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The British Journal of Surgery May 2017Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a minimally invasive approach under investigation as a novel treatment for patients with peritoneal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a minimally invasive approach under investigation as a novel treatment for patients with peritoneal carcinomatosis of various origins. The aim was to review the available evidence on mechanisms, clinical effects and risks.
METHODS
This was a systematic review of the literature on pressurized intraperitoneal chemotherapy published between January 2000 and October 2016. All types of scientific report were included.
RESULTS
Twenty-nine relevant papers were identified; 16 were preclinical studies and 13 were clinical reports. The overall quality of the clinical studies was modest; five studies were prospective and there was no randomized trial. Preclinical data suggested better distribution and higher tissue concentrations of chemotherapy agents in PIPAC compared with conventional intraperitoneal chemotherapy by lavage. Regarding technical feasibility, laparoscopic access and repeatability rates were 83-100 and 38-82 per cent. Surgery-related complications occurred in up to 12 per cent. Postoperative morbidity was low (Common Terminology Criteria for Adverse Events grade 3-5 events reported in 0-37 per cent), and hospital stay was about 3 days. No negative impact on quality of life was reported. Histological response rates for therapy-resistant carcinomatosis of ovarian, colorectal and gastric origin were 62-88, 71-86 and 70-100 per cent respectively.
CONCLUSION
PIPAC is feasible, safe and well tolerated. Preliminary good response rates call for prospective analysis of oncological efficacy.
Topics: Aerosols; Antineoplastic Agents; Carcinoma; Combined Modality Therapy; Epidemiologic Methods; Feasibility Studies; Humans; Peritoneal Neoplasms; Pressure; Quality of Life; Treatment Outcome
PubMed: 28407227
DOI: 10.1002/bjs.10521 -
Injury Jun 2017Traumatic injuries to the lower gastrointestinal tract (rectum and anus) have been largely reported in the military setting with sparse publications from the civilian... (Review)
Review
INTRODUCTION
Traumatic injuries to the lower gastrointestinal tract (rectum and anus) have been largely reported in the military setting with sparse publications from the civilian setting. Additionally, there remains a lack of international consensus regarding definitive treatment pathways. This systematic review aimed to assess the current literature and propose a standardised treatment algorithm to aid management in the civilian setting.
METHODS
A systematic review of available literature from 1999 to 2016 that was performed. Primary endpoints were the assessment and surgical management of reported rectal and anal trauma.
RESULTS
Seven studies were included in this review, reporting on 1255 patients. 96.3% had rectal trauma and 3.7% had anal trauma. Gunshot wounds are the most common mechanism of injury (46.9%). The overwhelming majority of injuries occurred in males (>85%) and were associated with other pelvic injuries. Surgical management has substantially evolved over the last five decades, with no clear consensus on best management strategies.
CONCLUSION
There remains significant international discrepancy regarding the management of penetrating trauma to the rectum. Key management principals include the varying use of the direct primary closure, faecal diversion, pre-sacral drainage and/or distal rectal washout (rarely used). To date, there is sparse evidence regarding the management of penetrating anal trauma.
Topics: Algorithms; Anal Canal; Clinical Protocols; Digestive System Surgical Procedures; Drainage; Emergency Medicine; Fecal Incontinence; Humans; Peritoneal Lavage; Practice Guidelines as Topic; Proctoscopy; Rectum; Wounds, Penetrating
PubMed: 28292518
DOI: 10.1016/j.injury.2017.03.002 -
Surgical Laparoscopy, Endoscopy &... Apr 2017Diverticular disease is a first-class health care problem and one of the most common gastrointestinal disorders in western industrialized countries, causing significant... (Review)
Review
BACKGROUND/AIM
Diverticular disease is a first-class health care problem and one of the most common gastrointestinal disorders in western industrialized countries, causing significant morbidity and mortality. In this review of the literature, we aim to assess the feasibility and effectiveness of the laparoscopic approach in both elective and emergency setting of diverticular disease.
MATERIALS AND METHODS
A bibliographic search of articles was performed using the electronic database Medline from PubMed. Of 341 articles identified, 279 were excluded, resulting in 62 full-text articles for review. Our final review included 16 articles.
RESULTS
The 16 articles included in the final review consisted of 6 retrospective studies, 5 prospective studies, 2 randomized controlled trials, 1 systematic review and meta-analysis, and 2 systematic reviews. Seven articles considered elective laparoscopic sigmoid resection, 7 articles evaluated laparoscopic peritoneal lavage, and 2 articles considered emergency laparoscopic sigmoid resection for perforated diverticulitis. The elective laparoscopic approach is feasible and safe. Laparoscopic peritoneal lavage has emerged as a safe and effective minimally invasive procedure for the treatment of perforated diverticulitis. Furthermore, in selected patients, emergency laparoscopic sigmoidectomy could also be feasible for perforated diverticulitis with generalized peritonitis.
