Is colonic lavage a suitable alternative for left-sided colonic emergencies?

BACKGROUND The use of intra-operative colonic lavage(IOCL)with primary anastomosis remains controversial in the emergency left-sided large bowel pathologies,with alternatives including Hartmann’s procedure,manual decompression and subtotal colectomy.AIM To compare the peri-operative outcomes of IOCL to other procedures.METHODS Electronic databases were searched for articles employing IOCL from inception till July 13,2020.Odds ratio and weighted mean differences(WMD)were estimated for dichotomous and continuous outcomes respectively.Single-arm meta-analysis was conducted using DerSimonian and Laird random effects.RESULTS Of 28 studies were included in this meta-analysis,involving 1142 undergoing IOCL,and 634 other interventions.IOCL leads to comparable rates of wound infection when compared to Hartmann’s procedure,and anastomotic leak and wound infection when compared to manual decompression.There was a decreased length of hospital stay(WMD=-7.750;95%CI:-13.504 to-1.996;P=0.008)compared to manual decompression and an increased operating time.Single-arm meta-analysis found that overall mortality rates with IOCL was 4%(CI:0.03-0.05).Rates of anastomotic leak and wound infection were 3%(CI:0.02-0.04)and 12%(CI:0.09-0.16)respectively.CONCLUSION IOCL leads to similar rates of post-operative complications compared to other procedures.More extensive studies are needed to assess the outcomes of IOCL for emergency left-sided colonic surgeries.

Foregut bypass vs.restrictive bariatric procedures for nonalcoholic fatty liver disease:a meta-analysis of 3,355 individuals

Background:Bariatric surgery represents an important treatment option for severely obese patients with nonalcoholic fatty liver disease(NAFLD).However,there remains inadequate data regarding the effects of different bariatric procedures on various NAFLD parameters,especially for histological outcomes.Thus,this meta-analysis aimed to compare the effects of restrictive bariatric procedures and foregut bypass on the metabolic,biochemical,and histological parameters for patients with NAFLD.Methods:Medline and Embase were searched for articles relating to bariatric procedures and NAFLD.Pairwise meta-analysis was conducted to compare efficacy of bariatric procedures pre-vs.post-procedure with subgroup analysis to further compare restrictive against foregut bypass procedures.Results:Thirty-one articles involving 3,355 patients who underwent restrictive bariatric procedures(n=1,460)and foregut bypass(n=1,895)were included.Both foregut bypass(P<0.01)and restrictive procedures(P=0.03)significantly increased odds of fibrosis resolution.Compared to restrictive procedures,foregut bypass resulted in a borderline non-significant decrease in fibrosis score(P=0.06)and significantly lower steatosis score(P<0.001).For metabolic parameters,foregut bypass significantly lowered body mass index(P=0.003)and low-density lipoprotein(P=0.008)compared to restrictive procedures.No significant differences were observed between both procedures for aspartate aminotransferase(P=0.17)and alkaline phosphatase(P=0.61).However,foregut bypass resulted in significantly lower gamma-glutamyl transferase than restrictive procedures(P=0.01)while restrictive procedures resulted in significantly lower alanine transaminase than foregut bypass(P=0.02).Conclusions:The significant histological and metabolic advantages and comparable improvements in biochemical outcomes support the choice of foregut bypass over restrictive bariatric procedures in NAFLD management.

Clinical utility of non-invasive tests to predict clinical outcomes in non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease(NAFLD)is the leading cause of chronic liver disease,and the fastest-growing cause of hepatocellular carcinoma(HCC)worldwide(1,2).As the number of people with NAFLD is too great to perform surveillance in all,risk-stratification strategies are increasingly important to identify those at the highest risk of decompensation and HCC(3,4).

Liver resection versus liver transplantation for hepatocellular carcinoma within Milan criteria:a meta-analysis of 18,421 patients

Background:Outcomes after liver resection(LR)and liver transplantation(LT)for hepatocellular carcinoma(HCC)are heterogenous and may vary by region,over time periods and disease burden.We aimed to compare overall survival(OS)and disease-free survival(DFS)between LT versus LR for HCC within the Milan criteria.Methods:Two authors independently searched Medline and Embase databases for studies comparing survival after LT and LR for patients with HCC meeting the Milan criteria.Meta-analyses and meta-regression were conducted using random-effects models.Results:We screened 2,278 studies and included 35 studies with 18,421 patients.LR was associated with poorer OS[hazard ratio(HR)=1.44;95%confidence interval(CI):1.14-1.81;P<0.01]and DFS(HR=2.71;95%CI:2.23-3.28;P<0.01)compared to LT,with similar findings among intention-to-treat(ITT)studies.In uninodular disease,OS in LR was comparable to LT(P=0.13)but DFS remained poorer(HR=2.95;95%CI:2.30-3.79;P<0.01).By region,LR had poorer OS versus LT in North America and Europe(P≤0.01),but not Asia(P=0.25).LR had inferior survival versus LT in studies completed before 2010(P=0.01),but not after 2010(P=0.12).Cohorts that underwent enhanced surveillance had comparable OS after LT and LR(P=0.33),but cohorts undergoing usual surveillance had worse OS after LR(HR=1.95;95%CI:1.24-3.07;P<0.01).Conclusions:Mortality after LR for HCC is nearly 50%higher compared to LT.Survival between LR and LT were similar in uninodular disease.The risk of recurrence after LR is threefold that of LT.