Showing papers in "British Journal of Surgery in 2012"

Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer

Abstract: Background: Laparoscopic resection is used widely in the management of colorectal cancer; however, the data on long-term outcomes, particularly those related to rectal cancer, are limited. The results of long-term follow-up of the UK Medical Research Council trial of laparoscopically assisted versus open surgery for colorectal cancer are presented. Methods: A total of 794 patients from 27 UK centres were randomized to laparoscopic or open surgery in a 2:1 ratio between 1996 and 2002. Long-term follow-up data were analysed to determine differences in survival outcomes and recurrences for intention-to-treat and actual treatment groups. Results: Median follow-up of all patients was 62·9 (interquartile range 22·9 − 92·8) months. There were no statistically significant differences between open and laparoscopic groups in overall survival (78·3 (95 per cent confidence interval (c.i.) 65·8 to 106·6) versus 82·7 (69·1 to 94·8) months respectively; P = 0·780) and disease-free survival (DFS) (89·5 (67·1 to 121·7) versus 77·0 (63·3 to 94·0) months; P = 0·589). In colonic cancer intraoperative conversions to open surgery were associated with worse overall survival (hazard ratio (HR) 2·28, 95 per cent c.i. 1·47 to 3·53; P < 0·001) and DFS (HR 2·20, 1·31 to 3·67; P = 0·007). In terms of recurrence, no significant differences were observed by randomized procedure. However, at 10 years, right colonic cancers showed an increased propensity for local recurrence compared with left colonic cancers: 14·7 versus 5·2 per cent (difference 9·5 (95 per cent c.i. 2·3 to 16·6) per cent; P = 0·019). Conclusion: Long-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Systematic review of serious games for medical education and surgical skills training

Abstract: Background: The application of digital games for training medical professionals is on the rise. So-called ‘serious’ games form training tools that provide a challenging simulated environment, ideal for future surgical training. Ultimately, serious games are directed at reducing medical error and subsequent healthcare costs. The aim was to review current serious games for training medical professionals and to evaluate the validity testing of such games. Methods: PubMed, Embase, the Cochrane Database of Systematic Reviews, PsychInfo and CINAHL were searched using predefined inclusion criteria for available studies up to April 2012. The primary endpoint was validation according to current criteria. Results: A total of 25 articles were identified, describing a total of 30 serious games. The games were divided into two categories: those developed for specific educational purposes (17) and commercial games also useful for developing skills relevant to medical personnel (13). Pooling of data was not performed owing to the heterogeneity of study designs and serious games. Six serious games were identified that had a process of validation. Of these six, three games were developed for team training in critical care and triage, and three were commercially available games applied to train laparoscopic psychomotor skills. None of the serious games had completed a full validation process for the purpose of use. Conclusion: Blended and interactive learning by means of serious games may be applied to train both technical and non-technical skills relevant to the surgical field. Games developed or used for this purpose need validation before integration into surgical teaching curricula.

Systematic review and meta‐analysis of outcomes following pathological complete response to neoadjuvant chemoradiotherapy for rectal cancer

Abstract: Background: Following neoadjuvant chemoradiotherapy (CRT) and interval proctectomy, 15–20 per cent of patients are found to have a pathological complete response (pCR) to combined multimodal therapy, but controversy persists about whether this yields a survival benefit. This systematic review evaluated current evidence regarding long-term oncological outcomes in patients found to have a pCR to neoadjuvant CRT. Methods: Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The systematic review included all original articles reporting long-term outcomes in patients with rectal cancer who had a pCR to neoadjuvant CRT, published in English, from January 1950 to March 2011. Results: A total of 724 studies were identified for screening. After applying inclusion and exclusion criteria, 16 studies involving 3363 patients (1263 with pCR and 2100 without) were included (mean age 60 years, 65·0 per cent men). Some 73·4 per cent had a sphincter-saving procedure. Mean follow-up was 55·5 (range 40–87) months. For patients with a pCR, the weighted mean local recurrence rate was 0·7 (range 0–2·6) per cent. Distant failure was observed in 8·7 per cent. Five-year overall and disease-free survival rates were 90·2 and 87·0 per cent respectively. Compared with non-responders, a pCR was associated with fewer local recurrences (odds ratio (OR) 0·25; P = 0·002) and less frequent distant failure (OR 0·23; P < 0·001), with a greater likelihood of being alive (OR 3·28; P = 0·001) and disease-free (OR 4·33, P < 0·001) at 5 years. Conclusion: A pCR following neoadjuvant CRT is associated with excellent long-term survival, with low rates of local recurrence and distant failure. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis

Abstract: Background: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigat ...