CONCLUSIONS
Laparoscopic approach can be a safe and effective option in both elective and emergency setting of diverticular disease. Large, prospective, randomized studies should be conducted to confirm these findings.
Topics: Adult; Aged; Aged, 80 and over; Diverticulitis, Colonic; Elective Surgical Procedures; Emergency Treatment; Epidemiologic Methods; Humans; Laparoscopy; Middle Aged; Young Adult
PubMed: 28212260
DOI: 10.1097/SLE.0000000000000386 -
Techniques in Coloproctology Feb 2017This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A... (Comparative Study)
Comparative Study Meta-Analysis Review
This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A systematic review of the literature was performed on PubMed until June 2016, according to preferred reporting items for systematic reviews and meta-analyses guidelines. All randomised controlled trials comparing laparoscopic lavage with surgical resection, irrespective of anastomosis or stoma formation, were analysed. After assessment of titles and full text, 3 randomised trials fulfilled the inclusion criteria. Overall the quality of evidence was low because of serious concerns regarding the risk of bias and imprecision. In the laparoscopic lavage group, there was a statistically significant higher rate of postoperative intra-abdominal abscess (RR 2.54, 95% CI 1.34-4.83), a lower rate of postoperative wound infection (RR 0.10, 95% CI 0.02-0.51), and a shorter length of postoperative hospital stay during index admission (WMD = -2.03, 95% CI -2.59 to -1.47). There were no statistically significant differences in terms of postoperative mortality at index admission or within 30 days from intervention in all Hinchey stages and in Hinchey stage III, postoperative mortality at 12 months, surgical reintervention at index admission or within 30-90 days from index intervention, stoma rate at 12 months, or adverse events within 90 days of any Clavien-Dindo grade. The surgical reintervention rate at 12 months from index intervention was significantly lower in the laparoscopic lavage group (RR 0.57, 95% CI 0.38-0.86), but these data included emergency reintervention and planned intervention (stoma reversal). This systematic review and meta-analysis did not demonstrate any significant difference between laparoscopic peritoneal lavage and traditional surgical resection in patients with peritonitis from perforated diverticular disease, in terms of postoperative mortality and early reoperation rate. Laparoscopic lavage was associated with a lower rate of stoma formation. However, the finding of a significantly higher rate of postoperative intra-abdominal abscess in patients who underwent laparoscopic lavage compared to those who underwent surgical resection is of concern. Since the aim of surgery in patients with peritonitis is to treat the sepsis, if one technique is associated with more postoperative abscesses, then the technique is ineffective. Even so, laparoscopic lavage does not appear fundamentally inferior to traditional surgical resection and this technique may achieve reasonable outcomes with minimal invasiveness.
Topics: Abdominal Abscess; Adolescent; Adult; Aged; Aged, 80 and over; Diverticulitis; Female; Humans; Intestinal Perforation; Intestines; Laparoscopy; Length of Stay; Male; Middle Aged; Peritoneal Lavage; Peritonitis; Postoperative Complications; Randomized Controlled Trials as Topic; Reoperation; Severity of Illness Index; Surgical Stomas; Treatment Outcome; Young Adult
PubMed: 28197792
DOI: 10.1007/s10151-017-1585-0 -
International Journal of Surgery... Feb 2017Laparoscopic peritoneal lavage (LPL) has been proposed as an alternative, less invasive technique in the treatment of acute perforated sigmoid diverticulitis (APSD). The... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Laparoscopic peritoneal lavage (LPL) has been proposed as an alternative, less invasive technique in the treatment of acute perforated sigmoid diverticulitis (APSD). The aim of this meta-analysis is to compare the effectiveness of LPL versus surgical resection (SR) in terms of morbidity and mortality in the management of APSD.
METHODS
A comprehensive search was conducted for randomised controlled trials (RCTs) comparing LPL versus SR in the treatment of APSD. The end points included peri-operative mortality, severe adverse events, overall mortality, post-operative abscess, percutaneous reinterventions, reoperation, operative time, postoperative stay, and readmissions.
RESULTS
Three RCTs with a total of 372 patients, randomised to either LPL or SR were included. There was no significant difference in peri-operative mortality between LPL and SR (OR 1.356, 95% CI 0.365 to 5.032, p = 0.649), or serious adverse events (OR = 1.866, 95% CI = 0.680 to 5.120, p = 0.226). The LPL required significantly less time to complete than SR (WMD = -72.105, 95% CI = -88.335 to -55.876, p < 0.0001). The LPL group was associated with a significantly higher rate of postoperative abscess formation (OR = 4.121, 95% CI = 1.890 to 8.986, p = 0.0004) and subsequent percutaneous interventions (OR = 5.414, 95% CI 1.618 to 18.118, p = 0.006).
