Balloon dissection versus telescopic dissection during laparoscopic totally extraperitoneal (TEP) inguinal hernia repair: a systematic review, meta-analysis, and trial sequential analysis

OBJECTIVES

To compare the outcomes of balloon dissection and telescopic dissection in patients undergoing laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

METHODS

A systematic review in accordance with PRISMA statement standards was conducted. A search of electronic information sources was conducted to identify all studies comparing the outcomes of balloon dissection and telescopic dissection in patients undergoing laparoscopic TEP inguinal hernia repair. Random effects modelling was applied to calculate pooled outcome data.

RESULTS

A total of 936 patients from eight studies were included. The included population in both groups were comparable in terms of baseline characteristics. There was no difference between the two techniques in terms of operation time (MD: - 4.14 min, P = 0.05), conversion to another technique (RD: - 0.02, P = 0.29), recurrence (RD: - 0.00, P = 0.84), haematoma (OR: 1.34, P = 0.61), seroma (OR: 0.63, P = 0.56), surgical site infection (RD: 0.00, P = 1.00), urinary retention (OR: 0.92, P = 0.86), postoperative pain score on day 1 (MD: - 0.16, P = 0.69) and day 7 (MD: - 0.16, P = 0.61). Trial sequential analysis of randomised trials suggested that evidence for operative time and conversion to other technique is subject to type 1 and type 2 error.

CONCLUSIONS

Balloon dissection and telescopic dissection during TEP inguinal hernia repair are comparable in terms of operative and postoperative outcomes. The available evidence for operative time and conversion to other technique is subject to type 1 and type 2 error. In presence of comparative clinical outcomes, the cost-effectiveness analysis in future studies may play an important role in determining the dissection technique of choice.

Should routine surgical wound drainage after ventral hernia repair be avoided? A systematic review and meta-analysis

AIMS

To evaluate outcomes of drain use vs. no-drain use during ventral hernia repair.

METHODS

A PRISMA-compliant systematic review was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Studies comparing use of drains with no-drain during ventral hernia repair (primary or incisional) were included. Wound-related complications, operative time, need for mesh removal and early recurrence were the evaluated outcome parameters.

RESULTS

Eight studies reporting a total number of two thousand four hundred and sixty-eight patients (drain group = 1214; no-drain group = 1254) were included. The drain group had a significantly higher rate of surgical site infections (SSI) and longer operative time compared with the no-drain group [odds ratio (OR): 1.63, P = 0.01] and [mean difference (MD): 57.30, P = 0.007], respectively. Overall wound-related complications [OR: 0.95, P = 0.88], seroma formation [OR: 0.66, P = 0.24], haematoma occurrence [OR: 0.78, P = 0.61], mesh removal [OR: 1.32, P = 0.74] and early hernia recurrence [OR: 1.10, P = 0.94] did not differ significantly between the two groups.

CONCLUSION

The available evidence does not seem to support the routine use of surgical drains during primary or incisional ventral hernia repairs. They are associated with increased rates of SSIs and longer total operative time with no significant advantage in terms of wound-related complications.

OC-080 COMPLETE VERSUS PARTIAL EXCISION OF AN INFECTED MESH FOLLOWING ABDOMINAL WALL HERNIA REPAIR: A SYSTEMATIC REVIEW AND META-ANALYSIS

Aims

To evaluate comparative outcomes of complete and partial excision of infected mesh following abdominal wall hernia repair.

Methods

A systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits was conducted. Surgical site infection (SSI), chronic sinus formation, recurrent hernia and need for reoperation were the evaluated outcome measures.

Results

Six comparative observational studies were identified, reporting a total of 317 patients of whom 193 underwent complete mesh excision and the remaining 123 patients underwent partial mesh excision for an infected mesh following abdominal wall hernia repair. The complete mesh excision was associated with significantly lower rates of SSIs (OR: 0.36; 95% CI, 0.16–0.81, p=0.01), chronic sinus formation (OR: 0.11; 95% CI, 0.02–0.71, p=0.02), and reoperation (OR: 0.10; 95% CI, 0.03–0.33, p=0.0001) compared to the partial mesh excision. There was no significant difference in hernia recurrence rate (OR: 3.96.16, 95% CI 0.62–25.44, p=0.15) between two groups.

