Body composition assessment and sarcopenia in patients with pancreatic cancer: a systematic review and meta-analysis

Impact of preoperative nutritional support and rehabilitation therapy in patients undergoing pancreaticoduodenectomy

BACKGROUND

Sarcopenia is closely associated with morbidity after pancreatic surgery. We investigated the impact of preoperative nutritional support and rehabilitation on patients undergoing pancreaticoduodenectomy.

METHODS

This was a retrospective analysis of 101 patients who underwent pancreaticoduodenectomy. Skeletal muscle (SM) loss was defined using the SM index (cutoff level: 42 cm²/m² in men and 38 cm²/m² in women). A total of 33 and 30 patients received preoperative nutrition and prehabilitation, respectively. The neutrophil-to-lymphocyte ratio (NLR), Prognostic Nutritional Index (PNI), and modified Glasgow Prognostic Score (mGPS) values were calculated during the first visit and immediately before surgery.

RESULTS

SM loss was present in 65 of 101 patients and was significantly correlated with female sex, older age, lower body mass index, and low PNI. Preoperative nutritional support and prehabilitation prevented the decrease in PNI values in patients with SM loss. The NLR significantly improved in patients with SM loss who received nutritional support and prehabilitation. In patients with SM loss, the lack of preoperative nutrition and prehabilitation was an independent risk factor for postoperative pancreatic fistula.

CONCLUSIONS

Preoperative nutritional support and prehabilitation may reduce the incidence of pancreatic fistula in patients with SM loss and improve the surgical outcomes of patients undergoing pancreaticoduodenectomy.

Prognostic value of early changes in CT-measured body composition in patients receiving chemotherapy for unresectable pancreatic cancer

OBJECTIVES

Skeletal muscle mass is a prognostic factor in pancreatic ductal adenocarcinoma (PDAC). However, it remains unclear whether changes in body composition provide an incremental prognostic value to established risk factors, especially the Response Evaluation Criteria in Solid Tumors version 1.1 (RECISTv1.1). The aim of this study was to determine the prognostic value of CT-quantified body composition changes in patients with unresectable PDAC starting chemotherapy.

METHODS

We retrospectively evaluated 105 patients with unresectable (locally advanced or metastatic) PDAC treated with FOLFIRINOX (n = 64) or gemcitabine-based (n = 41) first-line chemotherapy within a multicenter prospective trial. Changes (Δ) in skeletal muscle index (SMI), subcutaneous (SATI), and visceral adipose tissue index (VATI) between pre-chemotherapy and first follow-up CT were assessed. Cox regression models and covariate-adjusted survival curves were used to identify predictors of overall survival (OS).

RESULTS

At multivariable analysis, adjusting for RECISTv1.1-response at first follow-up, ΔSMI was prognostic for OS with a hazard ratio (HR) of 1.2 (95% CI: 1.08-1.33, p = 0.001). No significant association with OS was observed for ΔSATI (HR: 1, 95% CI: 0.97-1.04, p = 0.88) and ΔVATI (HR: 1.01, 95% CI: 0.99-1.04, p = 0.33). At an optimal cutoff of 2.8 cm²/m² per 30 days, the median survival of patients with high versus low ΔSMI was 143 versus 233 days (p < 0.001).

CONCLUSIONS

Patients with a lower rate of skeletal muscle loss at first follow-up demonstrated improved survival for unresectable PDAC, regardless of their RECISTv1.1-category. Assessing ΔSMI at the first follow-up CT may be useful for prognostication, in addition to routine radiological assessment.

KEY POINTS

• In patients with unresectable pancreatic ductal adenocarcinoma, change of skeletal muscle index (ΔSMI) in the early phase of chemotherapy is prognostic for overall survival, even after adjusting for Response Evaluation Criteria in Solid Tumors version 1.1 (RECISTv1.1) assessment at first follow-up. • Changes in adipose tissue compartments at first follow-up demonstrated no significant association with overall survival. • Integrating ΔSMI into routine radiological assessment may improve prognostic stratification and impact treatment decision-making at the first follow-up.

