A systematic review of systematic reviews and panoramic meta-analysis: staples versus sutures for surgical procedures

Hyperthermic intraoperative peritoneal chemotherapy and cytoreductive surgery for people with peritoneal metastases: a systematic review and cost-effectiveness analysis

Background

We compared the relative benefits, harms and cost-effectiveness of hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery ± systemic chemotherapy versus cytoreductive surgery ± systemic chemotherapy or systemic chemotherapy alone in people with peritoneal metastases from colorectal, gastric or ovarian cancers by a systematic review, meta-analysis and model-based cost-utility analysis.

Methods

We searched MEDLINE, EMBASE, Cochrane Library and the Science Citation Index, ClinicalTrials.gov and WHO ICTRP trial registers until 14 April 2022. We included only randomised controlled trials addressing the research objectives. We used the Cochrane risk of bias tool version 2 to assess the risk of bias in randomised controlled trials. We used the random-effects model for data synthesis when applicable. For the cost-effectiveness analysis, we performed a model-based cost-utility analysis using methods recommended by The National Institute for Health and Care Excellence.

Results

The systematic review included a total of eight randomised controlled trials (seven randomised controlled trials, 955 participants included in the quantitative analysis). All comparisons other than those for stage III or greater epithelial ovarian cancer contained only one trial, indicating the paucity of randomised controlled trials that provided data. For colorectal cancer, hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy probably results in little to no difference in all-cause mortality (60.6% vs. 60.6%; hazard ratio 1.00, 95% confidence interval 0.63 to 1.58) and may increase the serious adverse event proportions compared to cytoreductive surgery ± systemic chemotherapy (25.6% vs. 15.2%; risk ratio 1.69, 95% confidence interval 1.03 to 2.77). Hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy probably decreases all-cause mortality compared to fluorouracil-based systemic chemotherapy alone (40.8% vs. 60.8%; hazard ratio 0.55, 95% confidence interval 0.32 to 0.95). For gastric cancer, there is high uncertainty about the effects of hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy versus cytoreductive surgery + systemic chemotherapy or systemic chemotherapy alone on all-cause mortality. For stage III or greater epithelial ovarian cancer undergoing interval cytoreductive surgery, hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy probably decreases all-cause mortality compared to cytoreductive surgery + systemic chemotherapy (46.3% vs. 57.4%; hazard ratio 0.73, 95% confidence interval 0.57 to 0.93). Hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy may not be cost-effective versus cytoreductive surgery + systemic chemotherapy for colorectal cancer but may be cost-effective for the remaining comparisons.

Limitations

We were unable to obtain individual participant data as planned. The limited number of randomised controlled trials for each comparison and the paucity of data on health-related quality of life mean that the recommendations may change as new evidence (from trials with a low risk of bias) emerges.

Conclusions

In people with peritoneal metastases from colorectal cancer with limited peritoneal metastases and who are likely to withstand major surgery, hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy should not be used in routine clinical practice (strong recommendation). There is considerable uncertainty as to whether hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy or cytoreductive surgery + systemic chemotherapy should be offered to patients with gastric cancer and peritoneal metastases (no recommendation). Hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy should be offered routinely to women with stage III or greater epithelial ovarian cancer and metastases confined to the abdomen requiring and likely to withstand interval cytoreductive surgery after chemotherapy (strong recommendation).

Future work

More randomised controlled trials are necessary.

Study registration

This study is registered as PROSPERO CRD42019130504.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/135/02) and is published in full in Health Technology Assessment; Vol. 28, No. 51. See the NIHR Funding and Awards website for further award information.

Complications and influence of cutaneous closure technique on subdermal plexus flaps in 97 dogs (2006-2022)

OBJECTIVE

To determine the incidence and severity of complications for subdermal plexus flaps in dogs and compare the complications when using sutures or staples for cutaneous closure of subdermal plexus flaps.

STUDY DESIGN

Retrospective monocentric study.

SAMPLE POPULATION

Ninety-seven client-owned dogs.

METHODS

Dogs that underwent wound reconstruction using subdermal plexus flaps were retrospectively identified. Type of flap, cutaneous closure technique, complications and level of complication associated with their use were recorded. Follow-up was considered adequate if it was more than 10 days postoperatively or until a complication occurred.

RESULTS

Complications were seen in 52 dogs (53.6%), of which 13/18 (72.2%) of dogs had cutaneous closure with skin staples versus 39/79 (49.3%) with skin sutures. The location of the mass/wound on the head and use of an advancement flap was associated with lower incidence of complications (p < .001; p = .018 respectively). Location of the mass/wound on the proximal pelvic limb was associated with a low level of complications (p = .01) on univariable analysis only. On multivariable analysis, only an increased bodyweight was associated with an increased incidence of complications (p = .029).