Conclusions

Our meta-analysis demonstrated that complete mesh excision may be associated with lower SSI, chronic sinus formation and need for reoperation when compared to the partial mesh excision in an infected mesh event. However, the available evidence has failed to report the outcomes with respect to the main confounding factors which, together with other important outcomes such as fistula formation, should be considered by future high quality research.

82 Acute Acalculous Cholecystitis Caused by Epstein–Barr Virus Infection: Cohort Study of Literature

Aim

To perform a cohort study of literature to provide the best available evidence on clinical features and management of acute acalculous cholecystitis (AAC) caused by acute Epstein-Barr virus (EBV) infection

Method

A comprehensive search of electronic information sources was performed to identify all reported cases in the literature comprising patients of any age or gender who were found to have AAC due to acute EBV infection. Simple descriptive statistics were applied to present outcome data.

Results

Overall, 42 eligible patients were identified. The mean age of the included population was 17; 83% were female and 17% were male. Overall, 62% were from Europe; 21% from North America, 17% from Asia. Abdominal pain was present in all patients; sore throat in 62%; pharyngitis or tonsillitis in 50%; cervical lymphadenopathy in 62%; jaundice in 36%, hepatosplenomegaly in 60%; positive Murphy's sign in 69%. All patients had gallbladder wall thickening on imaging. Overall, 98% of patients were treated conservatively. Among those who were treated conservatively, all recovered with conservative management. The patient's preference was the reason for surgery in the patient who was not treated conservatively. As part of conservative management, antibiotics were used in 48% of patients. The mean length of hospital stay was 10 days

Conclusions

AAC caused by EBV infection is a rare condition that occurs in young patients and is more common in females and in European countries. EBV-associated AAC has a very good clinical prognosis and can be treated conservatively without a need for antibiotics or surgical intervention.

435 Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials Comparing Standard Versus Extended Lymphadenectomy Pancreatoduodenectomy For Adenocarcinoma of The Head of Pancreas

Aim

To compare baseline demographics, operative, and survival outcomes of randomized controlled trials (RCTs) comparing standard versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer

Method

we performed a meta-analysis of baseline demographics, operative, and survival outcomes of RCTs comparing standard versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The uncertainties associated with varying follow-up periods among the included studies were resolved by analysis of time-to-event outcomes. Moreover, we performed trial sequential analysis (TSA) to determine whether the available evidence is conclusive and to assess the risk of type 1 or type 2 errors.

Results

Overall, 724 patients from 5 RCTs were included. There was no difference between standard and extended lymphadenectomy in terms of pancreatic fistula (OR0.64, P = 0.11), delayed gastric emptying (OR 0.68, P = 0.40), bile leak (OR 0.33, P = 0.06), wound infection (OR 0.53, P = 0.06), abscess (OR 0.83, P = 0.63), total complications (OR 0.73, P = 0.27), postoperative mortality (OR 1.01, P = 0.85), and overall survival (HR 1.10, P = 0.46). TSA suggested that meta-analysis was conclusive with low risk of type 2 error.

Conclusions

Robust evidence from randomized controlled trials (Level 1) suggests no difference in postoperative and survival outcomes between standard and extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The findings were consistent in patients with positive and negative lymph node status and in studies from the West or East.

1575 Predictive Ability of Neutrophil-To-Lymphocyte Ratio in Acute Appendicitis

Aim

Neutrophil-to-lymphocyte ratio (NLR) predicts both diagnosis and severity of appendicitis. We aimed to evaluate accuracy of NLR to predict acute appendicitis and whether it can distinguish between uncomplicated and complicated appendicitis.

Method

Patients of any age and gender presenting with clinical history of acute appendicitis over a 4 month period were included. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of NLR were evaluated considering the cut-off values of 4.7 for acute appendicitis and 8.8 for complicated appendicitis.

Results

A total of 54 patients were included. Thirty-eight patients had acute appendicitis of whom 21 (55.2%) had complicated appendicitis. NLR was associated with sensitivity of 89.4%, specificity of 81.2%, PPV 91.8%, NPV of 76.5%, and accuracy of 87.0% for acute appendicitis. Moreover, it was associated with sensitivity of 61.4%, specificity of 78.9%, PPV 76.5%, NPV of 65.2%, and accuracy of 70.0% for complicated appendicitis.

