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doi: 10.1002/bjs.9055pmid: 23335021
Still a controversial Issue
Bekelis, K; Moses, Z; Missios, S; Desai, A; Labropoulos, N
doi: 10.1002/bjs.9027pmid: 23288608
BackgroundThere is significant variation in the indications for intervention in patients with recurrent carotid artery stenosis. The aim of the present study was to describe these indications in a contemporary cohort of patients.MethodsThis was a systematic review of all peer-reviewed studies reporting on the indications for carotid intervention in patients with recurrent stenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS) that were published between 1990 and 2012.ResultsThere were 50 studies reporting on a total of 3524 patients undergoing a carotid procedure; of these, 3478 underwent CEA as the initial intervention. Reintervention was by CEA in 2403 patients and by CAS in 1121. Only 54·7 per cent of the patients were treated for any symptoms and, importantly, just 444 (23·1 per cent of 1926 symptomatic patients) underwent intervention for documented ipsilateral symptoms. None of the studies reported whether the patients were evaluated for other sources of emboli. The remaining 45·3 per cent of patients had asymptomatic restenosis and in the majority of the studies were treated when the degree of stenosis exceeded 80 per cent. The time to repeat intervention was significantly longer in patients with recurrent atherosclerosis, in asymptomatic patients and in patients undergoing CEA.ConclusionThe reported criteria for retreatment of carotid stenosis were not rigorous and there is still significant ambiguity surrounding the indications for intervention.
doi: 10.1002/bjs.9029pmid: 23378201
Opinions regarding how best to treat recurrent stenosis after carotid intervention are often strongly held but based on the flimsiest of evidence. This systematic review by Bekelis and colleagues highlights the lack of quality data. True, we now have a contemporary update on the proportions of patients with symptomatic and asymptomatic restenoses undergoing reintervention. True, reinterventions seem to be associated with remarkably low procedural risks (publication bias?). And true, carotid artery stenting (CAS) seems to be a reasonable (probably safer) alternative to redo carotid endarterectomy (CEA). But did the majority really need any reintervention in the first place? Only a small proportion presented with bona fide carotid territory symptoms referable to an ipsilateral restenosis, and no-one would deny that these patients benefit from reintervention. The vast majority, however, were either definitely, or probably, asymptomatic. Little evidence exists to support reintervention in patients with asymptomatic restenoses, especially those aged over 75 years (probably a significant proportion in the Bekelis review). Moreover, it is hard to reconcile that the evidence apparently justifies reintervention in patients with asymptomatic restenoses, but usually not if the patient develops another restenosis thereafter. This year, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) reported that five (9 per cent) of 56 patients in the CEA group with at least 70 per cent restenosis suffered a late ipsilateral stroke within 2 years, a significantly higher proportion than the 12 (1·2 per cent) of 1004 with less than 70 per cent restenosis. This compares with one (2 per cent) of 55 patients with at least 70 per cent restenosis suffering a late ipsilateral stroke compared with 18 (1·8 per cent) of 980 without in the CAS group. Will these CREST data change my attitude towards surveillance (currently to discharge patients at 4 weeks after CEA)? No. CREST has informed the debate, but there would be a much stronger case for surveillance and reintervention if any of the other large-scale randomized trials (Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis, EVA-3S; Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy, SPACE; International Carotid Stenting Study, ICSS) found any association between restenosis and late ipsilateral stroke. To date, they have not. There is not even a trend. Disclosure The author declares no conflict of interest. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
Coughlin, P A; Jackson, D; White, A D; Bailey, M A; Farrow, C; Scott, D J A; Howell, S J
doi: 10.1002/bjs.9018pmid: 23254440
BackgroundRepair of an abdominal aortic aneurysm (AAA) is undertaken to prevent rupture. Intervention is by either open repair (OR) or a more minimally invasive endovascular repair (EVAR). Quality-of-life (QoL) analysis is an important health outcome and a number of single studies have assessed QoL following OR and EVAR. This was a meta-analysis of published studies to assess the effect of an intervention on QoL in patients with an AAA.MethodsA systematic literature search was undertaken for studies prospectively reporting QoL analysis in patients with an AAA undergoing elective intervention. A multivariable meta-analysis model was developed in which the outcomes were mean changes in QoL scores over time, both for all AAA repairs (OR and EVAR) and comparing OR with EVAR.ResultsData were collated from 16 studies (14 OR, 12 EVAR). The results suggested that treating an AAA had an effect on patient-reported QoL, evident from the statistically significant changes predominantly in domains assessing physical ability and pain. QoL was affected most within the first 3 months after any form of intervention, and was more pronounced following OR. Furthermore, a deterioration in the Physical Component Summary score following an AAA repair (either OR or EVAR) was evident at 12 months after intervention.ConclusionTreating an AAA deleteriously affects patient-reported QoL over the first year following intervention.
