Indocyanine green fluorescence angiography versus standard intraoperative methods for prevention of anastomotic leak in colorectal surgery: meta-analysis

BACKGROUND

Assessment of anastomotic blood perfusion with intraoperative indocyanine green fluorescence angiography (ICG-FA) may be effective in preventing anastomotic leak compared with standard intraoperative methods in colorectal surgery.

METHODS

MEDLINE, PubMed, Cochrane Central Register of Controlled Trials and the Cochrane Library were searched for RCTs and observational studies on intraoperative ICG-FA to May 2020. Odds ratios (ORs), risk differences and mean differences (MDs) were calculated with 95 per cent c.i. based on intention-to-treat analysis. The number needed to treat for an additional beneficial outcome was also estimated.

RESULTS

Twenty-five comparative studies included a total of 7735 patients. The use of intraoperative ICG fluorescence angiography was linked with a significant reduction in all grades anastomotic leak (OR 0.39 (95 per cent c.i. 0.31 to 0.49), P < 0.001; number needed to treat for an additional beneficial outcome (NNTB) 23) and length of hospital stay (MD -0.72 (95 per cent c.i. -1.22 to -0.21) days, P = 0.006). A significantly lower incidence of grade A (OR 0.33 (0.18 to 0.60), P < 0.001), grade B (OR 0.58 (0.35 to 0.97), P = 0.04) and grade C (OR 0.59 (0.38 to 0.92), P = 0.02) anastomotic leak was demonstrated in favour of ICG-FA. For low or ultra-low rectal resection, the odds of developing anastomotic leakage was 0.32 (0.23 to 0.45) (P < 0.001; NNTB 14). There were no differences in duration of surgery, and no adverse events related to ICG fluorescent injection.

CONCLUSION

The use of ICG-FA instead of standard intraoperative methods to assess anastomosis blood perfusion in colorectal surgery leads to a significant reduction in anastomotic leakage and in the need for surgical reintervention for anastomotic leak, especially in patients with low or ultra-low rectal resections.

Development and validation of a staging system for gastric adenocarcinoma after neoadjuvant chemotherapy and gastrectomy with D2 lymphadenectomy

BACKGROUND

Neoadjuvant chemotherapy followed by gastrectomy with D2 lymphadenectomy is commonly used for patients with locally advanced gastric adenocarcinoma. The eighth AJCC ypTNM staging system was validated based on patients undergoing more limited lymphadenectomy (less than D2). The aim of this study was to develop a system for accurate staging of patients with locally advanced gastric adenocarcinoma who receive neoadjuvant chemotherapy followed by gastrectomy with D2 lymphadenectomy.

METHODS

A modified system of ypTNM was developed, based on overall survival (OS) of patients receiving neoadjuvant chemotherapy followed by gastrectomy with D2 lymphadenectomy at Memorial Sloan Kettering Cancer Center, and validated using data from an international cohort of patients who had similar treatment.

RESULTS

Of 325 patients in the derivation cohort, 33 (10·2 per cent) had ypT0 N0/+ tumours, which are not classifiable under the AJCC system. The 5-year OS rate for modified ypTNM stages I, II, IIIA and IIIB was 89, 71, 42·3 and 10 per cent respectively, compared with 82, 65·2 and 24·1 for AJCC stages I, II and III respectively. The concordance index (0·730 versus 0·709), estimated area under the curve (0·765 versus 0·740) and time-dependent receiver operating characteristic (ROC) curve throughout the observation period were all superior for modified ypTNM staging. For the validation cohort of 186 patients, the modified system was again better at separating patients into prognostic groups for OS.

CONCLUSION

The modified ypTNM staging system improves the accuracy of OS prediction for patients treated with neoadjuvant chemotherapy followed by gastrectomy with D2 lymphadenectomy.

A rare case of perforation of the subhepatic appendix by a toothpick in a patient with intestinal malrotation: laparoscopic approach

Foreign body ingestion is not an uncommon problem in clinical practice. While most ingested foreign bodies pass uneventfully through the gastrointestinal tract, sharp foreign bodies such as toothpicks should cause intestinal perforation. We reported the case of a perforation of the appendix caused by a toothpick, which also pierced the liver without hepatic damages, in a male with an intestinal malrotation and subhepatic appendix. The patient was admitted to our hospital for abdominal pain in the right upper quadrant. An abdominal computed tomography scan revealed the anomalous position of the first portion of the large intestine with inflamed appendix. A laparoscopic appendicectomy and the exploration of the abdominal cavity was performed using minimally invasive technique.

Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) may offer advantages over conventional laparoscopic cholecystectomy (LC).

METHODS

MEDLINE, Embase, PubMed, CINAHL, Cochrane Central Register of Controlled Trials and the Cochrane Library were searched for randomized clinical trials on SILC versus LC until May 2012. Odds ratio (OR) and weight mean difference (WMD) were calculated with 95 per cent confidence intervals (c.i.) based on intention-to-treat analysis.

RESULTS

Thirteen randomized clinical trials included a total of 923 procedures. SILC had a higher procedure failure rate than LC (OR 8·16, 95 per cent c.i. 3·42 to 19·45; P < 0·001), required a longer operating time (WMD 16·55, 95 per cent c.i. 9·95 to 23·15 min; P < 0·001) and was associated with greater intraoperative blood loss (WMD 1·58, 95% of c.i. 0·44 to 2·71 ml; P = 0·007). There were no differences between the two approaches in rate of conversion to open surgery, length of hospital stay, postoperative pain, adverse events, wound infections or port-site hernias. Better cosmetic outcomes were demonstrated in favour of SILC as measured by Body Image Scale questionnaire (WMD -0·97, 95% of c.i. -1·51 to -0·43; P < 0·001) and Cosmesis score (WMD -2·46, 95% of c.i. -2·95 to -1·97; P < 0·001), but this was based on comparison with procedures in which multiple and often large ports (10 mm) were used.

