonstrated a favorable dose-dependent effect for cell migration and wound closure. Collectively, mastic essential oil may exert its promising cytoprotective properties through indirect antioxidant mechanisms

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)