Is magnetic anal sphincter augmentation still an option in fecal incontinence treatment: a systematic review and meta-analysis

PURPOSE

Magnetic anal sphincter (MAS) augmentation is a novel surgical option for the treatment of fecal incontinence. Current clinical evidence is conflicting. The purpose of this meta-analysis was to report the safety profile, potential benefits, and the functional efficacy of this device.

METHODS

The study followed the PRISMA guidelines. Literature databases (Medline, Scopus, Web of Science, CENTRAL) were screened for eligible articles. The primary endpoint was the pooled effect of MAS in the Cleveland Clinic Incontinence Score (CCIS) score. Quality evaluation was based on the ROBINS-I and Risk of Bias 2 tool.

RESULTS

Overall, 8 studies with 205 patients were included. MAS resulted in a significant reduction of CCIS values (p = 0.019), and improvement only in the embarrassment domain of FIQoL scores (p = 0.034). The overall morbidity rate was 61.8%. Postoperative adverse events included MAS explantation in 12%, infection in 5.1%, pain in 10% and obstructed defecation in 5.8% of patients.

CONCLUSION

The application of MAS in patients with fecal incontinence results in the improvement of some clinical parameters with a notable morbidity rate. Due to several study limitations, further, high-quality RCTs are required to delineate the efficacy and safety of MAS.

Obstructive Sleep Apnea and Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia, increasing with age and comorbidities. Obstructive sleep apnea (OSA) is a chronic sleep disorder more common in older men. It has been shown that OSA is linked to AF. Nonetheless, the prevalence of OSA in patients with AF remains unknown because OSA is significantly underdiagnosed. This review, including 54,271 patients, carried out a meta-analysis to investigate the association between OSA and AF. We also performed a meta-regression to explore cofactors influencing this correlation. A strong link was found between these two disorders. The incidence of AF is 88% higher in patients with OSA. Age and hypertension independently strengthened this association, indicating that OSA treatment could help reduce AF recurrence. Further research is needed to confirm these findings. Atrial Fibrillation (AF) is the most common arrhythmia, increasing with age and comorbidities. Obstructive sleep apnea (OSA) is a regulatory respiratory disorder of partial or complete collapse of the upper airways during sleep leading to recurrent pauses in breathing. OSA is more common in older men. Evidence exists that OSA is linked to AF. Nonetheless, the prevalence of OSA in patients with AF remains unknown because OSA is underdiagnosed. In order to investigate the incidence of AF in OSA patients, we carried out a meta-analysis including 20 scientific studies with a total of 54,271 subjects. AF was present in 4801 patients of whom 2203 (45.9%) had OSA and 2598 (54.1%) did not. Of a total of 21,074 patients with OSA, 2203 (10.5%) had AF and 18,871 (89.5%) did not. The incidence of AF was 88% higher in patients with OSA. We performed a meta-regression to explore interacting factors potentially influencing the occurrence of AF in OSA. Older age and hypertension independently strengthened this association. The clinical significance of our results is that patients with OSA should be referred early to the cardiologist. Further research is needed for the definition of the mechanisms of association between AF and OSA.

Patient survival in severe low-flow, low-gradient aortic stenosis after aortic valve replacement or conservative management

Background and aim

Classical and paradoxical low‐flow, low‐gradient (LFLG) aortic stenosis (AS) are the most challenging subtypes of AS. The current therapeutic options are aortic valve replacement (AVR) and conservative management: AVR promotes long‐term survival but is invasive, while conservative management yields a poor prognosis but is noninvasive since it uses no aortic valve replacement (noAVR). The present meta‐analysis investigated the rate of survival of patients with LFLG AS undergoing either AVR or noAVR interventions.

Methods

The meta‐analysis compared the outcomes of AVR with those of noAVR in terms of patient survival. In both groups, a meta‐regression was conducted to investigate the impact on patient survival of the left ventricular ejection fraction (LVEF), either preserved (paradoxical LFLG AS) or reduced (classical LFLG AS).

Results

The relative risk of survival between the AVR and noAVR groups was 1.99 [1.40, 2.82] (p = .0001), suggesting that survival tends to be better in AVR patients than in noAVR patients. The meta‐regression revealed that a reduced LVEF may be related to a higher survival in AVR patients when compared to a preserved LVEF (p = .04). Finally, the analysis indicated that LVEF seems not to be prognostic of survival in noAVR patients (p = .18).

Conclusions

Patients with LFLG AS have better survival if they undergo AVR. In AVR patients, reduced LVEF rather than preserved LVEF is related to better survival, whereas there seems to be no difference in prognostic value between reduced and preserved LVEF in noAVR patients.

Quantification of Death Risk in Relation to Sex, Pre-Existing Cardiovascular Diseases and Risk Factors in COVID-19 Patients: Let's Take Stock and See Where We Are

Patients with pre-existing cardiovascular disease (CVD) might be more susceptible to infection from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and have higher mortality rates. Nevertheless, the risk of mortality has not been previously quantified. The aim of this meta-analysis is to quantify the risk of mortality in coronavirus disease 2019 (COVID-19) patients. A meta-analysis was conducted analyzing the impact of (1) sex, (2) age, (3) CVD with coronary artery disease (CAD), (4) CAD alone, (5) CVD without CAD, (6) hypertension, (7) cerebrovascular diseases, and (8) diabetes on mortality. Relative risk was assessed for dichotomous variables, mean difference for continuous variables. Twenty-six studies were included, encompassing 8497 patients. Males had 16% higher risk of mortality than females (p < 0.05) and elderly patients had higher chance of dying than younger patients (p < 0.0001). Patients with overall CVD have a 1.96-fold higher mortality risk (p < 0.0001). CAD increases risk of mortality by 1.90-fold (p < 0.05). CVD-CAD were found to increase risk up to 2.03-fold (p < 0.05). Hypertension, cerebrovascular disease and diabetes increase the risk of death up to 1.73-fold, 1.76-fold and 1.59-fold, respectively (p < 0.0001, p < 0.0001, p < 0.05, respectively). Sex, age, presence of CAD and/or other types of CVD, hypertension, cerebrovascular diseases and diabetes mellitus increase mortality in patients with COVID-19.