CONCLUSIONS

Increased weight may be associated with an increased risk of complications with subdermal plexus flaps. No risk factor was found to be associated with the severity of complications.

CLINICAL SIGNIFICANCE

Overall incidence of complications for subdermal plexus flaps in dogs in this study was 53.6%. The number of dogs included in the study was not sufficient to assess if the skin closure technique affects the incidence of complications.

Risk factors for wound healing complications after revascularization for MMD with complete Y-shaped incision

Moyamoya disease (MMD) is a chronic occlusive cerebrovascular disease that can be treated with revascularization. Surgery increases the risk of poor wound healing (PWH) due to the impact on the blood supply to the flap. We aimed to analyze risk factors for PWH in MMD with a complete Y-shaped incision. A total of 125 patients with MMD were enrolled in this prospective observational study. The wounds were assessed and measured on the third and seventh days after surgery. The mean age of these patients was 43.3 ± 10.0 years. The ratio of male to female was 1:1.3. 15 (12.0%) patients had incision complications. 5 patients (4.0%) had redness; 2 patients (1.6%) had swelling; 2 patients (1.6%) had fat necrosis; 3 patients (2.4%) had incision infection; and 3 patients (2.4%) had flap necrosis. Student's t test showed significant differences in BMI (P = 0.040) and fever time (P = 0.050). The standard chi-squared test showed significant differences in incision infection (P = 0.010), suture mode (P = 0.047), and cutting off large branch vessels in the flap (P < 0.001). Multivariate logistic regression analysis suggested that incision infection (P = 0.026, OR 12.958), using a skin stapler (P = 0.030, OR 4.335), cutting off large branch vessels in the flap (P = 0.009, OR 5.227), and BMI (P = 0.027, OR 1.204) were risk factors. The area under the curve for risk factors for PWH on a receiver operating characteristic curve was 0.853. Incision infection, using a skin stapler, higher BMI, and cutting off large branch vessels in the flap are risk factors for PWH.

Comparing intracorporeal mechanical anastomosis vs. hand-sewn esophagojejunostomy after total laparoscopic gastrectomy for esophagogastric junction cancer: a single-center study

OBJECTIVE

This study aimed to compare the effects of continuous hand-sewn esophagojejunostomy with barbed suture and mechanical anastomosis in total laparoscopic gastrectomy for esophagogastric junction cancer.

MATERIALS AND METHODS

The clinical data of 60 patients who underwent total laparoscopic total gastrectomy from January 2020 to October 2021 were collected retrospectively. Baseline data and short-term surgical results of patients in the hand-sewn anastomosis (n = 30) and mechanical anastomosis (n = 30) groups were analyzed.

RESULTS

No significant differences were detected in the baseline data between groups. Meanwhile, the hand-sewn group had a shorter anastomosis time (21.2 ± 4.9 min vs. 27.9 ± 6.9 min, p < 0.001) and a decreased operation cost (CNY 70608.3 ± 8106.7 vs. CNY 76485.6 ± 3149.9, p = 0.001). The tumor margin distance in the hand-sewn group was longer than in the mechanical group (2.7 ± 0.4 cm vs. 2.2 ± 0.75 cm, p = 0.002). In esophagojejunostomy anastomosis, the distance between the jejunal opening and jejunal stump in the hand-sewn group was significantly shorter than that in the mechanical group (2.2 ± 0.54 cm vs. 5.7 ± 0.6 cm, p < 0.001). No significant difference was detected in the incidence of postoperative anastomotic complications.

CONCLUSION

The continuous hand-sewn anastomosis with barbed suture in total laparoscopic gastrectomy for esophagogastric junction cancer is practical, safe, and cost-effective. It is also an effective supplementary technique for mechanical anastomosis.

Controlling the controls: what is negative pressure wound therapy compared to in clinical trials?

AIM

Surgical site infections (SSIs) are common following colorectal operations. Clinical trials suggest that closed incision negative pressure wound therapy (ciNPWT) may reduce SSIs compared to a 'standard of care' group. However, wound management in the standard of care group may vary. The aim of this review was to assess the control arms in trials of ciNPWT for potential confounding variables that could influence the rates of SSI and therefore the trial outcomes.

METHODS

A mapping review of the PubMed database was undertaken in the English language for randomized controlled trials that assessed, in closed surgical wounds, the use of ciNPWT compared to standard of care with SSI as an outcome. Data regarding wound care to assess potential confounding factors that may influence SSI rates were compared between the ciNPWT and standard of care groups. Included were the method of wound closure, control dressing type, frequency of dressing changes and postoperative wound care (washing).