Meta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms

Abstract: Background: Surveillance is a common management strategy for small abdominal aortic aneurysm (AAA) (3·0–5·4 cm in diameter). Individual characteristics, other than diameter, may influence aneurysm growth or rupture rates. Methods: Individual data were collated from 15 475 people under follow-up for a small aneurysm in 18 studies. The influence of co-variables (including demographics, medical and drug history) on aneurysm growth and rupture rates (analysed using longitudinal random-effects modelling and survival analysis with adjustment for aneurysm diameter) were summarized in an individual patient meta-analysis. Results: The mean aneurysm growth rate of 2·21 mm/year was independent of age and sex. Growth rate was increased in smokers (by 0·35 mm/year) and decreased in patients with diabetes (by 0·51 mm/year). Mean arterial pressure had no effect and antihypertensive or other cardioprotective medications had only small, non-significant effects on aneurysm growth, consistent with the observation that calendar year of enrolment was not associated with growth rate. Rupture rates were almost fourfold higher in women than men (P < 0·001), were double in current smokers (P = 0·001) and increased with higher blood pressure (P = 0·001). Conclusion: Follow-up schedules for individuals with a small AAA may need to consider diabetes and smoking, in addition to aneurysm diameter. The differing risk factors for growth and rupture suggest that a lower threshold for surgical intervention in women may be justified. No single drug used for cardiovascular risk reduction had a major effect on the growth or rupture of small aneurysms. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Body Composition and Outcome in Patients Undergoing Resection of Colorectal Liver Metastases

Abstract: Background: Recent evidence suggests that depletion of skeletal muscle mass (sarcopenia) and an increased amount of intra-abdominal fat (central obesity) influence cancer statistics. This study investigated the impact of sarcopenia and central obesity on survival in patients undergoing liver resection for colorectal liver metastases (CLM). Methods: Diagnostic imaging from patients who had hepatic resection for CLM in one centre between 2001 and 2009, and who had assessable perioperative computed tomograms, was analysed retrospectively. Total cross-sectional areas of skeletal muscle and intra-abdominal fat, and their influence on outcome, were analysed. Results: Of the 196 patients included in the study, 38 (19·4 per cent) were classified as having sarcopenia. Five-year disease-free (15 per cent versus 28·5 per cent in patients without sarcopenia; P = 0·002) and overall (20 per cent versus 49·9 per cent respectively; P < 0·001) survival rates were lower for patients with sarcopenia at a median follow-up of 29 (range 1–97) months. Sarcopenia was an independent predictor of worse recurrence-free (hazard ratio (HR) 1·88, 95 per cent confidence interval 1·25 to 2·82; P = 0·002) and overall (HR 2·53, 1·60 to 4·01; P < 0·001) survival. Central obesity was associated with an increased risk of recurrence in men (P = 0·032), but not in women (P = 0·712). Conclusion: Sarcopenia has a negative impact on cancer outcomes following resection of CLM. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Incidence, prevalence and risk factors for peritoneal carcinomatosis from colorectal cancer

Abstract: Background: This was a population-based cohort study to determine the incidence, prevalence and risk factors for peritoneal carcinomatosis (PC) from colorectal cancer. Methods: Prospectively collec ...

Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare.

Abstract: Background: The demand for the highest-quality patient care coupled with pressure on funding has led to the increasing use of quality improvement (QI) methodologies from the manufacturing industry. The aim of this systematic review was to identify and evaluate the application and effectiveness of these QI methodologies to the field of surgery. Methods: MEDLINE, the Cochrane Database, Allied and Complementary Medicine Database, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Embase, Health Business™ Elite, the Health Management Information Consortium and PsycINFO® were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Empirical studies were included that implemented a described QI methodology to surgical care and analysed a named outcome statistically. Results: Some 34 of 1595 articles identified met the inclusion criteria after consensus from two independent investigators. Nine studies described continuous quality improvement (CQI), five Six Sigma, five total quality management (TQM), five plan-do-study-act (PDSA) or plan-do-check-act (PDCA) cycles, five statistical process control (SPC) or statistical quality control (SQC), four Lean and one Lean Six Sigma; 20 of the studies were undertaken in the USA. The most common aims were to reduce complications or improve outcomes (11), to reduce infection (7), and to reduce theatre delays (7). There was one randomized controlled trial. Conclusion: QI methodologies from industry can have significant effects on improving surgical care, from reducing infection rates to increasing operating room efficiency. The evidence is generally of suboptimal quality, and rigorous randomized multicentre studies are needed to bring evidence-based management into the same league as evidence-based medicine. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial of robot-assisted versus standard laparoscopic right colectomy.

