Author Archives: Hannah

The STITCH trial: a summary

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One discussion this week mentioned the STITCH trial.

Reference: Deerenberg EB, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised control trial. Lancet. 2015 Sep 26;386(10000):1254-1260. doi: 10.1016/S0140-6736(15)60459-7.

Summary: Incisional hernia is a frequent complication of abdominal operations with an incidence of 10–23%, which can increase to 38% in specific risk groups. It is associated with pain and discomfort, resulting in a decreased quality of life. Incarceration and strangulation of abdominal contents can take place, for which emergency surgery is indicated, with associated morbidity and mortality. The authors (2015) estimate about 348,000 operations for incisional hernia are done every year in the US with $3.2 billion in annual associated costs.

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The use of mesh reinforcement in hiatal hernia repair

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Rausa E, et al. Prosthetic Reinforcement in Hiatal Hernia Repair, Does Mesh Material Matter? A Systematic Review and Network Meta-Analysis. J Laparoendosc Adv Surg Tech A. 2021 Oct;31(10):1118-1123.

Results: Seventeen articles based on 1857 patients were enrolled in this article. The point estimation showed that when compared against the control group (NAM), the HH recurrence risk in AM and cruroplasty group was higher (relative ratio [RR] 2.3; CrI 0.8-6.3, RR 3.6; CrI 2.0-8.3, respectively). Postoperative complication rates were alike in all groups. The prevalence of mesh erosion after HHR is low.

Conclusions: This network meta-analysis showed that prosthetic reinforcement significantly reduced HH recurrence when compared with cruroplasty alone. However, there is not enough evidence to compare different mesh compositions.

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World Health Organization: In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI?

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World Health Organization. Summary of a systematic review on antimicrobial prophylaxis in the presence of a drain and wound drain removal. WHO Surgical Site Infection Prevention Guidelines, Web Appendix 27 (30p.).

Summary: In the WHO SSI prevention guidelines, one of the PICO questions addressed is:

In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI?

  • Population: inpatients and outpatients of any age undergoing a surgical
    operation (any type of procedure) with the presence of postoperative drainage
  • Intervention: prolonged antibiotic prophylaxis postoperatively
  • Comparator: single-dose antibiotic prophylaxis (or repeated intraoperatively
    according to the duration of the operation)
  • Outcomes: SSI, SSI-attributable mortality

Their findings are quoted below:

Seven RCTs were identified with an SSI outcome comparing prolonged antibiotic prophylaxis in the presence of a wound drain vs. single-dose perioperative prophylaxis, possibly repeated intraoperatively according to the duration of the procedure. The number of days for antibiotic prophylaxis prolongation in the postoperative period varied among studies. Three studies prolonged antibiotic administration until the wound drain was removed. In the remaining trials, patients continued intravenous administration for 3 or 5 days. Included patients were adults undergoing several types of surgical procedures (general surgery, kidney transplantation, and pilonidal sinus surgery). One trial evaluated whether prolonged antibiotic prophylaxis reduced the risk of infectious complications for patients undergoing elective thoracic surgery with tube thoracostomy. The antibiotic was continued for 48 hours after the procedure or until all thoracostomy tubes were removed, whichever came first.

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Guidelines for the perioperative management of anticoagulants

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One discussion this week focused on the perioperative management of NOACs.

Reference:  DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 -. Record No. 227537, Periprocedural management of patients on long-term anticoagulation; [updated 2018 Oct 10, cited 2018 Oct 12; [about 26 screens]. Emory login required.

Summary: The information below is from DynaMed Plus (2018). To view full information on the topic, click on the citation above.

Vitamin K antagonists in patients undergoing major surgery or procedures

  • Consider continuing vitamin K antagonist (VKA) therapy in patients who require minor dental procedures, minor dermatological procedures, or cataract surgery.
  • In those having a minor dental procedure, consider coadministering an oral hemostatic agent or stopping the VKA 2 to 3 days before the procedure.
  • In those undergoing implantation of a pacemaker or an implantable cardioverter device, consider continuing VKA therapy.
  • In those having a major surgery or procedure, stop VKA therapy 5 days before surgery.
  • Resume VKA therapy 12-24 hours after surgery when there is adequate hemostasis.

