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The Cochrane Database of Systematic... Dec 2019Ascites is the accumulation of fluid within the abdominal cavity. Most women with advanced ovarian cancer and some women with advanced endometrial cancer need repeated... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Ascites is the accumulation of fluid within the abdominal cavity. Most women with advanced ovarian cancer and some women with advanced endometrial cancer need repeated drainage for ascites. Guidelines to advise those involved in the drainage of ascites are usually produced locally and are generally not evidence-based. Managing drains that improve the efficacy and quality of the procedure is key in making recommendations that could improve the quality of life (QoL) for women at this critical period of their lives.
OBJECTIVES
To evaluate the effectiveness and adverse events of different interventions for the management of malignant ascites drainage in the palliative care of women with gynaecological cancer.
SEARCH METHODS
We searched CENTRAL, MEDLINE, and Embase to 4 November 2019. We checked clinical trial registries, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) of women with malignant ascites with gynaecological cancer. If studies also included women with non-gynaecological cancer, we planned to extract data specifically for women with gynaecological cancers or request the data from trial authors. If this was not possible, we planned to include the study only if at least 50% of participants were diagnosed with gynaecological cancer.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected studies, extracted data, evaluated the quality of the included studies, compared results, and assessed the certainty of the evidence using Cochrane methodology.
MAIN RESULTS
In the original 2010 review, we identified no relevant studies. This updated review included one RCT involving 245 participants that compared abdominal paracentesis and intraperitoneal infusion of catumaxomab versus abdominal paracentesis alone. The study was at high risk of bias in almost all domains. The data were not suitable for analysis. The median time to the first deterioration of QoL ranged from 19 to 26 days in participants receiving paracentesis alone compared to 47 to 49 days among participants receiving paracentesis with catumaxomab infusion (very low-certainty evidence). Adverse events were only reported among participants receiving catumaxomab infusion. The most common severe adverse events were abdominal pain and lymphopenia (157 participants; very low-certainty evidence). There were no data on the improvement of symptoms, satisfaction of participants and caregivers, and cost-effectiveness.
AUTHORS' CONCLUSIONS
Currently, there is insufficient evidence to recommend the most appropriate management of drainage for malignant ascites among women with gynaecological cancer, as there was only very low-certainty evidence from one small RCT at overall high risk of bias.
Topics: Ascites; Drainage; Endometrial Neoplasms; Female; Humans; Ovarian Neoplasms; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 31825525
DOI: 10.1002/14651858.CD007794.pub3 -
Anaesthesiology Intensive Therapy 2019Without timely diagnosis, acute primary abdominal compartment syndrome (ACS) is a potentially fatal syndrome and often goes unrecognized until severe symptoms appear....
BACKGROUND
Without timely diagnosis, acute primary abdominal compartment syndrome (ACS) is a potentially fatal syndrome and often goes unrecognized until severe symptoms appear. Early diagnosis may significantly improve the prognosis of these patients.
CASE PRESENTATION
We present the case of a 54-year-old man, successfully treated for acute myeloid leukemia with cytosine arabinoside, admitted to the intensive care unit with severe shock, refractory to standard therapy with antibiotics, fluid resuscitation, and vasopressors. Early diagnosis of acute primary abdominal syndrome was made based on an intra-abdominal pressure of 20 mm Hg (3 kPa) with new onset organ failure, after which decompressive laparotomy was performed. Stool cultures grew Clostridium difficile. Despite abdominal decompression, the abdominal compartment syndrome persisted with the development of toxic megacolon and a total colectomy was performed with favorable evolution.
METHODS
A systematic review of published case reports was performed describing a primary ACS due to C. difficile toxic megacolon. A PubMed database search was performed with the following search terms, single or in combination: 'clostridium difficile', 'toxic megacolon', 'abdominal compartment syndrome', and 'CDI'. The latest search was performed for March 2019; only case reports after 1998 were included.
RESULTS
We found a total of 19 case reports with C. difficile toxic megacolon (including the present case). The male/female ratio was 12/7, and there were 3 children. The mean age was 48.7 ± 23.5 years. The reason for admission was sepsis in 6, trauma in 2, postoperative in 4, enterocolitis in 5, pregnancy in 1 and abdominal complaints after topical antibiotics in 1. Three patients did not develop diarrhea. Five patients presented with diarrhea on average 5.8 ± 5.1 (median 4, 1-14) days prior to hospital admission while 7 patients developed diarrhea on average after 10 ± 19.6 (median 3, 0-54) days during admission. The intra-abdominal pressure (measured in 6 patients, including ours) was 29.2 ± 11 (20-50) mm Hg (3-7 kPa). Treatment consisted of (a combination of) vancomycin (orally or via rectal enemas), metronidazole (orally or intravenously), and surgical intervention (with decompressive laparotomy). Three patients died (15.8%).