Abstract: Background: Robotic surgery was invented to overcome the demerits of laparoscopic technique. However, it is unclear whether robot-assisted colectomy (RAC) has significant clinical advantages over laparoscopically assisted colectomy (LAC) in treating colonic cancer. The aim of this study was to compare the surgical outcomes of RAC versus LAC for right-sided colonic cancer. Methods: Patients with right-sided colonic cancer were randomized to receive RAC or LAC. The primary outcome measure was length of hospital stay. Secondary outcomes were duration of operation, morbidity, postoperative pain, hospital costs and pathological quality of the specimen. Results: Of 71 patients randomized, 70 (35 in each group) were included in the analysis. Hospital stay, surgical complications, postoperative pain score, resection margin clearance and number of lymph nodes harvested were similar in both groups. The duration of surgery was longer in the RAC group (195 versus 130 min; P < 0·001). No conversion to open surgery was needed in either group. Overall hospital costs were significantly higher for RAC (US $ 12 235 versus $ 10 320; P = 0·013); the higher costs were attributed primarily to the costs of surgery, including consumables. Conclusion: Robotic-assisted laparoscopic right colectomy was feasible but provided no benefit to justify the greater cost. Registration number: NCT01042743 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality

Abstract: Background: The impact of nationwide centralization of pancreaticoduodenectomy (PD) on mortality is largely unknown. The aim of this study was to analyse changes in hospital volumes and in-hospital mortality after PD in the Netherlands between 2004 and 2009. Methods: Nationwide data on International Classification of Diseases, ninth revision (ICD-9) code 5-526 (PD, including Whipple), patient age, sex and mortality were retrieved from the independent nationwide KiwaPrismant registry. Based on established cut-off points of annually performed PDs, hospitals were categorized as very low (fewer than 5), low (5-10), medium (11-19) or high (at least 20) volume. A subgroup analysis based on a cut-off age of 70 years was also performed. Results: Some 2155 PDs were included. The number of hospitals performing PD decreased from 48 in 2004 to 30 in 2009 (P = 0.011). In these specific years, the proportion of patients undergoing PD in a medium-or high-volume centre increased from 52.9 to 91.2 per cent (P <0.001). Nationwide mortality rates after PD decreased from 9.8 to 5.1 per cent (P = 0.044). The mortality rate during the 6-year period was 14.7, 9.8, 6.3 and 3.3 per cent in very low-, low-, medium-and high-volume hospitals respectively (P <0.001). The difference in mortality between medium-and high-volume centres was statistically significant (P = 0.004). The volume-outcome relationship was not influenced by age (P = 0.467). The mortality rate after PD in patients aged at least 70 years was 10.4 per cent compared with 4.4 per cent in younger patients (P <0.001). Conclusion: With nationwide centralization of PD, the in-hospital mortality rate after this procedure decreased. Further centralization of PD is likely to decrease mortality further, especially in the elderly.

Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy

Abstract: Background: In selected patients with early low rectal cancer, locoregional excision combined with neoadjuvant therapy may be an alternative treatment option to total mesorectal excision (TME). Methods: This prospective randomized trial compared endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery versus laparoscopic TME in the treatment of patients with small non-advanced low rectal cancer. Patients with rectal cancer staged clinically as cT2 N0 M0, histological grade G1–2, with a tumour less than 3 cm in diameter, within 6 cm of the anal verge, were randomized to ELRR or TME. All patients underwent long-course neoadjuvant chemoradiotherapy. Results: Fifty patients in each group were analysed. Overall tumour downstaging and downsizing rates after neoadjuvant chemoradiotherapy were 51 and 26 per cent respectively, and were similar in both groups. All patients had R0 resection with tumour-free resection margins. At long-term follow-up, local recurrence had developed in four patients (8 per cent) after ELRR and three (6 per cent) after TME. Distant metastases were observed in two patients (4 per cent) in each group. There was no statistically significant difference in disease-free survival (P = 0·686). Conclusion: In selected patients, ELRR had similar oncological results to TME. Unique Protocol ID: URBINO-LEZ-1995; registration number: NCT01609504 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

'Artery-first' approaches to pancreatoduodenectomy.

Abstract: Artery-first pancreaticoduodenectomy (PD) is a technique to ligate the feeding arteries before the division of the pancreas with intents to reduce the blood loss and to perform more oncologic resection. The superior mesenteric artery (SMA) is the most common site of positive margins after PD, especially in the setting of borderline resectable and locally advanced pancreatic cancer. We use the “Tora-no-Ana” approach, which consists of a division of the ligament of Treitz, an entry into the retroperitoneal space behind the pancreatic body, and dissection around SMA. In order to determine feasibility to achieve negative margins, SMA is first approached in this technique. The R0 ratio has been satisfactory high in our practice utilizing “Tora-no-Ana” approach.

Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening.