Diet and Exercise Interventions in Patients With Pancreatic Cancer: A Scoping Review

Diet and exercise interventions may help reverse malnutrition and muscle wasting common in pancreatic cancer. We performed a scoping review to identify the knowledge gaps surrounding diet and exercise interventions. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Embase, ProQuest Theses and Dissertations, and Google Scholar using the umbrella terms of "pancreatic cancer," "diet/nutrition," and "exercise." Included were articles reporting on ambulatory adults with diagnosed pancreatic cancer. Excluded were studies examining prevention and/or risk, animal, or cell lines. Of the 15,708 articles identified, only 62 met the final inclusion criteria. Almost half of the articles were randomized controlled studies (n = 27). Most studies were from the United States (n = 20). The majority examined dietary interventions (n = 41), with 20 assessing the use of omega-3 fatty acids. Exercise interventions were reported in 13 studies, with 8 examining a diet and exercise intervention. Most studies were small and varied greatly in terms of study design, intervention, and outcomes. We identified 7 research gaps that should be addressed in future studies. This scoping review highlights the limited research examining the effect of diet and exercise interventions in ambulatory patients with pancreatic cancer.

Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer

Simple Summary

Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life.

Abstract

Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.

Elderly patients have increased perioperative morbidity and mortality from oesophagectomy for oesophageal cancer: A systematic review and meta-analysis

BACKGROUND

Although oesophagectomy remains technically challenging and associated with high morbidity and mortality, it is now increasingly performed in an ever-ageing population with improvement in perioperative care. However, the risks in the elderly population are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of oesophagectomy for cancer in the elderly population compared to younger patients.

METHOD

A systematic literature search of PubMed, EMBASE and the Cochrane Library databases was conducted including studies reporting oesophagectomy for cancer in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were pulmonary and cardiac complications, anastomotic leaks, overall and disease-free survival.

RESULTS

This review identified 37 studies incorporating 30,836 patients. Increasing age was significantly associated with increased rates of overall complications (OR 1.67, CI_95%: 1.42-1.96), pulmonary complications (OR 1.87, CI_95%: 1.48-2.35), and cardiac complications (OR: 2.22, CI_95%: 1.95-2.53). However, there was no increased risk of anastomotic leak (OR: 0.98, CI_95%: 0.85-1.18). Elderly patients were significantly more likely to have lower rates of 5-year overall survival (OR: 1.36, CI_95%: 1.11-1.66) and 5-year disease-free survival (OR: 1.72, CI_95%: 1.51-1.96).

CONCLUSION

Elderly patients undergoing oesophagectomy for cancer are at increased risk of overall, pulmonary and cardiac complications, irrespective of age subgroups, albeit no difference in anastomotic leaks. Therefore, they represent high-risk patients warranting implementation of preoperative pathways such as prehabilitation to improve cardiopulmonary fitness prior to surgery, although benefit of prehabilitation is yet to be proven. This information will also aid future pre-operative counselling and informed consent.

Body Composition and Response and Outcome of Neoadjuvant Treatment for Pancreatic Cancer

To assess the correlation of body composition with the response and outcome of neoadjuvant treatment (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). One hundred and nineteen PDAC patients underwent curative resection after NAT. Computed tomography scans of the third lumbar vertebra were used to assess the body composition of these patients before and after NAT. Three distinct wasting phenotypes were identified during NAT, with 51 patients (42.9%) developing muscle and fat wasting (MFW), 17 patients (14.3%) developing fat-only wasting (FW), and 51 patients (42.9%) having no wasting (NW). The response rate was higher in the NW phenotype than in the MFW and FW phenotypes (P = 0.007). In univariate and multivariate analyses, histological grade, sarcopenia before NAT, and MFW during NAT were associated with decreased overall survival (OS). Sarcopenia before NAT and MFW during NAT were associated with decreased disease-free survival (DFS). Body composition was associated with the response and outcome of patients undergoing NAT for PDAC. The response rate was higher in patients having NW during NAT. Sarcopenia before NAT and MFW during NAT were associated with decreased OS and DFS.

Development of Sarcopenia in Patients With Bladder Cancer: A Systematic Review

OBJECTIVE

Sarcopenia is known to influence cancer-related complications and overall survival. However, the effect of cancer treatment on the development or progression of sarcopenia is relatively unknown. The primary aim of this systematic review was to determine the prevalence and development of sarcopenia among people with bladder cancer.

DATA SOURCES

A systematic search was performed in PubMed, Web of Science, and EMBASE. Studies with ≥2 assessments of sarcopenia were eligible for inclusion. Five retrospective cohorts were included with a total of 438 participants. The baseline prevalence of sarcopenia across studies varied from 25% to 69% and post-treatment prevalence from 50% to 81%. The average loss of muscle mass was 2.2% to 10% during a time course of 3 to 12 months.

