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BMJ Open Mar 2015To compare outcomes following totally transanal endorectal pull-through (TTERPT) versus pull-through with any form of laparoscopic assistance (LAPT) for infants with... (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVE
To compare outcomes following totally transanal endorectal pull-through (TTERPT) versus pull-through with any form of laparoscopic assistance (LAPT) for infants with uncomplicated Hirschsprung's disease.
DESIGN
Systematic review and meta-analysis.
SETTING
Five hospitals with a paediatric surgical service.
PARTICIPANTS
405 infants with uncomplicated Hirschsprung's disease.
INTERVENTIONS
TTERPT versus LAPT.
PRIMARY OUTCOMES
mortality, postoperative enterocolitis, faecal incontinence, constipation, unplanned laparotomy or stoma formation, and injury to abdominal viscera.
SECONDARY OUTCOMES
Haemorrhage requiring transfusion of blood products, abscess formation, intestinal obstruction, intestinal ischaemia, enteric fistula formation, urinary incontinence or retention, impotency and duration of procedure.
RESULTS
Five eligible studies comprising 405 patients were identified from 2107 studies. All studies were retrospective case series, with variability in outcome assessment quality and length of follow-up. Operative duration was 50.29 min shorter with TTERPT (95% CI 39.83 to 60.74, p<0.00001). There were no significant differences identified between TTERPT and LAPT for incidence of postoperative enterocolitis (OR=0.78, 95% CI 0.44 to 1.38, p=0.39), faecal incontinence (OR=0.44, 95% CI 0.09 to 2.20, p=0.32) or constipation (OR=0.84, 95% CI 0.32 to 2.17, p=0.71).
CONCLUSIONS
This meta-analysis did not find any evidence to suggest a higher rate of enterocolitis, incontinence or constipation following TTERPT compared with LAPT. Further long-term comparative studies and multicentre data pooling are needed to determine whether a purely transanal approach offers any advantages over a laparoscopically assisted approach to rectosigmoid Hirschsprung's disease.
TRIAL REGISTRATION NUMBER
PROSPERO registry- CRD42013005698.
Topics: Anal Canal; Colon; Digestive System Surgical Procedures; Hirschsprung Disease; Humans; Infant; Laparoscopy; Megacolon; Postoperative Complications
PubMed: 25805527
DOI: 10.1136/bmjopen-2014-006063 -
Techniques in Coloproctology Mar 2014This literature review looks at the epidemiology, clinical manifestations, diagnostics and current medical and surgical management of Clostridium difficile (C.... (Review)
Review
This literature review looks at the epidemiology, clinical manifestations, diagnostics and current medical and surgical management of Clostridium difficile (C. difficile) infection. A literature search of PubMed and Cochrane database regarding C. difficile infection was performed. Information was extracted from 43 published articles from 2000 to the present day which met inclusion criteria. C. difficile is a gram-positive, anaerobic bacillus, which is widely found in the environment, especially in the soil. The occurrence of more resistant strains, which is mainly connected with the wide use of antibiotics, resulted in the rapid spread of the bacteria to different hospital departments. Particularly, elderly patients in surgical wards and intensive care units are at significant risk of developing C. difficile infection, which greatly increases morbidity and mortality. Symptoms of infection with C. difficile vary greatly. At one end of the spectrum, there are asymptomatic carriers, at the other patients with life-threatening toxic megacolon. Metronidazole is considered to be the drug of choice, but recent guidelines recommend Vancomycin. Fulminant colitis and toxic megacolon warrant surgical intervention. The optimal time for surgery is within 48 h of initiating conservative treatment without seeing a response, the development of multiple organ failure or a bowel perforation. A factor that has become increasingly important and relevant is the escalating expense of treatment for patients with C. difficile infection. It is, therefore, highly recommended to consider reviewing all hospital antibiotic policies and clinical guidelines that may contribute to the prevention of the infection.
Topics: Anti-Bacterial Agents; Clostridioides difficile; Cross Infection; Enterocolitis, Pseudomembranous; Humans
PubMed: 24178946
DOI: 10.1007/s10151-013-1081-0 -
Annals of Surgery Apr 2005A subgroup of patients with intractable constipation has persistent dilatation of the bowel, which in the absence of an organic cause is termed idiopathic megabowel... (Comparative Study)
Comparative Study Review
OBJECTIVE
A subgroup of patients with intractable constipation has persistent dilatation of the bowel, which in the absence of an organic cause is termed idiopathic megabowel (IMB). The aim of this systematic review was to evaluate the published outcome data of surgical procedures for IMB in adults.
METHODS
Electronic searches of the MEDLINE (PubMed) database, Cochrane Library, EMBase, and Science Citation Index were performed. Only peer-reviewed articles of surgery for IMB published in the English language were evaluated. Studies of all surgical procedures were included, providing they were performed on 3 or more patients, and overall success rates were documented. Studies were critically appraised in terms of design and methodology, inclusion criteria, success, mortality and morbidity rates, and functional outcomes.
RESULTS
A total of 27 suitable studies were identified, all evidence was low quality obtained from case series, and there were no comparative studies. The studies involved small numbers of patients (median 12, range 3-50), without long-term follow-up (median 3 years, range 0.5-7). Inclusion of subjects, methods of data acquisition, and reporting of outcomes were extremely variable. Subtotal colectomy was successful in 71.1% (0%-100%) but was associated with significant morbidity related to bowel obstruction (14.5%, range 0%-29%). Segmental resection was successful in 48.4% (12.5%-100%), and recurrent symptoms were common (23.8%). Rectal procedures achieved a successful outcome in 71% to 87% of patients. Proctectomy, the Duhamel, and pull-through procedures were associated with significant mortality (3%-25%) and morbidity (6%-29%). Vertical reduction rectoplasty (VRR) offered promising short-term success (83%). Pelvic-floor procedures were associated with poor outcomes. A stoma provided a safe alternative but was only effective in 65% of cases.
CONCLUSIONS
Outcome data of surgery for IMB must be interpreted with extreme caution due to limitations of included studies. Recommendations based on firm evidence cannot be given, although colectomy appears to be the optimum procedure in patients with a nondilated rectum, restorative proctocolectomy the most suitable in those with dilatation of the colon and rectum, and VRR in those patients with dilatation confined to the rectum. Appropriately designed studies are required to make valid comparisons of the different procedures available.
Topics: Adolescent; Adult; Age Distribution; Anastomosis, Surgical; Child; Child, Preschool; Clinical Trials as Topic; Colectomy; Colorectal Surgery; Female; Follow-Up Studies; Humans; Incidence; Male; Megacolon; Postoperative Complications; Proctocolectomy, Restorative; Rectal Diseases; Reproducibility of Results; Risk Assessment; Severity of Illness Index; Sex Distribution; Treatment Outcome
PubMed: 15798457
DOI: 10.1097/01.sla.0000157140.69695.d3