Abstract: Background: The long-term effects of abdominal aortic aneurysm (AAA) screening were investigated in extended follow-up from the UK Multicentre Aneurysm Screening Study (MASS) randomized trial. Methods: A population-based sample of men aged 65–74 years were randomized individually to invitation to ultrasound screening (invited group) or to a control group not offered screening. Patients with an AAA (3·0 cm or larger) detected at screening underwent surveillance and were offered surgery after predefined criteria had been met. Cause-specific mortality data were analysed using Cox regression. Results: Some 67 770 men were enrolled in the study. Over 13 years, there were 224 AAA-related deaths in the invited group and 381 in the control group, a 42 (95 per cent confidence interval 31 to 51) per cent reduction. There was no evidence of effect on other causes of death, but there was an overall reduction in all-cause mortality of 3 (1 to 5) per cent. The degree of benefit seen in earlier years of follow-up was slightly diminished by the occurrence of AAA ruptures in those with an aorta originally screened normal. About half of these ruptures had a baseline aortic diameter in the range 2·5–2·9 cm. It was estimated that 216 men need to be invited to screening to save one death over the next 13 years. Conclusion: Screening resulted in a reduction in all-cause mortality, and the benefit in AAA-related mortality continued to accumulate throughout follow-up. Registration number: ISRCTN37381646 (http://www.controlled-trials.com). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction

Abstract: Background: Use of self-expanding metallic stents (SEMS) as a bridge to surgery has been suggested as an alternative management for acute malignant left-sided colonic obstruction, as emergency surgery has a high risk of morbidity and mortality. This meta-analysis evaluated high-quality evidence comparing preoperative SEMS with emergency surgery. Methods: Relevant randomized clinical trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PubMed (1990–2011). Primary outcomes were primary anastomosis, stoma and in-hospital mortality rates. Secondary outcomes included anastomotic leak, 30-day reoperation and surgical-site infection rates. Results: Four RCTs with 234 patients were included. Technical and clinical success rates for stenting were 70·7 per cent (82 of 116) and 69·0 per cent (80 of 116) respectively. The clinical perforation rate was 6·9 per cent (8 of 116) and the silent perforation rate 14 per cent (11 of 77). SEMS intervention resulted in significantly higher successful primary anastomosis (risk ratio (RR) 1·58, 95 per cent confidence interval 1·22 to 2·04; P < 0·001) and lower overall stoma (RR 0·71, 0·56 to 0·89; P = 0·004) rates. There was no difference in primary anastomosis, permanent stoma, in-hospital mortality, anastomotic leak, 30-day reoperation and surgical-site infection rates. Three trials were stopped prematurely, one because the emergency surgery group had a significantly increased anastomotic leak rate, and two others because of stent-related complications and increased 30-day morbidity following SEMS management. Conclusion: Technical and clinical success rates for stenting were lower than expected. SEMS is associated with a high incidence of clinical and silent perforation. However, as a bridge to surgery, SEMS has higher successful primary anastomosis and lower overall stoma rates, with no significant difference in complications or mortality. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Exhaled volatile organic compounds identify patients with colorectal cancer

Abstract: Background: An effective screening tool for colorectal cancer is still lacking. Analysis of the volatile organic compounds (VOCs) linked to cancer is a new frontier in cancer screening, as tumour growth involves several metabolic changes leading to the production of specific compounds that can be detected in exhaled breath. This study investigated whether patients with colorectal cancer have a specific VOC pattern compared with the healthy population. Methods: Exhaled breath was collected in an inert bag (Tedlar®) from patients with colorectal cancer and healthy controls (negative at colonoscopy), and processed offline by thermal-desorber gas chromatography–mass spectrometry to evaluate the VOC profile. During the trial phase VOCs of interest were identified and selected, and VOC patterns able to discriminate patients from controls were set up; in the validation phase their discriminant performance was tested on blinded samples. A probabilistic neural network (PNN) validated by the leave-one-out method was used to identify the pattern of VOCs that better discriminated between the two groups. Results: Some 37 patients and 41 controls were included in the trial phase. Application of a PNN to a pattern of 15 compounds showed a discriminant performance with a sensitivity of 86 per cent, a specificity of 83 per cent and an accuracy of 85 per cent (area under the receiver operating characteristic (ROC) curve 0·852). The accuracy of PNN analysis was confirmed in the validation phase on a further 25 subjects; the model correctly assigned 19 patients, giving an overall accuracy of 76 per cent. Conclusion: The pattern of VOCs in patients with colorectal cancer was different from that in healthy controls. The PNN in this study was able to discriminate patients with colorectal cancer with an accuracy of over 75 per cent. Breath VOC analysis appears to have potential clinical application in colorectal cancer screening, although further studies are required to confirm its reliability in heterogeneous clinical settings. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Critical appraisal of the ‘wait and see’ approach in rectal cancer for clinical complete responders after chemoradiation