Conclusions

NLR has acceptable sensitivity, specificity, PPV, NPV and accuracy to predict uncomplicated and complicated appendicitis with relatively better ability to predict the former. NLR can be utilised for prioritising cases for surgery, for monitoring conservatively treated patients and for patients who do not routinely undergo CT scan (pregnant or paediatric patients).

346 Meta-Analysis of Simultaneous Versus Staged Colorectal and Hepatic Resections for Colorectal Cancer with Synchronous Hepatic Metastases

Aim

To evaluate the comparative outcomes of simultaneous and staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases

Method

We conducted a systematic search of electronic information sources, and bibliographic reference lists. Perioperative morbidity and mortality, anastomotic leak, wound infection, bile leak, bleeding, intra-abdominal abscess, sub-phrenic abscess, reoperation, recurrence, 5-year overall survival, procedure time, and length of hospital stay were the evaluated outcome parameters. Combined overall effect sizes were calculated using random-effects models.

Results

We identified 41 comparative studies reporting a total of 12,081 patients who underwent simultaneous (n = 5,013) or staged (n = 7.068) resections for colorectal cancer with synchronous hepatic metastases. The simultaneous resection was associated with significantly lower rate of bleeding (OR: 0.60, p = 0.03) and shorter length of hospital stay (MD:-5.40, p < 0.00001) compared to the staged resection. However, no significant difference was found in perioperative morbidity (OR:1.04, p = 0.63), mortality (RD:0.00, p = 0.19), anastomotic leak (RD:0.01, p = 0.33), bile leak (OR:0.83, p = 0.50), wound infection (OR:1.17, p = 0.19), intra-abdominal abscess (RD:0.01, p = 0.26), sub-phrenic abscess (OR:1.26, p = 0.48), reoperation (OR:1.32, p = 0.18), recurrence (OR:1.33, p = 0.10), 5-year overall survival (OR:0.88, p = 0.19), or procedure time (MD:-23.64, p = 041) between two groups.

Conclusions

Despite demonstrating nearly comparable outcomes, the best available evidence (level 2) regarding simultaneous and staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases is associated with major selection bias. It is time to conduct high quality randomised studies with respect to burden and laterality of disease. We recommend the staged approach for complex cases.

98 Intracorporeal Versus Extracorporeal Anastomosis in Laparoscopic Right Hemicolectomy: Meta-Analysis of Randomised Controlled Trials

Aim

To evaluate comparative outcomes of intracorporeal (ICA) and extracorporeal (ECA) anastomosis in laparoscopic right hemicolectomy.

Method

We conducted a systematic search of electronic databases and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Overall perioperative morbidity, anastomotic leak, surgical site infection (SSI), paralytic ileus, bleeding, postoperative pain within 5 days, conversion to an open procedure, length of incision and procedure time were the evaluated outcome parameters. Combined overall effect sizes were calculated using random-effects models.

Results

We identified 4 randomised controlled trials reporting a total of 399 patients evaluating outcomes of ICA (n = 199) and ECA (n = 200) in laparoscopic right hemicolectomy. The ICA was associated with significantly shorter length of incision (MD:-1.82, P < 0.00001), lower postoperative pain score on day 2 (MD:-0.69, P = 0.0007), day 3 (MD:-0.80, P = 0.02), day 4 (MD:-0.83, P = 0.01) and day 5 (MD:-0.49, P < 0.00001) when compared to ECA. Moreover, it was associated with significantly shorter length of hospital stay (MD:-0.27, p = 0.03). However, there was no significant difference in overall perioperative morbidity (RR:0.79, P = 0.47), anastomotic leak (RR:1.29, P = 0.65), SSI (RR:0.61, P = 0.42), bleeding (RR:0.70, P = 0.71), ileus (RR:0.60, P = 0.45), conversion to open (RD:-0.02, P = 0.45), number of harvested lymph nodes (MD:0.82, p = 0.06), and procedure time (MD:16.04, p = 0.06) between two groups.