Chan, D S Y; Reid, T D; Howell, I; Lewis, W G
doi: 10.1002/bjs.9015pmid: 23319427
BackgroundThe prognostic role and definition of circumferential resection margin (CRM) involvement in operable oesophageal cancer remain controversial. The College of American Pathologists (CAP) and Royal College of Pathologists (RCP) define CRM involvement as tumour found at the cut resection margin and within 1 mm of the cut margin respectively. This systematic review and meta-analysis was performed to determine the influence of CRM involvement on survival in operable oesophageal cancer.MethodsPubMed, MEDLINE and the Cochrane Library (January 1990 to June 2012) were searched for studies correlating CRM involvement with 5-year mortality. Statistical analysis of dichotomous variables was performed using the odds ratio (OR) as the summary statistic.ResultsFourteen studies involving 2433 patients with oesophageal cancer who had undergone potentially curative oesophagectomy were analysed. Rates of CRM involvement were 15·3 per cent (173 of 1133) and 36·5 per cent (889 of 2433) according to the CAP and RCP criteria respectively. Overall 5-year mortality rates were significantly higher in patients with CRM involvement compared with CRM-negative patients according to both CAP (OR 4·02, 95 per cent confidence interval (c.i.) 2·25 to 7·20; P < 0·001) and RCP (OR 2·52, 1·96 to 3·25; P < 0·001) criteria. CRM involvement between 0·1 and 1 mm was associated with a significantly higher 5-year mortality rate than CRM-negative status (involvement more than 1 mm from CRM) (OR 2·05, 95 per cent c.i. 1·41 to 2·99; P < 0·001).ConclusionCRM involvement is an important predictor of poor prognosis. CAP criteria differentiate a higher-risk group than RCP criteria, but overlook a patient group with similar poor outcomes.
Wang, Z X; Jiang, C P; Cao, Y; Ding, Y T
doi: 10.1002/bjs.9062pmid: 23338685
BackgroundSurgical-site infections (SSIs) increase morbidity and mortality in surgical patients and represent an economic burden to healthcare systems. Experiments have shown that triclosan-coated sutures (TCS) are beneficial in the prevention of SSI, although the results from individual randomized controlled trials (RCTs) are inconclusive. A meta-analysis of available RCTs was performed to evaluate the efficacy of TCS in the prevention of SSI.MethodsA systematic search of PubMed, Embase, MEDLINE, Web of Science®, the Cochrane Central Register of Controlled Trials and internet-based trial registries for RCTs comparing the effect of TCS and conventional uncoated sutures on SSIs was conducted until June 2012. The primary outcome investigated was the incidence of SSI. Pooled relative risks with 95 per cent confidence interval (c.i.) were estimated with RevMan 5.1.6.ResultsSeventeen RCTs involving 3720 participants were included. No heterogeneity of statistical significance across studies was observed. TCS showed a significant advantage in reducing the rate of SSI by 30 per cent (relative risk 0·70, 95 per cent c.i. 0·57 to 0·85; P < 0·001). Subgroup analyses revealed consistent results in favour of TCS in adult patients, abdominal procedures, and clean or clean-contaminated surgical wounds.ConclusionTCS demonstrated a significant beneficial effect in the prevention of SSI after surgery.