CONCLUSIONS
Monitoring of intra-abdominal pressure allows early detection of abdominal compartment syndrome and is warranted in patients with C. difficile infection and/or toxic megacolon. Early decompression can lead to improved outcomes in patients with severe shock and organ failure.
Topics: Adult; Aged; Anti-Bacterial Agents; Clostridioides difficile; Clostridium Infections; Colectomy; Decompression, Surgical; Female; Humans; Intra-Abdominal Hypertension; Laparotomy; Male; Megacolon, Toxic; Middle Aged
PubMed: 31741357
DOI: 10.5114/ait.2019.89189 -
World Journal of Gastroenterology Oct 2019Laparoscopy has been widely used in general surgical procedures, but total laparoscopic pancreaticoduodenectomy (TLPD) is still a complex and challenging surgery that is... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Laparoscopy has been widely used in general surgical procedures, but total laparoscopic pancreaticoduodenectomy (TLPD) is still a complex and challenging surgery that is only performed in a small number of patients at a few large academic medical centers. Although the safety and feasibility of TLPD have been established, few studies have compared it with open pancreaticoduodenectomy (OPD) with regard to perioperative and oncological outcomes. Therefore, we carried out a meta-analysis to evaluate whether TLPD is superior to OPD.
AIM
To compare the treatment outcomes of TLPD and OPD in order to assess the safety and feasibility of TLPD.
METHODS
We conducted a systematic search of studies comparing TLPD with OPD that were published in the PubMed, EMBASE, and Cochrane Library databases through December 31, 2018. The studies comparing TLPD and OPD with at least one of the outcomes we were interested in and with more than 10 cases in each group were included in this analysis. The Newcastle-Ottawa scale was used to assess the quality of the nonrandomized controlled trials and the Jadad scale was used to assess the randomized controlled trials. Intraoperative data, postoperative complications, and oncologic outcomes were evaluated. The meta-analysis was performed using Review Manager Software version 5.3. Random or fixed-effects meta-analyses were undertaken to measure the pooled estimates.
RESULTS
A total of 4790 articles were initially identified for our study. After screening, 4762 articles were excluded and 28 studies representing 39771 patients (3543 undergoing TLPD and 36228 undergoing OPD) were eventually included. Patients who underwent TLPD had less intraoperative blood loss [weighted mean difference (WMD) = -260.08 mL, 95% confidence interval (CI): (-336.02, -184.14) mL, < 0.00001], a lower blood transfusion rate [odds ratio (OR) = 0.51, 95%CI: 0.36-0.72, = 0.0001], a lower perioperative overall morbidity (OR = 0.82, 95%CI: 0.73-0.92, = 0.0008), a lower wound infection rate (OR = 0.48, 95%CI: 0.34-0.67, < 0.0001), a lower pneumonia rate (OR = 0.72, 95%CI: 0.60-0.85, = 0.0002), a shorter duration of intensive care unit (ICU) stay [WMD = -0.28 d, 95%CI (-2.88, -1.29) d, < 0.00001] and a shorter length of hospital stay [WMD = -3.05 d, 95%CI (-3.93, -2.17), < 0.00001], a lower rate of discharge to a new facility (OR = 0.55, 95%CI: 0.39-0.78, = 0.0008), and a lower 30-d readmission rate (OR = 0.81, 95%CI: 0.68-0.95, = 0.10) than those who underwent OPD. In addition, the TLPD group had a higher R0 rate (OR = 1.28, 95%CI: 1.13-1.44, = 0.0001) and more lymph nodes harvested (WMD = 1.32, 95%CI: 0.57-2.06, = 0.0005) than the OPD group. However, the patients who underwent TLPD experienced a significantly longer operative time (WMD = 77.92 min, 95%CI: 40.89-114.95, < 0.0001) and had a smaller tumor size than those who underwent OPD [WMD = -0.32 cm, 95%CI: (-0.58, -0.07) cm, = 0.01]. There were no significant differences between the two groups in the major morbidity, postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, bile leak, gastroenteric anastomosis fistula, intra-abdominal abscess, bowel obstruction, fluid collection, reoperation, ICU admission, or 30-d and 90-d mortality rates. For malignant tumors, the 1-, 2-, 3-, 4- and 5-year overall survival rates were not significantly different between the two groups.