Bridging therapy in patients undergoing major surgery or procedures

  • If at low risk for thrombosis, consider omitting bridging therapy.
  • If at moderate risk for thrombosis, assess individual patient- and surgery-related factors when considering bridging therapy.
  • If at high risk for thrombosis consider bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH).
  • For those receiving bridging therapy with UFH, stop UFH 4-6 hours before surgery.
  • For those receiving bridging therapy with therapeutic-dose LMWH, stop LMWH 24 hours before surgery.
  • For those receiving bridging therapy with UFH or therapeutic-dose LMWH and undergoing non-high-bleeding-risk surgery, consider resuming heparin 24 hours after surgery.
  • For those receiving bridging therapy with UFH or therapeutic-dose LMWH and undergoing high-bleeding-risk surgery, consider resuming heparin 48-72 hours after surgery.

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Signet-ring cell carcinoma: a look at the rare colorectal cancer

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A discussion this week included signet ring cell carcinoma.

Reference: Nitsche U, et al. Mucinous and signet-ring cell colorectal cancers differ from classical adenocarcinomas in tumor biology and prognosis. Annals of Surgery. 2013 Nov;258(5):775-782; discussion 782-783. doi:10.1097/SLA.0b013e3182a69f7e

Additional Reading: Korphaisarn K, et al. Signet ring cell colorectal cancer: genomic insights into a rare subpopulation of colorectal adenocarcinoma. British Journal of Cancer. 2019 Sep;121(6):505-510. doi:10.1038/s41416-019-0548-9

Summary: In a study analyzing clinical, histopathological, and survival data of 3479 patients undergoing surgery for primary colorectal cancer between 1982 and 2012, Nitsche et al (2013) compared the characteristics of classical adenocarcinomas (AC) to the less common mucinous adenocarcinomas (MAC) and to the rare signet-ring cell carcinomas (SC).

SC

Approximately 10% of all colorectal cancers are MAC, and about 1% are SC. Because of their relatively rare occurrence, in particular, the evaluation of the clinical impact of SC is difficult. However, compared with AC, both MAC and SC have been shown to be associated with young age, advanced tumor stage, accumulation in female patients, and distinct molecular patterns, such as microsatellite instability and activating mutations of the BRAF gene. Although ambiguous, recent data and meta-analyses suggest that the
histological subtype MAC may be associated with worse outcome compared with AC. Poor prognosis of SC is more evident, mainly due to high rates of synchronous and metachronous distant organ metastasis associated with this histological subtype.

In describing SC, the authors state: “SC have been described as being positive for intestinal trefoil factor and MUC2, 2 peptides that are usually produced only by goblet cells. Thus, SC could arise from different cells of origin than AC. Although they can be localized in the colorectum, SC may be genetically more related to signet-ring cell cancers of other organs (eg, gastric cancer) than to AC or MAC of the colorectum. The
absence of E-cadherin/β-catenin and amplification of Bcl-2 are features typically shared with signet-ring cell cancer of the stomach but not with classical colorectal adenocarcinomas” (p.781).

The authors conclude that patients with MAC and SC could profit from closer follow-up or even intensified adjuvant therapy because of their high rates of local and distant recurrence. The biological behavior of SC differs in specific, and these patients require special awareness, despite the relatively rare prevalence.

AAA repair: retroperitoneal vs transperitoneal approach

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One discussion this week included transperitoneal vs retroperitoneal  approach following AAA repair.

Reference: Buck DB, et al. Transperitoneal vs retroperitoneal approach for open abdominal aortic aneurysm repair in the targeted vascular NSQIP. Journal of Vascular Surgery. 2016 Sept;64(3):585-591. doi:10/1016/j.jvs.2016.01.055.

Summary: This study aims to identify the demographic and anatomical differences between patients currently selected for elective transperitoneal versus retroperitoneal AAA repair and to assess differences in intra-operative details, and perioperative mortality and complications.

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The PAUSE study: Safety of perioperative DOAC management in patients with atrial fibrillation

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A discussion during a previous conference included the perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant (DOAC).

Reference: Douketis JD, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Internal Medicine. 2019 Aug 5; doi:10/1001/jamainternmed.2019.2431

Summary: Each year, 1 in 6 patients with AF, or an estimated 6 million patients worldwide, will require perioperative anticoagulant management. When DOAC regimens became available for clinical use in AF, starting in 2010, no studies had been conducted to inform the timing of perioperative DOAC therapy interruption and resumption, whether heparin bridging should be given, and whether preoperative coagulation function testing was needed. Uncertainty about the perioperative management of DOACs may be associated with unsubstantiated practices and increased harm to patients.

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