Conclusions

The meta-analysis of level 1 evidence demonstrated that ICA and ECA have comparable perioperative outcomes in laparoscopic right colectomy although the former may be associated with less postoperative pain probably due to shorter incision length.

Comparison of extended right hemicolectomy, left hemicolectomy and segmental colectomy for splenic flexure colon cancer: a systematic review and meta-analysis

AIM

The aim of this work was to compare the outcomes of extended right hemicolectomy (ERH), left hemicolectomy (LH) and segmental colectomy (SC) for the surgical management of splenic flexure tumours.

METHOD

In compliance with PRISMA statement standards, a systematic review was performed to identify all studies comparing outcomes of ERH, LH and SC for the surgical management of splenic flexure tumours. Primary outcomes included anastomotic leakage and all postoperative complications. The secondary outcomes included operative time, R0 resection, number of harvested lymph nodes, > 12 harvested lymph nodes, severe complications, postoperative mortality, paralytic ileus, wound infection, pancreatic fistula, intra-abdominal abscess, need for reoperation, length of hospital stay, 5-year overall survival and 5-year disease-free survival. The ROBINS-I tool and GRADE system were used to assess the risk of bias and certainty of evidence, respectively.

RESULTS

Analysis of 956 patients from seven observational studies showed that ERH was associated with more paralytic ileus than LH (OR 2.74, P = 0.002) and SC (OR 6.67, P < 0.0001) and the operative time was shorter in SC than in ERH (mean difference 25.48, P < 0.0001) and LH (mean difference -17.94, P = 0.0002). There were no differences between ERH, LH and SC in terms of anastomotic leakage, postoperative complications, R0 resection, severe complications, postoperative mortality, wound infection, pancreatic fistula, intra-abdominal abscess, need for reoperation, length of hospital stay, > 12 harvested lymph nodes, 5-year overall survival and 5-year disease-free survival.

CONCLUSIONS

The available evidence, limited to observational studies, suggests that there is no difference between ERH, LH and SC in terms of postoperative morbidity and mortality, lymph node yield and cancer survival. Randomized controlled trials are required for definite conclusions.

Meta-analysis of the demographic and prognostic significance of right-sided versus left-sided acute diverticulitis

AIM

The aim of this work was to compare demographic factors, outcomes and prognosis for right-sided versus left-sided acute colonic diverticulitis.

METHOD

We searched MEDLINE, CINAHL, EMBASE, CENTRAL, Scopus and unpublished literature to identify all observational studies comparing demographic factors and outcomes of right-sided versus left-sided acute colonic diverticulitis (PROSPERO registration number CRD42020180075). We used the QUIPS tool to assess the risk of bias of included studies. Random effects modelling was applied to calculate pooled outcome data.

RESULTS

Analysis of 2933 patients from nine studies suggests that right-sided diverticulitis affects younger patients [mean difference (MD)  -14.16 (-17.19, -11.14), P < 0.00001] and more male patients [odds ratio (OR) 1.33 (1.04, 1.71), P = 0.02] compared with left-sided diverticulitis. Smoking [OR 2.23 (1.50, 3.32), P < 0.0001], alcohol consumption [OR 1.85 (1.26, 2.71), P = 0.002] and comorbidity [OR 0.21 (0.15, 0.30), P < 0.00001] were more common in patients with right-sided diverticulitis. The risk of complicated diverticulitis was lower in the right-sided group [OR 0.21 (0.08, 0.55), P = 0.001]. More patients in the right-sided diverticulitis group had modified Hinchey Stage I disease [OR 10.21 (3.34, 31.22), P < 0.0001] while more patients in the left-sided group had Stage II [OR 0.19 (0.10, 0.38), P < 0.00001], Stage III [OR 0.08 (0.01, 0.54), P = 0.009] or Stage IV disease [OR 0.02 (0.00, 0.08), P < 0.00001]. Right-sided diverticulitis was associated with a lower risk of recurrence [OR 0.49 (0.25, 0.98), P = 0.04], failure of conservative management [OR 0.14 (0.04, 0.43), P = 0.0006], the need for emergency surgery [OR 0.13 (0.05, 0.36), P < 0.00001] and a shorter length of hospital stay [MD -1.70 (-3.08, -0.33), P = 0.02].