doi: 10.1002/bjs.9006pmid: 23203909
BackgroundMany patients develop discomfort after open repair of a groin hernia. It was hypothesized that suture fixation of the mesh is a cause of these symptoms.MethodsThis patient- and assessor-blinded randomized multicentre clinical trial compared a self-gripping mesh (Parietene Progrip®) and sutured mesh for open primary repair of uncomplicated inguinal hernia by the Lichtenstein technique. Patients were assessed before surgery, on the day of operation, and at 1 and 12 months after surgery. The primary endpoint was moderate or severe symptoms after 12 months, including a combination of chronic pain, numbness and discomfort.ResultsThe intention-to-treat population comprised 163 patients with self-gripping mesh and 171 with sutured mesh. The 12-month prevalence of moderate or severe symptoms was 17·4 and 20·2 per cent respectively (P = 0·573). There were no significant differences between the groups in postoperative complications (33·7 versus 40·4 per cent; P = 0·215), rate of recurrent hernia within 1 year (1·2 per cent in both groups) or quality of life.ConclusionThe avoidance of suture fixation using a self-gripping mesh was not accompanied by a reduction in chronic symptoms after inguinal hernia repair. Registration number: NCT00815698 (http://www.clinicaltrials.gov).
Lemanu, D P; Singh, P P; Berridge, K; Burr, M; Birch, C; Babor, R; MacCormick, A D; Arroll, B; Hill, A G
doi: 10.1002/bjs.9026pmid: 23339040
BackgroundOptimized perioperative care within an enhanced recovery after surgery (ERAS) protocol is designed to reduce morbidity after surgery, resulting in a shorter hospital stay. The present study evaluated this approach in the context of sleeve gastrectomy for patients with morbid obesity.MethodsPatients were allocated to perioperative care according to a bariatric ERAS protocol or a control group that received standard care. These groups were also compared with a historical group of patients who underwent laparoscopic sleeve gastrectomy at the same institution between 2006 and 2010, selected using matched propensity scores. The primary outcome was median length of hospital stay. Secondary outcomes included readmission rates, postoperative morbidity, postoperative fatigue and mean cost per patient.ResultsOf 116 patients included in the analysis, 78 were allocated to the ERAS (40) or control (38) group and there were 38 in the historical group. There were no differences in baseline characteristics between groups. Median hospital stay was significantly shorter in the ERAS group (1 day) than in the control (2 days; P < 0·001) and historical (3 days; P < 0·001) groups. It was also shorter in the control group than in the historical group (P = 0·010). There was no difference in readmission rates, postoperative complications or postoperative fatigue. The mean cost per patient was significantly higher in the historical group than in the ERAS (P = 0·010) and control (P = 0·018) groups.ConclusionThe ERAS protocol in the setting of bariatric surgery shortened hospital stay and was cost-effective. There was no increase in perioperative morbidity. Registration number: NCT01303809 (http://www.clinicaltrials.gov).
Kashiwagi, S; Yashiro, M; Takashima, T; Aomatsu, N; Kawajiri, H; Ogawa, Y; Onoda, N; Ishikawa, T; Wakasa, K; Hirakawa, K
doi: 10.1002/bjs.9021pmid: 23319435
BackgroundAs patients with basal-like breast cancer (BLBC) have a poor prognosis and there is no specifically tailored therapy, molecular biological characterization of BLBC is necessary. c-Kit is a transmembrane receptor tyrosine kinase known to play important roles in various solid cancers. This study classified BLBCs from patients with breast carcinoma, and addressed the significance of c-Kit expression in these tumours.MethodsPrimary breast tumours were stained with antibodies against oestrogen receptor, progesterone receptor, human epidermal growth factor receptor (HER) 2, epidermal growth factor receptor (EGFR), cytokeratin 5/6 and c-Kit. The association between c-Kit, BLBC and survival was analysed.ResultsA total of 667 patients with breast cancer were followed up for a median of 39 (range 6–72) months. Some 190 tumours (28·5 per cent) were classified as triple-negative for breast cancer (negative for oestrogen receptor, progesterone receptor and HER2) and 149 (78·4 per cent) had characteristics of BLBC (positive for cytokeratin 5/6 and/or EGFR). c-Kit expression was detected in 111 (16·6 per cent) of 667 tumours. c-Kit-positive tumours were more commonly found among patients with BLBC (42 of 149, 28·2 per cent; P < 0·001) and in patients with nodal metastasis (47 of 216, 21·8 per cent; P = 0·014) than in those without. In patients with BLBC, the prognosis was significantly worse in those with c-Kit expression (P < 0·001). Multivariable logistic regression analysis revealed c-Kit as an independent negative prognostic factor for cancer-specific survival in patients with BLBC (hazard ratio 2·29, 95 per cent confidence interval 1·11 to 4·72).Conclusionc-Kit might be a prognostic marker and possible molecular target for therapy in patients with BLBC.
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