RESULTS

Twenty-seven trials were included in the mapping review. There was heterogeneity in ciNPWT duration. There was little control in the comparator standard of care groups with a variety of wound closure techniques and different control dressings used. Overall standard of care dressings were changed more frequently than the ciNPWT dressing and there was no control over wound care or washing. No standard for 'standard of care' was apparent.

CONCLUSION

In randomized trials assessing the intervention of ciNPWT compared to standard of care there was considerable heterogeneity in the comparator groups and no standard of care was apparent. Heterogeneity in dressing protocols for standard of care groups could introduce potential confounders impacting SSI rates. There is a need to standardize care in ciNPWT trials to assess potential meaningful differences in SSI prevention.

A reinforced suture method for stapled gastrointestinal anastomosis to reduce gastrointestinal hemorrhage during Whipple operation in laparoscopy

Purpose

Laparoscopy is being increasingly accepted for pancreaticoduodenectomy. Stapled anastomosis (SA) is used extensively to facilitate laparoscopic pancreaticoduodenectomy (LPD); however, the incidence of anastomotic bleeding after stapled gastrointestinal anastomosis is still high.

Methods

One hundred and thirty-nine patients who underwent LPD using Whipple method were enrolled in our study. We performed the SA with our reinforced method (n = 68, R method) and without the method (n = 71, NR method). We compared the clinical characteristics and anastomosis methods of patients with or without gastrointestinal-anastomotic hemorrhage (GAH), and operative parameters were also compared between the anastomotic methods.

Results

Of the 139 patients undergoing LPD, 15 of them developed GAH. The clinical characteristics of patients with or without GAH were not significantly different except in the anastomotic method (P < 0.001). In the univariate logistic regression analyses, only the anastomotic method was associated with GAH. Furthermore, patients with the NR method had significantly higher incidences of GAH (P < 0.001) and Clavien-Dindo grade ≥ III complications (P < 0.001).

Conclusion

Our retrospective analysis showed that the SA performed with reinforced method might be a reform of SA without the reinforcement, as indicated by the lower incidence of GAH. However, further research is necessary to evaluate the utility of this reinforced method.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

The evidence for cognitive behavioural therapy in any condition, population or context: a meta-review of systematic reviews and panoramic meta-analysis

The majority of psychological treatment research is dedicated to investigating the effectiveness of cognitive behavioural therapy (CBT) across different conditions, population and contexts. We aimed to summarise the current systematic review evidence and evaluate the consistency of CBT's effect across different conditions. We included reviews of CBT randomised controlled trials in any: population, condition, format, context, with any type of comparator and published in English. We searched DARE, Cochrane, MEDLINE, EMBASE, PsycINFO, CINAHL, CDAS, and OpenGrey between 1992 and January 2019. Reviews were quality assessed, their data extracted and summarised. The effects upon health-related quality of life (HRQoL) were pooled, within-condition groups. If the across-condition heterogeneity was I2 < 75%, we pooled effects using a random-effect panoramic meta-analysis. We summarised 494 reviews (221 128 participants), representing 14/20 physical and 13/20 mental conditions (World Health Organisation's International Classification of Diseases). Most reviews were lower-quality (351/494), investigated face-to-face CBT (397/494), and in adults (378/494). Few reviews included trials conducted in Asia, South America or Africa (45/494). CBT produced a modest benefit across-conditions on HRQoL (standardised mean difference 0.23; 95% confidence intervals 0.14-0.33, I2 = 32%). The effect's associated prediction interval -0.05 to 0.50 suggested CBT will remain effective in conditions for which we do not currently have available evidence. While there remain some gaps in the completeness of the evidence base, we need to recognise the consistent evidence for the general benefit which CBT offers.

Bowel anastomosis leakage following endometriosis surgery: an evidence based analysis of risk factors and prevention techniques

BACKGROUND

Deep endometriosis most commonly involves the rectosigmoid junction and its management often requires a colorectal resection. Anastomotic leakage is a severe complication after resection and affects 1-6% of the cases.

OBJECTIVE

To evaluate the risk factors related to anastomotic leakage following endometriosis sur-gery, its prevention techniques and the role of protective stomas.

METHODS

A comprehensive literature review was carried out for English-language publications in Pubmed and Google Scholar. We included all studies including the following MeSH terms and key words: Anastomotic leakage AND bowel surgery OR Endometriosis OR Colorectal surgery OR Bowel endometriosis. Two authors independently made a selection and analysed relevant abstracts according to the aim of this review.