CONCLUSION

Right-sided acute diverticulitis predominantly affects younger male patients compared with left-sided disease and is associated with favourable outcomes as indicated by the lower risk of complications, failure of conservative management, need for emergency surgery, recurrence and shorter length of hospital stay. More studies are required to compare the postoperative outcomes in patients with right-sided and left-sided diverticulitis undergoing emergency surgery.

Suture fixation versus self-gripping mesh for open inguinal hernia repair: a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

Morbidity following open inguinal hernia repair is mainly related to chronic pain. ProGrip™ is a self-gripping mesh which aims to reduce rates of chronic pain. The aim of this study is to perform an update meta-analysis to consolidate the non-superiority hypothesis in terms of postoperative pain and recurrence and perform a trial sequential analysis.

METHODS

Systematic review of randomised controlled trials performed according to PRISMA guidelines. Pooled odds ratios with 95% confidence intervals (CI) were calculated using the Mantel-Haenszel (M-H) method. The primary outcome measure was postoperative pain and secondary outcomes were recurrence, operative time, wound complications, length of stay, re-operation rate, and cost. Trial sequential analysis was performed.

RESULTS

There were 14 studies included in the quantitative analysis with 3180 patients randomised to self-gripping mesh (1585) or standard mesh (1595). At all follow-up time points, there was no significant difference in the rates of chronic pain between the self-gripping and standard mesh (risk ratio, RR 1.10, 95% confidence interval, CI 0.83-1.46). There were no significant differences in recurrence rates (RR 1.13, CI 0.84-2.04). The mean operating time was significantly shorted in the ProGrip™ mesh group (MD - 7.32 min, CI - 10.21 to - 4.44). Trial sequential analysis suggests findings are conclusive.

CONCLUSION

This meta-analysis has confirmed no benefit of a ProGrip™ mesh when compared to a standard sutured mesh for open inguinal hernia repair in terms of chronic pain or recurrence. No further trials are required to address this clinical question.

Open darn repair vs open mesh repair of inguinal hernia: a systematic review and meta-analysis of randomised and non-randomised studies

OBJECTIVES

To compare the outcomes of open darn repair vs open mesh repair in patients undergoing inguinal hernia repair.

METHODS

We performed a systematic review and conducted a search of electronic information sources to identify all observational studies and randomised controlled trials (RCTs) investigating outcomes of open darn repair vs open mesh repair for inguinal hernias. Hernia recurrence was considered as the primary outcome measure. The secondary outcome measures included surgical site infection (SSI), haematoma, seroma, neuralgia, urinary retention, length of hospital stay, time to return to normal activities or work, testicular atrophy, operative time and chronic pain. Random or fixed effects modelling was applied to calculate pooled outcome data.

RESULTS

Six RCTs, enrolling 1480 patients with 1485 hernias, and 4 observational studies, enrolling 1564 patients with 1641 hernias, were included. Meta-analysis of RCTs showed no significant difference in terms of recurrence (RD 0.00, 95% CI - 0.01 to 0.01, P = 0.86), SSI (OR 0.83, 95% CI 0.46-1.49, P = 0.52), haematoma (OR 1.21, 95% CI 0.62-2.38, P = 0.57), seroma (OR 0.83, 95% CI 0.42-1.65, P = 0.60), neuralgia (OR 1.05, 95% CI 0.29-3.73, P = 0.94), urinary retention (OR 1.44, 95% CI 0.64-3.21, P = 0.38), length of hospital stay (MD 0.09, 95% CI - 0.28 to 0.46, P = 0.63), time to return to normal activities or work (MD 0.88, 95% CI - 0.90 to 2.66, P = 0.33), testicular atrophy (RD 0.00, 95% CI - 0.02 to 0.02, P = 1.00), and operative time (MD 2.69, 95% CI - 1.75 to 7.14, P = 0.62) between the darn repair and mesh repair groups. Meta-analysis of observational studies also showed no significant difference in terms of recurrence (RD 0.00, 95% CI - 0.02 to 0.02, P = 0.99), SSI (OR 0.47, 95% CI 0.14-1.62, P = 0.23), haematoma (OR 1.07, 95% CI 0.45-2.55, P = 0.89), seroma (OR 0.12, 95% CI 0.01-2.27, P = 0.16), neuralgia (OR 0.25, 95% CI 0.05-1.21, P = 0.08), urinary retention (OR 1.53, 95% CI 0.20-11.96, P = 0.69), time to return to normal activities or work (MD 2.13, 95% CI - 2.18 to 6.44, P = 0.33), testicular atrophy (RD - 0.01, 95% CI - 0.02 to 0.01, P = 0.49), and operative time (MD - 4.76, 95% CI - 13.23 to 3.71, P = 0.27) between the two groups. The evidence was inconclusive for chronic pain. The quality of available evidence was moderate.