CONCLUSION

SILC has a higher procedure failure rate with more blood loss and takes longer than LC. No trial was adequately powered to assess safety.

Is inferior mesenteric artery ligation during sigmoid colectomy for diverticular disease associated with increased anastomotic leakage? A meta-analysis of randomized and non-randomized clinical trials

AIM

A meta-analysis was conducted to compare preservation with ligation of the inferior mesenteric artery (IMA) during sigmoidectomy for diverticular disease.

METHOD

Randomized and non-randomized clinical trials were identified using the following electronic databases: Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, Science Citation Index, Greynet, SIGLE, National Technological Information Service, British Library Integrated Catalogue. The analysed end-points were the anastomotic leakage rate, overall morbidity and 30-day postoperative mortality.

RESULTS

Four studies were included involving 400 patients. The anastomotic leakage rate was 7.3% in the preservation group and 11.3% in the ligation group. There was no statistically significant difference between the groups (OR 0.72, 95% CI 0.11-4.76; P=0.73). Overall morbidity and 30-day postoperative mortality were not compared since these data were reported in only one study.

CONCLUSION

The meta-analysis did not show any advantage for preservation of the IMA during sigmoid colectomy for diverticular disease in terms of anastomotic leakage.

Fluoronaphthyridines and -quinolones as antibacterial agents. 5. Synthesis and antimicrobial activity of chiral 1-tert-butyl-6-fluoro-7-substituted-naphthyridones

A series of novel 7-substituted-1-tert-butyl-6-fluoronaphthyridone-3- carboxylic acids has been prepared. These derivatives are characterized by chiral aminopyrrolidine substituents at the 7 position. In this paper we report the full details of the asymmetric synthesis of this series of compounds. Structure-activity relationship studies indicate that the absolute stereochemistry at the asymmetric centers of the pyrrolidine ring is critical for maintaining good activity. Compounds 60 and 61 (3-amino-4-methylpyrrolidine enantiomers) were selected for preclinical evaluation.

Induction of tumor necrosis factor, IFN-gamma, and acute lethality in mice by toxic and non-toxic forms of lipid A

The effect of the i.v. administration of endotoxin (LPS), diphosphoryl lipid A, and the non-toxic derivative monophosphoryl lipid A (MPL), on the production of serum cachectin (TNF), IFN-gamma, and the appearance of endotoxin shock have been measured in mice primed with Listeria monocytogenes. All three of the lipid A varieties induced the production of TNF in a dose-dependent manner. Although comparable peak levels of TNF were produced (5 X 10(5) to 1 X 10(6) U/ml), treatments with LPS or diphosphoryl lipid A were lethal whereas those with MPL were not. A study following TNF in the mouse sera for up to 24 h after treatment with the lipid A types showed that serum levels of TNF peaked 90 min after the treatment, and that TNF levels induced by LPS treatment were maintained for several hours longer than those induced by lipid A or MPL. All three molecules also resulted in the production of IFN-gamma in the serum, which peaked at 4 to 5 h after treatment. After 90 min there were no significant differences in the levels of serum IFN-gamma in any of the groups of treated animals. However, as was observed with the TNF, the levels of IFN in animals treated with LPS persisted longer than those induced by MPL or lipid A. These results suggest that the non-toxic MPL as well as the toxic forms of lipid A can induce the production of TNF by macrophages. Furthermore, although it is essential, TNF alone is not necessarily sufficient to induce septic shock in mice.

Induction of tumor necrosis factor, IFN-gamma, and acute lethality in mice by toxic and non-toxic forms of lipid A

The effect of the i.v. administration of endotoxin (LPS), diphosphoryl lipid A, and the non-toxic derivative monophosphoryl lipid A (MPL), on the production of serum cachectin (TNF), IFN-gamma, and the appearance of endotoxin shock have been measured in mice primed with Listeria monocytogenes. All three of the lipid A varieties induced the production of TNF in a dose-dependent manner. Although comparable peak levels of TNF were produced (5 X 10(5) to 1 X 10(6) U/ml), treatments with LPS or diphosphoryl lipid A were lethal whereas those with MPL were not. A study following TNF in the mouse sera for up to 24 h after treatment with the lipid A types showed that serum levels of TNF peaked 90 min after the treatment, and that TNF levels induced by LPS treatment were maintained for several hours longer than those induced by lipid A or MPL. All three molecules also resulted in the production of IFN-gamma in the serum, which peaked at 4 to 5 h after treatment. After 90 min there were no significant differences in the levels of serum IFN-gamma in any of the groups of treated animals. However, as was observed with the TNF, the levels of IFN in animals treated with LPS persisted longer than those induced by MPL or lipid A. These results suggest that the non-toxic MPL as well as the toxic forms of lipid A can induce the production of TNF by macrophages. Furthermore, although it is essential, TNF alone is not necessarily sufficient to induce septic shock in mice.

An examination of O-2-isocephems as orally absorbable antibiotics

The synthesis and structure-activity relationships of a series of orally absorbed O-2-isocephems are described. These compounds possessed a D-[(p-hydroxyphenyl)glycyl]amino substituent at the 7-position while the substituent at the 3-position was varied. Relative to the analogous cephems, the O-2-isocephems exhibited comparable to better activity against Gram-positive organisms. Against Gram-negative organisms, their activity was variable but did indicate a lower beta-lactamase stability. Following oral administration, the O-2-isocephems generally exhibited longer half-lives but lower Cmax's and urinary recoveries.