RESULTS

Risk factors and preventive measures were categorised considering the patient condition, the intra- operative setting and the surgical procedure itself. Level I and II recommendations include modifiable risk factors such as the use of stapled or handsewn anastomosis; intra-operative air leak test to check the integrity of the anastomosis; systematic use of pelvic and trans-anal drainage; application of protective or ghost ileostomy in low rectal resections; vaginal closure before the bowel resection; use of oral antibiotics the day before surgery and performing partial mesorectal resection near the bowel wall. Diverting stomas may decrease the morbidity and the clinical consequences of leakage over 65% of low rectal resections but may cause significant adverse effects.

CONCLUSION

Evidence-based protective actions are crucial to reduce clinical consequences of anastomotic leakage and to minimise the use of protective stomas in endometriosis surgery.

BEVA primary care clinical guidelines: Wound management in the horse

BACKGROUND

There are currently no evidence summaries on wounds in the horse.

OBJECTIVES

To develop evidence-based guidelines on wound management in the horse.

STUDY DESIGN

Evidence review using the GRADE framework.

METHODS

Research questions were proposed by a panel of veterinarians, and developed into PICO format. Evidence in the veterinary literature was evaluated using the GRADE evidence-to-decision framework. Searches for human evidence summaries were conducted in the NICE, Cochrane and JBI databases. Final recommendations were based on both veterinary and human evidence.

RESULTS AND RECOMMENDATIONS

The research questions were categorised into three areas: A. Wound lavage and topical treatments; B. Wound debridement and closure; C. Therapeutics for wound healing. Three hundred and six veterinary publications were identified across thirteen different topics. Fourteen papers were assessed using the GRADE criteria. Twenty-five human evidence summaries were reviewed. The results were developed into recommendations: Wound lavage and topical treatments: (i) Tap water should be considered instead of saline for lavage; (ii) Povidone iodine lavage should be considered for contaminated wounds; (iii) Topical silver sulfadiazine may not be suitable for acute wounds; (iv) Optimal lavage pressures are around 13 psi. Wound debridement and closure: (i) Debridement pads should be considered for wound preparation; (ii) Larvae debridement should be considered in selected cases; (iii) Hydrosurgery should be considered in acute contaminated wounds. Therapeutics for wound healing: (i) Honey may reduce duration of some phases of wound healing. There was insufficient evidence to draw conclusions on the use of chemical debridement, therapeutic ultrasound, laser therapy, wound closure with staples compared to sutures, or identify optimal concentrations of antiseptic lavage solutions.

MAIN LIMITATIONS

Low quality evidence in veterinary literature; majority of recommendations were based on human evidence.

CONCLUSIONS

These findings should be used to inform decision-making in equine primary care practice.

Surgical wound closure by staples or sutures?: Systematic review

AIM

To compare the effects of sutures and staples for skin closure of surgical wounds.

MATERIAL AND METHODS

We included published and unpublished randomized controlled trials (RCTs) and cluster-randomized trials comparing staples with sutures. Patients were adults (aged 18 years or over) who had undergone any type of surgery. The primary outcomes were risk of overall and severe wound infection. Secondary outcomes included length of hospital stay, readmission rate, adverse events, patient satisfaction with cosmetic results, postoperative pain.

RESULTS

Forty-two very low to low quality RCTs with a total of 11,067 patients were included. Sutures resulted in slightly fewer overall wound infections (4.90%) compared to staples (6.75%) but it is uncertain whether there is a difference between the groups (risk ratio [RR] 1.20, 95% confidence intervals [CI] 0.80-1.79; patients = 9864; studies = 34; I = 70%). The evidence was also insufficient to state a difference in terms of severe wound infection (staples 1.4% vs sutures 1.3%; RR 1.08, 95% CI 0.61-1.89; patients = 3036; studies = 17; I = 0%), grade of satisfaction (RR 0.99, 95% CI 0.91-1.07; patients = 3243; studies = 14; I = 67%) and hospital stay. Staples may increase the risk of adverse events (7.3% for staples vs 3.5% for sutures; RR 2.00, 95% CI 1.44-2.79; patients = 6246; studies = 21; I = 33%), readmission rate (RR 1.28, 95% CI 0.18-9.05; patients = 2466; studies = 5; I = 66%) and postoperative pain (standardized mean difference [SMD] 0.41,95%CI -0.35 to 1.16; I = 88%, patients = 390 patients, studies = 5).