CONCLUSION
This meta-analysis indicates that TLPD is safe and feasible, and may be a desirable alternative to OPD, although a longer operative time is needed and only smaller tumors can be treated.
Topics: Blood Transfusion; Clinical Trials as Topic; Disease-Free Survival; Feasibility Studies; Hospital Mortality; Humans; Laparoscopy; Neoplasm Recurrence, Local; Operative Time; Pancreas; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Tumor Burden
PubMed: 31602170
DOI: 10.3748/wjg.v25.i37.5711 -
World Journal of Hepatology Jul 2019Spontaneous peritonitis is an infection of ascitic fluid without a known intra-abdominal source of infection. spontaneous fungal peritonitis (SFP) is a potentially fatal...
BACKGROUND
Spontaneous peritonitis is an infection of ascitic fluid without a known intra-abdominal source of infection. spontaneous fungal peritonitis (SFP) is a potentially fatal complication of decompensated cirrhosis, defined as fungal infection of ascitic fluid in the presence of ascitic neutrophil count of greater than 250 cells/mL.
AIM
To determine the prevalence of fungal pathogens, management and outcomes (mortality) of SFP in critically ill cirrhotic patients.
METHODS
Studies were identified using PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus databases until February 2019. Inclusion criteria included intervention trials and observation studies describing the association between SFP and cirrhosis. The primary outcome was in-hospital, 1-mo, and 6-mo mortality rates of SFP in cirrhotic patients. Secondary outcomes were fungal microorganisms identified and in hospital management by anti-fungal medications. The National Heart, Lung and Blood Institute quality assessment tools were used to assess internal validity and risk of bias for each included study.
RESULTS
Six observational studies were included in this systematic review. The overall quality of included studies was good. A meta-analysis of results could not be performed because of differences in reporting of outcomes and heterogeneity of the included studies. There were 82 patients with SFP described across all the included studies. Candida species, predominantly was the fungal pathogen in majority of the cases (48%-81.8%) followed by (15%-25%) and (6.66%-20%). (53.3%) was the other major fungal pathogen. Antifungal therapy in SFP patients was utilized in 33.3% to 81.8% cases. The prevalence of in hospital mortality ranged from 33.3% to 100%, whereas 1-mo mortality ranged between 50% to 73.3%.
CONCLUSION
This systematic review suggests that SFP in end stage liver disease patient is associated with high mortality both in the hospital and at 1-mo, and that antifungal therapy is currently underutilized.
PubMed: 31388401
DOI: 10.4254/wjh.v11.i7.596 -
Transplantation Direct Jul 2019Adult kidney transplantation is most commonly into an extraperitoneal potential space, and surgically placed drains are used routinely in many centers. There is limited...
BACKGROUND
Adult kidney transplantation is most commonly into an extraperitoneal potential space, and surgically placed drains are used routinely in many centers. There is limited evidence of clinical benefit for prophylactic drainage in other major abdominal and vascular surgery. Transplantation is, however, a unique setting combining organ dysfunction and immunosuppression, and the risks and benefits of prophylactic drain placement are not known. This study attempts to examine existing literature to determine whether prophylactic intraoperative drains have an impact on the likelihood of perigraft fluid collections and other wound-related complications following kidney transplantation.
METHODS
A literature search of MEDLINE and EMBASE was conducted to identify published comparative studies, including recipients receiving prophylactic drains to recipients in whom drains were omitted. The main outcomes were the incidence of peritransplant fluid collections and wound-related complications. Meta-analysis was performed on these data.
RESULTS
Four retrospective cohort studies were deemed eligible for quantitative analysis and 1 additional conference abstract was included in qualitative discussion. A total of 1640 patients, 1023 with drains and 617 without, were included in the meta-analysis. There was a lower rate of peritransplant collections associated with the drain group (RR 0.62; 95% confidence interval, 0.42-0.90). There was no significant difference in the incidence of wound-related complications between the groups (RR 0.85; 95% confidence interval, 0.34-2.11).
CONCLUSIONS
These data associate a higher rate of peritransplant fluid collections with omission of prophylactic drainage, without a difference in the incidence of wound-related complications. Further research is required to definitively determine the impact of drains in this patient group.