Abstract: Background: Some 10–20 per cent of patients with locally advanced rectal cancer achieve a pathological complete response (pCR) at surgery following preoperative chemoradiation (CRT). Some demonstrate a sustained clinical complete response (cCR), defined as absence of clinically detectable residual tumour after CRT, and do not undergo resection. The aim of this review was to evaluate non-operative treatment of rectal cancer after CRT, and the outcome of patients observed without radical surgery. Methods: A systematic computerized search identified 30 publications (9 series, 650 patients) evaluating a non-operative approach after CRT. Original data were extracted and tabulated, and study quality evaluated. The primary outcome measure was cCR. Secondary outcome measures included locoregional failure rate, disease-free survival and overall survival. Results: The most recent Habr-Gama series reported a low locoregional failure rate of 4·6 per cent, with 5-year overall and disease-free survival rates of 96 and 72 per cent respectively. These findings were supported by a small prospective Dutch study. However, other retrospective series have described higher recurrence rates. All studies were heterogeneous in staging, inclusion criteria, study design and rigour of follow-up after CRT, which might explain the different outcomes. The definition of cCR was inconsistent, with only partial concordance with pCR. The results suggested that patients who are observed, but subsequently fail to sustain a cCR, may fare worse than those who undergo immediate tumour resection. Conclusion: The rationale of a ‘wait and see’ policy relies mainly on retrospective observations from a single series. Proof of principle in small low rectal cancers, where clinical assessment is easy, should not be extrapolated uncritically to more advanced cancers where nodal involvement is common. Long-term prospective observational studies with more uniform inclusion criteria are required to evaluate the risk versus benefit. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Risk of anastomotic leakage with non-steroidal anti-inflammatory drugs in colorectal surgery.

Abstract: Background: With the implementation of multimodal analgesia regimens in fast-track surgery programmes, non-steroidal anti-inflammatory drugs (NSAIDs) are being prescribed routinely. However, doubts have been raised concerning the safety of NSAIDs in terms of anastomotic healing. Methods: Data on patients who had undergone primary colorectal anastomosis at two teaching hospitals between January 2008 and December 2010 were analysed retrospectively. Exact use of NSAIDs was recorded. Rates of anastomotic leakage were compared between groups and corrected for known risk factors in both univariable and multivariable analyses. Results: A total of 795 patients were divided into four groups according to NSAID use: no NSAIDs (471 patients), use of non-selective NSAIDs (201), use of selective cyclo-oxygenase (COX) 2 inhibitors (79), and use of both selective and non-selective NSAIDs (44). The overall leak rate was 9•9 per cent (10•0 per cent for right colonic, 8•7 per cent for left colonic and 12•4 per cent for rectal anastomoses). Known risk factors such as smoking and use of steroids were not significantly associated with anastomotic leakage. Stapled anastomosis was identified as an independent predictor of leakage in multivariable analysis (odds ratio (OR) 2•22, 95 per cent confidence interval 1•30 to 3•80; P = 0•003). Patients on NSAIDs had higher anastomotic leakage rates than those not on NSAIDs (13•2 versus 7•6 per cent; OR 1•84, 1•13 to 2•98; P = 0•010). This effect was mainly due to non-selective NSAIDs (14•5 per cent; OR 2•13, 1•24 to 3•65; P = 0•006), not selective COX-2 inhibitors (9 per cent; OR 1•16, 0•49 to 2•75; P = 0•741). The overall mortality rate was 4•2 per cent, with no significant difference between groups (P = 0•438). Conclusion: Non-selective NSAIDs may be associated with anastomotic leakage. Critical appraisal Value of the article The article provides a retrospective data analysis addressing an important research question related to the risk of anastomotic leakage with the use of non-steroidal anti-inflammatory drugs (NSAID) after colorectal surgery within

Systematic review of outcomes after intersphincteric resection for low rectal cancer

Abstract: Background: For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer. Methods: A systematic review of the literature was undertaken to evaluate evidence regarding oncological outcomes, morbidity and mortality after ISR for low rectal cancer. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included all original articles reporting outcomes after ISR, published in English, from January 1950 to March 2011. Results: Eighty-four studies were identified. After applying inclusion and exclusion criteria, 14 studies involving 1289 patients were included (mean age 59·5 years, 67·0 per cent men). R0 resection was achieved by ISR in 97·0 per cent. The operative mortality rate was 0·8 per cent and the cumulative morbidity rate 25·8 per cent. Median follow-up was 56 (range 1–227) months. The mean local recurrence rate was 6·7 (range 0–23) per cent. Mean 5-year overall and disease-free survival rates were 86·3 and 78·6 per cent respectively. Functional outcome was reported in eight studies; among these, the mean number of bowel motions in a 24-h period was 2·7. Conclusion: Oncological outcomes after ISR for low rectal cancer are acceptable, with diverse, often imperfect functional results. These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma.