CONCLUSION

The prevalence of sarcopenia markedly increased during cancer treatment in patients with bladder cancer. Further research into the effect of different treatment regimens on the development of sarcopenia, and how these changes might affect functional capacity and survival is needed.

IMPLICATIONS FOR NURSING PRACTICE

The development of sarcopenia is important to understand because of its negative affect on quality of life, complications, and mortality. Further, understanding how sarcopenia develops during treatment could potentially strengthen nurses' future care plans for patients with bladder cancer.

Impact of musculoskeletal degradation on cancer outcomes and strategies for management in clinical practice

The prevalence of malnutrition in patients with cancer is one of the highest of all patient groups. Weight loss (WL) is a frequent manifestation of malnutrition in cancer and several large-scale studies have reported that involuntary WL affects 50-80% of patients with cancer, with the degree of WL dependent on tumour site, type and stage of disease. The study of body composition in oncology using computed tomography has unearthed the importance of both low muscle mass (sarcopenia) and low muscle attenuation as important prognostic indications of unfavourable outcomes including poorer tolerance to chemotherapy; significant deterioration in performance status and quality of life (QoL), poorer post-operative outcomes and shortened survival. While often hidden by excess fat and high BMI, muscle abnormalities are highly prevalent in patients with cancer (ranging from 10 to 90%). Early screening to identify individuals with sarcopenia and decreased muscle quality would allow for earlier multimodal interventions to attenuate adverse body compositional changes. Multimodal therapies (combining nutritional counselling, exercise and anti-inflammatory drugs) are currently the focus of randomised trials to examine if this approach can provide a sufficient stimulus to prevent or slow the cascade of tissue wasting and if this then impacts on outcomes in a positive manner. This review will focus on the aetiology of musculoskeletal degradation in cancer; the impact of sarcopenia on chemotherapy tolerance, post-operative complications, QoL and survival; and outline current strategies for attenuation of muscle loss in clinical practice.

Sarcopenia and adverse health-related outcomes: An umbrella review of meta-analyses of observational studies

OBJECTIVE

The purpose of this umbrella review was to assess the associations between sarcopenia and adverse health-related outcomes.

DESIGN

An umbrella review of meta-analyses of observational studies.

SETTING AND PARTICIPANTS

Patients with sarcopenia and controls without sarcopenia were included.

MEASURES

The PubMed, Web of Science and Embase were searched for relevant systematic review and meta-analysis. AMSTAR and GRADE system were used for methodological quality and evidence quality assessments, respectively.

RESULTS

Totally 54 outcomes extracted from 30 meta-analyses were analyzed. Twenty out of 21 prognostic outcomes indicated that sarcopenia was significantly associated with poorer prognosis of gastric cancer, hepatocellular cancer, urothelial cancer, head and neck cancer, hematological malignancy, pancreatic cancer, breast cancer, colorectal cancer, lung cancer, esophageal cancer, and ovarian cancer. Besides, 10 out of 16 postoperative outcomes suggested that sarcopenia significantly increased the risk of multiple postoperative complications and prolonged the length of hospitalization of patients with digestive cancer. In age-related outcomes, sarcopenia significantly increased the risk of dysphagia, cognitive impairment, fractures, falls, hospitalization, and all-cause mortality of elderly populations. Moreover, sarcopenia was also associated with higher level of albuminuria, risk of depression, and several metabolic diseases.

CONCLUSIONS AND IMPLICATIONS

Sarcopenia significantly affected a wide range of adverse health-related outcomes, particularly in patients of tumor and elderly populations. Because evidences of most outcomes were rated as "low" and "very low," more prospective cohort studies are required in the future.

Prediction of clinically relevant pancreatic fistula after pancreatic surgery using preoperative CT scan: A systematic review and meta-analysis

BACKGROUND

Body composition analysis has emerged as a practical tool for predicting outcomes following pancreatic surgery. However, the impact of body composition disorders on clinically relevant postoperative pancreatic fistula (CR-POPF) remains inconclusive. The aim of this study was to review and analyse whether radiographically assessed body composition is predictive of CR-POPF.

METHODS

PubMed, MEDLINE, Web of Science, and the Cochrane Library databases were searched up to January 2020 to identify relevant studies. CR-POPF was defined according to the definition and grading system proposed by the International Study Group on Pancreatic Surgery (ISGPS). Pooled odds ratios (OR) for CR-POPF were calculated to evaluate the predictive values of radiographically assessed body composition.