CONCLUSION
Laparoscopic peritoneal lavage is a safe and quick alternative in the management of APSD. In comparison to SR, LPL results in higher rates of postoperative abscess formation requiring more percutaneous drainage interventions without any difference in perioperative mortality and serious morbidity.
Topics: Diverticulitis, Colonic; Humans; Intestinal Perforation; Laparoscopy; Peritoneal Lavage; Randomized Controlled Trials as Topic; Reoperation; Treatment Outcome
PubMed: 28089941
DOI: 10.1016/j.ijsu.2017.01.020 -
Clinics (Sao Paulo, Brazil) Dec 2016Intraperitoneal free cancer cells in gastric adenocarcinoma are associated with a poor outcome. However, the true prognostic value of intraperitoneal free cancer cells... (Meta-Analysis)
Meta-Analysis Review
Intraperitoneal free cancer cells in gastric adenocarcinoma are associated with a poor outcome. However, the true prognostic value of intraperitoneal free cancer cells is still unclear, leading to a lack of consensus in the management of gastric cancer. The aim of the present study is to perform a systematic review and meta-analysis to analyze intraperitoneal free cancer cells-positive patients with regard to tumor oncologic stage, recurrence, grade of cellular differentiation, and survival rates and to analyze the clinical significance of intraperitoneal free cancer cells with regard to prognosis. Databases were searched up to January 2016 for prognostic factors associated with intraperitoneal free cancer cells, including oncologic stage, depth of neoplasm invasion, lymph nodal spread, differentiation grade of the tumor, and recurrence and survival rates. A total of 100 studies were identified. Meta-analysis revealed a clear association between intraperitoneal free cancer cells and a poor prognosis. intraperitoneal free cancer cells -positive patients had higher rates of nodal spread (risk difference: 0.29; p<0.01), serosal invasion (risk difference: 0.43; p<0.01), recurrence (after 60 months of follow-up, risk difference: 0.44; p<0.01), and mortality (after 60 months of follow-up, risk difference: 0.34; p<0.01). Intraperitoneal free cancer cells are associated with a poor outcome in gastric cancer. This surrogate biomarker should be used to guide therapy both prior to and after surgery.
Topics: Adenocarcinoma; Gastric Lavage; Humans; Lymphatic Metastasis; Neoplasm Recurrence, Local; Peritoneal Cavity; Prognosis; Reproducibility of Results; Risk Assessment; Stomach Neoplasms
PubMed: 28076519
DOI: 10.6061/clinics/2016(12)10 -
Journal of Surgical Oncology Nov 2016The poor survival of patients with resectable pancreatic cancer might be related to the presence of occult peritoneal tumor cells (OPTC). This systematic review studies... (Review)
Review
The poor survival of patients with resectable pancreatic cancer might be related to the presence of occult peritoneal tumor cells (OPTC). This systematic review studies the prognostic value of cytology and carcinoembryonic antigen (CEA) by real-time polymerase chain reaction in peritoneal fluid. The results suggest that presence of OPTC is related to a worse survival in patients with resectable pancreatic cancer. Future studies should investigate its possible role in selecting patients for specific treatment strategies. J. Surg. Oncol. 2016;114:743-751. © 2016 Wiley Periodicals, Inc.
Topics: Adenocarcinoma; Ascitic Fluid; Carcinoembryonic Antigen; Humans; Pancreatectomy; Pancreatic Neoplasms; Peritoneal Lavage; Peritoneal Neoplasms; Prognosis; Real-Time Polymerase Chain Reaction; Survival Rate
PubMed: 27642007
DOI: 10.1002/jso.24402 -
Annals of Surgery Apr 2017To compare the outcomes of laparoscopic lavage and sigmoid resection in perforated diverticulitis with purulent peritonitis. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To compare the outcomes of laparoscopic lavage and sigmoid resection in perforated diverticulitis with purulent peritonitis.
BACKGROUND
Peritonitis secondary to perforated diverticulitis has conventionally been managed by resection and stoma formation. Case series have suggested that patients can be safely managed with laparoscopic lavage, resulting in reduced mortality and stoma formation. Recently, 3 randomized controlled trials have published contradictory conclusions.