CONCLUSIONS

Due to the lack of high quality evidence, we could not state if sutures are better than staples in terms of wound infection, readmission rate, adverse events, and postoperative pain. With a low quality of evidence, sutures reduce postoperative pain and improve grade of satisfaction with the cosmetic outcome.

Cannabis use and psychosis: a review of reviews

We conducted a systematic review of meta-analyses and systematic reviews to evaluate the impact of cannabis use on the onset and course of psychoses. Following a systematic literature search of five data bases (2005-2016) and consecutive structured evaluation, we were able to include 26 systematic reviews and meta-analyses. The methodological quality of the included publications were in the range of high and poor. The scientific literature indicates that psychotic illness arises more frequently in cannabis users compared to non-users, cannabis use is associated with a dose-dependent risk of developing psychotic illness, and cannabis users have an earlier onset of psychotic illness compared to non-users. Cannabis use was also associated with increased relapse rates, more hospitalizations and pronounced positive symptoms in psychotic patients. We make recommendations about the type of research that is required to better characterize the relationship between cannabis use and the development and outcomes of psychosis.

Nylon Skin Sutures Carry a Lower Risk of Post-Operative Infection than Metal Staples in Open Posterior Spine Surgery: A Retrospective Case-Control Study of 270 Patients

Background: Controversy still exists regarding the optimal method for post-operative skin closure in orthopedic surgery. In total knee replacement, closure with metal staples is faster but carries a higher surgical site infection (SSI) risk. Other studies have found differing results in foot and ankle and hip surgery. Very little evidence exists on this subject after spine surgery. The aim of this study was to determine whether closure of the skin incision in open posterior spine surgery carries a different rate of post-operative SSI when using nylon sutures compared with metal staples. Methods: Up to 2006, virtually all skin incisions at our spine surgery unit were closed with metal staples and from 2006 onward with nylon sutures. This was a retrospective historical control study comparing the incidence of SSIs in patients operated on before (n = 127; staples) and after (n = 143; sutures) the transition date. Results: The staples group had an overall 11.8% combined deep and superficial infection rate whereas the nylon suture group had a 4.2% rate (p = 0.017). The two groups also differed in the type of antibiotic prophylaxis used, likelihood of incisional discharge, and the number of days the vacuum drains remained. Conclusions: In our departmental setting, closure of the skin incision with nylon sutures after open posterior spine surgery carried a significantly lower risk of post-operative SSI compared with metal staples. The generalizability of our findings is unclear, but they warrant further investigation.

Impact of surgical site infection (SSI) following gynaecological cancer surgery in the UK: a trainee-led multicentre audit and service evaluation

OBJECTIVES

Surgical site infection (SSI) complicates 5% of all surgical procedures in the UK and is a major cause of postoperative morbidity and a substantial drain on healthcare resources. Little is known about the incidence of SSI and its consequences in women undergoing surgery for gynaecological cancer. Our aim was to perform the first national audit of SSI following gynaecological cancer surgery through the establishment of a UK-wide trainee-led research network.

DESIGN AND SETTING

In a prospective audit, we collected data from all women undergoing laparotomy for suspected gynaecological cancer at 12 specialist oncology centres in the UK during an 8-week period in 2015. Clinicopathological data were collected, and wound complications and their sequelae were recorded during the 30 days following surgery.

RESULTS

In total, 339 women underwent laparotomy for suspected gynaecological cancer during the study period. A clinical diagnosis of SSI was made in 54 (16%) women. 33% (18/54) of women with SSI had prolonged hospital stays, and 11/37 (29%) had their adjuvant treatment delayed or cancelled. Multivariate analysis found body mass index (BMI) was the strongest risk factor for SSI (OR 1.08[95% CI 1.03 to 1.14] per 1 kg/m2 increase in BMI [p=0.001]). Wound drains (OR 2.92[95% CI 1.41 to 6.04], p=0.004) and staple closure (OR 3.13[95% CI 1.50 to 6.56], p=0.002) were also associated with increased risk of SSI.

CONCLUSIONS

SSI is common in women undergoing surgery for gynaecological cancer leading to delays in discharge and adjuvant treatment. Resultant delays in adjuvant treatment may impact cancer-specific survival rates. Modifiable factors, such as choice of wound closure material, offer opportunities for reducing SSI and reducing morbidity in these women. There is a clear need for new trials in SSI prevention in this patient group; our trainee-led initiative provides a platform for their successful completion.