PubMed: 31334342
DOI: 10.1097/TXD.0000000000000908 -
The Cochrane Database of Systematic... Jun 2019Plasma volume expanders are used in connection to paracentesis in people with cirrhosis to prevent reduction of effective plasma volume, which may trigger deleterious... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Plasma volume expanders are used in connection to paracentesis in people with cirrhosis to prevent reduction of effective plasma volume, which may trigger deleterious effect on haemodynamic balance, and increase morbidity and mortality. Albumin is considered the standard product against which no plasma expansion or other plasma expanders, e.g. other colloids (polygeline , dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol have been compared. However, the benefits and harms of these plasma expanders are not fully clear.
OBJECTIVES
To assess the benefits and harms of any plasma volume expanders such as albumin, other colloids (polygeline, dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol versus no plasma volume expander or versus another plasma volume expander for paracentesis in people with cirrhosis and large ascites.
SEARCH METHODS
We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CNKI, VIP, Wanfang, Science Citation Index Expanded, and Conference Proceedings Citation Index until January 2019. Furthermore, we searched FDA, EMA, WHO (last search January 2019), www.clinicaltrials.gov/, and www.controlled-trials.com/ for ongoing trials.
SELECTION CRITERIA
Randomised clinical trials, no matter their design or year of publication, publication status, and language, assessing the use of any type of plasma expander versus placebo, no intervention, or a different plasma expander in connection with paracentesis for ascites in people with cirrhosis. We considered quasi-randomised, retrieved with the searches for randomised clinical trials only, for reports on harms.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. We calculated the risk ratio (RR) or mean difference (MD) using the fixed-effect model and the random-effects model meta-analyses, based on the intention-to-treat principle, whenever possible. If the fixed-effect and random-effects models showed different results, then we made our conclusions based on the analysis with the highest P value (the more conservative result). We assessed risks of bias of the individual trials using predefined bias risk domains. We assessed the certainty of the evidence at an outcome level, using GRADE, and constructed 'Summary of Findings' tables for seven of our review outcomes.
MAIN RESULTS
We identified 27 randomised clinical trials for inclusion in this review (24 published as full-text articles and 3 as abstracts). Five of the trials, with 271 participants, assessed plasma expanders (albumin in four trials and ascitic fluid in one trial) versus no plasma expander. The remaining 22 trials, with 1321 participants, assessed one type of plasma expander, i.e. dextran, hydroxyethyl starch, polygeline, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus another type of plasma expander, i.e. albumin in 20 of these trials and polygeline in one trial. Twenty-five trials provided data for quantitative meta-analysis. According to the Child-Pugh classification, most participants were at an intermediate to advanced stage of liver disease in the absence of hepatocellular carcinoma, recent gastrointestinal bleeding, infections, and hepatic encephalopathy. All trials were assessed as at overall high risk of bias. Ten trials seemed not to have been funded by industry; twelve trials were considered unclear about funding; and five trials were considered funded by industry or a for-profit institution.We found no evidence of a difference in effect between plasma expansion versus no plasma expansion on mortality (RR 0.52, 95% CI 0.06 to 4.83; 248 participants; 4 trials; very low certainty); renal impairment (RR 0.32, 95% CI 0.02 to 5.88; 181 participants; 4 trials; very low certainty); other liver-related complications (RR 1.61, 95% CI 0.79 to 3.27; 248 participants; 4 trials; very low certainty); and non-serious adverse events (RR 1.04, 95% CI 0.32 to 3.40; 158 participants; 3 trials; very low certainty). Two of the trials stated that no serious adverse events occurred while the remaining trials did not report on this outcome. No trial reported data on health-related quality of life.We found no evidence of a difference in effect between experimental plasma expanders versus albumin on mortality (RR 1.03, 95% CI 0.82 to 1.30; 1014 participants; 14 trials; very low certainty); serious adverse events (RR 0.89, 95% CI 0.10 to 8.30; 118 participants; 2 trials; very low certainty); renal impairment (RR 1.17, 95% CI 0.71 to 1.91; 1107 participants; 17 trials; very low certainty); other liver-related complications (RR 1.10, 95% CI 0.82 to 1.48; 1083 participants; 16 trials; very low certainty); and non-serious adverse events (RR 1.37, 95% CI 0.66 to 2.85; 977 participants; 14 trials; very low certainty). We found no data on heath-related quality of life and refractory ascites.