RESULTS

Fifteen studies published between 2008 and 2019 with a total of 3136 patients were included. There was a significant increase in the incidence of CR-POPF in patients with visceral obesity (OR 2.97, 95% CI 2.05-4.29, P < 0.00001) and sarcopenic obesity (OR 2.88, 95% CI 1.31-6.34, P = 0.009). Conversely, the impact of sarcopenia (OR 0.91, 95% CI 0.65-1.28, P = 0.59) and low muscle attenuation (MA) on CR-POPF did not reach statistical significance.

CONCLUSION

Preoperative visceral obesity and sarcopenic obesity are more effective at predicting CR-POPF than decreased muscle quantity and quality. This finding may lead to appropriate management and early intervention of patients at risk of CR-POPF.

Quantitative Imaging of Body Composition

Body composition refers to the amount and distribution of lean tissue, adipose tissue, and bone in the human body. Lean tissue primarily consists of skeletal muscle; adipose tissue comprises mostly abdominal visceral adipose tissue and abdominal and nonabdominal subcutaneous adipose tissue. Hepatocellular and myocellular lipids are also fat pools with important metabolic implications. Importantly, body composition reflects generalized processes such as increased adiposity in obesity and age-related loss of muscle mass known as sarcopenia.In recent years, body composition has been extensively studied quantitatively to predict overall health. Multiple imaging methods have allowed precise estimates of tissue types and provided insights showing the relationship of body composition to varied pathologic conditions. In this review article, we discuss different imaging methods used to quantify body composition and describe important anatomical locations where target tissues can be measured.

Prehabilitation prior to surgery for pancreatic cancer: A systematic review

INTRODUCTION

Prehabilitation aims to improve fitness and outcomes of patients undergoing major surgery. This systematic review aimed to appraise current available evidence regarding the role of prehabilitation in patients undergoing oncological pancreatic resection.

METHODS

A systematic literature search of PUBMED, MEDLINE, EMBASE databases identified articles describing prehabilitation programmes before pancreatic resection for malignancy. Data collected included timing of prehabilitation, programme type, duration, adherence and post-operative outcome reporting.

RESULTS

Six studies, including 193 patients were included in the final analysis. Three studies included patients undergoing neoadjuvant therapy followed by resection and 3 studies included patients undergoing upfront resection. Time from diagnosis to surgery ranged between 2 and 22 weeks across all studies. Two studies reported a professionally supervised exercise programme, and four described unsupervised programmes. Exercise programmes varied from 5 days to 6 months in duration. Adherence to exercise programmes was better with supervised programmes (99% reaching weekly activity goal vs 85%) and patients not undergoing neoadjuvant therapy (90% reaching weekly activity goal vs 82%). All studies reported improvement in muscle mass or markers of muscle function following prehabilitation. Two studies reported the impact of Prehabilitation on postoperative outcomes and Prehabilitation was associated with lower delayed gastric emptying and a shorter hospital stay with no impact on other postoperative outcomes.

CONCLUSION

Early evidence demonstrates that Prehabilitation programmes may improve postoperative outcomes following pancreatic surgery. However current Prehabilitaton programmes for patients undergoing pancreatic resection report diverse exercise regimens with no consensus regarding timing or length of Prehabilitation, warranting a need for standardisation of Prehabilitation programmes in pancreatic surgery.

Impact of neoadjuvant therapy on post-operative pancreatic fistula: a systematic review and meta-analysis

INTRODUCTION

The use of neoadjuvant therapy (NAT) for pancreatic cancer is increasing, although its impact on post-operative pancreatic fistula (POPF) is variably reported. This systematic review and meta-analysis aimed to assess the impact of NAT on POPF.

METHODS

A systematic literature search until October 2019 identified studies reporting POPF following NAT (radiotherapy, chemotherapy or chemoradiotherapy) versus upfront resection. The primary outcome was overall POPF. Secondary outcomes included grade B/C POPF, delayed gastric emptying (DGE), post-operative pancreatic haemorrhage (PPH) and overall and major complications.

RESULTS

The search identified 24 studies: pancreatoduodenectomy (PD), 19 studies (n = 19 416) and distal pancreatectomy (DP), five studies (n = 477). Local staging was reported in 17 studies, with borderline resectable and locally advanced disease comprising 6% (0-100%) and 1% (0-33%) of the population, respectively. For PD, any NAT was significantly associated with lower rates of overall POPF (OR: 0.57, P < 0.001) and grade B/C POPF (OR: 0.55, P < 0.001). In DP, NAT was not associated with significantly lower rates of overall or grade B/C POPF.