Abstract: PBD does not affect overall mortality in jaundiced patients with hilar cholangiocarcinoma, but there may be a difference between patients undergoing right-sided versus left-sided hepatectomy. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Systematic review of intraoperative cholangiography in cholecystectomy.

Abstract: Intraoperative cholangiography (IOC) is used to detect choledocholithiasis and identify or prevent bile duct injury. The aim of this study was systematically to review the randomized clinical trials of IOC for these two indications.

Systematic review of trocar-site hernia.

Abstract: Background: Broad implementation of laparoscopic surgery has made trocar-related complications clinically important. Trocar-site hernia (TSH) is an uncommon, but potentially serious, complication that occasionally requires emergency surgery. This systematic review was conducted to establish the prevalence and risk factors for TSH. Methods: The review was conducted according to the PRISMA guidelines. MEDLINE, Embase, Web of Science and the Cochrane Library were searched to 7 June 2010 for studies on TSH. Results: Twenty-two articles were included. One study was a randomized clinical trial, five were prospective cohort studies and 16 were retrospective cohort studies. The prevalence of TSH is low, with a median pooled estimate of 0·5 (range 0–5·2) per cent. No meta-analysis on risk factors could be performed. Pyramidal trocars, 12-mm trocars and a long duration of surgery were identified as the most important technical risk factors for TSH. Older age and a higher body mass index were observed to be patient-related risk factors. Conclusion: TSH is an uncommon complication of laparoscopic surgery. The most important technical risk factors are the design and size of the trocars. The scientific evidence for recommendations to avoid TSH is sparse. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Systematic review of outcomes of liver resection for early hepatocellular carcinoma within the Milan criteria.

Abstract: Background: Long-term overall survival after liver resection in patients with hepatocellular carcinoma (HCC) within the Milan criteria has been reported to improve in recent years. This study systematically reviewed the outcomes of surgical resection for HCC in patients with good liver function and meeting the Milan criteria for early HCC, published in the past 10 years. Methods: A literature search was conducted in PubMed for papers on outcomes of surgical resection for HCC published between January 2000 and December 2010. Cochrane systematic review methodology was used for this review. The primary outcome was overall survival. Secondary outcomes included operative mortality and disease-free survival. Studies that focused on geriatric populations, paediatric populations, a subset of the Milan criteria (such solitary tumours) or included patients with incidental tumours were excluded, as were case reports, conference abstracts, and studies with a large proportion of Child–Pugh grade C liver cirrhosis or unknown Child–Pugh status. Results: Of 152 studies reviewed, two randomized clinical trials and 27 retrospective case series were eligible for inclusion. The 5-year overall survival rate after resection of HCC ranged from 27 to 81 (median 67) per cent, and the median disease-free survival rate from 21 to 57 (median 37) per cent. There was a trend towards improved overall survival in recent years. The operative mortality rate ranged from 0 to 5 (median 0·7) per cent. Conclusion: Surgical resection offers good overall survival for patients with HCC within the Milan criteria and with good liver function, although recurrence rates remain high. Outcomes have tended to improve in more recent years. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy.

Abstract: Background: Postoperative pancreatic fistula (POPF) remains one of the most common causes of morbidity following pancreaticoduodenectomy (PD). This randomized trial examined whether external stent drainage of the pancreatic duct decreases the rate of POPF after PD and subsequent pancreaticojejunostomy (PJ). Methods: Consecutive patients who underwent PD with subsequent construction of a duct-to-mucosa PJ were randomized into a stented and a non-stented group. The primary outcome was the incidence of clinically relevant POPF. Secondary outcomes were morbidity and mortality rates, and hospital stay. Results: Of 114 PD procedures, 93 were suitable for inclusion in the study after informed consent. The rate of clinically relevant POPF was significantly lower in the stented group than in the non-stented group: three of 47 (6 per cent) versus ten of 46 (22 per cent) (P = 0·040). Among patients with a dilated duct, rates of POPF were similar in both groups. Among patients with a non-dilated duct, clinically relevant POPF was significantly less common in the stented group than in the non-stented group: two of 21 (10 per cent) versus eight of 20 (40 per cent) (P = 0·033). No significant differences in morbidity or mortality were observed. Univariable analysis identified body mass index (BMI), pancreatic cancer, pancreatic texture, pancreatic duct size and duct stenting as risk factors related to clinically relevant POPF. Multivariable analysis taking these five factors into account identified high BMI (risk ratio (RR) 11·45; P = 0·008), non-dilated duct (RR 5·33; P = 0·046) and no stent (RR 10·38; P = 0·004) as significant risk factors. Conclusion: External duct stenting reduced the risk of clinically relevant POPF after PD and subsequent duct-to-mucosa PJ. Registration number: UMIN000000952 (http://www.umin.ac.jp/ctr/index-j.htm). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy.