AUTHORS' CONCLUSIONS
Our systematic review and meta-analysis did not find any benefits or harms of plasma expanders versus no plasma expander or of one plasma expander such as polygeline, dextrans, hydroxyethyl starch, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus albumin on primary or secondary outcomes. The data originated from few, small, mostly short-term trials at high risks of systematic errors (bias) and high risks of random errors (play of chance). GRADE assessments concluded that the evidence was of very low certainty. Therefore, we can neither demonstrate or discard any benefit of plasma expansion versus no plasma expansion, and differences between one plasma expander versus another plasma expander.Larger trials at low risks of bias are needed to assess the role of plasma expanders in connection with paracentesis. Such trials should be conducted according to the SPIRIT guidelines and reported according to the CONSORT guidelines.
Topics: Humans; Ascites; Liver Cirrhosis; Paracentesis; Plasma Substitutes; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 31251387
DOI: 10.1002/14651858.CD004039.pub2 -
Endoscopic Ultrasound 2019Postoperative pancreatic fluid collection (POPFC) is an important complication following abdominal surgery. POPFC causes significant morbidity and mortality. Management... (Review)
Review
Postoperative pancreatic fluid collection (POPFC) is an important complication following abdominal surgery. POPFC causes significant morbidity and mortality. Management options are time-consuming and severely affect patient's quality of life. Surgical and/or percutaneous drainage (PCD) is the traditional mainstay of treatment. Studies have shown that EUS could have a role to play in the management of POPFC. Data are limited in the comparison of clinical outcomes with EUS as compared to PCD to this end. We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Google Scholar, LILACS, and Web of Science databases (earliest inception through September 2018) to identify studies that reported on the clinical outcomes of EUS and PCD in the management of POPFC. The goals were to estimate and compare the pooled rates of technical success, clinical success, adverse events, and POPFC recurrence with EUS and PCD. A total of 13 studies were included in the analysis. Ten studies (239 patients) used EUS and 6 studies (267 patients) used PCD in the management of POPFC. The pooled rate of clinical success with EUS was 93.2% (95% confidence interval [CI] 88.2-96.2, I = 0) and with PCD was 79.8% (95% CI 70-87, I = 74). The difference was statistically significant, P = 0.002. Recurrence rate was significantly lower with EUS as compared to PCD (9.4%: 95% CI 5.2-16.5 vs. 25.7%: 95% CI 24.3-41.7; P = 0.02). Pooled rates of technical success and adverse events were similar with EUS and PCD. Our meta-analysis shows that EUS has significantly better clinical outcomes, in terms of clinical success and disease recurrence, in the management of POPFC as compared to PCD.
PubMed: 31249160
DOI: 10.4103/eus.eus_18_19 -
Critical Care (London, England) Jun 2019Perioperative goal-directed therapy (GDT) reduces the risk of renal injury. However, several questions remain unanswered, such as target, kind of patients and surgery,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Perioperative goal-directed therapy (GDT) reduces the risk of renal injury. However, several questions remain unanswered, such as target, kind of patients and surgery, and role of fluids and inotropes. We therefore update a previous analysis, including all studies published in the meanwhile, to clarify the clinical impact of this strategy on acute kidney injury.
MAIN BODY
Randomized controlled trials enrolling adult patients undergoing major surgery were considered. GDT was defined as perioperative monitoring and manipulation of hemodynamic parameters to reach normal or supranormal values by fluids alone or with inotropes. Trials comparing the effects of GDT and standard hemodynamic therapy were considered. Primary outcome was acute kidney injury, whichever definition was used. Meta-analytic techniques (analysis software RevMan, version 5.3) were used to combine studies, using random-effect odds ratios (OR) and 95% confidence intervals (CI). Trial sequential analyses were performed including all trials and considering only low risk of bias trials. Sixty-five trials with an overall sample of 9308 patients were included. OR for the development of renal injury was 0.64 (95% CI, 0.62-0.87; p = 0.0003), with no statistical heterogeneity. Trial sequential analyses and sensitivity analysis including studies with low risk of bias confirmed the main results. A significant decrease in renal injury rate was observed in studies that adopted cardiac output and oxygen delivery as hemodynamic target and that used both fluids and inotropes. The postoperative kidney injury rate was significantly lower in trials enrolling "high-risk" patients and major abdominal and orthopedic surgery.