The effect of postoperative closed incision negative pressure therapy on the incidence of donor site wound dehiscence in breast reconstruction patients: DEhiscence PREvention Study (DEPRES), pilot randomized controlled trial

AIM

Wound dehiscence is a serious postoperative complication associated both with high morbidity and mortality. It has a significant rate of occurrence in breast reconstruction surgeries with a deep internal epigastric perforator (DIEP) and with a profunda artery perforator (PAP) flap. Risk factors for wound dehiscence include smoking, diabetes mellitus, chronic obstructive pulmonary disease, and obesity. The aim of this pilot study was to assess whether postoperative treatment with closed incision negative pressure therapy (ciNPT) decreases the incidence of donor site wound dehiscence in breast reconstruction patients.

METHOD

Women undergoing a breast reconstruction with a DIEP or PAP flap were enrolled in a pilot randomized controlled trial and assigned treatment with either ciNPT or adhesive strips. The primary outcome was wound dehiscence upon follow-up after four weeks. Secondary outcomes that were evaluated included wound infection, pain, and allergy. There was no loss to follow-up.

RESULTS

This pilot study included 51 women (n = 25 ciNPT, n = 26 adhesive strips). The two groups did not differ significantly in patients demographics or comorbidities. Wound dehiscence occurred in 11 patients (n = 2 ciNPT, n = 9 adhesive strips). This difference was statistically significant: p = 0.038. There were no statistically significant differences in secondary outcomes between the two groups.

CONCLUSION

In this pilot study, postoperative treatment with ciNPT decreased the incidence of donor site wound dehiscence in breast reconstruction patients. Further research is ongoing by the same hospital. This trial was registered in the Netherlands Trial Register (NTR) under ID no. NTR5808.

Roux-en-Y Gastric Bypass: Does the Direction of Staples Matter?

PURPOSE

Mechanical gastro-intestinal anastomosis using stapler is a critical step in laparoscopic Roux-en-Y gastric bypass (RYGB). To date the effect of the direction of staples on anastomotic leak has not been investigated. The study aim was to investigate the impact of the direction of staples on the integrity of the gastro-jejunal anastomosis.

MATERIALS AND METHODS

Eight gastro-jejunostomy (GJ) models were performed using porcine stomach and small intestine. Specimens were divided into group A where the cartridge was in the gastric lumen with the anvil in the jejunal lumen and vice versa in group B. Enterotomy was closed and gastric and jejunal ends were stapled off. Burst pressure (BP) was measured by infusion of methylene blue saline into the GJ model until leak occurred. Site of leak, BP, and total volume (TV) infused were recorded. Compliance (C) was calculated from the equation ΔTV/ΔBP.

RESULTS

The BP was greater in group A compared to group B (18 mmHg (range 15-25) versus 11 mmHg (range 8-15); p = 0.045) despite similar TV between the groups 60.00 mL (range 55.00-65.00) versus 51.25 mL (range 40.00-60.00); p = 0.11). The compliance did not significantly differ between groups A and B (6.38 mL/mmHg (range 4.34-8.59) versus 5.61 mL/mmHg (range 3.93-7.21); p = 0.48).

CONCLUSION

BP recorded when the stapler cartridge was introduced in the gastric lumen was higher than when it was introduced from the jejunal lumen. The lack of difference in compliance between groups suggests that the difference in BP was due to the difference in the direction of staples.

Lurasidone in the Treatment of Bipolar Depression: Systematic Review of Systematic Reviews

INTRODUCTION

A burgeoning number of systematic reviews considering lurasidone in the treatment of bipolar depression have occurred since its Food and Drug Administration extended approval in 2013. While a paucity of available quantitative evidence still precludes preliminary meta-analysis on the matter, the present quality assessment of systematic review of systematic reviews, nonetheless, aims at highlighting current essential information on the topic.

METHODS

Both published and unpublished systematic reviews about lurasidone mono- or adjunctive therapy in the treatment of bipolar depression were searched by two independent authors inquiring PubMed/Cochrane/Embase/Scopus from inception until October 2016.

RESULTS

Twelve included systematic reviews were of moderate-to-high quality and consistent in covering the handful of RCTs available to date, suggesting the promising efficacy, safety, and tolerability profile of lurasidone. Concordance on the drug profile seems to be corroborated by a steadily increasing number of convergent qualitative reports on the matter.

LIMITATIONS

Publication, sponsorship, language, citation, and measurement biases.

CONCLUSIONS

Despite being preliminary in nature, this overview stipulates the effectiveness of lurasidone in the acute treatment of Type I bipolar depression overall. As outlined by most of the reviewed evidence, recommendations for future research should include further controlled trials of extended duration.

An Effective New Intestinal Anastomosis Method

Background

This study aimed to establish an easy, safe, and cost-saving intestinal anastomotic method.