Are recurrence of ischemic mitral regurgitation and left ventricular reverse remodeling after restrictive annuloplasty ring dependent?

OBJECTIVE

This meta-analysis investigates MR recurrence and degree of left ventricular reverse remodeling (LVRR) in CIMR patients in mitral annuloplasty employing different ring designs.

BACKGROUND

The deeper understanding of complex changes caused by chronic ischemic mitral regurgitation (CIMR) have led to new generations of rings that, by maintaining normal 3D annular geometry are supposed to enhance long-term repair durability.

METHODS

A meta-analysis of all available reports in literature of MV repair through different ring design was conducted. Meta-regression was performed to investigate the impact of mitral ring characteristics related to flexibility, planarity, symmetry and single type utilized. Twenty studies encompassing a total of 1876 patients were included at the end of the selection process.

RESULTS

At meta-regression recurrence of MR was not influenced by the ring employed. Nonetheless, the event rate of MR recurrence in planar rings was 19%. Vs. 11% observed with non-planar rings. Recurrence rate in patients implanted with symmetric rings was 14% whereas it was 7% in asymmetric rings. The non-planar asymmetric IMR-ETlogix showed the lowest recurrence rate (6%). Furthermore, in planar group the reduction of pre- and post-operative LVEDD was - 4%. In the non-planar group, the LVEDD was reduced by 8.6%. In patients implanted with symmetric rings LVEDD reduction was 10.8%. LVRR in the asymmetric group was -5.8%.

CONCLUSION

MR recurrence occurred the least with asymmetric rings with less disproportionate asymmetry. In contrast, LVRR occurred at a greater extent in symmetric rings.

Clinical outcomes of automated anastomotic devices: A metanalysis

Background and Aims

We investigated neurological events, graft patency, major adverse cardiovascular events (MACEs), and mortality at 1 year following coronary artery bypass grafting (CABG) surgery using automated proximal anastomotic devices (APADs) and compared the overall rates with the current literature.

Methods

A systematic review of all available reports of APADs use in the literature was conducted. Cumulative incidence and 95% confidence interval (CI) were the main statistical indexes. Nine observational studies encompassing a total of 718 patients were included at the end of the selection process.

Results

The cumulative event rate of neurological complications was 4.8% (lower‐upper limits: 2.8‐8.0, P < .001; I² = 72.907%, P = .002; Egger's test: intercept = –2.47, P = 0.16; Begg and Mazumdar test: τ = −0.20, p = 0.57). Graft patency was 90.5% (80.4 to 95.7, P < .001; I² = 76.823%, P = .005; Egger's test: intercept = –3.04, P = .10; Begg and Mazumdar test: τ = −0.67, P = .17). Furthermore, the overall incidence of MACEs was 3.7% (1.3‐10.4, P < .001; I² = 51.556%, P = .103; Egger's test: intercept = –1.98, P =  < .11; Begg and Mazumdar test: τ = −0.67, P = .17). Finally, mortality within 1 year was 5% (3.5‐7, P < .001; I² = 29.675%, P = .202; Egger's test: intercept = –0.91, P = .62; Begg and Mazumdar test: τ = −0.04, P = .88).

Conclusions

APADs do not seem to be correlated with a reduction of either neurological events or mortality. By contrast, these tools showed satisfactory one‐year graft patency and a low incidence of MACEs. Further research on this topic is warranted.

Association between atrial fibrillation and Helicobacter pylori

The connection between atrial fibrillation (AF) and H. pylori (HP) infection is still matter of debate. We performed a systematic review and metanalysis of studies reporting the association between AF and HF. A systematic review of all available reports in literature of the incidence of HP infection in AF and comparing this incidence with subjects without AF were analysed. Risk ratio and 95% confidence interval (CI) and risk difference with standard error (SE) were the main statistics indexes. Six retrospective studies including a total of 2921 were included at the end of the selection process. Nine hundred-fifty-six patients (32.7%) were in AF, whereas 1965 (67.3%) were in normal sinus rhythm (NSR). Overall, 335 of 956 patients with AF were HP positive (35%), whereas 621 were HP negative (65%). In addition, 643 of 1965 NSR patients (32.7%) were HP positive while 1,322 were negative (67.3%; Chi-square 2.15, p = 0.21). The Cumulative Risk Ratio for AF patients for developing an HP infection was 1.19 (95% CI 1.08–1.41). In addition, a small difference risk towards AF was found (0.11 [SE = 0.04]). Moreover, neither RR nor risk difference were influenced by the geographic area at meta-regression analysis. Finally, there was a weak correlation between AF and HP (coefficient = 0.04 [95% CI −0.01–0.08]). We failed to find any significant correlation between H. pylori infection and AF and, based on our data, it seems unlikely than HP can be considered a risk factor for AF. Further larger research is warranted.