Abstract: Background: Single-incision laparoscopic cholecystectomy (SILC) may offer advantages over conventional laparoscopic cholecystectomy (LC). Methods: MEDLINE, Embase, PubMed, CINAHL, Cochrane Central Register of Controlled Trials and the Cochrane Library were searched for randomized clinical trials on SILC versus LC until May 2012. Odds ratio (OR) and weight mean difference (WMD) were calculated with 95 per cent confidence intervals (c.i.) based on intention-to-treat analysis. Results: Thirteen randomized clinical trials included a total of 923 procedures. SILC had a higher procedure failure rate than LC (OR 8·16, 95 per cent c.i. 3·42 to 19·45; P < 0·001), required a longer operating time (WMD 16·55, 95 per cent c.i. 9·95 to 23·15 min; P < 0·001) and was associated with greater intraoperative blood loss (WMD 1·58, 95% of c.i. 0·44 to 2·71 ml; P = 0·007). There were no differences between the two approaches in rate of conversion to open surgery, length of hospital stay, postoperative pain, adverse events, wound infections or port-site hernias. Better cosmetic outcomes were demonstrated in favour of SILC as measured by Body Image Scale questionnaire (WMD − 0·97, 95% of c.i. − 1·51 to − 0·43; P < 0·001) and Cosmesis score (WMD − 2·46, 95% of c.i. − 2·95 to − 1·97; P < 0·001), but this was based on comparison with procedures in which multiple and often large ports (10 mm) were used. Conclusion: SILC has a higher procedure failure rate with more blood loss and takes longer than LC. No trial was adequately powered to assess safety. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Comprehensive national analysis of emergency and essential surgical capacity in Rwanda

Abstract: Background: Disparities in the global availability of operating theatres, essential surgical equipment and surgically trained providers are profound. Although efforts are ongoing to increase surgical care and training, little is known about the surgical capacity in developing countries. The aim of this study was to create a baseline for surgical development planning at a national level. Methods: A locally adapted World Health Organization survey was conducted in November 2010 to assess emergency and essential surgical capacity and volumes, with on-site interviews at 44 district and referral hospitals in Rwanda. Results were compiled for education and capacity development discussions with the Rwandan Ministry of Health and the Rwanda Surgical Society. Results: Among 10·1 million people, there were 44 hospitals and 124 operating rooms (1·2 operating rooms per 100 000 persons). There was a total of 50 surgeons practising full- or part-time in Rwanda (0·49 total surgeons per 100 000 persons). The majority of consultant surgeons worked in the capital (covering 10 per cent of the population). Anaesthesia was performed primarily by anaesthesia technicians, and six of 44 hospitals had no trained anaesthesia provider. Continuous availability of electricity, running water and generators was lacking in eight hospitals, and 19 reported an absence or shortage in the availability of pulse oximetry. Equipment for life-saving surgical airway procedures, particularly in children, was lacking. A dedicated emergency area was available in only 19 hospitals. In 2009 and 2010 over 80 000 surgical procedures (major and minor) were recorded annually in Rwanda. Conclusion: A comprehensive countrywide assessment of surgical capacity in resource-limited settings found severe shortages in available resources. Immediate local feedback is a useful tool for creating a baseline of surgical capacity to inform country-specific surgical development. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Explaining the decrease in mortality from abdominal aortic aneurysm rupture

Abstract: Background: A steady rise in mortality from abdominal aortic aneurysm (AAA) was reported in the 1980s and 1990s, although this is now declining rapidly. Reasons for the recent decline in mortality from AAA rupture are investigated here. Methods: Routine statistics for mortality, hospital admissions and procedures in England and Wales were investigated. All data were age-standardized. Trends in smoking, hypertension and treatment for hypercholesterolaemia (statins), together with regression coefficients for mortality, were available from public sources for those aged at least 65 years. Deaths from ruptured AAA avoided in this age group were estimated by using the IMPACT equation: deaths avoided = (deaths in index year) × (risk factor decline) × β-coefficient. Results: From 1997, deaths from ruptured AAA have decreased sharply, almost twofold in men. Hospital admissions for elective AAA repair have increased modestly (from 40 to 45 per 100 000 population), attributable entirely to more procedures in those aged 75 years and over (P < 0·001). Admissions for ruptured AAA have declined from 18·6 to 13·5 per 100 000 population, across all ages, with the proportion offered and surviving emergency repair unchanged. From 1997, mortality from ruptured aneurysm in those aged at least 65 years has fallen from 65·9 to 44·6 per 100 000 population. An estimated 8–11 deaths per 100 000 population were avoided by a reduced prevalence of smoking and a similar number from an increase in the number of elective AAA repairs. Estimates for the effects of blood pressure and lipid control are uncertain. Conclusion: The reduction in incidence of ruptured AAA since 1997 is attributable largely to changes in smoking prevalence and increases in elective AAA repair in those aged 75 years and over. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Systematic review of haemorrhage and rupture of hepatocellular adenomas