Material/Methods

Between January 2014 and February 2016, a total of 150 patients with gastric cancer who underwent surgery in the Department of General Surgery of Xuzhou Medical University Affiliated Hospital were divided into 2 groups: the treatment group (80) using new hand-sewn anastomoses, and the control group (70) using stapled anastomoses. Briefly, a new hand-sewn anastomosis of continuous suture without inversion was performed, with the first layer encompassing the entire layer of the intestinal wall. The edge was about 5 mm, and the stitch spacing was about 6 mm. Continuous suturing was performed only in the seromuscular layer of intestinal wall for the second layer, with the same edge and stitch spacing as the first layer. All 70 patients in the control group underwent intestinal stapled anastomoses. Surgical anastomotic time and cost, postoperative anastomotic bleeding, leakage, and stricture were recorded and analyzed.

Results

The surgical anastomotic time using the new method was relatively short compared with the control group (8±1.6 min vs. 9±2.8 min), and the cost of anastomosis using the new method was significantly lower compared to the control group ($30±6.8 vs. $1000±106.2). The new method exhibited lower anastomotic bleeding (0/80 vs. 2/70) and anastomotic leakage (0/80 vs. 1/70), but similar anastomotic stricture (0/80 vs. 0/70).

Conclusions

Our results suggest the new hand-sewn intestinal anastomosis is a safe, easy-to-learn, cost-saving, and time-saving method that also avoids some of the drawbacks of the stapled anastomoses.

Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together

BACKGROUND

Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation.

METHODS

Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies).

RESULTS

The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL.

CONCLUSION

Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.

Refinement of Tissue-Engineering Chamber Implantation in the Rat

PURPOSE

Rodent in vivo models that successfully generate new adipose, muscle, or vascular tissue in a tissue-engineering chamber (TEC) has advanced in the last decade. In this article, technical refinements in these operative foreign body implantations have been described to improve the execution of animal models in a way so that they can reduce wastage of time and resources.

MATERIALS & METHODS

Male Sprague-Dawley rats were studied and randomly divided into two equal sized groups. In each group, a different operative procedure was used for implanting the TEC. Twenty animals were operated with diagonal incisions in the groin region, followed by staples for wound closure after TEC implantation. The remaining 20 animals received longitudinal incisions in the abdominal region followed by wound closure with ongoing intradermal nonresorbable sutures and skin glue. The outcome of both procedures with regard to complications, animal growth, and experimental failure was compared. Statistical analysis was performed using the nonparametric chi-squared (χ²) test.

RESULTS

Significant difference in wound dehiscence was recorded in Group I as compared to Group II (p = 0.0001). Consequently, 55% of the experiments had to be aborted in Group I and the animals were removed from the experiment. On the contrary, in Group II, all the animals could be kept.

CONCLUSION

Median longitudinal incisions and thorough wound closure with ongoing intradermal nonresorbable sutures, followed by application of skin glue, are strongly recommended to prevent surgical site complications, such as wound dehiscence, animal harm, and failure of the individual experiment.

Stapled versus handsewn intestinal anastomosis in emergency laparotomy: a systemic review and meta-analysis

BACKGROUND

The optimal technique for gastrointestinal anastomosis remains controversial in emergency laparotomy. The aim of this meta-analysis was to compare outcomes of stapled versus handsewn anastomosis after emergency bowel resection.

METHODS

A systematic review was performed for studies comparing outcomes after emergency laparotomy using stapled versus handsewn anastomosis until July 2014 (PROSPERO registry number: CRD42013006183). The primary endpoint was anastomotic failure, a composite measure of leak, abscess and fistula. Odds ratio (OR; with 95% CI) and weighted mean differences were calculated using meta-analytical techniques. Subgroup analysis was conducted for trauma surgery (TS) and emergency general surgery (EGS) cohorts. Risk of bias for each study was calculated using the Newcastle-Ottawa scale for cohort studies, and Cochrane Collaboration's tool for randomized trials.

RESULTS

The final analysis included 7 studies of 1,120 patients, with a total of 1,205 anastomoses. There were 5 TS studies and 2 EGS studies. There were no differences in anastomotic failure between handsewn and stapled techniques on an individual anastomosis level (OR, 1.53; 95% CI, 0.97-2.43; P = .070), or on an individual patient level (OR, 1.44; 95% CI, 0.92-2.25; P = .110). There were no differences in the individual rates of anastomotic leak, abscess, fistulae, or postoperative deaths between techniques. Subgroup analysis of EGS and TS studies demonstrated no superior operative technique.