SHORT CONCLUSION
The present meta-analysis suggests that targeting GDT to perioperative systemic oxygen delivery, by means of fluids and inotropes, can be the best way to improve renal perfusion and oxygenation in high-risk patients undergoing major abdominal and orthopedic surgery.
Topics: Acute Kidney Injury; Critical Illness; Fluid Therapy; Hemodynamics; Humans; Patient Care Planning; Postoperative Complications; Postoperative Period
PubMed: 31242941
DOI: 10.1186/s13054-019-2516-4 -
BMC Geriatrics Jun 2019Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not specifically designed for older...
BACKGROUND
Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not specifically designed for older patients. The objective of this study was to review the components, adherence and outcomes of ERPs in older patients (≥65 years) undergoing elective colorectal surgery.
METHODS
Pubmed, Embase and Cinahl were searched between 2000 and 2017 for randomised and non-randomised controlled trials, before-after studies, and observational studies. The methodological quality of the studies was evaluated using the MINORS quality assessment. The review was performed and reported according to the PRISMA guidelines.
RESULTS
Twenty-one studies, including 3495 ERP patients aged ≥65 years, were identified. The ERPs consisted of a median of 13 intervention components. Adherence rates were reported in 9 studies and were the highest (≥80%) for pre-admission counselling, no bowel preparation, limited pre-operative fasting, antithrombotic and antimicrobial prophylaxis, no nasogastric tube, active warming, and limited intra-operative fluids. The median post-operative length of stay was 6 days. The median post-operative morbidity rate (Clavien-Dindo I-IV) was 23.5% in-hospital and 29.8% at 30 days. The in-hospital post-operative mortality rate was 0% in most studies and amounted to a median of 1.4% at 30 days. The median 30-day readmission rate was 4.9% and the median reoperation rate was 5.0%.
CONCLUSIONS
ERPs in older patients were in accordance with the ERP consensus guidelines. Although the number of intervention components applied increased over time, outcomes in earlier and later studies remained comparable. Adherence rates were under-reported. Future studies should explore adherence and age-related factors, such as frailty profile, that could influence adherence.
TRIAL REGISTRATION
PROSPERO 2018 CRD42018084756 .
Topics: Aged; Colorectal Surgery; Elective Surgical Procedures; Humans; Recovery of Function; Treatment Outcome
PubMed: 31170933
DOI: 10.1186/s12877-019-1158-3 -
BMC Surgery May 2019Duodenal stump fistula (DSF) remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patient's life. DSF is related to...
BACKGROUND
Duodenal stump fistula (DSF) remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patient's life. DSF is related to high mortality (16-20%) and morbidity (75%) rates. DSF-related morbidity always leads to longer hospitalization times due to medical and surgical complications such as wound infections, intra-abdominal abscesses, intra-abdominal bleeding, acute pancreatitis, acute cholecystitis, severe malnutrition, fluids and electrolytes disorders, diffuse peritonitis, and pneumonia. Our systematic review aimed at improving our understanding of such surgical complication, focusing on nonsurgical and surgical DSF management in patients undergoing gastric resection for gastric cancer.
METHODS
We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. PubMed/MEDLINE, EMBASE, Scopus, Cochrane Library and Web of Science databases were used to search all related literature.
RESULTS
The 20 included articles covered an approximately 40 years-study period (1979-2017), with a total 294 patient population. DSF diagnosis occurred between the fifth and tenth postoperative day. Main DSF-related complications were sepsis, abdominal abscess, wound infection, pneumonia, and intra-abdominal bleeding. DSF treatment was divided into four categories: conservative (101 cases), endoscopic (4 cases), percutaneous (82 cases), and surgical (157 cases). Length of hospitalization was 21-39 days, ranging from 1 to 1035 days. Healing time was 19-63 days, ranging from 1 to 1035 days. DSF-related mortality rate recorded 18.7%.
CONCLUSIONS
DSF is a rare but potentially lethal complication after gastrectomy for gastric cancer. Early DSF diagnosis is crucial in reducing DSF-related morbidity and mortality. Conservative and/or endoscopic/percutaneous treatments is/are the first choice. However, if the patient clinical condition worsens, surgery becomes mandatory and duodenostomy appears to be the most effective surgical procedure.
Topics: Abdominal Abscess; Duodenal Diseases; Gastrectomy; Humans; Intestinal Fistula; Peritonitis; Postoperative Complications; Stomach Neoplasms; Wound Healing
PubMed: 31138190
DOI: 10.1186/s12893-019-0520-x