CONCLUSIONS

Our results suggest that open darn repair is comparable with open mesh repair for inguinal hernias. Considering that consequences of mesh complications in inguinal hernia repair, albeit rare, can be significant, open darn repair provides an equally credible alternative to open mesh repair for inguinal hernias. Further studies are required to investigate patient-reported outcomes and to elicit a superior non-mesh technique.

Effect of beta-blockers on perioperative outcomes in vascular and endovascular surgery: a systematic review and meta-analysis

BACKGROUND

To investigate the role of perioperative beta-blocker use in vascular and endovascular surgery.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. The review protocol was registered with International Prospective Register of Systematic Reviews (registration number:CRD42016038111). We searched electronic databases to identify all randomized controlled trials and observational studies investigating outcomes of patients undergoing vascular and endovascular surgery with or without perioperative beta blockade. We used the Cochrane tool and the Newcastle-Ottawa scale to assess the risk of bias of trials and observational studies, respectively. Random-effects models were applied to calculate pooled outcome data.

RESULTS

We identified three randomized trials, five retrospective cohort studies, and three prospective cohort studies, enrolling a total of 32,602 patients. Our analyses indicated that perioperative use of beta-blockers did not reduce the risk of all-cause mortality [odds ratio (OR) 1.10, 95% confidence interval (CI) 0.59-2.04, P = 0.77], cardiac mortality (OR 2.62, 95% CI 0.86-8.05, P = 0.09), myocardial infarction (OR 0.89, 95% CI 0.59-1.35, P = 0.58), unstable angina (OR 1.34, 95% CI 0.41- 4.38, P = 0.63), stroke (OR 2.45, 95% CI 0.89-6.75, P = 0.08), arrhythmias (OR 0.76, 95% CI 0.41-1.43, P = 0.40), congestive heart failure (OR 1.12, 95% CI 0.77-1.63, P = 0.56), renal failure (OR 1.48, 95% CI 0.90-2.45, P = 0.13), composite cardiovascular events (OR 0.88, 95% CI 0.55-1.40, P = 0.58), rehospitalisation (OR 0.86, 95% CI 0.48-1.52, P = 0.60), and reoperation (OR 1.17, 95% CI 0.42-3.27, P = 0.77) in vascular surgery.

CONCLUSIONS

Beta-blockers do not improve perioperative outcomes in vascular and endovascular surgery.

Effect of mesalazine on recurrence of diverticulitis in patients with symptomatic uncomplicated diverticular disease: a meta-analysis with trial sequential analysis of randomized controlled trials

AIM

he aim was to investigate the effect of mesalazine on the recurrence of diverticulitis in patients with symptomatic uncomplicated diverticular disease (SUDD).

METHODS

We performed a systematic review and conducted a search of electronic information sources to identify all randomized controlled trials (RCTs) investigating the effect of mesalazine on the recurrence of diverticulitis in patients with SUDD. We used the Cochrane tool to assess the quality of included studies. Random effects models were applied to calculate pooled outcome data. Trial sequential analysis was performed to assess the possibility of type I or II errors and to compute the information size required for conclusive meta-analysis.

RESULTS

We identified six RCTs which enrolled a total of 1918 patients. There was no difference in the recurrence of diverticulitis between the mesalazine and placebo groups (OR 1.20, 95% CI 0.96-1.50, P = 0.11). A low level of heterogeneity among the studies existed (I²  = 9%, P = 0.36). When the mesalazine dose was ≤ 2 g/day, there was no difference in recurrence rate between the two groups (OR 1.10, 95% CI 0.79-1.54, P = 0.58). When the mesalazine dose was > 2 g/day, the risk of recurrence was higher in the mesalazine group (OR 1.28, 95% CI 1.02-1.62, P = 0.04). The information size was calculated as 2461 patients. Trial sequential analysis showed that the meta-analysis was conclusive and the risk of type II error was minimal.