CONCLUSION

Available evidence is sparse and at high risk of bias, and neither stapling nor handsewing is justifiably favored in emergency laparotomy. Surgeons might therefore select the technique of their own choice with caution owing to unresolved uncertainty.

Scientific hypotheses can be tested by comparing the effects of one treatment over many diseases in a systematic review

OBJECTIVES

To describe the use of systematic reviews or overviews (systematic reviews of systematic reviews) to synthesize quantitative evidence of intervention effects across multiple indications (multiple-indication reviews) and to highlight issues pertaining to such reviews.

STUDY DESIGN AND SETTING

MEDLINE was searched from 2003 to January 2014. We selected multiple-indication reviews of interventions of allopathic medicine that included evidence from randomized controlled trials. We categorized the subject areas evaluated by these reviews and examined their methodology. Utilities and caveats of multiple-indication reviews are illustrated with examples drawn from published literature.

RESULTS

We retrieved 52 multiple-indication reviews covering a wide range of interventions. The method has been used to detect unintended effects, improve precision by pooling results across indications, and examine scientific hypotheses across disease classes.

CONCLUSION

Systematic reviews of interventions are typically used to evaluate the effects of treatments, one indication at a time. Here, we argue that, with due attention to methodological caveats, much can be learned by comparing the effects of a given treatment across many related indications.

Integrated care programmes for adults with chronic conditions: a meta-review

OBJECTIVE

To review systematic reviews and meta-analyses of integrated care programmes in chronically ill patients, with a focus on methodological quality, elements of integration assessed and effects reported.

DESIGN

Meta-review of systematic reviews and meta-analyses identified in Medline (1946-March 2012), Embase (1980-March 2012), CINHAL (1981-March 2012) and the Cochrane Library of Systematic Reviews (issue 1, 2012).

MAIN OUTCOME MEASURES

Methodological quality assessed by the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) checklist; elements of integration assessed using a published list of 10 key principles of integration; effects on patient-centred outcomes, process quality, use of healthcare and costs.

RESULTS

Twenty-seven systematic reviews were identified; conditions included chronic heart failure (CHF; 12 reviews), diabetes mellitus (DM; seven reviews), chronic obstructive pulmonary disease (COPD; seven reviews) and asthma (five reviews). The median number of AMSTAR checklist items met was five: few reviewers searched for unpublished literature or described the primary studies and interventions in detail. Most reviews covered comprehensive services across the care continuum or standardization of care through inter-professional teams, but organizational culture, governance structure or financial management were rarely assessed. A majority of reviews found beneficial effects of integration, including reduced hospital admissions and re-admissions (in CHF and DM), improved adherence to treatment guidelines (DM, COPD and asthma) or quality of life (DM). Few reviews showed reductions in costs.

CONCLUSIONS

Systematic reviews of integrated care programmes were of mixed quality, assessed only some components of integration of care, and showed consistent benefits for some outcomes but not others.

Objective assessment of the suture ligature method for the laparoscopic intestinal anastomosis model using a new computerized system

BACKGROUND

The purpose of this study was to develop a new objective assessment system for the suture ligature method employed in the laparoscopic intestinal anastomosis model. Suturing skills were evaluated objectively using this system.

METHODS

This study compared 17 expert surgeons, each of whom had performed >500 laparoscopic procedures, with 36 novice surgeons, each of whom had performed <15 laparoscopic procedures. Each examinee performed a specific skill assessment task using an artificial model that mimics living tissue, which is linked with the Suture Simulator Instruction Evaluation Unit. The model used internal air pressure measurements and image processing to evaluate suturing skills. Five criteria were used to evaluate the skills of participants.

RESULTS

The volumes of air pressure leak in the expert and novice groups were 21.13 ± 6.68 and 8.51 ± 8.60 kPa, respectively. The numbers of full-thickness sutures in the expert and novice groups were 2.94 ± 0.24 pairs and 2.47 ± 0.77 pairs, respectively. Suture tensions in the expert and novice groups were 60.99 ± 11.81 and 80.90 ± 16.63 %, respectively. The areas of wound-opening in the expert and novice groups were 1.76 ± 2.17 and 11.06 ± 15.37 mm(2), respectively. The performance times in the expert and novice groups were 349 ± 120 and 750 ± 269 s, respectively. Significant differences between the expert and novice groups for each criterion were observed. The acceptable range of values for each criterion except for the number of full-thickness sutures was statistically defined by the performance of the expert group.

CONCLUSIONS

Our system is useful for the quantitative assessment of suturing skill in laparoscopic surgery. We believe that this system is a useful tool for training and assessment of laparoscopic surgeons.