Abstract: Background: Although benign in itself, hepatocellular adenoma (HCA) can be complicated by hormone-induced growth, and subsequent haemorrhage and rupture. The exact risk of haemorrhage and rupture is not known. This systematic review of the literature was carried out with the aim of estimating the risk of haemorrhage and rupture in HCA. Methods: A systematic literature search of the PubMed and Embase databases was performed for all articles relevant to haemorrhage and/or rupture of HCA, published between 1969 and March 2011. Results: Twenty-eight articles met the selection criteria, containing a total of 1176 patients. Haemorrhage was reported with an overall frequency of 27·2 per cent among patients, and in 15·8 per cent of all HCA lesions. Rupture and intraperitoneal bleeding were reported in 17·5 per cent of patients. Bleeding was the first symptom in 68·5 per cent of patients with a bleeding HCA. Six of 13 articles reporting the size of HCA lesions in which bleeding occurred mentioned haemorrhage in HCAs smaller than 5 cm. Conclusion: Haemorrhage and rupture are common in patients with HCA. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Risk factors for postoperative bleeding after thyroid surgery

Abstract: Background: Postoperative bleeding after thyroid surgery is a feared and life-threatening complication. The aim of the study was to identify risk factors for postoperative bleeding, with special emphasis on the impact of the individual surgeon and the time to diagnosis of the complication. Methods: Data on consecutive thyroid operations were collected prospectively in a database over 30 years and analysed retrospectively for potential risk factors for postoperative bleeding. Results: There were 30142 operations and postoperative bleeding occurred in 519 patients (1·7 per cent). Risk factors identified were older age (odds ratio (OR) 1·03 per year), male sex (OR 1·64), extent of resection (OR up to 1·41), bilateral procedure (OR 1·99) and operation for recurrent disease (OR 1·54). The risk of complications among individual surgeons differed by up to sevenfold. Postoperative bleeding occurred in 336 (80·6 per cent) of 417 patients within the first 6 h after surgery. Postoperative bleeding was diagnosed after 24 h in ten patients (2·4 per cent), all of whom had bilateral procedures. Nine patients required urgent tracheostomy. Three patients died, giving a mortality rate of 0·01 per cent overall and 0·6 per cent among patients who had surgery for postoperative bleeding. Conclusion: Observation for up to 24 h is recommended for the majority of patients undergoing bilateral thyroid surgery in an endemic goitre area. Same-day discharge is feasible in selected patients, especially after a unilateral procedure. Quality improvement by continuous outcome monitoring and retraining of individual surgeons is suggested.

Preoperative short-course radiotherapy with delayed surgery in primary rectal cancer.

Abstract: Background: Short-course radiotherapy (SRT) with immediate surgery and long-course chemoradiotherapy (CRT) are currently the standard preoperative treatment options for rectal cancer. SRT with surgery delayed for 4-8 weeks (SRT-delay) is an option described for patients with locally advanced tumours who are not fit for CRT. This study examined early toxicity, response to radiotherapy (RT) and short-term outcomes of SRT-delay. Methods: Patients in the Stockholm region diagnosed with rectal cancer between January 2002 and December 2008, who received SRT (25 Gy over 5-7 days) and had surgery with resection of the primary tumour more than 4 weeks after the start of RT, were identified from a prospective register. Additional data were obtained by retrospective review of clinical records. Results: A total of 112 patients had SRT and delayed surgery. The reasons given for SRT included primary unresectable disease and co-morbidities. Severe RT-induced toxicity was noted in six patients (5.4 per cent). Signs of tumour regression were seen on magnetic resonance imaging in 74 per cent of patients reassessed after RT. Pathological stage (44.9 versus 60.7 per cent stage 0-II; P < 0.001), tumour category (11.9 versus 29.4 per cent T0-T2; P < 0.001) and node category (45.8 versus 63.6 per cent N0; P = 0.014) were significantly lower than those at initial assessment. Nine patients (8.0 per cent) had a complete pathological response. Conclusion: The SRT-delay schedule was a feasible alternative with low toxicity. The study indicated a downstaging effect of SRT if surgery was delayed.

Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy

Abstract: Background Laparoscopic appendicectomy has gained wide acceptance as an alternative to open appendicectomy during pregnancy. However, data regarding the safety and optimal surgical approach to appendicitis in pregnancy are still controversial.