METHODS
MEDLINE from 1946 to present, Cochrane Database of Systematic Reviews, and Cochrane database of Registered clinical trials and EMBASE (all via OVID) were searched using the terms "laparoscopy" AND ("primary resection" OR "Hartmann procedure", OR "sigmoidectomy"), AND "Diverticulitis", AND "Peritonitis" AND "therapeutic irrigation" or "lavage" AND randomized controlled trial and any derivatives of those terms. We included all randomized controlled trials. Data were extracted from each study using a purpose-designed template. Statistical analysis was undertaken using Revman 5.
RESULTS
Three randomized controlled trials were identified from 48 potential studies. The analysis included 307 patients of whom 159 underwent laparoscopic lavage. Overall, the rate of reintervention within 30 days postoperatively was 45/159 (28.3%) in the lavage group and 13/148 (8.8%) in the resection group (relative risk 3.01, 95% confidence interval 1.15-7.90). There was no significant difference in Intensive Care Unit admissions, 30 and 90-day mortality, or stoma rates at 12 months.
CONCLUSION
Laparoscopic lavage used in the management of Hinchey grade III diverticulitis leads to more reinterventions within 30 days postoperatively, but does not increase the 30 or 90-day mortality rates compared with sigmoid resection.
Topics: Diverticulitis; Diverticulum, Colon; Female; Hospital Mortality; Humans; Laparoscopy; Male; Peritoneal Lavage; Peritonitis; Prognosis; Randomized Controlled Trials as Topic; Risk Assessment; Severity of Illness Index; Survival Rate; Treatment Outcome
PubMed: 27631772
DOI: 10.1097/SLA.0000000000002005 -
Pancreas Jul 2016The aim of this study was to assess the efficiency and safety of peritoneal lavage in patients with severe acute pancreatitis. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The aim of this study was to assess the efficiency and safety of peritoneal lavage in patients with severe acute pancreatitis.
METHODS
A comprehensive search was performed to identify randomized controlled trials that compared peritoneal lavage with conservative treatment for severe acute pancreatitis. The primary outcome was all-cause mortality. Secondary outcomes included complications rate, proportion of need for operation, length of hospital stay, and medical costs.
RESULTS
A total of 899 patients from 15 studies were subjected to this systematic review. Peritoneal lavage did significantly decrease the mortality (relative risk, 0.47; 95% confidence interval, 0.34-0.66; P < 0.01), with low heterogeneity among the studies (I = 7%). Peritoneal lavage also seemed to significantly alter any of the other end points.
CONCLUSIONS
Peritoneal lavage shows robustly beneficial effect in patients with severe acute pancreatitis in this systematic review. However, the results should be interpreted with caution due to the general high risk of bias in these included studies.
Topics: Acute Disease; Humans; Length of Stay; Pancreatitis; Peritoneal Lavage; Randomized Controlled Trials as Topic; Risk Factors; Severity of Illness Index; Survival Rate; Treatment Outcome
PubMed: 27295532
DOI: 10.1097/MPA.0000000000000530 -
European Journal of Surgical Oncology :... Sep 2016The most common cause of tumour progression in advanced gastric cancer is peritoneal carcinosis (PC). The necessity to increase the survival in advanced diseases... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The most common cause of tumour progression in advanced gastric cancer is peritoneal carcinosis (PC). The necessity to increase the survival in advanced diseases suggested to deliver the chemotherapy directly in the peritoneal cavity also in Cy+/PC- and to experiment the effect of massive peritoneal lavage to wash out the tumour cells. The aim of this study is to investigate the gain in term of survival and peritoneal recurrence rate of the intraperitoneal chemotherapy and/or peritoneal lavage in patients with Cy+/PC-.
MATERIAL AND METHODS
A systematic review with meta-analysis of trials about the effect of intraperitoneal chemotherapy (IPC) and/or peritoneal lavage (PL) on positive cytology in gastric cancer without carcinosis.
RESULTS
Three trials have been included (164 patients: 76 received surgery alone, 51 surgery + IPC and 37 surgery + IPC + PL). Two- and five-years survival is increased by IPC (RR = 1.62, RR = 3.10). 2 and 5 years survival is further increased by IPC + PL (RR = 2.33, RR = 6.19). Peritoneal recurrence is reduced by IPC (OR = 0.45) and by IPC + PL (OR = 0.13).
CONCLUSIONS
Two- and five-years overall survival in patients with free cancer cells without carcinosis is incremented by intraperitoneal chemotherapy. Peritoneal lavage further increases these survival rates and also it further decreases the peritoneal recurrence rate.
Topics: Antineoplastic Agents; Carcinoma; Humans; Infusions, Parenteral; Peritoneal Cavity; Peritoneal Lavage; Peritoneal Neoplasms; Prognosis; Stomach Neoplasms; Survival Rate; Therapeutic Irrigation
PubMed: 27134147
DOI: 10.1016/j.ejso.2016.03.035