CONCLUSIONS

Mesalazine does not prevent the recurrence of diverticulitis in patients with SUDD. Further studies are required to investigate the role of mesalazine as an adjunct to other medical agents in the prevention of diverticulitis in patients with SUDD.

Accuracy of co-morbidity data in patients undergoing abdominal wall hernia repair: a retrospective study

OBJECTIVES

To determine the baseline accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of routinely collected co-morbidity data in patients undergoing abdominal wall hernia repair.

METHODS

All patients aged > 18 who underwent umbilical, para-umbilical, inguinal or incisional hernia repair between 1 January 2015 and 1 November 2016 were identified. All parts of the clinical notes were searched for co-morbidities by two authors independently. The following co-morbidities were considered: hypertension, ischaemic heart disease (IHD), diabetes, asthma, chronic obstructive pulmonary disease (COPD), cerebrovascular disease (CVD), chronic kidney disease (CKD), hypercholesterolemia, obesity and smoking. The co-morbidities data from clinical notes were compared with corresponding data in hospital episode statistics (HES) database to calculate accuracy, sensitivity, specificity, PPV and NPV of HES codes for co-morbidities. To assess the agreement between clinical notes and HES data, we also calculated Cohen's Kappa index value as a more robust measure of agreement.

RESULTS

Overall, 346 patients comprising 3460 co-morbidity codes were included in the study. The overall accuracy of HES codes for all co-morbidities was 77% (Kappa: 0.13). When calculated separately for each co-morbidity, the accuracy was 72% (Kappa: 0.113) for hypertension, 82% (Kappa: 0.232) for IHD, 85% (Kappa: 0.203) for diabetes, 86% (Kappa: 0.287) for asthma, 91% (Kappa: 0.339) for COPD, 92% (Kappa: 0.374) for CVD, 94% (Kappa: 0.424) for CKD, 74% (Kappa: 0.074) for hypercholesterolemia, 71% (Kappa: 0.66) for obesity and 24% (Kappa: 0.005) for smoking. The overall sensitivity, specificity, PPV and NPV of HES codes were 9, 100, 100, and 77%, respectively. The results were consistent when individual co-morbidities were analyzed separately.

CONCLUSIONS

Our results demonstrated that HES co-morbidity codes in patients undergoing abdominal wall hernia repair are specific with good positive predictive value; however, they have substandard accuracy, sensitivity, and negative predictive value. The presence of a relatively large number of false negative or missed cases in HES database explains our findings. Better documentation of co-morbidities in admission clerking proforma may help to improve the quality of source documents for coders, which in turn may improve the accuracy of coding.

Neuromuscular electrical stimulation for thromboprophylaxis: A systematic review

OBJECTIVE

To evaluate the effect of neuromuscular electrical stimulation on lower limb venous blood flow and its role in thromboprophylaxis.

METHOD

Systematic review of randomised and non-randomised studies evaluating neuromuscular electrical stimulation, and reporting one or more of the following outcomes: incidence of venous thromboembolism, venous blood flow and discomfort profile.

RESULTS

Twenty-one articles were identified. Review of these articles showed that neuromuscular electrical stimulation increases venous blood flow and is generally associated with an acceptable tolerability, potentially leading to good patient compliance. Ten comparative studies reported DVT incidence, ranging from 2% to 50% with neuromuscular electrical stimulation and 6% to 47.1% in controls. There were significant differences, among included studies, in terms of patient population, neuromuscular electrical stimulation delivery, diagnosis of venous thromboembolism and blood flow measurements.

CONCLUSION

Neuromuscular electrical stimulation increases venous blood flow and is well tolerated, but current evidence does not support a role for neuromuscular electrical stimulation in thromboprophylaxis. Randomised controlled trials are required to investigate the clinical utility of neuromuscular electrical stimulation in this setting.