CONCLUSION

NAT is associated with significantly lower rates of POPF after PD but not after DP. Further studies are required to determine whether NAT should be added to POPF risk calculators.

Prognostic Impact of Preoperative Nutritional Risk in Patients Who Undergo Surgery for Pancreatic Adenocarcinoma

BACKGROUND

Nutritional derangements are common hallmarks of pancreatic cancer (PC). Their early detection and management are usually overlooked in routine practice. This study aimed to explore preoperative nutritional status and its prognostic value in patients undergoing surgery for PC.

METHODS

Data from 73 patients who underwent surgery for PC from November 2015 to January 2018 at the General and Pancreatic Surgery Unit, The Pancreas Institute, University Hospital of Verona Hospital, Verona, Italy, were retrospectively evaluated. The Nutritional Risk Screening (NRS)-2002 was used to evaluate the preoperative nutritional risk. Body composition was assessed using bioimpedance vectorial analysis (BIVA) on the day prior to surgery. The effect of clinical, pathological, and nutritional characteristics on overall survival (OS) was investigated using a Cox and logistic regression model. Kaplan-Meier curves were compared using the log-rank test.

RESULTS

Most patients (80.8%) were at preoperative risk of malnutrition (NRS-2002 ≥ 3) despite a mean BMI of 24.1 kg/m²(± 4.3). Twenty-four patients (32.9%) received neoadjuvant therapy prior to surgery. Preoperative NRS-2002 was significantly higher in this subset of patients (p = 0.026), with a significant difference by chemotherapy regimens (in favor of FOLFIRINOX, p = 0.035). In a multivariate analysis, the only independent prognostic factor for OS was the NRS-2002 score (HR 5.24, p = 0.013). Particularly, the likelihood of 2-year survival was higher in NRS < 3 (p = 0.009).

CONCLUSIONS

Our analysis confirms that preoperative malnutrition has a detrimental impact on OS in PC patients undergoing radical surgery for PC. Careful preoperative nutritional evaluation of PC patients should be mandatory, especially in those who are candidates for neoadjuvant therapy.

Computerised tomography skeletal muscle and adipose surface area values in a healthy Caucasian population

BACKGROUND

The analysis of computerised tomography (CT) images to provide body composition data has grown exponentially. Despite this, there remains limited published data defining the normal range of skeletal muscle area and adipose tissue area using CT. The aim of this study was to determine age- and sex-specific body composition values using CT at the level of the third lumbar vertebrae, in a Caucasian population with a healthy body mass index (BMI). In addition, we sought to develop threshold values for low skeletal muscle mass using these data.

METHODS

We included 107 healthy Caucasian patients (46 males; 61 females) with a healthy BMI (18-25 kg/m²) for analysis. Body composition data were obtained from a single transverse CT image at the mid-third lumbar vertebrae using ImageJ software. Tissue segmentation was performed using Hounsfield unit thresholds of -29 to +150 for muscle and -190 to -30 for adipose tissue.

RESULTS

The mean age of the study cohort was 47.8 ± 11.0 years (range 21-73) with a median BMI of 23.7 kg/m² (interquartile range 22.3-24.8). Patients were sub-divided into age above or below 50 years. Cut-offs for low muscle quantity, representing two standard deviations below the young healthy population mean values, were 43.5 cm²/m² for males and 30.0 cm²/m² for females.

CONCLUSIONS

Our data provide an insight into the distribution of skeletal muscle and adipose tissue surface area values measured on CT from a healthy Caucasian population. Our CT-derived cut-offs for low muscle quantity, based on international guidelines, are much lower than those previously suggested.

Preoperative adiposity at bioimpedance vector analysis improves the ability of Fistula Risk Score (FRS) in predicting pancreatic fistula after pancreatoduodenectomy

BACKGROUND

Anthropometric parameters have been associated with increased risk of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). Nonetheless, conventional metrics to predict POPF do not include the assessment of body composition. We aimed to validate the most used Fistula Risk Score (FRS), and to assess whether the appraisal of adipose compartment at bioimpedance vector analysis (BIVA) improves the accuracy of FRS in CR-POPF prediction.

METHOD

PD patients from 3 Italian academic institutions were prospectively included over a 2-year period. Patients with ASA score ≥3, heart failure, chronic kidney disease, or compartmentalized fluid collections were excluded. BIVA was performed on the day prior to surgery. CR-POPF occurrence and severity were classified per the ISGPS classification.

RESULTS

Out of 148 PDs, 84 patients (56.8%) had pancreatic cancer, and 29 (19.6%) experienced CR-POPF. FRS elements, namely soft pancreatic texture (p = 0.009), small pancreatic duct diameter (p = 0.029), but not blood loss (p = 0.450), as well as high BMI (p = 0.004) were associated with CR-POPF. Also, the preoperative fat mass (FM) amount measured at BIVA was significantly higher in patients who developed CR-POPF, compared to those who did not (median FM = 19.4 kg/m2 vs. 14.4 kg/m2, respectively; p = 0.005). The predictive ability of a multivariate model adding FM to the FRS, assessed at the receiver operating characteristics curve showed a higher accuracy than the FRS alone (AUC = 0.774 and AUC = 0.738, respectively).

CONCLUSIONS

Assessment of preoperative FM at BIVA can improve the accuracy of FRS in predicting CR-POPF following pancreatoduodenectomy.

Critical appraisal of gastric conduit ischaemic conditioning (GIC) prior to oesophagectomy: A systematic review and meta-analysis

INTRODUCTION

Anastomotic leaks remain a major complication following oesophagectomy, accounting for high morbidity and mortality. Recently, gastric ischaemic conditioning (GIC) has been proposed to improve anastomotic integrity through neovascularisation of the gastric conduit. This systematic review and meta-analysis aim to determine the impact of GIC on postoperative outcomes following oesophagectomy.

METHODS

A systematic literature search was performed to identify studies reporting GIC for any indication of oesophageal resection up to April 25, 2019. The primary outcome was anastomotic leak. Secondary outcomes were conduit necrosis, anastomotic strictures, overall and major complications or in-hospital mortality. Meta-analyses were conducted using random-effects modelling.

RESULTS

Nineteen studies reported on GIC, of which 13 were comparative studies. GIC was performed through ligation in 13 studies and embolisation in six studies. GIC did not appear to reduce anastomotic leakages (OR 0.80, CI_95: 0.51-1.24, p = 0.3), anastomotic strictures (OR 0.75, CI_95: 0.35-1.60, p = 0.5), overall complications (OR 1.02, CI_95: 0.48-2.16, p = 0.9), major complications (OR 1.06, CI_95: 0.53-2.11, p = 0.9), or in-hospital mortality (OR 0.70, CI_95: 0.32-1.53, p = 0.4). However, GIC was associated with reduced rates of conduit necrosis (OR 0.30, CI_95: 0.11-0.77, p = 0.013).

CONCLUSION

GIC does not appear to reduce overall rates of anastomotic leakage after oesophagectomy but seems to reduce severity of leakages. More in depth studies are recommended.

Is water-soluble contrast enema examination for integrity of rectal anastomosis necessary prior to ileostomy reversal?

Background and Aim

Routine use of water-soluble contrast enema (WSCE) to assess anastomotic integrity is debated. This study aimed to evaluate the role of WSCE to assess anastomotic integrity following anterior resections (AR) with defunctioning stoma prior to reversal and identify factors to limit its selective use.

Methods

This retrospective study evaluated all WSCE performed over a 7-year period at a high-volume colorectal unit. Risk factors for radiological abnormality/leak, including malignancy, chemoradiotherapy, and immediate postoperative complications, were recorded. A gastrointestinal specialist radiologist and surgeon validated all WSCEs reported as abnormal.

Results

Of the 486 WSCE studies identified, 92 were excluded (repeat studies (n = 51), pediatric cases [n = 2], no AR [n = 39]). A total of 394 WSCE studies were evaluated (260 cancer; 134 noncancer patients); 14% (37/260) of cancer patients and 8% (10/134) of noncancer patients had abnormal studies (P = 0.072). Of the 37 abnormal studies in cancer patients, 73% (27/37) radiological leaks were found, and 41% (n = 11/27) of these patients had postoperative complications. Of the 10 abnormal studies in noncancer patients, 20% (2/10) radiological leaks were found, but none of these patients had postoperative complications. Overall leak rates were 7% (29/394), and rates were significantly higher in cancer patients than noncancer patients (10 vs 2%, P = 0.005).

Conclusion

Routine use of WSCE may not be necessary prior to reversal. WSCE should be selectively used in event of postoperative leak or complications. Noncancer resections are less likely demonstrate a leak.